TN Discretionary Funding Fiscal Year 2020

Centerstone COVID-19 Emergency Response Suicide Prevention in Tennessee (TN-ERSP) will advance efforts during the COVID-19 pandemic to prevent suicide and suicide attempts among adults age 25 and older, including victims of domestic violence, in the geographic area comprising 30 Middle Tennessee counties. TN-ERSP anticipates serving, at minimum, an unduplicated total of 125 adults in the 16-month project period, based on considerations including area/population need, staff caseload/capacity, and timeframe for meeting client care needs. TN-ERSP’s focus population demographics are expected to mirror those of the catchment area, with 48% male, 52% female, 79% white, 13% African American, 5% Hispanic/Latino individuals ages 25+. TN-ERSP will emphasize supporting victims of domestic violence who face suicide risk factors (e.g., stress, anxiety, trauma) exacerbated by current conditions (e.g., stay-at-home orders). Prior to the pandemic, suicide rates among the focus population far exceeded the nation (22.7/100,000 vs. 14.5); and are expected to rise as a result of COVID-19. For example, local Middle Tennessee service providers/agencies have seen a 800% increase in suicide calls and a 55% increase in domestic violence helplines in Nashville alone, just one of the cities within the catchment area. In response to the COVID-19 pandemic and related behavioral health needs, TN-ERSP will provide rapid follow-up, including care transition/coordination services, among clients who have attempted suicide or experienced a suicidal crisis after discharge from emergency departments (EDs) and inpatient psychiatric units (IPUs), and help clients secure a mental health appointment within a week of discharge. TN-ERSP will assess clients’ risk level using the Patient Health Questionnaire-9, Columbia-Suicide Severity Rating Scale, and the Interpersonal Needs Questionnaire. A crisis management plan will be developed for those at high risk comprising of safety planning, reduced access to lethal means crisis intervention, continuous contact/monitoring, and rapid follow-up. Victims of domestic violence and their dependents will be provided enhanced services, including a safe place to stay if they are unable to remain safe in their home. TN-ERSP suicide-specific evidence-based practices include RELATE; the Interpersonal Theory of Suicide (ITS); Cognitive Behavioral Therapy-Suicide Prevention (CBT-SP); Suicide-Prevention Focused Narrative Exposure Therapy (S-NET); Dialectical Behavioral Therapy-Skills Treatment (DBT-ST); Attempted Suicide Short Intervention Program (ASSIP); and Counseling on Access to Lethal Means (CALM). TN-ERSP will accomplish the following goals: 1) Develop/implement a plan for rapid follow-up after discharge from EDs/IPUs; 2) Provide follow-up and care transition/coordination services; 3) Enhance/expand community and clinical service provider training; 4) Develop/expand collaborations with relevant state/community organizations/departments/systems to implement comprehensive suicide prevention; 5) Enhance/expand community recovery supports for clients and household members; and 6) Conduct a comprehensive evaluation. TN-ERSP objectives will measure the number of screenings/assessments and rapid follow-up conducted; services (including telehealth services), care transition, and care coordination delivered; and community/clinical trainings conducted, as well as outcomes related to substance use, employment status, housing stability, suicidality, and social connectedness among participants. TN-ERSP has secured commitments from partners, including domestic violence organizations, who are dedicated to the project’s success and who will serve as linkage/referral sources; provide recovery support services; and take part in project trainings, Advisory Council, and Evaluation activities.

The Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) will provide mental and substance use disorder treatment and other related recovery supports for individuals impacted by the COVID-19 pandemic through TN CBHCR: COVID-19 Behavioral Health Care Response. TN CBHCR will expand behavioral healthcare treatment to Tennessee residents by increasing services, including telehealth services, statewide. TN CBHCR activities will include, as appropriate: (1) screening/assessment; (2) evidence-based, population-appropriate treatment services; and (3) recovery support services, provided to a focus population of Tennessee residents with severe mental illness (SMI), mental disorders less severe than SMI, substance use disorders (SUD), and/or co-occurring SMI and SUD (COD). The COVID-19 pandemic has reached 87 of Tennessee's 95 counties, leading to 4,182 cases as of April 9. TDMHSAS anticipates an increase in need for behavioral healthcare services in the aftermath of the pandemic among the populations of focus within the state, including an estimated 252,000 Tennesseans with SMI; 685,000 with mental disorders; 377,000 with SUD; and 70,560 with COD. Additionally, Tennessee expects an increased need for TDMHSAS services among residents not eligible for the state's Medicaid program, driven by increased unemployment following the pandemic's impact, as indicated by a 30-fold increase in unemployment claims in late March over the previous average. TN CBHCR will also serve healthcare professionals affected by their role in responding to the pandemic. TN CBHCR will provide direct services at agencies statewide. TN CBHCR will strengthen service capacity at agencies with telehealth capabilities (i.e., video- and/or telephone-enabled) to (1) address treatment service needs in areas where the COVID-19 impact is concentrated, (2) enable access to Tennessee residents for whom distance is a barrier, and (3) increase options that allow providers and individuals receiving care to practice safe social distancing practices. TDMHSAS estimates that TN CBHCR will serve 1,523 focus population individuals affected by COVID-19 during project implementation. The project will provide substance abuse and recovery support services to 543 individuals with SUD; and mental health services to 980 individuals with SMI and/or healthcare professionals with mental disorders less severe than SMI. TN CBHCR will provide screenings and assessments, which will guide the provision of direct evidence-based mental health and/or substance abuse treatment services to eligible individuals affected by the COVID-19 pandemic. TN CBHCR will provide recovery services as appropriate and evaluate project progress during and after implementation. All TN CBHCR services will be guided by evidence-based practices and informed by CDC and SAMHSAs recommendations for behavioral health service provision specific to individuals affected by COVID-19 and its response.

In an effort to address substance misuse and anxiety, depression, and other mental health issues that may stem from natural disasters, the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) aims to provide mental and substance use disorder treatment, crisis counseling, and other related recovery supports to Tennesseans ages 18 and over impacted by the 2019 floods. The Tennessee Disaster Relief Initiative aims to develop and implement a comprehensive plan of evidence-based mental and/or substance use disorder treatment services, screen and assess clients for the presence of behavioral health conditions, provide treatment and recovery supports and make available crisis mental health services. It is estimated 3,000 Tennesseans will be served by this project.

Tennessee and other southeastern states are best described as experiencing an epidemic of substance abuse, particularly opioid abuse. The Tennessee Expansion of Social Work Practitioner Education program is intended to expand substance use disorder (SUD) education into the standard curriculum of relevant healthcare and health services education programs, beginning with the University of Tennessee Knoxville and Nashville campuses. Through the mainstreaming of this education, the ultimate goal is to expand the number of practitioners who will deliver high-quality, evidence-based SUD treatment and thus reduce the stigma associated with SUD. A comprehensive, evidence-based SUD-SBIRT curriculum will be developed, implemented and evaluated. The curriculum will include SBIRT screening, assessment and treatment strategies and their application, particularly with regard to alcohol, marijuana, stimulants, and opioids. Electronic modes of teaching, i.e., websites, chat rooms, CD ROM presentations, and electronic newsletters will be used in training social work students in the appropriate interventions and will allow for rapid and efficient dissemination of information to stakeholders. Upon completion, the SUD-SBIRT curriculum will be made available to other schools/colleges of social work in the Southeast and to healthcare professionals throughout the nation. The state-of-the-art electronic services provision will enable access to a significantly higher percentage of the population who currently lack such access to treatment services. The experiences and success of our five previous SAMHSA-funded e-therapy grants that have utilized SBIRT have paved the way for the implementation of the proposed program.

The title of this project is “Ensuring quality training on substance use disorders for counselors-in-training”. The project is designed to provide quality training and education in substance use disorders (SUD) for school counselor trainees, clinical mental health counselor trainees, clinicians, and counselor educators who provide mental health services to individuals in the South Central Appalachia region of Tennessee. This project will focus on the development of an evidence-based training curriculum on screening, brief intervention, and referral to treatment (SBIRT) strategies; assessment procedures; and treatment of substance use disorders. Individuals who live in the South Central Appalachia region experience a disproportionate amount of health disparities as compared to the national averages. There is a shortage of treatment providers in this area, which contributes to this number and serves as the emphasis of this project. Students in programs accredited by the Council for the Accreditation of Counseling and Related Education Programs (CACREP) are required to understand the theories of addictions and the signs and symptoms of substance use issues. Based on a comprehensive needs assessment of our current training, there is a need for a separate addictions course. This course would be required for both school counseling students and clinical mental health counseling students. The goals of this project are as follows: (1) Enhance the capacity of the counselor education program to sustain the delivery of a high quality, comprehensive curriculum with attention to evidence-based identification, assessment, and treatment of SUDs for MS Counseling trainees; (2) Increase the capacity of professional counselor trainees to utilize evidence-based screening, brief intervention, and referral to treatment (SBIRT), assessment, and treatment strategies in their anticipated work settings; (3) Enhance the capacity of doctoral-level trainees and site supervisors to utilize evidence-based screening, brief intervention and referral to treatment (SBIRT), assessment, and treatment strategies; and (4) Provide information to professional licensure boards and state legislators about the need to increase attention to evidence-based SUD competencies in professional counselor licensure and certification requirements. Objectives are connected to specific goals and will be completed throughout the life of the project. The objectives are measurable and will be evaluated at key points throughout the administration of the project. The project will annually serve at least 50 individuals, including counselor trainees, who will use the skills learned to work directly as interns with clients in the area; counselor educators, who will use the information to provide better and more comprehensive training in addictions throughout the program curriculum; and clinicians, who will use the information to affect positive change in clients who struggle with substance use disorders. We believe that this project will provide these stakeholders with the requisite knowledge and skill for addressing SUD concerns in the Appalachia region of Tennessee.

Centerstone's Certified Community Behavioral Health Clinic (C-CCBHC) project will establish Centerstone's Harriet Cohn Clinic in Clarksville as a CCBHC, improving access to/quality of community behavioral health services for individuals with serious mental illness (SMI), substance use disorders (SUD), opioid use disorders (OUD), co-occurring disorders (COD), and/or youth with serious emotional disturbance (SED). C-CCBHC will serve 1,000 unduplicated individuals from among the 5,300 that the clinic services yearly (Y1: 375; Y2: 625). C-CCBHC’s target population is expected to mirror those of the catchment area, comprising counties Cheatham, Houston, Montgomery, Stewart, and Robertson in Tennessee. Those ages 17 and under are expected to comprise 51% male, 49% female, 67% White, 15% African American, and 11% Hispanic/Latino individuals. Those 18+ are expected to comprise 49% male, 51% female, 76% white, 13% African American, and 6% Hispanic/Latino individuals. Of the catchment area’s population of 322,000, 4.9% (11,711) of adults are expected to have SMI, 3,362 children/youth ages 6-18, SED. Roughly 7% (16,730) of adults and 3.9% of adolescents 12-17 have SUD, and 0.7% (1,673) of adults and 0.4% of adolescents 12-17 have OUD. Nearly 33% of the 33,459 area Veterans are expected to have a mental health diagnosis. An estimated 7,495 (64%) adults with SMI and 5,800 (70%) youth ages 12-17 with SED have not received appropriate supports. An estimated 15,060 adults and 2,980 adolescents with SUD remain untreated. Without integrated care, 10,085 individuals with COD are at increased risk of physical illness/homelessness/incarcerations; 19,960 individuals with SUD are more vulnerable to heart disease and cancer; and those with SMI are expected to die up to 30 years prematurely. C-CCBHC will provide an array of integrated primary/behavioral health care services (e.g., crisis care; mental health screening, assessment, and diagnosis; primary care screening and monitoring of key health indicators; HIV/Viral Hepatitis screening and Hepatitis A/C vaccinations; integrated treatment planning; Medication Assisted Treatment and medication management; and telehealth). C-CCBHC’s evidence-based interventions are numerous and include Cognitive Behavioral Therapy, Motivational Interviewing, Assertive Community treatment, Illness Management and Recovery, Integrated Dual Disorder Treatment, and more. C-CCBHC will accomplish the following goals: 1) Continue delivery of comprehensive community-based mental and substance use disorder services for the target population, meeting all CCBHC criteria; 2) Enhance infrastructure/capacity for a full continuum of coordinated care; 3) Ensure access to/availability of timely services for the target population; 4) Improve health status and outcomes for C-CCBHC consumers engaged in treatment; and 5) Apply a CQI approach to drive outcome improvement and ensure ongoing service delivery. To support these goals, C-CCBHC will achieve the following measurable objectives: Decrease mental health symptomatology by 45%; Decrease substance use by 45%; Achieve 50% reported compliance with medication; Deliver personalized treatment plans for 100%; and Achieve 80% consumer/family reported satisfaction with their experience of care. Key C-CCBHC strategies include updating a full needs assessment and meeting all CCBHC certification requirements immediately upon award; expanding/enhancing access/services; convening the Advisory Work Group; collaborating with community providers to promote whole-person wellness and recovery; utilizing an experienced evaluation team; and applying a continuous quality improvement approach to drive improvements and sustainability.

The Zero Suicide Initiative (ZSI) will enhance/expand suicide prevention and intervention programs designed to raise awareness of suicide, establish referral processes, and improve care and outcomes for adults ages 25+ within Centerstone’s Health System (i.e., Florida, Illinois, Indiana, and Tennessee). ZSI will serve an unduplicated total of 47,285 adult Health System clients (Yr 1: 7,465; Yrs. 2-5: 9,955 annually). ZSI’s focus population is expected to mirror those of the Health System’s client population, with 43% male, 57% female, 72% white, 10% African American, 3% Hispanic/Latino, and 0.4% American Indian/Alaska Native individuals. Focus population clinical characteristics (e.g., 35% have SUD; 42%, a depressive disorder, etc.) are risk factors for suicide attempt/death. The focus area suicide rate (23.4/100,000) exceeds the U.S. rate (14.5). ZSI will screen/assess clients’ risk level using the Patient Health Questionnaire-9, Columbia-Suicide Severity Rating Scale, and the Interpersonal Needs Questionnaire. Those at high risk will be placed on a Suicide Prevention Pathway and treated according to a Suicide Care Management Plan comprising of safety planning, reduced access to lethal means crisis intervention, continuous contact/monitoring, and rapid follow-up. Integrated screenings will assure attention to preventing suicide among Health System clients receiving services for serious mental illness (SMI). Staff will provide added contact/support to engage and intervene with Veterans at risk for suicide but not currently receiving Veterans Affairs (VA) services. ZSI’s suicide-specific evidence-based practices include RELATE; the Interpersonal Theory of Suicide (ITS); Cognitive Behavioral Therapy-Suicide Prevention (CBT-SP); Suicide-Prevention Focused Narrative Exposure Therapy (S-NET); Dialectical Behavioral Therapy-Skills Treatment (DBT-ST); Attempted Suicide Short Intervention Program (ASSIP); and Counseling on Access to Lethal Means (CALM). ZSI will accomplish the following goals: 1) Expand a leadership-driven, safety-oriented culture committed to reducing suicide; 2) Develop a competent, confident, and caring workforce, 3) Systematically identify/assess client suicide risk; 4) Ensure timely needs-based pathways to care, including safety planning and lethal means restriction; 5) Use evidence-based treatments that directly target suicidal thoughts/behaviors; 6) Provide continuous contact/support, especially after acute care; and 7) Apply a data-driven, quality improvement approach leading to improved patient outcomes and better care for those at risk. ZSI will achieve the following measurable objectives: Provide suicide risk screenings for 262,680 Health System clients; Provide comprehensive assessment for 47,285 at-risk clients; Provide Suicide Prevention Pathway services for 2,840 clients; Provide care transition for 2,130 Pathway participants; Refer/connect 47,285 clients to mental health/related services; Follow-up with 2,840 Pathway participants; and Provide workforce training in evidence-based practices and protocols/processes for 2,500 clinical staff. ZSI has secured commitments from partners dedicated to the project’s success, including Veteran-serving organizations.

The Hamilton County TN Sheriff’s Office is seeking $3.39 million in SAMHSA funds to establish a forensic ACT Team/supportive housing project to serve 100 homeless adults with severe and persistent mental illness who are “frequent users” of County jails, hospitals, emergency rooms, crisis centers and psychiatric facilities. The Sheriff’s Office and its partners—BlueCross BlueShield of Tennessee, CHI Memorial hospital, Erlanger Health Systems, the City of Chattanooga and the state psychiatric facility Moccasin Bend Mental Health Institute—are replicating a methodology called FUSE (Frequent Users Systems Engagement) developed by the Corporation for Supportive Housing (CSH). More than 30 FUSE projects implemented across the country consistently demonstrate significant reductions in costly hospitalizations, incarcerations and crisis system use, 80% or higher housing stability rates, and increases in employment, health and other indicators of well-being. These outcomes often lead to changes in public policy and resource allocation. Over the last 18 months, the partners have formalized a FUSE Leadership Team, contributing decision-makers, staff resources and project operational funds. To date, the FUSE Leadership Team has established a Program Office and support committees, engaged CSH to provide technical assistance and secured the initial 50 Housing Choice rental vouchers. Pending requests for funding include ACT start-up funds from the Tennessee Department of Mental Health and Substance Abuse (TDMHSAS) and from the Sheriff’s Office for non-reimbursable housing and miscellaneous expenses. Centerstone of Tennessee (CST) has been selected to manage the ACT Team, Centerstone Research Institute (CRI) to conduct program evaluation and the Center for Evidence-based Practices (CEBP) at Case Western Reserve University to provide ACT technical assistance and to fidelity to the model. The City is working with the University of Tennessee at Chattanooga’s College of Engineering and Computer Science to develop a data warehouse that will allow hospitals, managed care organizations, behavioral health facilities, the homeless system and justice systems to share data in order to identify current and future ACT clients, and to conduct program evaluation, cost analysis and other research projects. Preliminary data collection is underway. Only two teams exist within the state of Tennessee. Hamilton County is prepared to establish and sustain the third, due in part to frequent user data presented to elected officials and community leaders 18 months ago: Between 2012 and 2016, seven homeless individuals with mental illness were arrested 149 times and spent 4,820 days incarcerated at a total cost of $419,000. Despite the "investment," the health and well-being of these individuals was no better at the end of five years than at the beginning.

Mental Health America of the MidSouth’s (MHA) Zero Suicide Project (ZSP) will implement a set of systematic practices to suicide prevention, altogether known as Zero Suicide (ZS), at 58 healthcare and behavioral health sites across the state of Tennessee, to serve adults aged 25 years and older. MHA will specifically target services to veterans, individuals with a serious mental illness (SMI), and incarcerated populations. MHA and its partners will meet a priority need identified by the National Action Alliance for Suicide Prevention to reduce suicide and suicidal behaviors within their treatment settings by implementing the ZS model. TN is home to 6,770,010 individuals with a high veteran population (8.2%), high poverty rate (15.3%), high SMI population (4.8%), and high rural population (57 of 95 counties). Mental health and suicide risk are major problems among state residents: In the past year, frequent mental distress increased 17%, from 13.7% to 16% of adults, ranking TN at 47th in the nation for mental health wellness. An equally concerning dearth of mental health providers in the state exacerbates the problem – TN ranks 45th in the nation with just 153 mental health providers per 100,000 residents. MHA ZSP goals are: 1) Increase the capacity for 58 healthcare and behavioral health sites across the state to accept and implement the ZS model and provide 1,740 individuals with ZS training, so that a diverse range of mental health systems will dramatically reduce suicides among persons receiving care. 2) Oversee implementation of the ZS model so that health systems more readily identify all patients at risk of suicide; promptly engage them in a suicide care management plan; and treat them through effective, evidence-based interventions in order to directly target suicidal thoughts and behaviors. 3) Apply a data-driven quality improvement model in order to inform system changes that lead to improved patient outcomes and better care for those at risk of suicide among the various health systems in TN. MHA will train clinical staff at all 58 healthcare sites in evidence-based suicide-specific interventions, such as Question, Persuade, Refer (QPR). Healthcare partners include: HCA Hospitals, the largest hospital system in the country; CoreCivic, the largest owner and manager of partnership correctional, detention, and residential re-entry facilities; Wellpath and Spero Health, the largest U.S. providers in their respective industries; the 51-member TN Charitable Care Network; and the Refuge Center for Counseling, one of the largest outpatient counseling centers in TN. The project will transform health systems, dramatically reducing the number of suicide deaths in the state of TN by convincing health systems to see and believe that the bold goal of zero suicides among persons receiving care is an aspirational challenge that all health systems should and must accept. Over the grant period, MHA will provide post-clinical case management services to 405 (90 annually after year 1) patients at risk of suicide, a subset of the thousands more who will receive treatment from one of MHA’s licensed mental health/behavioral health services treatment partners.

The Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) proposes "Tennessee Lives Count Connect2" to reduce suicidal ideation, suicide attempts, and suicide deaths among youth and young adults ages 10-24 by building on existing grant-funded suicide prevention and early intervention strategies to enhance and expand capacity statewide, including enhanced follow-up in 30 focus counties for 5,000 unduplicated individuals (Year 1: 750; Years 2-5: 1,063 annually). The focus area is the State of Tennessee, comprising urban and rural populations with multiple socioeconomic disparities (e.g., high poverty, unemployment) that contribute to high risk for suicidal ideation and behaviors among youth/young adults. Tennessee’s suicide rate for the state (16.8) exceeds the national rate (14.0), and 1,163 Tennesseans died by suicide in 2017. Among the focus population, 35% are enrolled in Supplemental Nutrition Assistance Program (SNAP) and 65% are enrolled in the state’s Medicaid program. Focus county schools serve over 6,200 students with an identified severe emotional disturbance/mental illness, with 31.5% of state high school youth reporting they felt so sad they stopped usual activities, 17% seriously considered suicide, and 14% made a suicide plan. Of the 128,000+ calls to the Statewide Crisis Line, 16% were made by youth under 17. TDMHSAS will partner with Tennessee Suicide Prevention Network and Centerstone of Tennessee to provide suicide prevention and postvention trainings for gatekeepers (schools, law enforcement, foster care, etc.) and training for primary/behavioral health professionals, screening/assessment, early intervention, follow-up, outreach/education, and linkages to treatment services, using the RELATE curriculum, based on evidence-based theory and incorporating evidence-based approaches, and the Columbia Suicide Severity Rating Scale (C-SSRS). Connect2 will also strengthen public/private collaborations and support higher learning institutions to train students in recognizing early signs of suicide and referring individuals needing help. Outcomes will include reduction in suicidal ideation and suicide attempts by 30% and suicide deaths by 10%. An existing Youth Advisory Leadership Council comprising stakeholders and focus population members will support Connect2’s goals/objectives: (1) increasing gatekeeper/stakeholder capacity to identify/refer youth at risk of suicide; (2) increasing stakeholder capacity to assess, manage, and treat youth/young adults at risk for suicide; (3) expanding provision of enhanced follow-up for youth experiencing suicidal ideation and/or a suicide attempt; (4) increasing risk identification, referral, and behavioral health services utilization; (5) increasing the promotion and utilization of crisis response services; (6) implementing key elements of the National Strategy for Suicide Prevention to reduce rates of suicidal ideation, attempts, and deaths for youths/young adults ages 10-24 in Tennessee; and (7) conducting a comprehensive evaluation and developing/disseminating a thoroughly documented service model for replication/adoption across the state and nation. Evaluation will report as required on participant outcomes and on progress and performance regarding infrastructure development.