Community-Based Services

The Acute Care Family Support (ACFS) program is available to help caregivers of people with serious mental illness cope during times of crisis. Many people with mental illness can live full and productive lives with treatment and supports. Screening may be the first step to helping your loved one achieve wellness. Funded by the New Jersey Division of Mental Health and Addiction Services, this program is offered in collaboration with Intensive Family Support Services (IFSS) of Middlesex County.

ACFS Brochure (pdf)

Adult Residential services support adults age 18 and older with mental health disorders, including individuals with co-occurring mental health and substance use disorders. Located in Camden, New Jersey, the program provides A+ level residential housing in a supportive environment designed to promote recovery, stability, and greater independence. Referrals are accepted from state psychiatric hospitals and community providers, with priority given to individuals referred by state psychiatric hospitals.

Residents receive individualized support that includes case management, medication monitoring, and linkage to community-based services and resources. Length of stay is based on each resident’s individual needs and progress, with residents encouraged and supported in transitioning to independent living when appropriate.

Community Support Services (CSS) helps adults with behavioral health needs live independently and thrive in their communities. Recovery-focused, person-centered services are tailored to each individual’s strengths and goals and may include daily living skills training, housing support, illness management, medication coordination, employment and education assistance, benefits navigation, and community integration. CSS promotes recovery, stable housing, independence, and improved quality of life for individuals in Essex, Middlesex, and Camden counties. Referrals are accepted from individuals, family members, healthcare professionals, and community agencies.

C-POP Peer Support Specialist work with individuals who have a history of an Substance Use Dis-order and who are within their first 90 days of incarceration from a
New Jersey state prison.

This program is voluntary. The program goals are to empower individuals beginning their period of incarceration to consider ways of reducing recidivism, preventing relapse, and improving their overall recovery and wellness while incarcerated. Additionally, participants are encouraged to pursue other programs, treatment options and educational opportunities to maximize the benefits available during their period of incarceration.

The Justice Involved Services (JIS) program supports adults in the Middlesex County Jail and the community who have been diagnosed with a serious and persistent mental illness. Funded by the New Jersey Division of Mental Health and Addiction Services (DMHAS), the program provides comprehensive reentry and recovery services designed to promote successful community reintegration and reduce recidivism.

Services include pre-release screening and assessment, individualized aftercare planning, linkage to mental health and substance use treatment, case management, housing and employment support, and support during their legal problems. The program works in close collaboration with criminal justice personnel, treatment providers, and family members to ensure continuity of care and ongoing support throughout the reentry process.

JIS brochure (pdf)

Integrated Case Management Services (ICMS) serves adults ages 18 and older residing in Middlesex County who are living with severe and persistent mental illness and have either been discharged from a psychiatric hospital or are at risk of hospitalization. Referrals are accepted from State and County Psychiatric Hospitals, Short Term Care Facilities (STCFs), and local mental health service providers. Services are funded through a Fee-for-Service model, with no upper limit on caseload capacity. The program provides assessment, treatment planning, monitoring, and linkage to mental health, medical, addiction, and other community-based supportive services designed to prevent rehospitalization and help individuals achieve stability and success in community settings. Services may be provided for up to 12 months.

ICMS brochure (pdf)

Intensive Recovery Treatment Support (IRTS™) program is a peer-driven reentry initiative that supports individuals with a history of substance use disorders during incarceration and throughout their transition back into the community. Through a team-based approach, Peer Support Specialists, Case Managers and Nurses provide mentorship, advocacy, and linkage to essential services including treatment, housing, healthcare, and recovery support. IRTS™ focuses on reducing overdose risk, promoting long-term recovery, and helping participants successfully reintegrate as contributing members of society. By combining lived experience with community-based support, the program builds trust, increases engagement, and improves overall outcomes for individuals returning from incarceration.

IRTS™ brochure (pdf)

Maternal Wraparound Program (M-WRAP) provides intensive case management and recovery support for pregnant and postpartum women with substance use disorders. The program helps participants access healthcare, treatment, and community resources through comprehensive care coordination while Recovery Support Specialists provide ongoing, non-clinical support for mothers and their families. M-WRAP aims to improve maternal health, promote healthy birth outcomes, and reduce the effects of prenatal substance exposure. Services are available in Essex, Hudson, Union, Hunterdon, Mercer, Middlesex, and Somerset counties. Referral forms are available for providers and individuals seeking services.

Mobile Outreach for Recovery and Education (MORE) provides case management and peer recovery services to individuals age 18 and older residing in Middlesex County who have an Opioid Use Disorder and may not currently be engaged in treatment. Services include linkages and referrals for housing, substance use and mental health treatment, benefits assistance, and other supportive services. Peer recovery specialists work closely with individuals to provide engagement, education, encouragement, and ongoing support throughout the recovery process. Community education and outreach are also essential components of the MORE program.

PATH serves adults ages 18 and older with severe and persistent mental illness who are homeless or at risk of homelessness in Middlesex County. Referrals are accepted from outpatient and inpatient providers, social service agencies, homeless shelters, and soup kitchens, with particular emphasis on individuals who are not currently connected to mental health services; individuals may also self-refer. Funded by the New Jersey Division of Mental Health and Addiction Services (DMHAS), the program serves approximately 95 individuals each year. Services include outreach and linkage to mental health care and other supportive resources designed to promote housing stability, develop independent living skills, and support successful community living. Services generally continue for approximately six months after successful linkage to housing and mental health services.

R-HOME provides case management and recovery support for individuals and families in Middlesex County who are experiencing homelessness or housing instability and have substance use disorders or co-occurring mental health conditions. Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), the program connects participants with substance use and mental health treatment, housing resources, and other essential community services. Referrals are accepted from healthcare providers, social service agencies, treatment programs, and individuals seeking assistance. Services are typically provided for 9–12 months, supporting approximately 100 individuals each year. Referral forms are available for those seeking services.

Specialized Case Management Outreach Services (SCMOS) serves young adults, adults, and elderly individuals in Middlesex County who are unengaged and in need of mental health services. Referrals are accepted from individuals, families, mental health providers, social service agencies, and Aging-In agencies. Funded by the County of Middlesex, the program provides outreach services focused on connecting individuals to mental health treatment, supportive social services, and other community-based resources to promote stability and well-being.

SCMOS brochure (pdf)

Support Team for Addiction Recovery (STAR) teams provide community-based outreach and engagement services to individuals impacted by substance use disorders and related crises. Using a compassionate, harm reduction and recovery-oriented approach, STAR teams connect individuals to treatment, healthcare, housing, peer support, and other essential community resources. Teams work collaboratively to reduce barriers to care, prevent overdose, and support long-term recovery and stability. Through ongoing engagement and person-centered support, STAR teams help individuals build safer, healthier, and more connected lives. Available in Mercer and Hunterdon Counties.