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The Vermont Family Centered Healthcare Home Project (VFCHP) is an integrated care delivery system that addresses the primary care, behavioral health and social support needs of children and their families who are at risk of, or have been diagnosed with, severe emotional disturbance (SED), and/or for youth and young adults transitioning to adult services. VFCHP service integration occurs between federally qualified health centers and community mental health centers. Vermont is the second most rural state in the nation and public transportation is largely non-existent. Nearly 30% of Vermont children and youth live below the federal poverty level, and 12.4 out of every 100 children have two or more chronic health conditions. More children in Vermont experience early adversity than the national average: 50.6% of Vermont children had one or more Adverse Family Experiences (AFEs) in 2012, vs. 47.9% of children nationally, and 23.3% of Vermont children had experienced two or more AFEs, vs. 22.6% nationally. The Vermont Department of Mental Health conservatively estimates that there are 12,000 children who have, or are at risk of, SED yet the percentage of Vermonters accessing behavioral health treatment is low. The VFCHP provides services in a person/family centered and directed manner with intensive care coordination that incorporates High Fidelity Wraparound. The VFCHP framework will involve core elements of the Chronic Care Model, the Improving Mood: Providing Access to Collaborative Treatment model, Managing and Adapting Practice System, the Attachment, Regulation and Competency model, Strengthening Families and the Four Quadrant Model. The VFCHP aims to: provide a safe, accessible and family-centered healthcare home for children, youth and families to receive comprehensive, integrated pediatric and behavioral health care services in a bidirectional manner; develop a model that truly invites and engages the family into the process of owning and directing their own healthcare through increased knowledge; clarity around options, risks and benefits; and support in making their own decisions; incorporate regular care plan meetings to allow for shared decision making and an increase in the development and implementation of shared care plans; improve health outcomes; and address social determinants of health. Children who are struggling with severe emotional disturbance are most likely to improve when their caregivers are actively engaged in their treatment and when they have a highly-coordinated treatment team. For example, children with, or at risk of, SED will enhance their resilience and their physical activity and their family’s nutritional practices will improve as their healthcare and the social context in which they live/work/attend school improves. The VFCHP will expand from two regions to four regions in year three. The unduplicated number of individuals to be served in the first two regions will be 5,400. It is estimated that this number will double making the total approximately 10,800 over the five-year period.

New York State Office of Alcoholism and Substance Abuse services (OASAS)in partnership with Acacia Networks and The National Center on Addiction and Substance Abuse (The Center) proposes to develop models for integrated care for individuals with opiate use disorders (OUDs). The PIPBHC project has five specific goals: (1) to build comprehensive, integrated care models into three Opioid Treatment Programs (OTPs); (2) build practices for identification, intervention, and MAT for OUD into three FQHCs and three mental health clinics; (3) provide whole person care to 2,280 people with OUD in order to improve physical and behavioral health outcomes; (4) document key elements of program implementation barriers and successes and disseminate throughout the State; and (5) make changes in infrastructure and policies in order to increase prevention, health promotion, and integrated care in OTPs, FQHCs, and MHCs. NYS OASAS oversees one of the nation’s largest substance use disorder services systems comprising nearly 1,600 prevention, treatment, and recovery programs, most of which are community-based and acutely aware of the demographic, cultural, and language characteristics of the local populations of focus. OASAS currently oversees 104 OTPs who serve over 41,000 individuals. Acacia Network, the leading Latino integrated care nonprofit in the nation, offers the community, from children to seniors, a pathway to behavioral and primary healthcare, housing, and empowerment. With roots in the Bronx since 1969, Acacia Network is the largest community based, Latino-led health and human services agency in NYS and serves as the holding company for 20 affiliates, including Promesa. The Network’s visionary leaders are transforming the organization to address the triple aim of high quality, great experience at a lower cost through triple integration-health care, housing and community impact. These leaders champion a collaborative environment to deliver vital health, housing and community building services The National Center on Addiction and Substance Abuse (The Center) is a non-profit research, policy, and practice improvement center that is at the forefront of improving substance use disorder treatment in New York. The Center has a strong track record in conducting scientifically rigorous evaluation and providing training and technical assistance. The team has conducted many projects with government partners in New York on topics such as care management for welfare populations, medication assisted treatment for disenfranchised injection drug users, supportive housing using Housing First models, and care management for high needs/high cost SUD treatment clients covered by Medicaid. The Center has extensive expertise in implementation science, system-level change strategies, implementation of evidence-based practices, evaluation of Statewide programs, advanced data analysis as well as collecting and analyzing GPRA data.

The Kentucky Department for Behavioral Health/Developmental and Intellectual Disabilities will implement Kentucky Care Integration (KCI), promoting primary and behavioral health care integration between selected providers, Centerstone of Kentucky and Mountain Comprehensive Care Center (MCCC), and federally qualified health centers, Family Health Centers and HomePlace Clinics. KCI will serve Kentucky focus populations who have behavioral health conditions and physical health conditions or chronic diseases. Centerstone will serve a total of 625 adults (Yr 1: 75; Yrs 2-3: 125, annually; Yrs 4-5: 150, annually) with substance use disorder (SUD) who have/are at risk for co-occurring physical health conditions/chronic diseases in Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer, and Trimble counties. The focus population is predominately male (52%) and white (84%), with 67% unemployed and 27% acquiring less than a high school education. Nearly 70% of clients with SUD use opioids; prevalent physical health conditions include hypertension (21%). MCCC will serve a total of 500 individuals (Yrs 1-5: 100, annually), including adults with mental illness, serious mental illness, and SUD, and children/adolescents with serious emotional disturbance who have/are at risk for physical health conditions/chronic diseases in Floyd, Johnson, and Pike counties. MCCC’s focus populations are primarily white (99%) and disproportionately impacted by poverty. Among those with SUD, 58% are male, 89% live below poverty, 35% are unemployed, and 38% have less than a high school education. The focus population with mental illness is 51% female, and 77% live in poverty, 14% are unemployed, and 25% have attained less than a high school education. Among the focus population with SMI, 60% are female, 82% live in poverty, and 42% have less than a high school education. The focus population with SED is 61% female and 78% live in poverty. Approximately 34% of MCCC clients experience anxiety disorders, 36%, hypertension, and 16%, diabetes. KCI will provide bidirectional and co-located integrated services related to the screening, diagnosis, prevention and treatment for the focus populations, implementing the Chronic Care Model and the following evidence-based/informed practice strategies/interventions: Integrated Dual Disorders Treatment, Twelve-Step Facilitation, The 4 R’s and 2 S’s for Strengthening Families Program, Whole Action Health Management, Nutrition and Exercise for Wellness and Recovery, and DIMENSIONS. Project goals include: establishing comprehensive health homes and wellness services; enhancing infrastructure/capacity to sustain services; improving client health status/outcomes; and developing/disseminating a replicable service model. Measurable objectives include: decreased risk factors related to hypertension, diabetes, hyperlipidemia, nicotine dependence, obesity, etc. for 30% of clients; decreased mental health symptomatology by 35% for SMI, 60% for mental illness, and 45% for SED clients; substance use abstinence by 45% for clients with SUD; and improved functional outcomes for 80% of clients with SMI and SUD. A multidisciplinary, integrated care team, including an integrated care manager, primary care provider, care coordinators, counselors/clinicians, peer wellness specialists, etc., will help clients develop/implement individualized care plans. KCI will utilize a meaningful-use certified EHR, population management tools, and data-sharing protocols across providers. KCI has obtained and will continue to pursue key community partnerships with other behavioral/primary health care providers and supports, nonprofits, and faith-based organizations.