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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.

Easterseals Michigan - FY2018 Certified Community Behavioral Health Clinic Expansion Grant Easterseals Michigan will implement a Certified Community Behavioral Health Clinic (CCBHC) to meet the underserved behavioral health (BH) needs of children, adults and families within Oakland County, Michigan. The CCBHC will serve indigent, un/under insured individuals with Substance Use Disorders (SUD), Serious Mental Illness (SMI), Serious Emotional Disorders (SED), including, complex co-morbid, high-risk youth, veterans and opiate addiction subgroups. Oakland County has a significant population living in poverty (108,823) with many having limited or no access to the essential array of comprehensive, integrated BH services to maintain optimal health and well-being resulting in high costs to themselves, their families and communities. Youth with depression/suicide risk is a pressing MH issue in Oakland County along with high rates of opioid addiction with low access to treatment for substance use disorders. Oakland County has a substantial Veterans population with well documented high rates of SMI and SUD needs and barriers accessing care. Easterseals Michigan (ESM) plans to meet the proposed CCBHC?s target population?s unmet BH needs by leveraging its extensive comprehensive behavioral health services experience from five strategically located ESM service centers and via designated collaborative organizations partnerships for state sanctioned crisis, primary care and medication assisted treatment. The CCBHC?s goals are to: expand & improve screening/increased access of BH care for the targeted children and adults in Oakland CO; implement complex care delivery approaches to expand coordination of care for individuals with co-morbid physical and behavioral health needs; increase the use of evidence based treatment interventions for individuals served; expand efforts to address youth ages 7-17 demonstrating risk of suicide and/or depression with additional evidenced based practice modalities; and increase access to specialized BH treatment for members of the Armed Forces, Veterans and their families. To accomplish its goals, The CCBHC will provide the full range of required BH activities including: 24 hour crisis services; screening, assessment and diagnostic services for all populations; patient/family centered, strength based treatment planning; comprehensive outpatient MH and SUD services; outpatient primary care screening and monitoring of key health indicators: targeted case management; psychiatric rehabilitation; social support -psycho-social rehabilitation; comprehensive community recovery supports; intensive community BH care for members of the Armed Forces/Veterans; Assertive Community Treatment; collaborative community ?partnerships?; and an Advisory Work Group representing the populations served. ESM?s CCBHC expects to serve 735 new CCBHC individuals/families by the end of year one and an additional 815 by the end of year two. In addition, the CCBHC anticipates serving 3108 of ESMs existing individuals in need of a fuller array of integrated primary care and behavioral health care via CCBHC expanded services over the two-year span.

Texas Health and Human Services Commission (HHSC) selected Integral Care as one of 8 sites in Texas to participate in the Certified Community Behavioral Health Clinic (CCBHC) certification process. Through partnership with HHSC staff, Integral Care received the approval as a CCBHC site in October 2016. This project entitled, ?Amplified Care through CCBHC? expands access to a fully integrated system of care, in the interests of improving the health status of Integral Care clients. This project will enroll approximately 250 individuals per year over 2 years for an unduplicated number of 500 individuals. The project would focus on adults and children annually who have serious mental illness, substance use disorder (SUD), serious emotional disturbances (SED), co-occurring disorders (COD), and/or a chronic medical condition. These conditions are often intertwined; estimates are that more than 40% of Integral Care clients have multiple diagnoses. Therefore, we have identified interventions to coordinate and amplify existing services including: 1) improved coordination and access to substance use and COD treatment services for children and adults; 2) increased access to routine whole-person integrated care and 3) implementation of health navigation services to improve continuity of care. Goal 1: Increase Integral Care?s capacity to provide coordinated and integrated substance use treatment services as measured by a) training 75% of management staff on Integrated Dual Disorder Treatment, b) fully staffing a Substance Use Treatment Hub to provide coordinated and integrated substance use services for children and adults with SUD or CODs, and c) increasing by 30% the number of individuals engaged in substance use treatment services. Goal 2: Increased access to culturally competent and routine mental health services as measured by a) increasing by 25% the number of individuals who receive routine services after hours and on the weekends, b) training 85% of direct staff on culturally competent care for active military personnel and veterans, and c) increasing by 30% the number of individuals who receive routine psychiatric services within 15 calendar days. Goal 3: Enhance care continuity and coordination via health navigation as measured by a) establishing a population health team to identify clients in need of intensive care management services and health navigation, b) fully staffing a care coordination team to promote linkages to care across the continuum, c) providing care coordination services to a minimum of 100 individuals.

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).

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.

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.

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.

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.

Project Abstract Summary BestSelf Behavioral Health (BBH) is requesting funding in the amount of $2,000,000 per year for 2 years to support the BestSelf CCBHC Services Enhancement Project. The proposed project will expand BBH?s current New York State Certified Community Behavioral Health Clinic (CCBHC) to include a 24/7 immediate access clinic, establish a community clubhouse, and expand Assertive Community Treatment (ACT) services. Currently, Erie County experiences a mental health provider shortage with 228 providers per 100,000 residents in a state where only 41% of mental health treatment capacity is met (https://www.omh.ny.gov). The county is currently amid an opioid use epidemic. The rates of opioid overdose deaths have been steadily increasing with 127 in 2014, 206 in 2015, and 301 in 2016 (http://www2.erie.gov). As a certified CCBHC, BBH provides all of the nine required services directly or through a Designated Collaborating Organization (DCO) agreement. The most significant barrier to care is for access to psychiatric medications, with BBH patients having to wait approximately 30-45 days for a psychiatric appointment, except in emergency situations. The other significant care gap facing the WNY community is hospitalization follow-up, which currently experiences a 45-50% no show rate. By project end, BestSelf CCBHC Services Enhancement will provide direct services to 1650 clients who will receive these additional services, reduce all-cause hospitalizations, and improve medication adherence rates. These CCBHC expansion services will supplement current activities and continue to enable BBH to provide comprehensive community-based mental and substance abuse disorder services in an approach that emphasizes recovery, wellness, trauma-informed care, and physical-behavioral health integration. All of the proposed interventions address the Interdepartmental Serious Mental Illness Coordinating Committee recommendations: 2.7: use telehealth and other technologies to increase access to care; 2.8 maximize the capacity of the behavioral health workforce; 3.1 provide a comprehensive continuum of care for people with SMI and SED; 3.9 make integrated services readily available to people with co-occurring mental illnesses and substance use disorders, including medication assisted treatment (MAT) for opioid use disorders and other substance use disorders, and; 5.8 Expand the Certified Community Behavioral Health Clinic (CCBHC) program.

Project Abstract 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.

Centerstone's Certified Community Behavioral Health Clinic (C-CCBHC) project will establish Centerstone's Bloomington Clinic as a CCBHC, improving access to/quality of community behavioral health services for 5 central Indiana counties. C-CCBHC will advance primary-behavioral health integration and use evidence-based practices to serve an unduplicated 4,175 individuals (Y1:1,675; Y2: 2,500) with serious mental illness (SMI), substance use disorders (SUD), co-occurring disorders (COD), and/or youth with serious emotional disturbance (SED). C-CCBHC's service area (Brown, Lawrence, Monroe, Morgan, and Owen counties, IN) is home to nearly 297,000 people. Of these, 20% (47,539) of adults experience any mental illness, 13% (7,886) of children ages 2-17 have an emotional/behavioral/developmental condition(s), and 7% (16,639) of adults and 4% (2,354) of adolescents 12-17 have SUD. Among those needing services, long-term and serious SUD (i.e., severe diagnosis), is expected among 31% of adults with SUD; SMI among 66% of adults; COD among 48% of adults and 6% of youth; and SED among 76% of children/adolescents. Monroe County is among the top 10% of Indiana counties in 5 categories of drug/alcohol use and the top 25% of counties on methamphetamine use. Without coordinated, whole-person care, the focus population is vulnerable to higher risk of mortality, suicide, substance abuse, hospitalization, incarceration, and homelessness. Service area rates exceed the state's for incarceration (401/100,000 vs. 375), suicide deaths (15.3 vs. 14.1), and hospitalizations related to attempted suicides (285 vs. 244). Roughly 28,500 area adults and 3,900 youth with mental illness did not receive needed services. An expected 2,400 adolescents and 16,200 adults need but have not received SUD treatment. 19,000 focus population members with SUD are at risk of associated physical health problems (e.g., cancer, heart disease), and the 38,700 adults in the catchment area with SMI are expected to die up to 30 years earlier than the general population, largely due to preventable health risk factors. The area's 5,900 youth with SED face undiagnosed physical health concerns (69%), suspension/expulsion (47%), and exposure to individuals with depression symptoms (72%) and/or drug or alcohol misuse (55%) at home. C-CCBHC will provide an array of integrated primary and behavioral health care services, including crisis care (e.g., 24/7 mobile crisis, walk-in clinics, ambulatory/medical detoxification); mental health screening, assessment, and diagnosis; outpatient primary care screening/monitoring of key health indicators; patient-centered, integrated treatment planning; MAT and medication management; and comprehensive, trauma-informed, evidence-based, outpatient mental health and substance use services (therapy, psychiatric rehabilitation, Assertive Community Treatment, peer/community social support, telehealth, etc.) C-CCBHC?s evidence-based practices are numerous and include CBT, DBT, Motivational Interviewing, Integrated Dual Disorder Treatment, EMDR, A-CRA/CRA, and more. C-CCBHC?s goals include decreasing mental health symptomatology by 30%; decreasing substance use by 40%, achieving 50% reported compliance with medication; delivering personalized treatment plans for 100%, and achieving 85% consumer-reported satisfaction with their experience of care. Key C-CCBHC strategies include conducting a full needs assessment and meeting all CCBHC certification requirements by 4 months after award; expanding/enhancing existing multidisciplinary treatment teams; assembling an Advisory Work Group; collaborating with community providers to promote whole-person wellness and recovery; utilizing an experienced evaluation team; and applying a continuous quality improvement approach to drive improvements and sustainability efforts.

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.

There is a dearth of behavioral health care services for people living in Ocean County, NJ (OC), a NY metropolitan shore town with approximately 600,000 with the largest groups consisting of veterans and adults ages 65 and older. Utilization of acute psychiatric services in the county provides the best depiction of need with the second highest screening volume in NJ, approximately 700 screenings per month (NJ DMHAS, 2012). In 2016 there were 201,000 emergency visits by individuals with a behavioral health diagnosis, over a 5% increase since 2012 (NJ Hospital Association, 2016). Further, forty percent of people across NJ referred to state psychiatric services were OC residents. Despite the utility of diversion programs in mediating hospitalizations, they consistently reach capacity by mid-month. From 2008-2010, behavioral health was one of the top five diagnoses for all hospital admissions for people ages 18-64 years of age living in OC (OC Community Health Improvement Plan, 2018). Substance use and co-occurring disorders have grown exponentially over the last decade. In 2016 OC had the second highest number of drug overdose deaths, trailing only Essex County, NJ, despite having close to 200,000 fewer people (NJ State Medical Examiner). During the same year, OC had the largest number of ER admissions (842) in the state due to alcohol liver disease. A county needs assessment identified the following prioritized health issues: Behavioral health, chronic disease prevention & education, childhood obesity, access to care, immunization compliance. Identified barriers to care were lack of insurance, poor accessibility of providers, long wait lists for services, and a dearth of psychiatric providers (OC Community Health Improvement Plan, 2018). CPC is the largest behavioral health care provider in the neighboring county of Monmouth serving approximately 9,000/year and a SAMHSA designated CCBHC. As a provider of integrated care for over 20 years delivering intensive case management, justice involved support, supported employment, housing support, and Assertive Community Treatment and our newly formed behavioral health home, the CCBHC was a natural extension of our approach that increased the capacity and breadth of our service offerings. Despite this growth, we remain troubled by the number of calls from OC residents in desperate search for behavioral healthcare services despite our lack of accessibility. Given the infrastructure and programming developed to offer CCBHC services in Monmouth County, we believe that we are well positioned to share our expertise and capacity with our southern neighbor to close the service gaps and reduce health disparities in OC through the provision of integrated services.

CCBHC PROJECT EXPANSION PROJECT ABSTRACT Vitality Unlimited, with one successful CCBHC celebrating our first anniversary, is seeking to expand our services by opening two CCBHCs in Carson City/County, Nevada and Dayton, Nevada with the hope of increasing our service base in rural Nevada by 1,000 new consumers. Carson City/County and Dayton, Nevada have a combined population of approximately 63,000 with a severe lack of services for the Serious Mental Illness (SMI), Serious Emotional Disturbance (SED), Substance Use Disorder (SUD) and Co-Occurring Disorders (COD). The Center for Mental Health Services has ranked Nevada as the worst among the 15 western states for mental illness prevalence. The study projected that 23.7% of Nevada residents will have a diagnosable mental disorder at some point in their lifetime. According to the Suicide Prevention Resource Center Nevada has the 4th highest rate in the nation and suicide is the 2nd leading cause of death for Nevadans ages 15 ? 24. More Nevadans die from suicide than from homicide, HIV-Aids or car crashes. Nevada adults over the age of 65 rank highest in the nation for suicide. Suicide behavior is known to correlate with certain psychiatric disorders; over the last could of decades, Nevada has ranked at the top of the nation for per capita suicides. The Behavioral Health Barometer for Nevada shows that 14.5% of all individual 12-20 reported binge alcohol use within the month prior to being surveyed and 61.6% of all adolescents aged 12 ? 17 perceived no great risk from having five or more drinks once or twice a week. These two new CCBHC?s will strengthen both Vitality?s and the State of Nevada?s behavioral health services, improve capacity, help improve the alignment between mental health and substance abuse disorder systems and increase proficiency in the use of evidence-based practices while integrating both behavioral and physical health care for our consumers. Our new locations will provide all nine core services without the use of DCOs. Vitality Unlimited opened our first state-of-the-art behavioral health clinic, a ?practice without walls? on July 1, 2017. On the anniversary of our first year of service to Elko, Nevada, a town of approximately 20,450 residents we had provided over 12,000 units of service to over 1,100 consumers. Over 23% of our consumers are below the age of 17 with the youngest consumer being 3 years old. This clinic is one of two rural frontier Certified Community Behavioral Health Clinics (CCBHC) in the United States. Vitality Unlimited, a 501(c)3 non-profit corporation was founded in 1971. Long ago Vitality Unlimited began to weave into the threads of our culture an integrated network of co-occurring treatment services with clinical and non-clinical modalities, designed so that an individual?s changing needs were met as the individual moves through the treatment and recovery process. Vitality Unlimited recognizes that success must be earned through innovation, hard work, responsiveness to client and employee needs, and integrity in all business practices.

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 supports yet 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 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.

MHMR Tarrant proposes to enhance its whole health services to treat adults with Substance Use Disorder (SUD) and Co-Occurring Disorders (COD) and children and youth with SUD through the CCBHC Expansion Grant. Research indicates that nearly 125,000 residents of Tarrant County are not receiving adequate care for SUD and COD and that this population is at high risk for unhealthy outcomes and overutilization of inappropriate treatment settings. MHMR will expand its Care Coordination model of services to its Adult and Youth SUD clinics to improve primary and behavioral health outcomes for this population. The proposed CCBHC Expansion Grant will provide a Care Team modality to this population, in which all individuals receiving SUD services will be assessed for behavioral health needs, screened for indicators of medical risk, and linked to appropriate treatment resources. MHMR Tarrant's Care Coordination model of services will be implemented, and it will include a Project Director, a Care Coordination Program Director, a Registered Nurse (RN) Wellness Coordinator, a Dietitian, Five Care Coordinators, a Peer Coordinator, five Peer staff, two Licensed Practitioners of the Healing Arts (Licensed Professional Counselor or Licensed Clinical Social Worker), two RN Wellness Nurses, a Medical Assistant, and one Licensed Vocational Nurse. This team will provide services to address primary and behavioral health issues, including linkage to internal and outside resources, follow up to referrals, and non-clinical support from Peers. The Care Team will place LPHA staff in the designated sites to provide assessment for behavioral health diagnoses and indicators of medical risk, and they will provide linkage to Care Coordinators. The Care Coordinators will work with their RN Wellness Coordinator to make appropriate linkages to treat identified concerns, within the agency or externally, if specialized services are required. Care Coordinators will provide ongoing support and follow up for people in services to facilitate access to care and to ensure continuity across all involved providers of services. Peers will also provide appropriate support and linkage to community resources. All people linked into MHMR integrated services will receive care using evidence based practices in an ongoing manner, and their needs will be assessed as needed to determine the most appropriate type of care. MHMR Tarrant is a certified CCBHC, and it will use the Care Coordination model is has developed through its two year participation in State CCBHC planning to expand its service provision. As the largest provide of behavioral health care in Tarrant County, MHMR has an established ability to effectively provide care for behavioral health, SUD, or primary health care needs. Though the agency will work with its community partners, no Designated Care Organizations will be used to provide services. Through this opportunity, MHMR plans to expand access to 1800 unduplicated individuals by the end of the grant period.

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.

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.

The purpose of the Kalamazoo Community Mental Health and Substance Abuse Services? CCBHC project is to improve the health of individuals in Kalamazoo county while advancing integration of behavioral health and physical health care, increasing use of evidence-based practices and expanding capacity, access and availability to high quality care. Target Population: KCMHSAS? CCBHC population of focus is Adults with Serious Mental Illness (SMI), Adults with Substance Use Disorders (SUD), Children/Adolescents with Serious Emotional Disturbance (SED), and Youth and Adults with co-occurring Substance Use Disorders (COD). Adults with SMI and co-occurring opioid and other substance use are identified as a sub-population of focus. Kalamazoo County?s population is 261,659 with 56,962 youth under the age of 18 and 14,625 veterans. The County, including the target population, has a diverse population with 81.7% White, 11.6% Black/African American, 0.5% American Indian and 4.8% Hispanic/Latino. Gender makeup is 50.9% male and 49.1% female; 3.8% LGBTQ. Strategies/Interventions: KCMHAS will provide: crisis mental health services, screening, assessment and diagnosis, patient centered treatment planning, risk assessment and crisis planning, outpatient behavioral health services, outpatient primary care screening and monitoring of health indicators and risks, clinical monitoring for adverse effects of medications, targeted case management, psychiatric rehabilitation services, clubhouse programming, peer recovery supports, veterans? behavioral health services, and assertive community treatment. Evidence based practices include: SBIRT, Motivational Interviewing, Matrix Model of treatment. Goal 1. Increase access to behavioral health services for population of focus. Objective 1a) Outreach staff will provide individual contacts to 1,200 people in the community by end of year 2. Objective 1b) Additional staff will be hired/trained to provide services to 1000 individuals. Goal 2. Deliver comprehensive and coordinated care that provides access to effective evidence based interventions for individuals with complex needs. Objective 2a) Provide evidence based treatment for 100% CCBHC enrolled individuals. Objective 2b) Provide care coordination for 100% CCBHC enrolled individuals. Objective 2c) Increase number of individuals receiving SUD services from implementation baseline by 100% by end of year 2. Goal 3. Deliver integrated care for behavioral health and physical health risks and needs. Objective 3a) All CCBHC enrolled individuals will receive primary care screening and monitoring of health indicators and risks identified in CCBHC Quality Measures. Objective 3b) Individuals identified with high behavioral and physical health risks will be assigned to a Nurse Care Coordinator for monitoring and follow up care. This project will serve 500 individuals Year 1 and 500 individuals Year 2 for a total of 1000 unduplicated individuals by end of Year 2.

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.

Project Name and Summary: The Mental Health Center of Boulder County, Inc., d/b/a Mental Health Partners (MHP) proposes a two-year project to become a Certified Community Behavioral Health Clinic (CCBHC) to enhance the standard of behavioral health assessment, treatment and recovery services available to Boulder and Broomfield County residents of all ages who have or are at risk for a behavioral health condition. Population to be Served: Individuals of all ages who have or are at risk for a mental illness or addictions disorder, including individuals with co-occurring disorders. Focus on three key underserved subpopulations to reduce disparities in healthcare access and outcomes: Hispanic individuals, individuals experiencing homelessness, and members of the Armed Forces and Veterans. MHP will provide comprehensive behavioral health services to 14,500 clients annually, reaching a total of 15,500 unduplicated individuals over the 2-year project. Strategies/Interventions: Certified Community Behavioral Health Clinic required services will be delivered through MHP?s Behavioral Health Home model of care to deliver a comprehensive spectrum of mental health, addictions and wellness services in both clinical and community-based settings. This team-based model provides immediate access to behavioral health assessment and support, psychiatric intervention and care coordination to best match each client?s individual treatment needs and motivation. Clients are matched to the appropriate level of care and treatment modality to achieve maximum benefit. MHP will also develop a team of Community Health Workers to provide targeted outreach and engagement. Project Goals and Measurable Objectives: Goal 1 is to raise MHP standard of care by achieving 100% of the CCBHC standards for Staffing, Access, Care Coordination, Scope of Services, Quality and Other Reporting, and Organizational Authority, Governance and Accreditation, as measured by establishing policies, procedures and ongoing process improvement plan to achieve 100% CCBHC criteria. Goal 2 is to improve MHP capacity to conduct data-informed population health management by increasing information systems staffing and functionality, as measured by hiring new information systems staff, completing electronic health record enhancements to increase functionality, building a client portal, and increasing capacity for data-informed population health management. Goal 3 is to increase MHP staff capacity to effectively treat client needs by increasing training in the identified evidence-based and best practice interventions, as measured by increasing facilitator capacity in Motivational Interviewing and Applied Suicide Intervention Skills Training, staff training in identified best practices, and supporting clinicians to obtain addictions credential. Goal 4 is to reduce population health disparities, as measured by developing a Community Health Worker team, conducting a community needs assessment, and delivering health promotion curriculum.

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.

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.

?Centerstone Certified Community Behavioral Health Clinic ? Kentucky? (C-CCBHC) will establish a CCBHC at Centerstone?s Bullitt County outpatient clinic, improving access to/quality of evidence-based community behavioral health and integrated primary care services for 7 north central Kentucky counties. C-CCBHC will serve an unduplicated 3,625 individuals (Y1: 2,500; Y2: 1,125) with serious mental illness (SMI), substance use disorders (SUD), co-occurring disorders (COD), and/or youth with serious emotional disturbance (SED). C-CCBHC's catchment area (Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer, and Trimble counties, Kentucky) is home to nearly 731,000 adults, comprising 48% male, 52% female, 79% white, 15% African American, and 3% Hispanic/Latino individuals. Approximately 8% of area adults are unemployed, 13% live below poverty, and 14% lack a high school diploma/equivalent. Nearly 11% of adults are Veterans. Approximately 228,000 are under age 18 in the catchment area and comprise 51% male, 49% female, 71% white, 21% African American, and 5% Hispanic/Latino individuals. Among this population, 22% experience poverty, and 6% of those ages 2-17 are not enrolled in school. Within the catchment area, 22% of adults experience any mental illness, 14% of children ages 2-17 have an emotional/behavioral/developmental condition(s), and 8% of adults and 4% of adolescents 12-17 have SUD. Among catchment area Bullitt clinic clients, 51% of adults experience SMI; 72% of children/adolescents, SED; and 34% of adults and 4% of children/adolescents, COD. Long-term and serious SUD (i.e., severe diagnoses) is expected among 40% of those with SUD. Without coordinated, whole person care options, the focus population is vulnerable to poor outcomes, at risk for higher rates of mortality, suicide, substance abuse, hospitalization, incarceration, and homelessness. C-CCBHC will provide an array of integrated primary and behavioral health care services/interventions, including crisis care; mental health screening, assessment, and diagnosis; outpatient primary care screening/monitoring of key health indicators; patient- and family-centered, integrated treatment planning (including risk assessment and crisis planning); Medication Assisted Treatment and medication management; and comprehensive, trauma-informed, evidence-based, outpatient mental health and substance use services (therapy, Assertive Community Treatment, Assisted Outpatient Treatment, targeted case management, peer/community social support, telehealth, etc.). A partnering Centerstone clinic in the catchment area will ensure psychiatric rehabilitation services for CCBHC clients. Other project goals include enhanced infrastructure/capacity to provide coordinated care; increased access to/availability to a comprehensive scope of services; improved health status/outcomes for the focus population; and improved systems and consumer care. Project strategies support goal achievement and include conducting a full needs assessment to ensure certification within 4 months of award; expanding/enhancing existing multidisciplinary treatment teams; assembling an Advisory Work Group; collaborating with community providers to promote whole-person wellness and recovery; utilizing an experienced evaluation team; and applying a continuous quality improvement and sustainable approach to services. C-CCBHC?s goals will result in decreased mental health symptomatology by 45%; decreased substance use by 45%; 50% reported adherence to medication regimens; personalized treatment plans for 100%; and 80% consumer-reported satisfaction with their experience of care.