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The Integrated System of Care (ISC) Program

The first of its kind in New Jersey, our ISC Program works with behavioral health providers to manage the complex physical, behavioral and social determinants of health (SDoH) needs of your patients.

How the ISC Program works
The ISC Program uses a virtually integrated care delivery system to provide timely, coordinated and outcome-driven care to our members with serious mental illness (SMI) and substance use disorders (SUD). Each Horizon member who is part of this program is assigned a care coordinator from the participating behavioral health providers that are part of the ISC Program. The care coordinator helps manage a patient’s unique behavioral, physical and social health treatment needs with health systems, primary care practices and social services.

How to refer a patient to the ISC Program

The ISC Program provider will:

  • Create a treatment plan for a patient’s overall health needs following a full assessment.
  • Coordinate the care provided by health systems, primary care practices and social service providers.
  • Help your patients get the services and support they need, to achieve and sustain an improved quality of life.

If your patient is already receiving mental health or substance use treatment

The ISC program can provide added support to those patients already receiving behavioral health care. Our ISC behavioral health partners can work with the patient or treating behavioral health provider to coordinate access to physical health treatment and community resources to address SDoH needs (e.g., referrals, helping patients schedule and keep specialist appointments, transportation, housing and food).

Patients with the following signs or symptoms may benefit from a referral to the ISC program

  • Patients who you suspect may have chronic and severe mental health conditions including, but not limited to, schizophrenia, major depressive disorder, bipolar disorder. These patients may have distorted thought processes, extreme mood swings from mania to depression, or may have very poor impulse control and are frequently seeking urgent care in office, emergency rooms, urgent care and hospital settings.
  • Patients who you suspect may need treatment for a substance use disorder.

Patients benefit from a variety of services
The ISC Program will help you connect your patients to additional resources beyond their benefits and traditional behavioral health care that address any issues related to social determinants of health, including access to food, transportation, child care, etc. The program is designed to help patients get and stay healthy with the peace of mind that comes with knowing all their needs are addressed.

Patient services include:

  • Psychiatric evaluation
  • Medication management
  • Medication Assisted Treatment and Ambulatory Withdrawal Management for substance use disorders
  • Care management to connect patients to support services, including scheduling appointments and providing transportation to medical appointments
  • Care coordination to ensure that ongoing patient care is communicated to the primary care provider
  • Care transition assistance after discharge from inpatient or rehabilitation settings
  • Links to community resources to assist with housing, education, employment, financial stressors, or any other social needs
  • Health education and techniques to motivate patients to engage in self-service management
  • Burlington, Mercer, Camden Counties:
    • Catholic Charities
      , option 2. Specify ISC

    • Oaks Integrated Care

  • Monmouth, Ocean Counties
    • CPC Behavioral Health
      Patients: 1-800-250-9811
      Providers: Julie Edwards, or call 1-732-802-6755

    • Ocean Mental Health
      Patients: 1-732-575-1111
      Providers: Alicia Mardirosian, 1-609-276-4127

Additional Resources
See this program in action. View our video featured on Horizon Health Works, a monthly video series highlighting innovations and initiatives to improve health care in New Jersey.