Project Abstract Summary Project Name: Seasons CCBHC Expansion Project Applicant: Northwest Iowa Mental Health Center dba Seasons Center for Behavioral Health Project Summary: To provide CCBHC services to nine rural counties in northwest Iowa to increase access to and improve the quality of community behavioral health services and care. Target Population to be Served: The target population for the proposed project is adults with a serious mental illness, children with a serious emotional disturbance, and individuals with co-occurring disorders, including opioid disorders. The project will target subpopulations: substance exposed infants and young children; youth in foster care, out of home placement, kinship care or adopted; and veterans and military families. Demographic and Clinical Characteristics of Target Population: The geographic service area for the project encompasses 9 counties in rural northwest Iowa: Buena Vista, Clay, Dickinson, Emmet, Lyon, O’Brien, Osceola, Palo Alto, and Sioux. The nine county region has a population of 138,501 residents (Census 2017 Estimates). Seasons provided behavioral health services to 5,338 individuals in 2017, including 2,448 children. Evidence-Based Strategies and Interventions: Assertive Community Treatment (ACT), Intensive Psychiatric Rehabilitation (IPR), Medication Assisted Treatment (MAT), Matrix Model, Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Seeking Safety (SS), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Parent Child Interactive Therapy (PCIT), Eye Movement Desensitization and Reprocessing (EMDR), and Registered Play Therapy (RPT). Project Goals: The goals of the project are: Goal I: To equip mental health professionals with skills, knowledge, and resources to provide high quality, evidence-based, trauma-informed, and culturally responsive CCBHC services. Goal II: To create consensus for understanding the key activities offered by Seasons as a CCBHC. Goal III: To ensure families are able to easily obtain behavioral health services, resources, and supports, along a continuum of prevention, early intervention, and treatment, within their local communities. Goal IV: To create the organizational capacity to lead and champion a sustained, high-quality CCBHC within a rural geographic service area. Number to be Served Annually and Throughout Lifetime of Project: The targeted number of individuals to be served by the project over the two-year project period is 1,150, targeting 800 individuals in Year 1 and 1,150 individuals in Year 2.
The SSTAR CBHC Expansion Project targets Opioid addicted adults with co-occurring mental illness in Fall River, MA, a predominantly Portuguese community that is plagued by high rates of addiction, socio-economic stressors, poor health status influenced by prevalence of smoking and obesity, and high incidence of depression and anxiety. SSTAR has been providing behavioral health services since 1977 and has long been a leader in integrated primary and behavioral health care, providing primary care through our FQHC located in the same building as our outpatient behavioral health clinic and Opioid Triage Center. This project will increase access to psychiatric services for children and adults, maximize capacity of the behavioral health workforce through use of technology to streamline workflows, through new recruitment strategies for attracting psychiatric providers, and through trainings that foster the adoption of evidence-based practices such as DBT for adults with co-occurring disorders, AF-CBT for children and youth, and trauma-informed care. Family support services will be enhanced through the development and implementation of a new model of Family Peer Recovery Coaching. Family support and education using the ARISE model of family intervention and the peer recovery coach services will lead to increased treatment engagement and outcomes for the addicted loved one, while overcoming cultural barriers that perpetuate stigma of both the disease of addiction and medication assisted treatment as a legitimate path to recovery. A new outpatient level care will be introduced to improve treatment engagement for people with opioid use disorder and mental illness through a structured outpatient (partial hospital) that incorporates Medication Assisted Treatment, a clinical program that addresses substance use disorder and psychiatric symptoms, and availability of psychiatric assessment and medication management. Introduction of a digital health and wellness solution – myStrength mobile phone app- and tobacco education and cessation initiatives will contribute to overall improved health status of our population. Through activities in this project, SSTAR will become eligible for Certification by Month 4. Among the strategies for sustainability of the expansion initiatives will be enhancing capacity to bill public and commercial insurance for new services. The project will reach 740 individuals over the project period at a cost of. 1,818,231 in Year I.
CCBC CCBHC Expansion Project ABSTRACT As an approved Certified Community Behavioral Health Clinic (CCBHC), Community Counseling of Bristol County (CCBC) submits this proposal to expand access to community based behavioral health services in the cities of Brockton, Taunton, Attleboro, and surrounding towns located in Southeastern Massachusetts (SE MA), one of the poorest areas of the state socioeconomically. CCBC currently operates a full continuum of community based mental health and substance use disorder services (SUDs) and programs serving persons with serious mental illness (SMI), co-occurring mental health and substance use disorders (CODs), and children with serious emotional disturbance (SED). With funding from SAMHSA, the CCBC CCBHC Expansion Project will enhance the existing services in the Taunton-Attleboro and Brockton area helping CCBC to establish a stronger foundation for community-based behavioral treatment and enhancing the resources to meet the challenging needs of persons with CODs and SUDs as well as to screen children with serious emotional disturbance (SED) for potential SUDs. A key initiative will be to expand access to outpatient mental health services for all populations CCBC serves. Access to outpatient services in Brockton is particularly difficult where the wait to access services can be up to twelve months. The expanded outpatient presence will include timely access to psychiatry, Medication Assisted Treatment (MAT), home-based counseling, and outpatient services at CCBC’s office. The CCBC CCBHC Expansion Project will also train physicians and nurse practitioners in MAT to address the growing population at risk for opiate use disorders (OUDs). Recovery Support Navigators will also be hired to engage the target population with outreach and support following an inpatient admission or use of the hospital Emergency Department (ED). Goals: CCBC will expand access to outpatient behavioral health services for the COD, SUD SMI and SED populations in Taunton-Attleboro and Brockton Catchment areas of Southeastern Massachusetts; reduce the wait time for psychiatry from several months to two weeks; implement a number of Evidence Based Practices (EBPs) for the COD population; expand Medication Assisted Treatment (MAT) for persons with OUDs in the two catchment areas. Objectives: CCBC will allocate 16 clinicians to this project including 3 clinicians to support the MAT clinics, 2 in-home therapy clinicians, 11 clinicians who will be reallocated from the current adult and children’s outpatient teams, a part time APRN, and two Recovery Support Navigators within three months of award; increase outpatient volume in the two catchment areas by 500 clients in Year 1, and 600 clients in year 2. This includes follow up outpatient behavioral health services to 50 clients in year one and 150 clients in year two in the Brockton area to persons referred from ED’s; expand MAT to 50 clients in the two catchment areas; train the clinical staff in EBPs for CODs and deliver that model to the COD population in both catchment areas. Objectives: CCBC will allocate 16 clinicians to this project including 3 clinicians to support the MAT clinics, 2 in-home therapy clinicians, 11 clinicians who will be reallocated from the current adult and children’s outpatient teams, a part time APRN, and two Recovery Support Navigators within three months of award; increase outpatient volume in the two catchment areas by 500 clients in Year 1, and 600 clients in year 2. This includes follow up outpatient behavioral health services to 50 clients in year one and 150 clients in year two in the Brockton area to persons referred from ED’s; expand MAT to 50 clients in the two catchment areas; train the clinical staff in EBPs for CODs and deliver that model to the COD population in both catchment areas.
The Center for Human Development, Inc. (CHD) CCBHC Expansion Grant Project will implement a Community Health Team (CHT) approach to address unmet behavioral health care needs for unserved and underserved persons who reside in Franklin and Hampden counties, in Massachusetts, and who experience serious mental illness, serious substance use disorders, or co-occurring disorders, including behavioral health and medical conditions. The target population includes African Americans, Latinos (limited- and non-English speaking), LGBTQ youth and young adults, young adults with serious mental illness and/or serious substance use disorders, homeless individuals and families, and uninsured or underinsured persons. CHD’S outpatient clinics located in Greenfield and Orange (Franklin County) and Holyoke and Springfield (Hampden County) will participate in the project. Each participating clinic will operate a Community Health Team to enhance and expand CCBHC capacity to provide integrated, coordinated behavioral health services and to reach consumers in their respective communities who are not currently served. Each CHT will include case managers, a Nurse/Health Educator, a Peer/Recovery Specialist, a licensed behavioral health clinician, and a medical prescriber. Other community providers, care coordination entities, and state agencies that serve target consumers will be asked to participate on each CHT in order to promote person-centered, coordinated, and comprehensive care. CHD’s CCBHC Expansion Project will address the most pressing behavioral health needs for unserved and underserved populations, by accomplishing the following goals: (1) reduce the incidence of opioid-related overdoses and deaths; (2) reduce adverse health outcomes for consumers with behavioral health and co-occurring medical conditions; and (3) increase the capacity of clinics to promote consumer-driven recovery goals through the provision of peer support and rehabilitation services. Measurable objectives for the target population include: (1) engage 400 consumers in Medication Assisted Treatments (MAT); (2) provide wraparound and peer support services to 400 MAT consumers; (3) conduct primary health screening and monitoring for 60% of all clinic consumers; (4) provide behavioral health assessments, brief treatment, and referral services to 920 community health center and family practice patients; and (5) assist 40% of target population consumers to obtain permanent housing, employment, or enrollment in education programs. The Project will serve 700 unduplicated people annually and 1,400 people over the 2-year grant period.
The St. Clair County Community Mental Health Improving Community Health CCBHC Project (CMH-ICH) focus is to increase access to high-quality, evidence-based community behavioral health and substance use disorder services. Project outcomes include improved mental and physical health among adults and children with serious mental illness, serious emotional disturbance, co-occurring disorders, and substance use disorders. This will be achieved by providing comprehensive community-based mental health and substance use disorder services (including opioid disorders), treatment of substance use disorders and co-occurring disorders, consistent implementation of evidence-based practices and improved access to high quality care. The CMH-ICH Project serves any individual, regardless of their ability to pay or their place of residence. CMH is planning up to a 25% increase in persons served, which amounts to an additional unduplicated 335 adults and 116 youth. Standardized and validated assessment tools are used at intake and during the patient-centered treatment planning process to identify level of care and monitor individual progress. Services provided include: Crisis mental health services; screening, assessment, and diagnosis; patient-centered treatment planning; comprehensive outpatient mental health and substance use disorder services; Outpatient primary care screening and monitoring of key health indicators; clinical medication monitoring; targeted case management; psychiatric rehabilitation services; social support opportunities; comprehensive community recovery supports; intensive community-based mental health care for members of the armed forces and Veterans; and Assertive Community Treatment. In addition, service provision includes several existing Evidence-Based Practices employed by CMH, and six newly implemented Evidence-Based Practices offered as a result of grant funding, which include Medication Assisted Treatment, Opioid Treatment Program, Adolescent Community Reinforcement Approach (A-CRA), Motivational Enhancement Therapy, Interactive Journaling, and Trauma Sensitive Yoga. A strong interdisciplinary treatment team will focus on ensuring comprehensive, high-quality coordinated services are provided in a recovery-focused, trauma-informed, person and family-centered manner that supports each person’s unique individual needs.
Washtenaw County Community Mental Health Project Abstract: The Washtenaw County Community Mental Health Certified Community Behavioral Health Clinic Expansion Grant will increase the total number of individuals served by providing Certified Community Behavioral Health Clinic (CCBHC) covered services to individuals who are uninsured or underinsured. The target population to be served under this grant will be adults with serious mental illness (SMI), youth with serious emotional disturbances (SED), and individuals with substance use disorders (SUD) and co-occurring mental health/substance use disorders (SUD). Through this expansion grant, Washtenaw County Community Mental Health (WCCMH) anticipates it will serve 1500 new individuals while reducing hospitalizations by 20 percent and criminal justice system involvement by 3 percent for the targeted population. Community stakeholders across Washtenaw County conducted a series of gaps assessments pertaining to the unmet needs of individuals in crisis and with mental health and/or substance use disorders. These analyses concluded that in our locale there is a need to expand SUD and co-occurring services, behavioral health services for youth, adult mental healthcare service capacity for uninsured and underinsured individuals, and crisis services capacity. In 2014, the State General Fund allocation to WCCMH was reduced by 60 percent resulting in severe service reduction for both uninsured individuals and insured individuals who did not have a form of Medicaid. Previously and for over 30 years, WCCMH provided services regardless of payer status to the SMI, SED, COD, and Intellectual/Developmental Disability populations. WCCMH does currently screen and assess all individuals presenting with behavioral health needs. However, individuals who do not have a form of Medicaid are often left with their community-based needs unmet subsequently resulting in less person-centered and more costly service provision in locations such as emergency rooms and the corrections system. The WCCMH CCBHC Expansion Grant will be utilized to increase capacity at WCCMH to serve this currently underserved target population. WCCMH will increase capacity of its 24 hour mobile crisis program, expand SUD services and provide CCBHC services to individuals who are uninsured and underinsured.
SERV Centers of New Jersey plans to implement the Partners in Wellness CCBHC program in Passaic County to facilitate consumer connections to and provision of quality treatment and recovery supports, so that individuals with complex needs can experience their valued place in the community with improved health and wellness. We plan to engage 100 new consumers into behavioral health (BH) treatment and/or support services in Year 1, totaling 115 in Year 2. Passaic County and its surrounding areas are a region of Northern New Jersey that is afflicted by high rates of incarceration, homelessness, and poverty, all of which influence the high prevalence of BH issues in relation to NJ and the US. This region has also been hit hard by the opioid crisis with high rates of related admissions. Our target population for CCBHC services includes children, adolescents, and adults in Passaic who experience SMI, SED and/or substance use (SU) disorders. There are only 104 mental health (MH) providers per 100,000 population in Passaic County, in contrast to 187 statewide and 214 nationwide. Given low MH provider rates in the county, screening, assessment, and treatment needs for children and adults are inadequate. A 2016 county needs assessment found that 5.3% of survey respondents (about 27,000 Passaic residents) were unable to obtain MH services in the past year; 52.7% perceived substance use to be a major problem; and 29.4% identified MH services as difficult to access in the community. Partners in Wellness aims to catch the consumers with acute needs, as well as those who may fall through the cracks and cannot access existing NJ BH services; either the NJ services under the Division of Mental Health and Addictions Services are too intensive and limited to those with higher acuity, or consumers may be well-functioning enough to be ineligible for wraparound/case management supportsyet need them to maintain stability in the community. Our approach to providing the required activities offers comprehensive, person-centered and culturally appropriate services to vulnerable populations in need of BH supports, that are tailored and managed based on individual/family needs, risk and level of functioning. Partners in Wellness plans to target a wide range of access points to maximize screening opportunities for adults and children who need services. In service of our primary goal, our objectives aim to: improve mental health outcomes and community tenure through our provision of individualized care coordination and wraparound supports; facilitate access to BH services for those who need them; improve treatment and service quality through person-centered planning and delivery of high-quality services as an integral component of a successful consumer support network. Recognizing that successful treatment outcomes are guided and fortified by recovery supports, we will use evidence-based approaches to empower consumers to activate their personal agency in setting and achieving their own goals in employment, housing, education, and family/social relationships that bolster their quality of life.
The Postgraduate Center for Mental Health (PCMH) proposes to provide a full continuum of co-located, clinical, residential and rehabilitation services to homeless (medically engaged), mentally ill, low-income individuals, families, veterans and children ages 5-17 living in the Bronx, Brooklyn, Queens and Manhattan boroughs. Unmet mental health needs were identified among these community's top five priorities. In Bronx County, poverty (31%) is one of the major trigggers for homelessness among the mentally ill. Also, drug related hospitalizations of 1761 and 1025 per 100,000 population, respectively in the Bronx and Manhattan, as well as alcohol related hospitalizations of 1633 and 1084 per 100,000, respectively, in the same areas and overdose deaths, which have risen by 66% over the past five years, document a disproportionate impact in low-income areas. Thus, the proposed goal of the CCBHC Program is to reduce the number of re-hospitalizations for PCMH clients by creating a menu of culturally and linguistically appropriate (CLAS) expanded behavioral health services that address and/or impact each client's psychological functioning, social functioning, therapeutic engagement and social network supports. A secondary goal is to monitor the client's performance and psychosocial changes during treatment as an indicator of their ability to master these measures, at their own pace and without the disruption of being re-hospitalized. The objectives supporting the above goals are: 1. By 9/29/2020 improve and enhance the menu of CLAS mental health and crisis services e.g., an ACT Team by 10% to reduce the number of critical incidents experienced by current clients. 2. By 9/29/2020 access to comprehensive, fully integrated primary care/behavioral health services at the Bronx (Adult and Child) and Manhattan (CAP) clinics will be improved by 20% thereby decreasing the incidence of homelessness and re-hospitalizations. 3. By 9/29/2020 add an ACT Team to reduce the number to reduce the number of hospitalizations/re-hospitalizations attritubed by exacerbations of poorly managed/coordinated diabetes and hypertension by 10%. 4. By 9/29/2020 implement 30 evidence based emergency interventions, including adding a RN to the Mobile Crisis Team, telepsychiatry and an EmPath Unit, to prevent hospitalizations. 5. By 9/29/2020 reduce re-hospitalizations by 20% with the addition of targeted case managers and/or navigators to ensure proper discharge comprehension and better post-care follow up. 6. By 9/29/2020 the use of medication assisted therapy (MAT) such as Buprenorphene, to prevent the effects of medication non-compliance will be increased by 10%. 7. By 9/29/2020, outcomes for child-age (5-17) clients of the Bronx Clinic will be improved by 15% through implementation of an evidence based surrogate support system for parents in crisis, such as the Family-Based Treatment Program or the Teaching Family Homes Program. NOTE: Baselines numbers = values present prior to implementing mental health expansion. PCMH proposes to serve a total of 1,200 unduplicated clients: 1,100 adults and 100 children - 45 SED adults , 425 SU/MH/COD adults and 630 SMI/COD adults - by the end of Year 2: 9/29/2020.
This project, titled CCBHC Access to Integrated Behavioral Health Urgent Care, will serve adults and children seeking mental or behavioral health (MH/BH) services in Orange County, New York. Access expects to serve 4,500 individuals in the first year and 12,000 individuals over the lifetime of the project. Access: Supports for Living Inc. (Access) is applying for SAMHSA funding to become a Certified Community Behavioral Health Center (CCBHC) to facilitate immediate access to appropriate, evidence-based screening, assessment and treatment services for children, veterans and any individual with MH/BH needs. By improving timely access to appropriate, integrated supports and services, Access will reduce health disparities and help close the existing gaps between available resources and individual health outcomes. Access is located in the Mid-Hudson Region of New York State where 7% of the population are veterans, 10% are disabled, 13% are 65 or older, 27% are 19 or under, and approximately 6% are individuals with intellectual or developmental disabilities (I/DD). The Mid-Hudson has the second highest rate of drug-related hospitalizations, among all DSRIP regions in New York (28 per 10,000) and a newborn drug-related diagnoses rate of 57 per 10,000. Approximately 3.8% of adults in the region experience serious mental illness (SMI), 54% of individuals do not have follow-up care following a hospital discharge for mental illness, current services do not have the capacity to provide timely access to psychiatric care, and 73% of individuals do not engage in substance use disorder (SUD) treatment within 30 days of initiation. Access proposes to (1) increase CCBHC capacity to appropriately and immediately treat any individual seeking MH/BH care; (2) increase the number of individuals who receive ongoing Medication Assisted Treatment (MAT) services; and (3) increase the number of individuals in Orange County with coordinated care plans. By January 2019, four months post-award, Access will increase staffing capacity at multiple locations to provide immediate walk-in availability; formalize relationships with local hospitals to provide next-day care after hospital discharge following naloxone administration and suboxone induction; and partner with the federally qualified health centers (FQHCs), local veterans' health facilities, and schools to increase the number of individuals with coordinated care plans.
Mental Health Association in Westchester County, New York’s (MHA) Certified Community Behavioral Health Clinic (CCBHC) Expansion Project is focused on enhancing our existing comprehensive set of community-based mental health services by adding substance use disorder and specialized veteran-oriented services for the medically uninsured and underinsured of the Metro North region of New York State in order to improve outcomes and increase health of the entire service area. MHA was founded in 1946 as the community’s first outpatient behavioral health clinic. It has been on the forefront of developing and testing innovative practices and implementing new evidence-based models of care. MHA has an established management structure and external relationships that will enable rapid incorporation of these new services in a high-quality and integrated fashion. Leadership has provided valuable input in the redesign of the New York State Behavioral Health Care System of which CCBHCs are a key component. Our behavioral model of care is person centered, trauma informed and recovery oriented. With funding support from this grant, MHA will implement community-based substance abuse services as an Article 32 provider certified by the New York State Office of Alcoholism and Substance Abuse Services. Through the efforts of outreach and engagement professional and peer staff supported by this grant, we will serve at least 75 uninsured or underinsured individuals with serious substance use disorders and those with co-occurring mental health and addiction disorders in year one of the grant and an additional 125 unduplicated individuals in the second year for a total of 200 individuals over the grant period. Of these, at least 60% will initiate treatment within 14 days of diagnosis of alcohol or other drug dependence, and at least 40% will engage in SUD treatment within 30 days of initiation, a significant improvement over current service area statistics. At least 90% of those engaged in SUD services will be screened within two months of enrollment and regularly monitored for key health indicators and health risk. At least 25 individuals will be treated with Medication Assisted Treatment in year one, and at least another unduplicated 35 individuals will be treated in year two for a total of at least 60 individuals during the grant period. In addition to offering our current mental health services to veterans/active military, we will develop services for post-traumatic stress disorder (PTSD) and other trauma-related conditions compliant with the clinical mental health guidelines established by the Veterans Health Administration in the Uniform Mental Health Services Handbook. In close collaboration with the local Veterans Administration, we will serve at least 20 uninsured or underinsured, non-service connected active military and veterans with PTSD, other mental health disorder and/or serious substance use disorders in year one of the grant and an additional 30 unduplicated individuals in the second year for a total of 50 individuals over the grant period. In addition we will provide behavioral health services to uninsured family members with this grant support.
The Rhode Island CCBHC Expansion Project expands evidence based practices to individuals with serious mental illness (SMI), children and adolescents with serious emotional disturbances (SED) and young adults with emerging SMI. Newport County Community Mental Health Center and its two direct contract organization partners, the Kent Center and Community Care Alliance, will provide expanded and enhanced CCBHC services to over 12,000 people across the State of Rhode Island in the first year of the project. A total of 24,500 people will be served over two years. The project will expand evidence based behavioral health practices to over 590 adults, children and families who currently do not have access to these services in the first year and over 1200 over the two year grant period. Rhode Island has a population of 1,059,639. Of this, 72.5% are white (not Hispanic or Latino), 15.5% Hispanic or Latino, 8.2% Black, and approximately 7.7% is Other. Rhode Island has the highest adult rate of mental illness nationally (24%) and 34% of Rhode Island children who needed mental health treatment or counseling in the past 12 months did not receive it. Psychiatric hospitalization rates for children and adults exceed those for other New England states and the needs assessment indicates a serious lack of availability of intensive in-home behavioral healthcare. Rates of attempted suicide and opioid overdose are above the national average. Young adults with first episode serious mental illness have had limited early access to research based treatment to increase recovery and reduce disability. The following evidenced practices will be expanded: Assertive Community Treatment, Individual Placement Services (Supportive Employment), Consolidated Specialty Care (young adult RAISE/Healthy Transitions), Multidimensional Family Therapy, and Positive Parenting Program (Triple P). Additional workforce development and infrastructure improvements (training in recovery/person-centered care, outreach and engagement, and infrastructure for telemedicine, expanded care management are targeted to improve both behavioral health and health outcomes of the people served. The Rhode Island CCBHC Project has three main goals: 1.) Newport County Community Mental Health Center (NCCMHC) will implement a fully operational Certified Community Behavioral Health Clinic providing a complete scope of CCBHC services to individuals eligible for Medicaid as well as those who are uninsured or under insured within 4 months of funding; 2.) NCCMHC together with its contract partners will enhance existing CCBHC services by expanding/initiating five evidence based practice, ACT, CSC, SE/IPS, MDFT and Triple P. and 3.) NCCMHC will implement infrastructure enhancements to improve the overall quality and coordination of care that will reduce the total cost of care for clients served by 10.5% over the two years of the project, train 500 staff in person-centered care and implement telemedicine to improve targeted health outcomes.
The Richmond Behavioral Health Authority (RBHA) proposes to increase the access and availability of high quality, integrated primary care, mental health (MH), and substance use disorders (SUDs) treatment and recovery support services to adults and children in Richmond, Virginia who suffer from one or more behavioral health conditions. RBHA’s CCBHC Project will deliver all required CCBHC components in addition to offering primary care services. Additionally, current hours and days of operation and available services/supports for individuals with co-occurring MH/SUD and youth with SED will be expanded. The project will serve 656 male and female adults and children over the two-year grant period: 286 clients Year 1; 370 clients Year 2. Proposed strategies and evidence-based services include: Medication Assisted Treatment, Collaborative Documentation, Trauma-Informed Services, Motivational Interviewing, Motivational Incentives, mobile and in house crisis services, screening, assessment & diagnosis; person-centered treatment planning; expanded outpatient services; integrated primary care screening and services; targeted case management; psychiatric rehabilitation; care coordination and a full continuum of addiction treatment with peer supports; Comprehensive outreach; HIV/HCV testing. Individuals currently served by RBHA are: 53% male; 46% female; 1% transgender; 62% African-American; 32% Caucasian; 6% Other; and 6-8% of those we serve identify as gay or lesbian. Co-occurring behavioral health disorders are prevalent in an estimated 42%, and the most common disorders we see are: major depressive, schizoaffective and bipolar disorders and severe SUDs, primarily opioid addiction. Most are economically dependent on others, have limited education and limited or nonexistent employment histories. Many were raised in urban neighborhoods characterized by multi-generational addiction, poverty, violence and trauma. Goals of the CCBHC Project are to: 1) Improve the overall health and recovery for adults and youth with behavioral health conditions by providing integrated primary care and behavioral health screening, assessment and treatment planning; 2) Increase staff and provider knowledge and skills related to primary/behavioral health to improve overall consumer care; 3) Ensure CCBHC service delivery meets all applicable requirements and is responsive to continuous input from consumers, their families, and the community; 4) Evaluate the effectiveness of the project in achieving the goals and objectives.