Nathaniel Wellness Program

The Intervention: Integrated primary and behavioral health services

Who is Served: Justice-involved adults with serious mental illness and chronic medical conditions

The Challenge

People with serious mental illness and a history of involvement in the criminal justice system experience high rates of chronic physical health conditions. For example, researchers have found that people with serious mental illness and a history of incarceration are

  • 40% more likely to have a chronic medical problem than the general population
  • 30% more likely to have multiple medical problems than individuals with serious mental illness who have no incarceration history1

These individuals typically face a complex array of psychosocial and socioeconomic problems, which tend to increase their risk for chronic health problems while decreasing their access to care.2 This high level of risk is often compounded by a distrust of the medical system, reluctance to participate in medical care, and/or disconnection from outpatient services, leading to excessive use of costly hospital emergency services.3 In 2014, CASES opened the Nathaniel Clinic, an outpatient mental health clinic in Central Harlem specializing in services for justice-involved people with mental illness. To date, in addition to their mental illness, at intake more than 40% of Nathaniel Clinic clients have a chronic physical health condition, including asthma, cardiovascular disease, diabetes, hepatitis, HIV/AIDS, and obesity.

The Nathaniel Wellness Approach

Co-located in Central Harlem with the Nathaniel Clinic’s outpatient mental health services, the Nathaniel Wellness Program (NWP) provides integrated primary care to adults with serious mental illness who have or are at risk for a chronic medical condition, with a focus on those who have current or previous involvement in the criminal justice system. Services are delivered by CASES in partnership with staff from the Institute for Family Health (IFH), one of New York’s largest nonprofit providers of health care services to disadvantaged and at-risk populations. IFH has a large office offering primary and specialty health care services near the location of CASES’ Nathaniel Clinic in Harlem.

NWP primary care services include

  • physical health assessments
  • ongoing health monitoring
  • referrals to specialty providers as needed

Program goals include promoting early intervention, effective self-care, access to specialty medical services, and reduction in medical crises. These goals are also supported by NWP’s preventative health activities, including:

  • Nutritional counseling and wellness self-management
  • Healthy living groups
  • Smoking cessation counseling
  • Exercise groups, including Zumba, tai chi, yoga, and walking

The Impact 

In 2015, CASES received one of 60 grants awarded nationally by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) to support primary and behavioral health care integration projects. With this support, CASES and IFH are delivering primary care services onsite that are integrated with clients’ ongoing mental health services at the Nathaniel Clinic or in CASES’ other State-licensed mental health treatment programs, including our assertive community treatment (ACT) and forensic assertive community treatment (FACT) programs. Together, CASES and IFH will leverage SAMHSA’s four-year, $1.6 million grant to establish a Federally Qualified Health Center co-located with the Nathaniel Clinic. This health center will have the capacity to annually provide integrated primary care services to hundreds of justice-involved clients with mental illness and physical health conditions.


1 Cuddeback, G.S., Scheyett, A., Pettus-Davis, C., & Morrissey, J. (2010, Jan.). General medical problems of incarcerated persons with severe and persistent mental illness: a population-based study. Psychiatric Services, 66(1), 45-49. Retrieved from ^

2 Kim, C., Sinco, B., & Kieffer, E.A. (2007, Jun.). Racial and ethnic variation in access to health care, provision of health care services, and ratings of health among women with histories of gestational diabetes mellitus. Diabetes Care 30(6), 1459-1465. Retrieved from^

3 Koyangi, C. (2004). Get it together: How to integrate physical and mental health care for people with serious mental disorders. Washington: The Bazelon Center for Mental Health Law. Retrieved from ^