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Berks Counseling Center (BCC)’s CCBHC expansion project will 1) expand our capacity of the behavioral health workforce, services and infrastructure that were not included in the Clinic model but have proven to be a major benefit to our clients, especially wellness activities; 2) increase access to screening and treatment for children and adolescents with SMI, SED or on the autism spectrum by expanding our transportation abilities and training opportunities for clinicians working with these subpopulations; 3) expand our capacity to support clients experiencing multiple social factors which mitigate their recovery including education, housing and employment and 4) pursue sustainability of physical health, wellness, and prevention programs through enrollment in physical health insurance networks. All of these goals and supporting activities are not funded through the CCBHC payment model. BCC is a CCBHC located in inner city Reading, Berks County PA serving a population base that is largely low income, on MA/Medicare or un(der) insured, heavily Hispanic, and with a high rate of concurrent SMI, substance abuse and comorbid chronic health conditions. A significant percentage (over 23%) of this population are children and adolescents of which 15% have mental health issues. An emphasis on outreach to pediatricians, foster care agencies, charter schools and educational intermediate units will enhance our ability to reach youth and adolescents. BCC currently provides all required CCBHC core services either directly or through our two DCOs which provide crisis mental health, including 24-hour mobile crisis teams, and psychiatric rehabilitation services. Specifically, BCC provides; comprehensive outpatient mental health and substance use services; screening, assessment, and diagnosis; patient-centered treatment; primary health screening; clinical monitoring of medications; targeted case management; Assertive Community Treatment, medication assisted treatment; peer support services including a decision support center; services specific to veterans and armed forces; and evidenced based practices selected by Pennsylvania’s Department of Human Services.

Through the CCBHC Expansion Grant Mercy Life Center Corporation (MLCC), a PA CCBHC awardee, will increase access and capacity and enhance and expand services for individuals with SMI, SUD, SED and COD within Allegheny County PA, by utilizing collaborative partnerships, enhanced clinical treatment teams and complex care coordination. The proposed services include expansion of a COD focused MAT program, coordination of and linkage to primary care screening and monitoring and expanding services via increased access to psychiatric services through tele-health portals. The proposed activities include expansion of care coordination services within the highly specialized MAT program; care management focused on risk stratification using predictive risk analytics to guide intervention activities; and coordination of and linkage to primary care screening and monitoring and mental health services utilizing telepsychiatry and teleconsultation. Expanding on a high fidelity CCBHC program, these proposed comprehensive population focused services 1) effectively screen, assess and coordinate care through a Complex Care Management Model, 2) provide increased access to MH, SUD & COD treatment, 3) institutes a safety net for community providers to coordinate and access care across systems, 4) provides access to telepsychiatry and teleconsultation services to address gaps in care related to readiness to engage, social disparities and provider shortage areas. Throughout the life of the grant 1700 individuals will be served. The project will utilize the Evidence-Based Practices Illness Management and Recovery (IMR), Motivational Interviewing (MI), Harm Reduction, and trauma informed approaches and interventions, in engaging and maintaining individuals in service. MLCC, building upon the CCBHC model, will expand capacity and sustain a program with the following objectives: (1) Outreach and engage individuals with mental health and substance use disorders, and screen and enroll (100) in year one and (300) over the life of the grant in Medication Assisted Treatment (MAT), with 85% continued engagement beyond 6 months. (2) Create a data driven quality measurement process to evaluate risk factors, effectiveness of interventions and decreased days/weeks/months of use for individuals enrolled in the MAT program. Decrease the frequency and days of use by 60% in the target population within 6 months of enrollment in the program (100) in year one and (300) over the life of the grant. (3) Improve coordination of care to and primary care screening and monitoring for 90% of new individuals in the targeted population (SMI, SED, SUD &COD), (1000) new individuals by the end of the grant period, (300) year 1, (700) year 2. (4) Improve access to behavioral health treatment, psychiatric evaluations and medication services to 400 individuals utilizing telepsychiatry and teleconsultation; (150) in year one and (250) in year two.

The Montrose Integrated Treatment Project will service 75 annually and 150 total unduplicated adult LGBTQ+ or people living with HIV consumers with mental health and substance use disorder in Houston/Harris County, TX. The Integrated Treatment for Co-occurring Disorders will be the primary evidence-based practice. Goal 1: Begin providing ITP services in the 4th month of the contract. Obj. 1-1: ITP process evaluation protocol, monthly, during the 1st 4 mos, QI team (Exec Dir, Evaluator, Compliance & Admissions Coord) will complete ITP readiness assessment checklist. Obj. 1-2: By the end of the 4th mo, QI team will train recovery coaches & referral source on how to refer and link potential clients for ITP intake. Goal 2: Enroll & retain 75 clients unduplicated clients per year (150 over 2 years of funding). Obj. 2-1: Begin mo 4, enroll on average 10.7 new clients in ITP, so that 150 new clients are enrolled in ITP by the end of month 18 and able to complete 6-month follow-up assessments. Obj. 2-2: Begin mo 4, complete the intake/initial evaluation for 90% of new clients w/in 10 business days. Obj. 2-3: Begin mo 6, retain at least 80% of clients who enroll in ITP for a min of 6 mos. Obj. 2-4: At 3 & 6-months from baseline, 80% of clients complete follow-up assessments. Goal 3: Implement a quality improvement process. Obj. 3-1: Begin mo 5, QI team will meet monthly for process & QI to review analyses & use to inform changes to service delivery protocols, documenting changes & reason for changes. Obj. 3-2: Consistent with ITP process evaluation protocol, by the end of the 6th mo & every six mos thereafter (mos 12, 18, & 24), QI team will collect process improvement data using the integrated fidelity scale, general organizational index, & measures of cultural competency. Obj. 3-3: In mos 6, 12, 18, & 24, QI team will facilitate community advisory meeting, review results of available analyses & solicit recommendations for program improvement, documenting changes & reason for changes.

Western Mental Health Center (WMHC) is proposing to implement a WMHC CCCBHC. WMHC’s catchment area covers five counties in the southwest region of Minnesota. They include Lincoln, Lyon, Murray, Redwood and Yellow Medicine counties. Western Mental Health Center serves as regional hub for mental health services therefore we see and service all populations including the Upper and Lower Sioux Tribal reservations. In the last year we have seen our crisis calls and face to face assessments quadruple and many are being referred for ongoing services that are uncovering serious mental illnesses. In 2017, WMHC served approximately 3,065 Adults with an SMPI or SMI diagnosis with over half of these having a dual diagnosis of CD and 1,080 children with SED. The goals for our project include: Goal 1: Increase the number of adults and adolescents served suffering with substance use disorders by 15% in our catchment area. Objective: Implement outpatient substance use programs through CCBHC Grant at Western Mental Health Center by December 2018 with the goal of serving 15 clients by the end of the year with additional clients to come in 2019. -hire CCBHC Project Coordinator -hire at least 2 additional professional staff to administer services - improve/include needed documentation and programming into our current EHR (Carelogic). Goal 2: Increase number of individuals with severe mental illness served under Care Coordination by 140% by Dec 2018 with the aid of the CCBHC Grant. Objective: Increase number of clients enrolled in care coordination services by December 2018 from 40 to 100 -hire CCBHC Project Coordinator -hire 3 CCBHC Care Coordinators as well as 2 certified Medical Assistants - improve/include needed documentation and programming into our current EHR (Carelogic). Goal 3: Re-establish a primary care clinic within Western Mental Health and create an advisory committee for the CCBHC by Dec 2018. We will utilize our current screening tools such as the PHQ-9, CASII, SDQ’s, WHODAS, CAGE-Aid, GAD7, CPSS-V-SR (TFCBT) ECSII, CBCL, Columbia, ACEs and ASQ3 in order to help us track and monitor individual client outcomes as well as overall agency outcomes for service delivery.

Cornerstone Montgomery serves people with mental health and/or substance abuse disorders in Montgomery County, Maryland with a population of just over 1 million residents. In Montgomery County, approximately 17% of people over the age of 18 have experienced some form of mental illness. Among population subgroups, NH-Black had the highest rates of ER visits, followed by NH-White, Hispanic, and Asian/PI; females had higher rates than males. People aged 18-34 had the highest ER visit rate, followed by ages 5-17, and 5-64 respectively. Illicit drug use for people aged 12 or older was over 8%, with 12% of high schools students admitting to misusing prescription drugs. Drug induced mortality rates in the County are on an upward trend consistent with the rest of the US; reaching over 12 deaths/100,000 residents (over 60 deaths/year on average). NH-White had the highest rate of death, with males dying than females, followed by NH-Black, Hispanic, and Asian/PI. Ages 18 – 34 have the highest mortality rate, followed by ages 35 – 64. Over 3% of adults over 18 and 15% of high school students have reported having suicidal thoughts. Suicide rates have fluctuated over time averaging 70 deaths each year. Those over 65 have the highest mortality rate (11%) followed by 35 – 64, 18 – 34, and 5 – 17 (1%) year olds. Research shows that people with a mental illness die on average 25 years earlier than the population at large . Chronic health conditions , Diabetes, Hypertension, Obesity, or Heart Disease, that impact They are dying from the same conditions as the general population, without accessing the care they need and/or the support to follow treatment guidelines from their PCP. Seventy percent of the people that we serve at Cornerstone Montgomery have at least one co-occurring medical condition including diabetes, hypertension, obesity, or heart disease. There is a critical need for intervention to support the health of our population. Even with the resources available in Montgomery County, only 41% of adults and 50% of children with mental illness access needed treatment ; less than 25% of people with substance use disorders access treatment. There is a clear need to educate the community about the availability of treatment resources and a need to expand resources to meet the current need in Montgomery County. To provide and attain the best possible outcomes for clients, there is a need for increased care coordination between behavioral health and primary care services; this is goal of CCBHC’s. Cornerstone Montgomery has a behavioral health home and partners with FQHC’s and PCP’s to provide integration of care. Our goal is to expand in this area. Other providers in Montgomery County serve the same population on a smaller scale. They include: Family Services, Inc. (they also serve children); Affiliated Sante (they also serve the DDA population); PEP (ACT services only); and Vesta (adults only). Cornerstone Montgomery is the largest provider of public Behavioral Health services in Montgomery County. We offer the widest continuum of services including an ACT program serving 100 clients and a Residential Crisis Services program with 24 beds. Cornerstone Montgomery has the only DBT residential program in Maryland and we are the only provider of ITCOD services in Montgomery County. Cornerstone Montgomery (a 2012 merger between Threshold Services and St. Luke’s House) has been providing behavioral health services in Montgomery County since 1971 as a 501c3. We currently provide the majority of the required activities and plan to contract with a DCO to deliver Child and Adolescent services. We are CARF accredited through August 2021. We have the applicable Maryland State Licensure. All pertinent staff is already in place, except for the Program Evaluator/Data Analyst which we will hire within 4 months after grant approval. Cornerstone Montgomery will use the grant funds to support and expand our direct services.

The Deschutes County Certified Community Behavioral Health Expansion Project will focus on increasing access to collaborative, integrated services for individuals with serious mental illness (SMI) or substance use disorders (SUD), including opioid disorders; children and adolescents with serious emotional disturbance (SED); and individuals with co-occurring disorders (COD) in Deschutes County, Oregon’s most rapidly-growing county. Along with the goal of increased access, the project’s other goals are: individuals served will experience improved behavioral and physical health and functioning; clients will receive person- and family-centered, trauma-informed care; all sources of available funding / support will be optimized in order to facilitate each client’s positive outcomes; and capacity of clinical competencies will be maximized in the behavioral health workforce. By July 1, 2020, the number of clients screened for any mental illness who then receive care at an integrated site will increase by 50%, up from 1,562 clients in 2017, to a total of 2,343 unduplicated clients served per year, resulting in a total of 4,686 unduplicated individuals receiving care during the two-year project term. Measurable objectives will be as follows: • By September 1, 2020, 25% additional staff will be certified to provide SUD and COD services, up from the current baseline of 28, for a total of 35 certified staff. • By September 1, 2020, there will be a 20% increase in the number of services provided to high risk clients with schizophrenia, schizoaffective, bipolar with psychotic features, and unspecified psychosis in rural communities, up from 222 services per quarter, to a total of 265 services per quarter. • By September 1, 2020, 300 individuals having received 6 months or greater of service will show an average increase of 5 in their DLA–20 score. • By September 1, 2020, 100 individuals with MDD, having received 6 months or greater of service, will show average decrease of 4 in PHQ-9 score. • By September 1, 2020, 300 unduplicated individuals with diabetes served in integrated physical/behavioral health program show 6 months or greater of control as measured by A1C less than 8. • By September 1, 2020, 300 unduplicated individuals with hypertension served in integrated physical/behavioral health program, will show 6 months or greater of hypertensive control measured by blood pressure less than 140/90 Health & Services Admin guideline (130/80 when HRSA guidelines are adjusted). • 100% of eligible services will be billed to clients’ insurance, or Medicaid / Medicare, so that CCBHC grant funding can support medically necessary services not covered by other payers.

Preferred Family Healthcare’s (PFH) Health Pathways project will focus on adolescents and adults aged 12+ with a substance use disorder (SUD), who experience a multitude of service gaps, barriers, and disparities related to treatment access, residing in the rural and economically disadvantaged 18 counties in north central and northeast Missouri. This will expand services to 36 outpatient mental health, 90 adult SUD and 35 adolescent SUD clients annually. The population of focus will be non?Medicaid eligible, with no other source of funding for treatment and medically and clinically appropriate for mental health/ SUD treatment. Significant barriers to service access exist due to rurality: lack of public transportation or availability of affordable transportation and distance/travel to treatment sites, lack of/minimal recovery support services (e.g. recovery/ transitional housing, community-based recovery groups, peer support, lack of/limited wraparound support services (e.g. vocational support/ job training, affordable/ available housing); lack of culturally/ linguistically responsive programs, and pervasive stigma related to substance use, and health professional shortages. Health Pathways will provide services through goals and quantified objectives to improve access and increase number of clients with SUD served, engaged, and retained through CCBHC project expansion. Goal 1: Expand CCBHC services to uninsured individuals who are in excess of the current funding available. Obj. 1.1 Enroll at least 36 outpatient mental health clients, 90 adult SUD clients, and 35 adolescent clients into the program in Years 1 and 2; Obj 1.2 All clients receive a comprehensive assessment to determine the needs. Obj 1.3 90% of the clients will remain engaged in the program by receiving at least 4 visits during the first 30 days of treatment. Goal 2: Provide integrated healthcare, including addressing needs of individuals with co-occurring disorders and opioid use disorders (OUD). Obj 2.1 80% of the individuals with an OUD will be referred to the agency physician to assess for the need for medication assisted treatment. Obj 2.2 90% of the SUD clients with a co-occurring mental health diagnosis will receive co-occurring individual counseling, mental health therapy and/or psychiatric treatment as necessary. Obj 2.3 100% of the clients admitted into the program will be screened for tobacco use. Obj 2.4 80% of the clients who reported tobacco use in the past 30 days will receive a tobacco cessation intervention. Obj 2.5 70% of participants will report improved physical health by six-month follow up and at successful discharge from the program. Obj 2.6 85% of the clients admitted with a SUD will report abstinence or a reduction in use at six-month follow up. Goal 3: Improve education and/or employment status of those participating in the program. Obj 3.1 90% of clients 17 or under who have not graduated from high school will either enroll in an education program/remain involved in an education program throughout duration of project. Obj 3.2 90% of clients seeking employment will receive assistance from employment specialist. Obj 3.3 65% of clients who report seeking employment will be gainfully employed by 6-month follow up.

Grand Lake Mental Health Center (GLMHC) proposes to increase access to expanded Integrated Health Services for all individuals who are characterized as SMI, SED and individuals diagnosed with a SUD and/or COD in an expanded geographical area. Our goal is to decrease inpatient psychiatric hospitalization by combining mobile technology solutions, community outreach, 24/7 outpatient and crisis stabilization services, utilizing evidence-based practices. We plan to improve access for Veterans and their families by expanding outreach and treatment options. GLMHC is an Oklahoma Certified Community Behavioral Health Center, providing 24-hour emergency mobile crisis services, crisis stabilization services, and all required CCBHC screening and assessment services. GLMHC strongly believes in the importance of patient and family-centered treatment planning, and all treatment plans include a Safety Plan, as well as regular depression and suicide screenings. We offer a complete array of outpatient mental health and substance use services, including Medication Assisted Treatment (MAT) and Assisted Outpatient Treatment (AOT). GLMHC has put a major focus on utilizing peer recovery support specialists with highly positive results. We also have full-time, dedicated, housing and employment specialists. In addition to targeted case management, GLMHC offers full wraparound service plans, with case managers and RN’s working hand-in-hand with family members, teachers, PCP’s, and other stakeholders to provide patient-centered, community-based care plans. GLMHC also screens all adults for tobacco use and offers free smoking cessation supplies and counseling services to those in need.

Summary: Monarch's CCBHC Expansion Project will increase the depth and breadth of mental health and substance use disorder services in rural North Carolina. As part of the project, Monarch will become CCBHC-certified within four months of award notification and will implement evidence-based interventions, case management/care coordination services and peer/family support services. Project Name: Monarch's CCBHC Expansion Project Population Served: The target population includes adults with serious mental illness (SMI), children with serious emotional disorders (SED), adults with substance use disorders (SUD) and adults with co-occurring disorders (COD). Number Served: Monarch projects it will serve more than 1,500 people annually and a total of 2,252 unduplicated individuals over the lifetime of this two-year CCBHC expansion project. Strategies/Interventions: Monarch will provide comprehensive, integrated care that directly addresses behavioral health issues; chronic health conditions (e.g. diabetes and heart disease); and adverse childhood/lifetime events such as physical abuse, hunger, poverty, and homelessness which impact treatment, recovery and overall health. Project Goals/Measurable Objectives: 1) Address the critical behavioral health needs of children and youth by increasing community outreach efforts; 2) Implement innovative substance abuse programs and/or evidence-informed practices to treat SUD; 3) Implement strategies that contribute to the physical and mental health of people supported; 4) Collaborate with local formal, informal and community supports to address the social and environmental factors that negatively impact health of people supported. Objectives include: 1) Contact 50% of Stanly County Schools in year one to increase awareness of its array of mental health and substance abuse services; 2) Educate youth and families on mental health and substance abuse-related topics through a variety of community programs at least four times annually; 3) Launch Medication-Assisted Treatment with up to 30 people supported at any given time in year one, as outlined by DATA 2000 Waiver requirements; 4) Incorporate the Integrated Dual Diagnosis Treatment EBP with a score of 3.0 on the DDCMHT Index in year one; 5) Establish cooperative relationships with three types of community physical health providers including private clinics, public health organizations and local hospitals; 6) Implement at least two new technologies that support care delivery and coordination such as electronic health record enhancements, health information exchange access, improved telehealth capabilities; 7) Expand electronic resource database to include resources specific to the four primary social determinants of health domains (SDOH); 8) Implement an electronic Social Determinants of Health screening instrument.

CCBHC Expansion Grant. The Guidance Center (TGC) has been providing behavioral health services to children since 1958 and adults since 1964. For the CCBHC Expansion Grant, TGC will serve 3,350 unduplicated children and 2,800 unduplicated adults (6,150 total) with SED, SMI, COD and SUD in FY19 and 6,300?in?total?in FY20. Supported Employment and substance use disorder treatment capacity will double and people with opioid addiction will receive medication assisted treatment. Specifically, the number of people served in Supported Employment will increase from 73 consumers in FY17 to 120 in FY19 and 160 in FY20; SUD/COD treatment will increase from 312 in FY17 to 500 in FY19 and 600 in FY20. Peer services will increase from serving 102 in FY17 to 150 in FY19 and 200 in FY20. Integrated care efforts will also be enhanced by developing care pathways and training peers as community health workers. TGC directly provides the following core CCBHC services:? Patient?centered treatment planning, screening, assessment, diagnosis, outpatient mental health and SUD treatment.? TGC also provides psychiatric rehabilitation, peer support, targeted case management and primary health screening. The requirement for emergency mobile crisis stabilization services is met through coordination with the Detroit Wayne Mental Health Authority’s (DWMHA) state-sanctioned crisis care continuum, in which specific organizations are contracted to provide mobile crisis stabilization and mobile crisis screening/pre-admission review (PAR) for all individuals with SED, SMI, COD and SUD in Wayne County. The CCBHC Expansion Grant Program goals are: Expand existing CCBHC outpatient services to uninsured consumers.? Increase capacity to provide services to consumers with SUD and COD. Expand MAT to include consumers with opioid addiction disorders.?? Expand 24/7 crisis response to include consumers in TGC’s adult and children’s outpatient programs that do not already have on-call staffing.? Increase capacity to provide Supported Employment and peer services for adults with SMI, COD and SUD. Increase efforts to ensure the healthcare needs of all consumers are met.? TGC uses multiple evidence-based practices (EBPs); all are implemented based on the needs of consumers, as evidenced by, customer satisfaction surveys, research or recommendations from SAMHSA, MDHHS or DWMHA and data from TGC’s electronic medical record (EMR) on diagnoses, hospitalizations, health conditions, trauma history, etc. We look forward to the opportunity to participate in the national cross-site evaluation of SAMHSA's CCBHC Expansion Grants. As providers of CMH services for sixty years, we have valuable experience to contribute to the evidence being gathered about effective community based mental health services.??

Options for Southern Oregon (Options) received Certified Community Behavioral Health Clinic (CCBHC) designation in 2017 for its Josephine County, Oregon clinics. Options will expand CCBHC services to its behavioral health clinics in neighboring Jackson County, Oregon with the CCBHC Expansion Project funding. This project will ensure an approach to health care that emphasizes recovery, wellness, trauma-informed care, and physical-behavioral health integration in Jackson County through the use of mobile personnel, outreach and engagement activities, tele-health and culturally relevant Veteran services. The populations of focus for this project includes: adults with severe mental illness (SMI), all ages with substance use disorders (SUD), adults and youth with mental illness (MI) or severe emotional disturbance (SED) and substance use disorders identified as co-occurring disorders (COD), CCBHC members at risk for or suffering from metabolic syndrome, and Veterans and active members of the Armed Forces. The goals of the project are: (1) reduce the mental health symptoms that are common among active members of the Armed Forces and Veterans; (2) increase capacity to provide evidence-based SUD/COD treatment to CCBHC adults and youth; (3) increase capacity to engage CCBHC members in physical and mental health care through Peer Wellness Coaches; and (4) to decrease the repeated use of hospital emergency departments for mental health and SUD-related needs. Options will meet these goals by providing culturally relevant, evidence-based mental health and SUD/COD treatment, emergency room follow-up outreach and engagement services and mobile peer wellness coaching. A minimum of 518 individuals will be served in year one and 774 in year two, resulting in a total minimum of 1,292 served during the grant period. In addition to providing services within the CBHC clinics, services will be provided in the community via mobile psychiatry, peers and clinicians. Tele-health services will be provided as well to ensure that care is readily available and timely. The project’s success will be evaluated using a variety of key indicators including: number of staff trained on military culture and Veterans, Veterans and members of the Armed Forces accessing evidence based trauma treatment, CCBHC members engaged in SUD/COD services including medication assisted treatment, CCBHC members’ development of personal wellness plans and engagement in Illness Management and Recovery treatment, increased engagement in needed services after SUD/MI related emergency room visits, adherence to fidelity for evidence based practices and improved physical health measurements for CCBHC members.

Helen Farabee Centers, SAMHSA CCBHC Expansion - The CCBHC Expansion affects a 19 county area in north Texas served by Helen Farabee Centers, a Local Mental Health Authority and Certified Community Behavioral Health Center. Grant funds are required to alleviate a funding shortage following the end of DSRIP funding and until payment models are established with Managed Care Organizations. The project focuses on adults, children, and adolescents receiving mental health, substance abuse, and physical healthcare at nine center locations. Strategies include establishing a dedicated Care Coordination Team, supporting ongoing provision of outpatient Substance Abuse services in six rural clinics, continuing the Certified Peer Specialist provider model system-wide, and maintaining quick access to psychiatric evaluations and first contacts with prescribers. The primary goal of the Care Coordination model is to help mental health clients with high-risk co-occurring health conditions and/or housing/ employment issues access appropriate referrals. The first objective toward that end is to hire four Care Coordinators with one Team Lead for region-wide service by the end of Fiscal Year 2019. The second is to maintain an average caseload of 75 per Care Coordinator by the end of Fiscal Year 2019. The third objective is to establish procedures for a team-based Care Coordination approach for mental health clients with complex needs by November 2018. The Center proposes an unduplicated annual service volume of 780. The primary goal of the outpatient substance abuse clinics is to help residents in the service area recover from substance use disorders, maintain sobriety, and lead productive lives. The first objective toward this goal is to obtain full funding in FY19 for the continued operation of six established outpatient substance abuse clinics located throughout the service area at current budget levels. The second objective is to maintain service volume during FY19 at levels observed in FY17/ 18, including screenings, outpatient care and follow-up rates. The Center proposes an unduplicated annual service volume of 266. The primary goal of the Certified Peer Specialist program is to help clients across the service region recover from mental illness and successfully navigate the treatment system by working with peers who have a shared lived experience that includes successful recovery. The first objective during FY19 is to increase the Certified Peer Specialist workforce from five to seven in order to make the Certified Peer Specialist program available to all mental health clients throughout the service area. The second objective during FY19 is to increase unduplicated number of clients receiving peer-led services from 350 to 420. The Center proposes an unduplicated annual service volume of 420. The primary goal of the Open Access program is to help mental health clients throughout the service area begin recovery through prescriber services faster, within 2 days of initial eligibility determination. The first objective is to renew a contract for 8 hours of on-demand psychiatric evaluation access through the current tele-video provider during FY19. The second objective is to use internal prescribers to provide at least four additional hours of psychiatric evaluations per day during FY19. This increases the system capacity from 8 hours per day to 12 hours per day of psychiatric evaluation access region-wide. The Center proposes an unduplicated annual service volume of 2500.

Catholic Charities Neighborhood Services, Inc. (CCNS) will expand access to and improve the quality of integrated community behavioral health (BH) services offered through our mental health and substance use disorder outpatient treatment clinics, both licensed by NYS and for which we are seeking CCBHC certification. We will expand access to services for adults with mental illness, children and adolescents with serious emotional disturbance (SED); individuals with substance use disorders (SUD) including opioid disorders; and, individuals with co-occurring disorders (COD) in the Brooklyn neighborhoods of: Flatlands, Midwood, Kensington, Flatbush, East Flatbush, Ditmas Park, and Crown Heights. We provide comprehensive, integrated BH services to individuals from every walk of life. Many clients face a myriad medical, behavioral, and social conditions and challenges. Over the grant period, we will increase the number of individuals we serve from 450 to 630 in the first year, and more than double the original number to over 1,000 individuals in this high-need area of Brooklyn by the end of the second year. CCNS will: (1) provide immediate access to a comprehensive range of community-based mental health and substance use disorder services, including crisis intervention, for which we will add our own 24-hour mobile crisis team to enhance the 24-hour crisis services we already offer; (2) treat additional individuals with COD; (3) advance integration of behavioral health (BH) with physical health; (4) expand use of evidence-based practices; and, (5) provide overall improved access and quality of care to all populations by: (a) leveraging the lived experience of individuals living with mental illness and SUD, including veterans, through increased peer involvement in the care we offer; (b) expanding our capacity to coordinate benefits for our clients to address social determinants; and, (c) augmenting our use of data to drive performance improvement. CCNS will achieve CCBHC certification within four months of award, with few new requirements to fulfill. CCNS has been expanding its capacity to provide services to meet the needs of individuals with SMI, SUD and COD since the early days of health care reform. In Brooklyn today, we provide nearly all CCBHC-required services in a client-centered and integrated manner at two locations; however, by April 1, 2019, we will advance our integrated model of delivery by moving both to a new, larger location in Brooklyn at 1625 Flatbush Avenue, Brooklyn, NY 11210, where we will also add primary care. Unlike many other providers, we offer immediate access to services through open-access/walk-in appointments, provide evidence based SUD assessments upon intake, and promote lived experience throughout our entire behavioral health portfolio. CCNS has been approved by OMH to provide Telehealth/Telepsychiatry services between clinics to ensure psychiatric coverage and medication availability for all clients. CCNS is well prepared to take the final steps in becoming a CCBHC and meet the high standards of this national model.

As one of three Indiana Community Mental Health Centers to receive certification as a CCBHC, Regional Health Systems is now applying for a CCBHC Expansion Grant in order to extend certification to all of our sites and, in doing so, to increase access to and improve the quality of behavioral health services in Lake County, Indiana. Regional Health Systems is a comprehensive health and human services agency that provides mental health and substance abuse treatment services, in addition to primary care and dental services, on a sliding fee scale. In 2016, Regional's Stark Center in East Chicago was certified through the State of Indiana as a CCBHC. Regional now intends to expand certification to all our sites, and to establish a team of integrated care professionals to implement population health management and to assist individuals with navigating our expansive system of care. Regional will use grant funding to hire additional support staff in psychiatric services, including a nurse and a medical assistant, in order to reduce the local shortage of psychiatric care. Additional psychiatrists will operate out of our primary care clinic sites to further integrate services. We also intend to expand our use of MAT by hiring a full-time addictionologist so we can provide Suboxone and Vivitrol on an outpatient basis. To expand services on the southern, more rural end of our county, we will hire an outreach staff member for our primary care clinic in Merrillville. The second major component of our project is to better integrate our system of care by expanding our team of primary care case managers, substituting nurses for some case managers. This team will be the connective tissue that assists consumers in navigating our CCBHC, with a particular focus on population health management for clients with chronic and/or co-occurring disorders. We will purchase population health management software to help keep track of individuals who are receiving psychotropic medications in order to better monitor health indicators. We will hire a data analyst to assist with data collection and management. Finally, as part of our outreach efforts, we will embed a staff member with a local mobile crisis team for veterans. We will invest in training for evidence based practices (including Motivational Interviewing, Trauma-Focused CBT, the Matrix Model, and Rapid Trauma Resolution), as well as cultural competency issues including poverty and trauma. We will train psychologist staff members on assessing clients for learning disabilities. We will invest in updating our community needs assessment, convening an advisory board, and hiring Spanish-speaking staff members, including a full-time translator who is trained on medical terminology.

The PFP CCBHC Expansion & Enhancement: Serving the Underserved project will expand and enhance the CCBHC services currently provided by Places for People (PfP) and address acute barriers to accessing science-based behavioral health services, particularly for those who are uninsured or under-insured in St. Louis City and County, Missouri. We will serve adults with Serious Mental Illness (SMI), Substance Use Disorder (SUD), COD Disorder (COD), as well as children and adolescents with Serious Emotional Disturbance (SED) and their families; more specifically, we will serve adults in these clinical population groups who are without Medicaid, Veterans who need services, and other adults and children who are unable to access the necessary and clinically appropriate services required due to insurance benefit restrictions, service capacity or a need for more assertive outreach and engagement. We intent to achieve the following project goals: 1.) Increase access to and utilization of EBPs for adults with SMI, COD or SUD and children (and their families) with SED who are uninsured or under-insured by enrolling a total of 525 adults with SMI/COD in either intensive community based (ACT, IDDT, ACCM, IPS, IMR) (75) or outpatient (medication management, CBT, DBT, Seeking Safety) (450) EBP's respectively, a total of 190 adults/adolescents with SUD in evidence-based treatment (CRA,ACRA,CRAFT), a total of 90 children with SED and their families in the recently implemented EBP (PCIT), and 40 children with SED in an emerging model for serving SED children with a parent or caretaker who also has SMI, COD or SUD. 2). All project participants will have access to integrated and coordinated physical health care assessment, monitoring and treatment as 100% of project participants will be connected to a primary care health provider, 90% of persons who enrolled in ACT or ACCM will have a physical health assessment, and 50% of outpatient service participants on psychotropic medication will have a metabolic screening and be provided related health education. 3.) Expand and improve the capacity and efficiency of the CCBHC by enhancing its infrastructure though hiring an EBP training coordinator to increase internal and regional system EBP provider capacity by conducting agency and regional trainings; improving reporting capabilities of electronic health record; implementing telemedicine home visit capacity; enhancing office telecommunications; implementing a benefits assistance program utilizing SOAR technology; and renting additional space for expansion of children/youth services. A total of 335 adults (SMI, COD), 95 adults/adolescents (SUD) and 65 children (SED) will be served in Year 1 with 525 adults (SMI/COD), 190 adults/adolescents (SUD) and 130 children (SED) served over the project.

In response to the Notice of Funding Opportunity, CDC-RFA-SM-18-019, FY2018 Certified Community Behavioral Health Clinic Expansion Grants, Community Mental Health Authority of Clinton, Eaton and Ingham Counties (CMHA-CEI) is requesting $1,892,490 per year for a two year project to expand services to 2,100 individuals annually with a diagnosis of Serious Mental Illness (SMI), Serous Emotional Disturbance (SED), Substance Use Disorder (SUD), or co-occurring disorders (COD) and are uninsured, underinsured, or have commercial insurance. Services will be provided through the addition of Nurse Care Managers, Mental Health Therapists, Recovery Coaches and the expansion of collaborating partnerships with Ingham County Health Department for primary care via their network of Community Health Centers and West Brook Recovery Center for expansion of outpatient Medically Assisted Treatment. Applying national and state rates to the Clinton, Eaton, and Ingham County population, it is estimated that there are 21,887 youth in the tri-county area with SED, 162,998 adults with SMI, and 40,123 individuals with SUD. Expanding the capacity to provide ongoing services to more of this population is vital in reducing, hospitalizations, re-admissions and ongoing management of chronic conditions to reduce the number of emergency department visits. Three primary goals have been identified for the project: Goal 1: Reduce hospital emergency department visits for individuals with SMI, SED, SUD, and COD, by improving management of chronic conditions and increasing care coordination with primary care. Goal 2: Reduce psychiatric hospitalizations for youth and adults by expanding mobile crisis intervention services, expanding the use of urgent care services, and increasing access to emergent psychiatric and emergent detoxification services. Goal 3: Reduce all causes of hospitalization readmissions of individuals by increasing participation in evidence-based practices. Evidence Based Practices (EBP’s) for adults include: Clubhouse, Medically Assisted Treatment (MAT), Dialectical Behavior Treatment (DBT) and Assertive Community Treatment (ACT). EBP’s for youth include: Trauma Focused Cognitive Behavioral Therapy (TFCBT) and Parent Management Training Oregon (PMTO). CMHA-CEI will work closely with external researchers to monitor the fidelity of implementation of the project, analyze output data collected through the project activities, and determine the impact of programs on participants and systems. The results will be used to improve all existing CMHA-CEI programs and systems.

The current healthcare system in our service area does not inherently support continuity of care and transitions among systems resulting in a higher rate of preventable emergency room visits, hospitalizations and jail bookings for those with behavioral health and co-occurring substance use needs. Recent briefs issued by the Agency for Healthcare Research and Quality suggests that care coordination models “assist patients and their support systems in managing medical conditions more effectively.” Further, the brief indicates that care coordination and management is key to managing population health outcomes. Through this grant application, Bluebonnet Trails Community Services intends to bridge the gaps supporting effective continuity of care resulting in higher rates of preventable emergency room visits, hospitalizations and jail bookings. By increasing care coordination to all individuals in our services regardless of indigent status or the program in which the individual is participating, individuals will receive timely, meaningful assistance in navigating multifaceted healthcare systems in their home communities, ensuring the individual receives needed primary and specialty care. In addition, the care coordinators foster clear communication between the individual and all providers of care improving the experience and healthcare outcomes for the individual.

The Project seeks to expand behavioral health care availability to individuals with serious mental illness (SMI), substance use disorders (SUD), co-occurring disorders (COD), and serious emotional disturbance (SED) through the development of a fully functioning Certified Community Behavioral Health Clinic (CCBHC) able to serve more than 8,000 individuals annually. Service capacity expansion specifically targets under and uninsured adults in the New River Valley of Virginia, a region with high rates of opioid use and overdose. Project goals include reducing local rates of opioid overdose deaths and reducing state hospitalization rates for the area. To reduce the overdose death rate, the Project will decrease wait times for SUD treatment and building capacity for medication assisted treatment (MAT). To decrease state hospitalization rates, the Project will increase capacity in Mental Health Skill Building (MHSB) and Assertive Community Treatment (ACT), expand mobile crisis services availability to 24 hours per day, and increase utilization of evidence based practices in outpatient care.

Ocean Mental Health Services (OceanMHS) proposes to establish Ocean Integrated Services (OIS) in response to Ocean County’s Opioid Crisis and the limited treatment capacity for persons with Substance Use Disorders and Co-Occurring Disorders. OceanMHS also proposes to integrate Behavioral Health and Physical Health Care and reduce health disparities within this population. Children impacted by parental substance use will also be served. Persons with Substance Use Disorders, as well as Co–Occurring Disorders, are frequent users of Ocean County Emergency Departments and are likely represented in Ocean County’s high number of deaths from Opioid use, rates of death by suicide, and early death to poor mental and physical health. Ocean Integrated Services (OIS) proposes to expand Crisis Stabilization Services into Ocean County Emergency Departments to reach the population at risk. OceanMHS will expand current efforts to identify, assess and treat, persons at risk, who are incarcerated and those who are homeless. Returning Veterans, who may also be homeless are often struggling with Co-Occurring Disorders and are a special project focus. OIS will serve 3000 adults, and 400 children, in the first year of the project. In year two, the number served will increase to 3836 adults and children. Persons identified and assessed by Crisis Stabilization as having an SUD or Co-Occurring Disorder will be referred to existing services, or to new/expanded services that OceanMHS will establish with the expansion grant. Proposed expansion services include ambulatory detox (873 persons) and an expanded Intensive Outpatient Program for persons with Co- Occurring Disorders (1000 persons). One thousand (1000) persons with SMI, SUD and Co- Occurring Disorders will be served in OIS’ Primary Care/Behavioral Health Clinic. OIS will also identify and assess 400 children with SED who have been impacted by Parental Substance Use. OceanMHS, through the efforts of OIS, expects to measure the impact of expansion services on Emergency Department BH Use Rates, the gap between unmet and met need for treatment among people with SMI, SUD, and Co-Occurring Disorders. OceanMHS, expects to reduce health disparities in the population served, which includes returning Veterans who may be homeless and who have Co-Occurring Disorders. Finally, in reaching children with SED, who are impacted by Parental Substance Use, positive outcomes, related to better school performance and reduced difficulties with authorities will be measured. Within, four months of an award, Ocean MHS expects to meet all criteria to become a Certified Community Behavioral Health Clinic (CCBHC).

Mosaic’s CCBHC will focus on two primary populations within Baltimore City, Maryland: 1) Individuals with mental health and/or substance use disorders lacking access to services due to limited capacity and/or insurance coverage, and 2) Individuals currently served by our outpatient mental health clinic and addiction treatment program who lack comprehensive care coordination. Mosaic will expand access to behavioral health services to 800 individuals each year, primarily for outpatient mental health clinic and Partners in Recovery addiction treatment, but also assertive community treatment, supported employment and psychiatric rehabilitation programs. In addition to addressing Baltimore City’s service access gaps, the Project will significantly expand comprehensive care coordination and case management services to all mental health clinic and addiction treatment clients in order to improve outcomes and reduce overall healthcare costs.

Under this application—Merakey Delaware County CCBHC Implementation— Merakey will fully implement the CCBHC model to serve adults with mental health and/or substance use disorders and children/youth with serious emotional/ behavioral disorders and/or substance use disorders living in the Merakey Delaware County CMHC geographic catchment area of the northern and eastern half of Delaware County, Pennsylvania—some 282,000 residents. Bordering Philadelphia, this area has a high population density with economically disadvantaged residents, a higher minority population (African-American) than the rest of Delaware county, higher unemployment rates, and high rates of individuals insured through Medical Assistance and Medicare. Historically, Merakey is one of two Base Service Unit comprehensive community mental health centers in the county. Under this grant proposal, Merakey will provide and expand mental health and substance use outpatient services and intensive outpatient services, mental health and substance use targeted case management services for adults and children, psychiatric rehabilitation and social rehabilitation services, supportive employment using the Individual Placement and Support model along with the contracted services of EDSI, peer and family support services, a forensic assertive community treatment team, and housing supports through its case management staff. For members of the armed forces and veterans, Merakey will provide the range of community based mental health care. In order to address physical health issues of individuals served, Merakey has an integrated care model with Delaware Valley Community Health, an FQHC, whose satellite primary care clinic is embedded in the Merakey clinic facility. As a Ryan White HIV/AIDS program provider, Delaware Valley Community Health provides a full range of HIV care and treatment services. Finally, Merakey will establish a Designated Collaborating Organization agreement with Elwyn so that Elwyn’s county-wide mobile psychiatric crisis team program will provide 24/7 crisis mental health services closely coordinated with Merakey services per the CCBHC requirements. Goals include reducing the stigma associated with behavioral health challenges and disorders, increasing the numbers of individuals who access behavioral health treatment, improving the primary/behavioral health coordination of care, improving coordination of MH and D&A services, and decreasing all cause hospital admission rates for “super-utilizers” of health care. Merakey will serve 3,500 individuals annually and some 4,500 individuals over the two years. Merakey Delaware County was certified by the state as a CCBHC in September, 2016. Substantive changes in the volume of individuals seen by Merakey during 2017 made the prospective payment system rate previously negotiated with the Commonwealth inadequate, and Merakey decided not to participate in the PA CCBHC two year demonstration project. This grant process resolves that issue. Given that Merakey has all of the CCBHC required services at the ready, this grant will allow full and quick implementation of the CCBHC model.

CCBHC Strategies/Interventions: Clinical and Support Options, Inc. (CSO), a large behavioral health organization already certified as a CCBHC, will provide residents of all ages with services to address serious mental illness, serious emotional disturbance, substance use disorder and co-occurring disorders by meeting all 9 CCBHC requirements, plus enhanced telehealth capacity. Population to be served: CSO will serve a minimum of 1000 people throughout the 3-county service area in predominantly rural Massachusetts: Franklin, Hampshire and northern Worcester (North Quabbin). CSO will serve all ages. Number of people to be served: The CCBHC program will serve an estimated 1,000 participants in each of Year 1 and 2. Project Goals: 1) CSO will develop the capacity to furnish all required services with no limitation on participant geography or ability to pay; 2) CSO will create maximum access to services; and 3) CSO will establish a care coordination capacity for all CCBHC consumers Measurable Objectives: 1a: CSO will furnish all nine (9) required behavioral health services with the staffing capacity to its consumers; 1b: CSO will have credentialed and certified professionals with training in evidence-based practices, person-centered, family-centered, trauma-informed, culturally competent, and recovery oriented care. 2a: Service availability at times and places convenient to consumers. 2b: CSO will develop and implement a sliding fee 2c: CSO services will offer intake and enrollment within 24 hours of referral; 3a: CSO staff will maintain communication and collaboration between CSO CCBHC staff and medical and community support organizations. 3b: CSO will track in its EHR, Credible, service utilization in its CCBHC programs and organizations that clients are referred and will monitor key health and behavioral health indicators.

In Linn County, IA, Abbe Center's CCBHC Project will increase its clinical capacity, timely access to services and increase partnerships with primary care for those at-risk for chronic health and/or behavioral health conditions. In 2017, Abbe Center served 7,272 individuals and anticipates serving an additional 1,000 (annually) and 2,000 (lifetime) unduplicated individuals as a result of this project by offering proactive targeted interventions and case management services. Specific population to be served are children and adults with mental illness (MI), serious mental illness (SMI), serious emotional disturbance (SED), substance use disorders (SUD) and co-occurring disorders (COD). Currently, there is an under-utilization of more cost-effective outpatient services due to a need for more timely access and case management to navigate the healthcare service system. This results in the over-utilization of the Emergency Department (ED) for both physical and mental health needs that could be cared for in an outpatient setting. Over the past 2 years, UnityPoint Health has seen an increase use of ED for mental health care needs. The fastest growing demographic group is teenagers ages 10-19. Common reasons cited for the increase in ED utilization for adults include acute psychosis, suicide risk, and individuals being out of or off of medications. In adolescents, most are newly experiencing symptoms and are unsure of where to go for help. Another alarming trend is the number of opioid treatment admissions in Iowa increased from 608 in 2005, to 2,274 in 2016 (Iowa Department of Public Health Opioid fact Sheet). From 2014-2017, there was also a three-fold increase in the need for individuals to be bedded in the ED while waiting for a behavioral health inpatient bed. In 2018, based on the trajectory, there will be a four-fold increase. Opportunities exist to help individuals before they are in crisis and seek emergency care or need to be admitted into the hospital. Goals for the project include: * Decrease ED utilization by CCBHC clients by 20% by increasing timely access to needed outpatient services *Increase comprehensive screening activities to ensure individuals receive the resources needed to maintain their health and well-being *Improve care coordination to address barriers to care, resulting in increasing engagement in outpatient services aimed at stabilization and health maintenance. Funding for Abbe Center's CCBHC Project will provide the critical, financial resources to strengthen Linn County's behavioral health services, improve service capacity and integrate physical and behavioral health care to increase the target populations health and well-being.

Human Development Center (HDC), a community mental health agency headquartered in Duluth, Minnesota, has been funded for approximately $2 million per year for two years under a SAMHSA funding opportunity for Expansion of Certified Community Behavioral Health Clinics (CCBHC). The grant will enable HDC to expand by at least 20% its comprehensive mental health and substance use programs, bringing hope to an additional 1,500 individuals annually, who currently do not have access to services. Since 1938, HDC has served the communities of four Minnesota counties in the Arrowhead region of northeastern Minnesota, serving over 7,500 clients annually with a comprehensive array of outpatient and community-based behavioral health services. We are excited about CCBHC. Previously, there was no statutory designation defining the services of a community mental health center. CCBHC defines the required outpatient and community-based services that must be offered, and how those services must be integrated for the benefit of the patient, in order to be certified. CCBHC will become an integral part of the healthcare safety net in America, serving people who suffer from serious mental illness, substance use disorder, or co-occurring disorder. Approximately 4.1% of the population suffers from serious mental illness, and more than 8% from substance use disorder. Many who suffer from these illnesses do not seek treatment, and many who do are not treated comprehensively. CCBHC has proven effective in creating greater access to services and with better outcomes for patients. HDC will have two main focuses for this grant. First, the intake process will be re-vamped to create greater access to screening and assessment for patients of all ages, with immediate referral to services that can be most helpful to the individual. Second, to address the opioid addiction crisis, HDC will expand its outpatient treatment program by offering the area’s first withdrawal management program and office-based Medication Assisted Therapy. Additionally, coordination of care is strongly emphasized with CCBHC, which means that a psychiatric nurse or case manager with behavioral health expertise will take charge of the care for each patient. The most exciting aspect of the CCBHC is the transformation of the practice, moving from a model of taking appointments, sometimes several weeks out, to a patient-centered approach with immediate access to services that can be helpful now, while the patient is in distress.

Samaritan Daytop Village’s (SDV) proposed, Suffolk Unleashing Potential and Enhancing Recovery (SUPER) Certified Community Behavioral Health Center to be located in Suffolk County, NY will expand and enhance the quality of integrated outpatient mental health, substance use and primary care services through the provision of culturally competent, person-family centered, evidenced-based treatment services. The population of focus (POF) will be primarily low income, minority children, adolescents, adults, and veterans having a SMI, SED, SUD or COD as they experience elevated rates of trauma, morbidity, visits to the Emergency Department (ED), preventable hospitalizations and mortality. In year 1, the SUPER CCBHC will provide comprehensive services to 180 people having SMI, SUD, SED and COD in order to expand the provision of comprehensive CCBHC services to 420 unique POF members over the 2-year period (180 in Yr. 1 and 240 in Yr. 2). The SUPER-CCBHC will expand access to critically needed trauma-informed, person-family centered assessment, treatment planning, comprehensive outpatient mental health and substance use treatment services, outpatient screening and monitoring of primary health indicators, medication administration and monitoring of medication for adverse effects, targeted case management, psychiatric rehabilitation services, social support opportunities, comprehensive recovery and family supports delivered by peer advocates, intensive treatment services for members of the armed services and veterans and the delivery of 24/7 crisis management and intervention services. The SUPER CCBHC will expand the use of evidence based treatment services by using: Motivational Interviewing, Integrated Dual Diagnosis Treatment, Individual Placement and Support, Cognitive Behavioral Therapy for anxiety and depression, Screening, Brief Intervention and Referral to Treatment, Cognitive Processing Therapy, and Multidimensional Family Therapy. The SUPER CCBHC has 4 overarching goals/objectives: (1) Decrease mental health symptoms and substance use among the POF by conducting screening, assessments, and treatment planning and providing evidence-based, person/family centered, integrated, outpatient mental health and substance use treatment services; (2) Improve health and decrease health disparities among the POF by providing integrated primary care screening and health monitoring services, increasing health insurance coverage and connection to a primary care physician; (3) Increase social connectedness and employment among the POF by providing psychiatric rehabilitation services (PRS) and social support opportunities; and (4) Decrease preventable Emergency Department visits and hospitalizations by providing access to 24/7 crisis services.