Integrated Health Home Program

The Integrated Health Home continues our overall mission to deliver the highest quality of care in the best possible environment. It is a wellness program designed to provide behavioral health and physical health services and ensures that each client has an ongoing relationship with both a medical- and a psychiatric-licensed independent practitioner in a co-located facility. Clients benefit from having access to team-based clinical providers offering integrated care and coordination of services that help them get healthy and stay healthy.

Servicing both Monmouth and Ocean Counties, the Integrated Health Home offers:

  • Enhanced Discharge Planning

  • Case Management

  • Care Coordination
  • Client and Caregiver Education
  • Staff and Provider Education
  • Social Support Assessment
  • Referral Interventions
  • Client Self-Care Plan
  • Screening Tools
  • Medical Home
  • Client Group Visit Plans
  • Nutritional Support
  • Home Visits

The Integrated Health Home Team Focus

  • Ensure that each patient has an ongoing relationship with medical and psychiatric-licensed practitioner in a co-located facility
  • Ensure coordination and access to chronic disease management, and screening and prevention services including self-management support and health navigation provided by community health workers to clients and their caregivers
  • Ensure treatment compliance by providing outreach to clients
  • Ensure the development of a single treatment plan that includes behavioral health issues, medical issues, substance abuse issues and social needs. This includes incorporating interventions such as nutrition monitoring, healthy lifestyle coaching and wellness activities
  • Ensure all client information is maintained on a secure electronic health record (EHR)

For more information, please contact our Integrated Health Home program at 732.923.6500 ext. 7

Patient Stories

  • Cathy is feeling "great" and continuing to improve.

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  • The Freehold resident finally found relief at The Spine Center at Monmouth Medical Center in nearby Long Branch, New Jersey.

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  • "Monmouth Medical Center’s incredible physicians saved my life, saved my brain and added to the quality of my life, now we want to pay it forward and get involved.”

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Patient Stories

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