PR Discretionary Funding Fiscal Year 2019

MHAASA proposes the ""PUEDO"", meaning ""I can"" Project, directed to youth of 16-25 years of age with SED/SMI, including moderate intellectual disability, and their families/caregivers from the San Juan and Ponce, Puerto Rico catchment areas. Using the Wraparound Strategies EBP and trauma-informed approaches, 500 participants will be given expanded access to quality treatment and support services to promote their self-sufficiency and recovery through this 5-year grant. Outreach will be done through promotion and awareness campaigns and strengthened collaboration with the Juvenile Justice, Child Welfare, Special Education systems and community support services providers and support groups, representatives of which will participate in an Advisory Council with youth/family peers to guide project planning and implementation. The two catchment areas are urban with about 500,000 total populations, 14% unemployment, 40-50% poverty rates, high criminal and family/youth violence, poor transportation, limited professionals to meet demands, and other barriers. Two licensed and experienced treatment providers are the MHAASA Rio Piedras MH Center for Children and Adolescents in San Juan and the Ponce Behavioral Health Clinic in Ponce, which will maximize third-party resources for treatment. Training will be given to project and collaborating partner entities' staff on SED/SMI, the Wraparound EBP with System of Care values and principles, referral procedures and related topics. The Spanish Traumatic Events Screening Inventory-Parent Report screening will be administered to identify youth who have trauma experiences. The Wraparound EBP has four phases of assessment, individualized planning, plan implementation and transition to recovery. Project goals include expanded access to EB treatment and support services for healthy transition to adulthood; improved cross-system collaboration, for increased service capacity related to transition aged youth with SED/SMI through infrastructure and organizational improvements at state and local levels; and planning and implementing public awareness and cross-system training to reduce stigma and increase support for SED/SMI youth/young adults by community, business and education leaders. Objectives include achieving self-management of behaviors, improved social relations and functioning, and self-sufficiency through education/employment in at least 85% of participants completing the EBP, as well as reducing risky and unhealthy ATOD use and sexual practices for a healthy transition to adult life. These will be achieved by integrating family and community support, linking youth/families to housing, basic living, education, vocational, peer support, social/economic benefits, legal and other service needs based on Individualized Care Plans. An experienced Project Director will lead the professional team to implement the Action Plan. A local Evaluator will carry out process, outcome and EB fidelity evaluations, results used to improve project operations. A total of $1 million per year is requested.

The MHAASA PR-MHAT Project will provide training to create awareness for early and correct identification and interventions with individuals showing signs and symptoms of mental illness. The need for the project is based on the vulnerability of the PR population to MH conditions post 2017 natural disasters (Hurricanes Maria and Irma) and the need for skill development in First Responders from varied systems related to crisis management and identification and intervention with persons showing signs of MH conditions. Using the Mental Health First aid (MHFA) EBP, over 3 years, 1,500 First Responders (600 from public education and 900 from law enforcement, veterans services and other systems) will be trained to recognize signs/symptoms of mental disorders, particularly SMI or SED. Linkages will be established with school and community-based agencies to refer those identified for appropriate treatment and other services. Training on appropriate crisis de-escalation techniques and available community resources for persons with MH conditions will be included. The IRESA Project of the University of Central Caribbean (UCC), using trainers certified in the MHFA EB Model, will be contracted as the primary training resource. The project will expand MHAASA's crisis and disaster mitigation and response efforts. Collaboration with public education, MH public and private treatment systems, Public Security (Police, Firemen, Emergency Management) and the VA healthcare will permit identification and recruitment of First Responders to be trained on the MHFA EBP, helping these responders to identify and intervene with potential MH patients and engage them in treatment with support services. The project will be directed to training participants Island wide, with the exception of the municipalities of Bayamon, Orocovis, Barranquitas, Naranjito, Vega Baja, Toa Alta, Cata¤o, Vega Alta, Comerio and Corozal, these being served through IRESE under another grant. For MH treatment, the MHAASA San Patricio Center for adults and Rio Piedras MH Center for Children and Adolescents, and Medicaid providers such as APS (all licensed and experienced) will be used. Under the MHFA, an 8-hour training will focus on identification and intervention with persons showing signs of mental illness, appropriate de-escalation techniques in crisis situations, appropriate engagement and referral procedures and resources that are available. Project goals/objectives include training 1,500 school, security and veterans staff; establishment of a bank of resources for referrals of populations of focus with which First Responders come in contact, or serve; development of follow-up tracking mechanisms related to referrals of populations of focus; utilization of the MH Advisory Council of MHAASA for input to the project; and awareness created on the importance of early identification and referral to reduce PTSD or other consequences and stigma toward persons with MH conditions. All training logistics will be carried out by the MHAASA T/TA Unit, the director of which will serve as Project Director with a full-time Coordinator for logistical training aspects. A Data Analyst will collect required data on process and statistical outcomes of trainings and on fidelity to the selected MHFA EBP, using standardized instruments of the model and those developed by training resources. A total of $125,000 per year is requested over the 3-year grant period, including funds for training, data collection, and evaluation.

The MHAASA of Puerto Rico (PR) will implement a System of Care Expansion and Sustainability Grant (SOC-ESG) Project to provide comprehensive mental health (MH) services dor children and youth. from birth through age 21, with SED and their families, and promote infrastructure development to ensure sustainable policies, legislation, financing and the integration of quality evidence-based practices in public and private service systems. The targeted areas will be local jurisdictions of Yauco in the Southern Region and Manati in the Northern MH services for children/youth. Emotional trauma in children increased recently due to severe damages from severe and continuing earthquakes impacting primarily Southern PR. The SOC-ESG will implement Required Activities to achieve the goals and objectives, including outpatient and intensive day treatment, offered in clinic in Yauco, supplemented by home visits, including to foster homes and group homes of children in protective care. Over a 4-year grant period, 350 children/youth with SED or symptoms of SMI and their families will be served. Individual, group and family counseling, with professional consultation and review and management of medications will be offered by a multi-disciplinary staff trained on the SOC and Wraparound EBP's. Arrangements will permit 24-hour/7-day a week emergency services through MHAASA's children's residential MH programs and collaborating partners, as well as intensive home-based services when the child is at imminent risk of out of home placement. The MHAASA has commitments of collaboration from the Special Education Program; Juvenile Justice System and Family Department Protective services, Foster Care and Independent Living Programs for referrals and for assisting youth in transition to MH services as adult. Collaboration through the PUEDO Project will permit other support (vocational education and employment skill development and placement) for youth with early onset of SED/SMI. The intensive wraparound strategies of the SOC-ESG will ensure services and supports sustain family participation, including peer support activities. A Governance Structure Board will be created for decision-making at the policy level, with authority and accountability for the SOC-ESG Project in both local jurisdictions, and multiple partnering agency, and family representation. To ensure that the project is sustainable, adoption by the Health Insurance Administration ("ASES" in Spanish) for treat Medicaid/CHIP eligible children, youth and families will be promoted. Using lessons learned form the pervious projects, the PR SOC-ESG will expand evidence based MH services in the Northern and Southern Regions of PR, and improve MH infrastructures through a Project Governance Body (composed by the project key staff, youth and family members) and two Interagency/Community Committees (ICC), comprised of child serving agencies in the local jurisdictions. One million per year is requested.

Puerto Rico Promoting Integration of Primary and Behavioral Health Care (PR-PIPBHC)

The MHAASA PR-MHAT Project will provide training for identification and interventions with person showing symptoms of mental illness and de-escalation techniques for crisis situations. Using MHFA, PFA and Trauma Informed EBP's, over 5 years, 2,500 First Responders, law enforcement officers, emergency staff, teachers and other school personnel, and caregivers of children with SED and older adults, including with SMI, will be trained. The Unit for Training and Technical Assistance (UCAT) will implement the project, handling all logistical arrangements. The Institute for Research (and Evaluation (IRESA) of the University of Central Caribbean (UCC), with certified trainers, will be contracted along with other trainers. At least 5 new MOU's will be developed with Departments of Education, Security, Emergency Management and Family Services, and CBO's that are MH providers to identify, select and refer participants for in-person or virtual services. Coordination of MH referrals will take place through APS, licensed MH provider for Medicaid-eligible populations. The MHFA EB training, an 8 hour course will focus on helping persons with MH symptoms or experiencing a crisis. Under PFA, training will be offered to survivors in the aftermath of a disaster or crisis. Developed by the National Child Traumatic Stress Network, this EBP is directed to preventing PTSD, helping responders understand reactions and how to assist survivors with adaptive coping skills for recovery. Under Trauma Informed Care, participants will be trained to understand impacts of trauma and help those with these experiences to develop coping skills for recovery. The MHAT goals/objectives include training about 500 participants per year implementing culturally appropriate curricula for Puerto Rico to increase knowledge about resources available for referral of persons needing MH treatment. MHAT staff will give follow-up to gather data on referrals. The project will operate under an experienced Project Director, with an experienced Training Coordinator and Data Analyst. Data will be collected on process (numbers of trainings and participants) and outcomes (learning and satisfaction) as well as fidelity to selected EBP's, using instruments of the 3 EB models. A total of $125,000 is requested for YR 01 and $625,000 is projected for the 5-year grant, including implementation, data collection and evaluation funds.

The MHAASA of Puerto Rico's PR-CMHC Project focuses on Hispanic children and adolescents between ages 3 and 17 and 11 months with SED or a co-occurring SED, affected emotionally by the COVID-19 Pandemic. Using EBP's of CBT for Children and Adolescents Trauma Informed CBT, ABC Crisis Intervention, Educational Support and Wraparound, 400 patients per year, including those referred from education, juvenile justice and child welfare agencies, will receive in-person and virtual outpatient treatment in the licensed Rio Piedras CMHC. All of the 78 municipalities of PR are included as the geographic focus area. As part of infrastructure enhancement, telehealth capacity and EHR development will be carried out in the clinic. Collaboration will be strengthened with the PR Departments of Health, Education, Family and JJ systems for outreach, screening and assessments to identify minors with symptoms of SED and COD, affected by COVID and to engage them in EB treatment. A total of 17,394 of the 110,113 confirmed COVID cases in PR, as of April 30, 2020, are minors under 18, representing 15.8%. Human and other losses, changes in routines and lifestyles (family, school, social) distancing from friends and relatives and other effects have provoked negative effects in the emotional state of children that they do not know how to manage. Adolescents have difficulty expressing feelings but manifest more severe behavioral changes such as aggression, neglecting of the appearance and hygiene, and some increase alcohol or other drug use or lose themselves in videogames. The MHAASA PAS Hotline provides assessment of MH services needs for all of the PR population, offering telephone and outreach crisis counseling and referrals to callers and parents of emotionally affected children, on a 24/7 basis. A total of 34,347 calls related to minors with symptoms of SED were received from March to December of 2020, Crisis Counselors referring 2,545 children and adolescents for psychiatric hospitalization. Coordination with the hotline will permit referrals of minors with SED for outpatient MH care, reducing hospitalizations. Outreach, screening and psychoeducational services in schools will help identify children needing treatment and assist students with SED in their academic progress and re-entry to school after a year of virtual classes Spanish versions of the screening tools of Trauma Symptom Checklist for Young Children (TSCYC) for 3-12 year olds, and Trauma Symptom Checklist for Children (TSCC) for 8-17 year old will be administered in the clinic, schools juvenile institutions and child welfare settings to diagnose patients, all of whom will be screened for trauma. Youth in drug use will be referred to the PR-TREE Project in the same clinic for counseling while they continue to receive MH treatment through the PR-CMHC Project. All FOA required activities will be carried out and most of the allowable activities. A Lead Evaluator will measure process aspects, EBP fidelity and outcomes, with resulting data, including GPRA, to be submitted in SAMHSA reports and used to improve services over the 2-year grant period. A total of $2,000,000 is requested for each year of the grant period, to cover infrastructure improvements, one time A/R to the clinic, EBP T/TA for staff, project required and allowed activities implementation and data collection and evaluation.

The Massachusetts Administrative Office of the Trial Court (AOTC) in partnership with Boston Medical Center (BMC) is applying for a $4 million SAMHSA Grant over the course of 4 years to design, develop, implement and evaluate a new program in the Boston Municipal Court to provide the first demonstration of Assisted Outpatient Treatment (AOT) in MA with seriously mentally ill (SMI) and criminally involved patients in need of more comprehensive and intensified services than are currently available. The population of focus includes patients who refuse to participate in our three mental health courts (MHCs), those who are ineligible for MHC due to the nature of their offenses, and those who have been involved with the MHC who have relapsed or require aftercare—patients frequently caught in a “revolving door” of repeated psychiatric hospitalizations. We expect BOAT patients to resemble clients of the MHCs—who are 48% Black and 17% Latinx. Their main diagnoses are psychotic disorders (40%), major depression (34%), and anxiety (15%). More than two-thirds reside with family members (36%) or on the street (35%). More than half (53%) have co-occurring SUDs, and (72%) are male. Our geographic service area is Boston Massachusetts, home to 694,583 residents in 2018. Although Massachusetts does not provide for AOT by way of legislation that allows for a civil involuntary commitment order, judges do have legal authority to order a person with SMI to participate in mental health treatment and maintain their recovery on an outpatient basis within the community. M.G.L. c. 276 sec. 87 provides for the imposition of terms of probation that enable a criminal defendant to remain in the community under the supervision of the court with conditions that he or she adhere to prescribed mental health and /or substance disorder treatment services. The goals and objectives of AOT are thereby satisfied. The BOAT Program will serve 75 patients in Year 1 and 100 each year thereafter, for a total of 375 patients over four years. BOAT patients will be assessed and treated by a multidisciplinary care team—the BOAT psychiatrist and a mental health clinician, case manager, peer specialist, recovery coach, and employment specialist. In addition, all patients will be referred to fully integrated primary care practices within BMC or one of the hospital’s 14 affiliated community health centers (CHCs), all of which offer master’s level counseling, psychiatric clinic sessions, and medication for addiction treatment. Within BMC, care coordination will be facilitated through our electronic health record and existing relationships with the CHCs. After a 90-day period of intensive outpatient services, patients will be transitioned to a “stepdown” outpatient program, and thereafter, to one of our integrated primary care practices. Monitoring, case management and support services will continue for an average 12-18 months. BOAT staff will maintain a REDCap database for the purposes of monitoring, case management and evaluation. Outcomes of interest include pre/post health-related quality of life, homelessness, arrests, psychiatric hospitalizations, employment and utilization and cost of acute care services.