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Promoting Integration of Primary and Behavioral Health Care Project Abstract Pennsylvania’s Promoting Integration of Primary and Behavioral Health Care includes four local physical health / behavioral health partnerships. These sites provide an opportunity to explore integration in diverse rural and urban areas of the state and with different populations of focus. The two urban and two rural sites propose to serve 463 individuals each year / 2,315 individuals during the five-year project period including adults with substance use disorder, children with serious emotional disturbance, and adults with mental illness. The purpose of the project is to: • Promote full integration and collaboration in clinical practices between primary and behavioral health care. • Support the improvement of integrated care models for primary and behavioral health care to improve the overall wellness and physical health status of adults with a mental illness, substance use disorder, SMI or children with a SED. • Promote integrated care services related to screening, diagnosis, prevention, and treatment of mental illness, substance use disorders, co-occurring physical health conditions, and chronic diseases. The local performance assessment is designed to assess the projects’ ability to reduce behavioral health disparities and achieve the following objectives: Program Development: • Develop an enhanced and expanded integrated care program to improve the quality and experience of patient care. • Promote full integration and collaboration in clinical practices between primary and behavioral health care systems. • Provide clinically appropriate primary care and behavioral health treatment and prevention services. Consumer health and functional outcomes: • Utilization of physical and mental health screenings to aid in assessment. • Increase referrals for treatment of conditions identified through screenings. • Improve individual consumer health outcomes. • Improve individual consumer functional outcomes. Expand and sustain integrated behavioral and physical health models: • Conduct local assessment of the effectiveness of the implementation models. • Identify and remediate policy and regulatory barriers to implementation and expansion of integrated care models. • Develop financial opportunities to support implementation of integrated care models. • Disseminate information to support broader implementation of integrated care models.

The State of Indiana proposes to work with three Federally Qualified Health Centers and their Community Mental Health Partners and school corporations on a project to integrate mental health care into primary care settings for special populations including mentally ill/seriously mentally ill adults and seriously emotionally disturbed children. The project is expected to improve health outcomes for 27,000 patients in Northwestern and West Central Indiana.

The Louisiana Department of Health, Office of Behavioral Health (OBH) proposes to implement the Louisiana Promoting Integration of Primary and Behavioral Health Care (LaPIPBHC) Program to promote the integration of primary and behavioral health care services. The overall goal of the LaPIPBHC Program is to provide a coordinate, comprehensive approach improve the overall wellness and status of adults with co-occurring mental illness and physical health conditions or chronic diseases, and individuals with a substance use disorder through improved health care delivery. The priority populations to be served by this grant are: (1) adults with mental illness who have co-occurring physical health conditions or chronic diseases and (2) individuals with a substance use disorder. The objectives are to 1) develop an integration team consisting of qualified community health programs, community health centers, family, youth, peers, and other consumer organizations to obtain guidance and feedback for quality improvement, sustainability, and scalability of increased access to health care services; 2) enhance integrated primary and behavioral health care services provided by four qualified community health programs (behavioral health centers) or community health centers (FQHCs); 3) provide integrated primary and behavioral health care services to 29,217 adults with co-occurring mental illness and physical health conditions or individuals with a substance use disorder (5,301 in Year 1, 5,602 in Year 2, 5,904 in Year 3, 6,105 in Year 4, and 6,305 in Year 5); 4) increase the number of policy changes completed as a result of coordinated, integrated care to four; 5) increase the number of qualified community health programs or community health centers that have implemented evidence-based practices/activities by four; and 6) provide screening, referral and treatment for mental health and substance abuse to 29,217 individuals. In order to achieve these objectives, OBH has identified four selected provider organizations, designated as Federally Qualified Health Centers (FQHC) or community mental health centers. Each selected provider organization has identified a partner provider organization, also designated as FQHCs or community mental health centers, to provide integrated services. Each selected provider organization has identified Evidence-Based Practice(s) (EBPs) to address physical and behavioral health conditions, including substance use disorder. OBH will monitor the provider organizations’ performance through data collection and evaluation, conducted by the Louisiana Public Health Institute (LPHI). This coordinated, comprehensive approach to integrated care will help to improve the overall wellness and physical health status of adults with co-occurring mental illness and physical health conditions or chronic diseases and individuals with substance use disorders.

This application will build upon the work of Delaware’s Department of Health and Social Services through its Division of Substance Abuse and Mental Health (DSAMH) and the Division of Public Health (DPH) along with several key community partners to address the needs of individuals within our communities with mental illness and substance use disorders. Two of Delaware’s Federally Qualified Health Centers (FQHCs), Westside Family Healthcare and La Red Health Center, will be key hubs to support improved care coordination for these individuals at high risk for poor health outcomes. Delaware’s strategy will focus on providing integrated care services for people with behavioral health disorders and the associated risk factors impacted by the social determinants of health. Specifically, integrated primary care and behavioral health services will directly target improved health outcomes, especially addressing the prevalence of obesity, diabetes, hypertension, and dyslipidemia. Delaware’s focus population will include individuals with substance use disorders (including prenatal patients with substance use disorders), adults with a serious mental illness who have co-occurring physical health conditions or chronic diseases, and adults with a mental illness who have co-occurring physical health conditions and/or chronic diseases. Through the use of Screening, Brief Intervention, and Referral to Treatment (SBIRT), FQHCs will use evidence-based screening materials in a variety of commonly-spoken languages to screen all patients for substance abuse and mental health conditions. Once identified, patients with mental health or substance use disorders will receive a more in-depth screening, conducted by a licensed behavioral health counselor, to determine the acuity of the patients’ needs. The patient will be assigned to a care manager who will establish a medical home within the FQHC for the patient, develop a care plan that is overseen by a doctor, and connect the patient with community-based support services. Depending on the level of behavioral health or recovery services needed for the patient, FQHCs will then either begin providing services to the patient in-house or refer patient to community providers, with ongoing coordination of care by the care manager. Other Evidence Based Practices to be used throughout this project include expanding the use of Medication Assisted Treatment (MAT), MAT with COR-12, Brief Cognitive Behavioral Therapy, and Motivational Interviewing Therapy. Primary care and behavioral health partners will provide trauma-informed care to treat both medical and behavioral health problems.

In Texas, behavioral health services - which encompass both mental health and substance use disorders (SUD) - have evolved over the last decade. A movement toward managed care, an improved psychiatric crisis system, as well as enhanced community collaboration, have all contributed to significant advancement in behavioral health care in Texas. The Promoting Integration of Primary and Behavioral Health Care (PIPBHC) grant provides the opportunity to build a sustainable model for promoting integration of primary care and behavioral health services. Through a two part approach - enhancing service delivery through care coordination between services, and increasing access points through co-location and innovative partnerships - Texas plans to build system capacity related to integrated health. Despite advancements in systems, gaps and fragmentation of care still continue to present significant barriers for populations with serious and persistent mental illness, emotional disturbances, and substance use disorders. As a result, clinical outcomes for these populations are often not optimal. Participation in the PIPBHC grant will provide Texas with a unique opportunity to partner with providers and stakeholders to develop an integrated service delivery framework, within a sustainable ""integrated health home"" approach for populations for which care is often fragmented and uncoordinated. Through the project, Texas will focus on four key populations who would benefit from the PIPBHC model: 1) adults with serious mental illness (SMI), 2) individuals with co-occurring mental illness and physical health conditions and chronic diseases, 3) children and adolescents with serious emotional disturbances who have co-occurring physical health and chronic conditions, and 4) individuals with substance use disorders. The Texas strategy for success will focus on building capacity of targeted clinic partnerships in select service areas to provide effective, evidence-based integrated healthcare. These partnerships will be supported at the state level through learning collaboratives, partnerships with managed care and integration experts, and community network building. Texas is ideally positioned to leverage this grant to transform service delivery, and align incentives to improve the lives and health outcomes of vulnerable populations by creating a more efficient and coordinated system.

Iowa proposes to provide integrated mental health care, primary health care and substance use services for adults with substance use disorders as the special population of focus. Sub-populations of focus will include individuals with SUD and chronic physical health conditions and individuals with SUD with SMI. Iowa’s Integration Project model will utilize an Integrated Care Team (ICT) that will provide bidirectional care through screening for behavioral health conditions, and expanding services to provide early intervention, assessment and diagnosis, person centered treatment planning, evidenced based practices, peer support services for primary and behavioral health care needs of individuals with substance use disorders. The overarching goal of Iowa’s Integration Project is to improve primary and behavioral health outcomes for the special population of focus, individuals with substance use disorders. Iowa PIPBHC will accomplish this through four primary goals: 1. Promote integrated health care services through a bidirectional model utilizing an Integrated Care Team approach. 2. To support the improvement of integrated health care services provided to individuals with SUD, SMI and co-occurring health conditions. 3. To increase the number of integrated health care services provided to individuals with SUD, SMI and co-occurring health conditions. 4. Implement an innovative and comprehensive care team approach between the Iowa Army National Guard (IAANG) and col-located substance use/mental health community providers. Iowa will provide services to 175 unduplicated individuals annually, 875 over the project period. Iowa’s population of focus will provide the services by the ICT annually to an estimated 127 individuals who identify as White, 25 who identify as African American, 7 who identify as Asian, 1 who identify as Native American, two individuals who identify as Multi-Racial, and 13 who identify in the Other Race category. Significant majority (101 clients) of persons served will be female compared to males (62 clients).

Promoting Integrated Care in Connecticut The Connecticut Department of Mental Health & Addiction Services (DMHAS), in partnership with primary care and behavioral health treatment providers in three CT communities with large populations of underserved adults with co-morbid behavioral health and medical conditions, proposes to launch Promoting Integrated Care in Connecticut (PIC-CT) to fill major gaps both in the integration of behavioral health into primary care as well as the integration of primary care into behavioral health. We would engage 2,250 individuals over the course of the grant period into primary care, behavioral health care including medication assisted treatment, care coordination including nurse care management, and peer health navigation services for health promotion, referrals, and support. Connecticut has considerable momentum to implement this project. We have recently implemented a Behavioral Health Home, authorized under Section 2703 of the Patient Protection and Affordable Care Act. This model serves individuals with serious mental illness (SMI) and co-occurring disorders who have Medicaid spend in excess of $10,000 in a calendar year, typically as a result of chronic co-morbid medical conditions. The core services articulated in SAMHSA’s FOA perfectly align with Connecticut’s CMS-approved State Plan Amendment for Health Homes. Primary providers identified to partner under this opportunity are not currently BHH providers and were targeted to expand the reach of integrated care in those communities. Lessons learned from BHH implementation will frame out best practices for this project. Three urban areas have been identified that have high rates of individuals who have high Medicaid spend, a behavioral health diagnosis, and are currently not being served by an integrated model of care: Hartford, Bridgeport, and Waterbury. The overarching goal of the project is to increase access to integrated care for individuals with substance use, mental health, and/or co-occurring disorders with a special focus on increasing health literacy, promoting health behavior change, and increasing access to medication-assisted treatment. We will accomplish these goals by: (1) implementing integrated care; (2) implementing evidence-based practices in the context of integrated primary and behavioral health care; and (3) improving overall wellness and physical health status for individuals. Through this project, we anticipate incremental improvement in health outcome indicators, co-occurring mental health and substance use disorders, including tobacco use. This measurement will contribute to an improvement in the overall health of people with SMIs and substance use disorders by addressing the basic risk factors related to high morbidity and mortality rates of individuals with SMIs and substance use disorders. In addition, patients will have increased immediate access to care; reduction of health disparities; and increased service linkage through care coordination.

Young people with SED and SMI exhibit high rates of health conditions and behaviors that lead to disparate morbidity and early mortality in people with SMI. For example, about half of young people have prehypertension or hypertension (high blood pressure), over half had abnormal lipids (cholesterol or triglycerides), about half are overweight or obese, and about half of this group smokes cigarettes. All of these problems contribute to the development of future chronic diseases and early mortality, but could be prevented or managed to reduce risk for future disease. The purpose of this proposed project is to improve the health and wellness of young people with SED and SMI in New Hampshire in order to prevent the health inequities experienced by this group. We will provide Health Homes – integrated physical health and wellness care combined with comprehensive behavioral health care in the community mental health center setting. Health Homes will provide integrated care for young people ages 16-35 with SED and SMI, with screening, detection and treatment of physical health conditions in concert with comprehensive, evidence-based behavioral health care. Mentors and coaches will implement an evidence-based wellness program that incorporates technology and incentives to improve nutrition and fitness and reduce weight and smoking while at the same time improving community integration, connectedness and positive identity. A peer – driven prevention program will avert smoking in those who haven’t started. We will provide this service within three partnerships between Community Mental Health Centers (primary contractor) and Federally Qualified Health Centers, in high-need regions covering 20% of the population of New Hampshire.

The primary purpose of Bridges to Wellness (B2W) is to significantly increase collaboration between behavioral health and primary care providers in rural New Mexico (NM) in order to improve access and utilization of integrated care and increase health promotion services aimed at improving the overall health and wellness of adults in NM with Mental Illness (MI) and/or Substance Abuse Disorders (SUDs) who have chronic physical health conditions. B2W services will create a person-centered system of care that addresses an individual’s holistic health and wellness, and is trauma-informed and culturally and linguistically responsive. The goals of B2W are first: increase collaboration between primary care (PC) and behavioral health (BH) providers to promote fully integrated care. Objectives to accomplish this goal include: incorporate BH and PC providers in team meetings that address both BH and PC needs and integrate Care Manager into treatment teams. The second goal is to provide integrated care that addresses individuals with MI and/or SUDs, and chronic illness by providing evidence-based screening, assessment and treatment that are culturally and linguistically responsive to improve functioning and quality of life. Objectives associated with this goal include: expand screening and assessment for MI, substance use, and chronic disease; increase utilization of PC and BH services; and improve functioning and quality of life. The third goal is to provide health prevention and promotion services that are often not provided or are inaccessible to individuals with MI and/or SUDs. Objectives associated with this goal include: integrate evidence-based health prevention and promotion activities into clinical services; and increase utilization of health prevention and promotion services. The fourth goal is to increase workforce capacity of peer support workers and community health workers to engage service recipients in health promotion activities and care coordination. Objectives to accomplish this goal include: train Community Health Workers (CHWs) and Certified Peer Support Workers (CPSWs) on health promotion Evidence-Based Practices (EBPs) and integrate CHWs and CPSWs into treatment teams to provide health promotion EBPs and care coordination. The fifth goal is to work to build an improved and sustainable comprehensive system of integrated care in NM. Objectives to accomplish this goal include: incorporate B2W services into other integrated care models used in NM; utilize B2W Coordination Team to examine sustainable funding streams for integrated care; and utilize data to promote sustainability of integrated care. It is anticipated that 120 consumers will be enrolled in year one, 185 consumers in year two, 185 consumers in year three, 185 consumers in year four, and 120 in year five, resulting in 795 consumers served over the life of the grant.

Promoting Integration of Primary and Behavioral Health Care in Illinois (PIPBH-IL), in collaboration with Centerstone Illinois/Southern Illinois Healthcare Foundation, Chestnut Health Systems/Chestnut Family Health Center, and LifeLinks Mental Health/Southern Illinois Healthcare Foundation)to integrate primary and behavioral health care for an estimated 1,635 individuals with serious mental illness and a variety of co-occurring illnesses or disorders. Through this grant, we will: 1) Promote full integration and collaboration in clinical practice between primary and behavioral healthcare in three largely rural counties, each having at least one significant population center. 2) Support the improvement of integrated care models for primary care and behavioral health care to improve the overall wellness and physical health status of adults with a serious mental illness (SMI) and children with serious emotional disturbance (SED. 3)Promote and offer integrated care services that include screening, diagnosis, prevention, and treatment of mental and substance abuse disorders, and co-occurring physical health conditions and chronic diseases. 4) Use lessons learned throughout the five year implementation project to support statewide planning and implementation of integrated health homes. 5) Create a learning collaborative or Center of Excellence to support all Illinois providers who are interested in exploring PIPBHC-IL implementation. A minimum of 220 consumers will be served in Year 1; a minimum of 1,635 consumers will be served throughout the five year project's lifespan.

Oklahoma Partnership for Integrated Health Care (OPIHC) The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) will form the Oklahoma Partnership for Integrated Health Care (OPIHC). Four community mental health centers (CMHCs) are partnering with five Federally Qualified Health Centers (FQHCs), to deliver integrated, bidirectional healthcare in a minimum of seven counties. Populations with greatest priority include: 1) adults with mental illness with co-occurring health conditions or chronic diseases; 2) adults with serious mental illness who have or are at imminent risk of having co-occurring physical health conditions or chronic diseases; 3) children and adolescents with serious emotional disturbance who have or are imminent risk of having co-occurring physical health conditions or chronic diseases; and 4) individuals with substance use disorder, who often have co-occurring mental and physical health conditions. The OPIHC will ensure that primary care, including prevention, wellness activities, tobacco cessation, screening assessment, and needed services, are an integral part of the behavioral health system, and are accessible to all who access our system regardless of pay source. Because of fully integrated, bidirectional behavioral- and primary-health care, adults and adolescents will have high behavioral health and medical appointment rates, take medications as prescribed, reduce tobacco use, and be screened for high blood pressure (BP) with follow up plans documented. Adults with hypertension will see a decrease of BP at six and 12 months, decrease high breath carbon monoxide levels, blood glucose levels. Children and adolescents who are in overweight obesity categories will see reductions in body mass index at 12 months and discharge. Children with hypertension at baseline will be in the non-clinical range at six and 12 months. Access to dentistry will be shown. Integrated care will be achieved by the 4th month of funding for a total of five rural and two urban counties. The OPICH workgroup will meet regularly to share information, bust barriers, and support each other to meet all project goals. By the end of year three, all locations will provide all of the components of integrated, person-centered care at the “best practice” level, to be assessed through independent integrated care fidelity assessments. Through a “no wrong door” approach, utilization of many community partnerships, multiple outreach and engagement strategies (including training all staff in evidence based motivational interviewing techniques), and co-located services, the OPIHC’s goal is to serve at least 500 individuals by the end of year one, 1,000 by the end of year two, 1,250 by the end of year three, 1,500 by the end of year four, and 2,000 by the end of year five.

The Mental Health and Anti-Addiction Services Administration (MHAASA) is the Single State Agency (SSA) for mental health (MH) and substance abuse (SA) prevention and treatment services in Puerto Rico (PR), and is herein submitting this application for funding under the Funding Opportunity Announcement (FOA) No. SM-17-008 to promote the Integration of Primary and Behavioral Health Care (PR-PIPBHC). The PR-PIPBHC Project will be implemented by the MHAASA, which is the Single State Agency (SSA) for the Mental Health and Substance Abuse Block Grants in Puerto Rico, through the collaboration with Federally Qualified Health Centers geographically located within the Western, Northern and Eastern Regions of PR. Lack of specialized PC and BH services beyond Health care services and access vary outside of the San Juan metro area. The greatest concern has been limited access to physicians. Seventy-two of Puerto Rico’s 78 Municipalities have been deemed medically underserved areas by the US Health Resources and Services Administration (HRSA). Within these areas, HRSA has identified 32 primary care health professional shortage areas (HPSAs) with a population-to–primary care provider ratio of 3,500:1 or higher. Additionally, 23 percent of municipalities had a shortage of pediatricians, 68 percent had a shortage of Ob-Gyn’s, and 64 percent had a shortage of psychiatrists, according to HRSA guidelines. The proposed PR-PIPBHC Project is directed to (1) Promote full integration and collaboration in clinical practices between primary and behavioral health care; (2)Support the improvement of integrated care models for primary care and behavioral health care to improve the overall wellness and physical health status of adults with a serious mental illness and (3) Promote integrated care services related to screening, diagnosis, prevention, and treatment of mental and substance use disorders, and co-occurring physical health conditions and chronic diseases.

The purpose of Michigan’s PIPBHC Program is to leverage Community Mental Health Service Provider (CMHSP) and Federally Qualified Health Center (FQHC) partnerships to augment primary and behavioral health care integration for Michigan’s most underserved populations. The Michigan Department of Health and Human Services (MDHHS) worked with the Michigan Primary Care Association and the Michigan Association of Community Mental Health Boards to help determine which areas of the state would most benefit from PIPBHC activities. Considering the above, MDHHS will target three underserved and disparate counties in Michigan—Barry, Saginaw, and Shiawassee Counties, all of which hold federal Health Professional Shortage Area designations for both mental health and primary care. These counties are distinct in terms of rural versus urbanicity, population size, race/ethnicity, socioeconomic status, and the health needs of the target population (those with SMI/SED [and SUD in Barry County]). Overall, there are 7,292 people with SMI/SED in these counties (5,905 persons with SMI and 1,387 children with SED). The project will serve 900 to 1,500 people annually, inclusive of a targeted total of 7,292 individuals with SMI/SED and over 100 persons with SUD in Barry County specifically. MDHHS will partner with three community organizations to execute the PIPBHC Program activities pursuant to SAMHSA requirements. In Barry County, MDHHS will partner with Cherry Health Services, an FQHC who will partner with the Barry County Community Mental Health Authority to bolster behavioral health services. In Saginaw and Shiawassee Counties, MDHHS will partner with the Saginaw and Shiawassee County Community Mental Health Authorities, who will partner with their shared FQHC, Great Lakes Bay Health Centers, to strengthen primary care services. Given the above, Michigan’s PIPBHC Program will be three models in one, leveraging synchronicities when appropriate. This affords MDHHS the ability to utilize both doors of integration and serve geographically diverse populations. MDHHS will also partner with a Michigan research university to execute the evaluation for the project. According to the Kaiser Family Foundation, Michigan is among the nation’s worst quartile in terms of alcohol/illicit drug use (for teens and adults), mental illness, opioid overdose deaths, and suicide. Michigan is also worse than the national average regarding cancer, diabetes, and heart disease. The selected PIPBHC counties suffer disproportionately compared to Michigan’s general population in these areas. For example, Barry County had 10.1 opioid deaths per 100,000 in 2016—higher than the state average of 7.0 deaths per 100,000—while Saginaw and Shiawassee Counties had higher than average rates of opioid hospitalizations and prescriptions per 100,000. Additionally, Saginaw County is among the top ten worst Michigan counties in terms of HIV prevalence with a rate of 134 per 100,000 population.