The Yukon Kuskokwim Health Corporation (YKHC) is seeking to implement a System of Care (SOC) that will integrate western treatment with cultural ways and values of the Yup'ik/Cup'ik and Athabaskan Tribal people who constitute 84% of the population in the Yukon Kuskokwim (YK) Delta region of southwestern Alaska. This program, known as “Calricaraq”, is derived from an ancient Yup’ik word meaning “the way to not have illness” or “the way to be healthy.” Prior to colonization, Calricaraq was the natural behavioral health system for our people. Its teachings were the medicine that kept our people healthy for generations. Today as we see our people suffering from high rates of depression, suicide and substance use that has negatively impacted our children with many forms of abuse, neglect, domestic violence and broken families, we are seeing a fundamental change that involves a return to these traditional values and practices to help our people heal from this chaos. YKHC’s Behavioral Health (BH) Division is submitting this proposal as a request to obtain funds to develop and expand a Calricaraq System of Care (SOC), incorporating these cultural ways and values of the YK Delta's Yup'ik people and bind together YKHC's western based BH service units, along with other tribal, state and local agencies working together as part of a coordinated team to help our children, youth and their families heal. Over the course of the four-year project we will serve 300 unduplicated youth, more than twice the current number our BH system serves. The Calricaraq SOC will use individual counseling, group counseling methods, and community-based gatherings to impact a large footprint of the YK Delta’s 27,000 residents, of which the population of focus – birth to 21 years – is approximately 12,000. The Calricaraq SOC Program will treat the whole family, and we will include families and communities in much of the work we do. Many of our activities will take place in the youth clients’ home communities, requiring a large amount of air travel to and from our villages, as all of our communities are inaccessible by road. Our evaluation plan includes both process and outcome studies to assess the extent our project's goals and objectives are achieved. By identifying and maintaining counts of participants in our SOC program, by maintaining contact with our collaborating partners and noting any programmatic changes to strengthen service delivery that emerge as a function of their involvement in the SOC, and by tracking participation of family members and consumers involved in the SOC, the success of YKHC’s Calricaraq SOC project will be documented. Data will be gathered using standardized measures provided by SAMHSA and the Alaska Division of Behavioral Health, as well as local data instruments developed by our Calricaraq SOC evaluators. The result will be a comprehensive data set capable of measure our program outcomes.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082223-01 YUKON-KUSKOKWIM HEALTH CORPORATION BETHEL AK DOMNICK ROSE $931,408

The purpose of the CONNECT initiative is to expand and sustain the statewide infrastructure and service delivery system in Connecticut through a Care Hub approach to CONNECTing Children and Families to Integrated Care. CareHubs are designed to address current system fragmentation between primary care, schools, behavioral health, and families. The System of Care Implementation Grant awarded to Connecticut in 2014 enabled the expansion, development and implementation of: a local, regional, and statewide Network of Care (NOC); a youth-guided, family-driven, and culturally responsive approach with youth and families as full partners; a statewide governance structure to guide SOC policy; and services and activities to enhance a comprehensive statewide data system for integration and quality. The 2014 grant yielded many successes at the systems and child-family levels. However, results from our network analyses clearly identified the need to develop a mechanism for caregivers, schools, pediatric primary care providers (PCPs) and community-based behavioral health providers to work collaboratively to provide support and services for youth with SED. The population of focus for this grant includes all Connecticut (CT) youth with serious emotional disturbance (SED) who are at risk for: inpatient hospitalization, admission to psychiatric residential treatment facilities, use of hospital emergency departments for behavioral health crisis, suicidal ideation, clinical high risk for psychosis or early/first episode psychosis. Connecticut is the 29th most populated state with 3.6 million residents of who 868,332 (or 24% are children and youth). Children with Serious Emotional and Disturbance are estimated at 10% or (over 86,000 children). More than 1,300 children/youth receive Wrap-around services annually however, the use of restrictive services remains too high and there is a need for more services/supports to occur through integrated community-based care. With a primary goal of reducing: 1) behavioral health visits to EDs; 2) utilization of state/private psychiatric/residential treatment facilities; 3) inpatient utilization; and, 4) youth suicide, this funding offers an opportunity to expand and apply our local infrastructure development through a CareHub model. The integrated CareHub model ensures that youth with SED/behavioral health needs are linked to appropriate locally-based care across the service array. With its request for 1,000,000 annually, this grant has four primary goals: 1) increase access to Connecticut’s service array for youth with SED through enhanced collaboration/communication between schools, PCPs, behavioral health agencies & families; 2) recruit, train, & support youth/families to participate as full partners & leaders in CT’s behavioral health system; 3) expand & sustain youth/family-driven local, regional, & statewide NOC infrastructure; and, 4) enhance & sustain comprehensive data system to promote integration & quality.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082195-01 CONNECTICUT DEPARTMENT CHILDREN/FAMILIES HARTFORD CT MARSHALL TIM $1,000,000

Broward County Human Services Department, Broward Behavioral Health Coalition, Broward County Public Schools, Child Welfare Lead Agency (ChildNet), South Florida Wellness Network, and the Children’s Services Council of Broward continue longstanding collaboration for the One Community Partnership 3 (OCP3) Initiative. OCP3 will expand and enhance the delivery of school and child welfare services to youth ages 12-21 with serious emotional disturbance (SED) and those with early signs and symptoms of serious mental illness (SMI), including first episode psychosis, and their families. OCP3 will transform the existing System of Care (SOC) by creating a youth and family driven and recovery-oriented community to best enable youth with complex needs to remain in the least restrictive setting, achieve wellness and recovery, and successfully transition to adulthood. The OCP1 and OCP2 initiatives created sustained transformation throughout Broward’s behavioral health system. OCP3 will further transform Broward’s overarching SOC by creating sustainable infrastructure and evidence-based practice (EBP) mental health service capacity within Broward’s school and child welfare systems. OCP3 will serve 25 youth in year one, 58 youth in year 2, 58 in year three, and 59 in year four, with a total of 200 unduplicated youth and their families (biological/foster) served through OCP3’s four years. School and child welfare Youth Navigation services will be created, and staff will be trained in the Wraparound model (for youth ages 12 to 13) and the Transition to Independence Process (TIP) Model, (for youth ages 14-21), both evidence-supported practices recognized as age-appropriate models. The Wraparound and TIP trained staff in both systems will also be trained to implement Moral Reconation Therapy (MRT), a cognitive-behavioral EBP that leads to enhanced moral reasoning, better decision making, decreased disciplinary infractions, and beneficial changes to personality traits. In creating a workforce trained in Wraparound, TIP, and MRT, the school and child welfare systems will be equipped to effectively engage youth and their families in evidence-based, strength-based, and recovery-oriented approaches that put the youth and family needs at the center of service planning and will achieve positive outcomes. OCP3’s overarching goals and objectives are to transform Broward’s school and child welfare systems by building and institutionalizing EBP mental health service capacity within both systems, increase youth and family engagement in services and recovery supports, and increase youth functioning in daily life. The OCP3 initiative will provide Broward with the opportunity to expand and enhance the existing System of Care into a new population of focus and to enhance service capacity throughout Broward’s school and child welfare systems with the goal of improved mental health outcomes for youth and families, by supporting systems level change.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082386-01 COUNTY OF BROWARD FORT LAUDERDALE FL LAWRENCE TIFFANY $1,000,000

The proposed project, Jacksonville System of Collaborative Care (JSOCC), will establish a scalable and replicable evidence-based Collaborative Care model for implementing Medical-Behavioral Health Homes (M-BHH) to provide communities access to and the capacity to provide medical, mental, behavioral, and transition health services to children and youth at-risk for or experiencing serious emotional disturbances (SEM) and serious mental illness (SMI). The populations to be served by the proposed JSOCC include children and youth (C&Y) from throughout Jacksonville who are screened and identified to be at risk for SED/SMI in the JSOCC network of M-BHHs, and (C&Y) known to be at risk for SED/SMI who are screened and referred into the JSOCC, including C&Y in the child welfare and juvenile justice systems, in Crisis Stabilization Units, in refugee communities, LGBTQIA C&Y, and C&Y incarcerated and opioid using parents. JSOCC strategies and interventions will build on the infrastructure of our current SAMHSA funded Jacksonville System of Care Initiative (JSOCI) to: a) transform the JSOCI network of collaborative care practices into JSOCC M-BHHs using the Center for Integrated Health Solutions framework, b) expand our Collaborative Care model to train additional child health providers in basic and advanced diagnosis, treatment and management of C&Y with SED/SMI, c) expand the network of Pediatric Well Centers that provide M-BHHs for C&Y with complex SED/SMI, and d) integrate new services, e.g., transitional care for youth with SMI and telepsychiatry. Proposal goals include: a) Goal 1. To expand the capacity of the JSOCC to provide the services required to care for C&Y with SED/SMI; b) Goal 2. To expand access to these services, and c) Goal 3. To ensure equity-sustainability of the JSOCC. Goal 1 objectives: a) 1.1. To establish 2 new Medical-Behavioral Health Homes per year that screen 2000 children/year for SED/SMI, for a total of 20,000 children screened and managed by Year 4; b) 1.2 To establish 1 - 2 Pediatric Wellness Centers per year to care for the most complex patients - 25 new patients per physician/year for a total of 250 patients with SED/SMI served by Year 4, c) 1.3. To care for 50 transitional youth/year (ages 18-21) with SMI, total of 200 patients served by Year 4; d) Objective 1.4 To refer 600 children/youth from at-risk populations identified with SED/SMI to JSOCC practices prepared to provide them trauma informed care - 2400 patients by Year 4. Goal 2. Objectives: a) 2.1. To add 3 telepsychiatry practices to the network; b) 2.2. To expand-sustain critical elements of the JSOCC, c) 2.3. To ensure families are involved in the development, implementation and evaluation of all elements of the JSOCC, d) 2.4. To engage C&Y with SED/SMI in all aspects of the JSOCC. Goal 3 objectives: a) 3.1. To integrate SOC principles into the JSOCC, b) 3.2. To enhance the governance structures, c) 3.3 To implement a financing plan, and d) 3.4 To continually improve performance and outcomes.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082201-01 KIDS HOPE ALLIANCE JACKSONVILLE FL WAYTOWICH VICKI $1,000,000

FSM SOC Expansion and Sustainability Project Abstract The Federated States of Micronesia (FSM) is an independent sovereign island nation consisting of four states spread across the Western Pacific Ocean. For SOC, the local community to be served will be in the FSM which is comprised of Chuuk State, Kosrae State, Pohnpei State and Yap State. The FSM SOC Expansion and Sustainability Project aims to improve the mental health outcomes for children and youth, birth through age 21, with serious emotional disturbance (SED), and their families. FSM suffers from substance abuse issues, high rates of suicide, domestic violence, and child neglect. Substance abuse and suicide are common among youth, and thus, tackling these issues at an early age are critical to child wellness and children's ability to succeed. Recent data shows that suicide ranks among the top ten causes of mortality in FSM youth frequently use tobacco, alcohol, marijuana, and other substances and start at a young age. The FSM as a whole, face barriers in its effort to improve service systems for young children, and efforts are ongoing to improve community linkages within the state. Importantly, FSM leadership is aware of the importance to the child of the multiple layers of relationships-with family, with outside providers, and with institutions, such as schools. FSM SOC has the following goals: Goal1: To support the implementation, expansion and integration of the SOC approach by creating sustainable infrastructure and services that are required as part of Comprehensive Community Mental Health Services for Children and their Families Program; Goal2: To support the provision of mental health and related recovery support services to children and youth with SED and those with early signs and symptoms of serious mental illness (SMI), including first episode of psychosis (FEP); Goal3: To build upon progress made in developping comprehensive SOC by focusing on sustainable financing, cross-agency collaboration, the creation of policy and infrastructure, and the development and implementation of evidence-based and evidence-informed services and supports. To achieve these goals, FSM SOC will implement the following culturally competent evidence based practices: diagnostic and evaluation services, intensive home-based services for children and their families, intensive day treatment services, assistance with transition from child services to services received as adults, and do other recovery support services such as the supported employment and focus effort to provide early treatment for those youth with early onset of SED/SMI. FSM SOC plans to target the population of about 50,000 0-21 of age and those with SED/SMI, along with their families.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082190-01 FSM DEPT OF HEALTH AND SOCIAL AFFAIRS POHNPEI FM VICTOR BENIDO $1,000,000

Abstract The Kentucky System of Care FIVE (KY SOC FIVE) grant will build upon Kentucky's 30-year history of developing a comprehensive system of care for children and youth (birth through age 21), who meet criteria for having a serious emotional disability (SED), and their families. It will achieve this by expanding existing infrastructure and service delivery to those with child welfare involvement, defined as families for whom a child abuse and/or neglect investigation results in a substantiation or services-needed finding. The grant has three overarching goals: - Enhancing inter-agency infrastructure to support the implementation, expansion, and integration of the System of Care approach for the population of focus; - Improving availability of and access to high quality, culturally- and linguistically-competent, evidence-based/evidence-informed (EB/EI) mental health services for the population of focus in the geographic catchments; and - Implementing strategies to promote and sustain the voice of children, youth, and their families with child welfare involvement at all levels of the system of care. Child welfare service regions were selected for implementation based on high need and limited accessibility to mental health services and supports. In Years One and Two, The Cumberland and Two Rivers service regions will implement, with The Lakes and Salt River Trail regions rolling out in Years Three and Four. As such, the grant will cover 69 of Kentucky's 120 counties and serve 1485 children and youth with grant-supported mental health services and supports over the life of the grant. Kentucky has a long history of implementing a system of care approach, having implemented four previous SOC grants, however previous efforts have not focused on families with child welfare involvement. Kentucky's rate of children and youth in out-of-home care reached a record high in late 2018, with nearly 1% of the state's total child population in placement. Transforming the child welfare system, including implementation of the Family First Prevention Services Act in October 2019, is a top governmental priority. As such, timing is opportune to integrate mental health services and supports throughout the child welfare system.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082203-01 KY ST CABINET/HEALTH/FAMILY SERVICES FRANKFORT KY JORDAN BETH $3,000,000

Led by the Boston Public Health Commission (the city’s health department), the proposed Boston FIRST (Family Independence, Resilience, Support, and Treatment SOC) focuses on young children ages 0-48 months and their families in Boston, Massachusetts who are involved with the state child welfare system and are diagnosed with or at risk of serious emotional disturbances (SED). Demographics and clinical concerns: The project focuses on Boston neighborhoods with the largest number of children and families (predominantly Black or Latino) involved with the Massachusetts Department of Children and Families (DCF). Children involved with child welfare may be at greater risk for mental and behavioral health issues than children in the general population because of histories of trauma, including experiencing maltreatment or separation from parents or siblings. Goals, objectives and strategies: The overarching goals of the FIRST SOC project are to: (1) improve access to high-quality, culturally competent, evidence-based behavioral health services through an innovative Family Partner/Clinician service model that will reach at least 210 children ages 0-48 months and their families in Boston who are involved with the child welfare system; and, (2) through evaluation, dissemination and infrastructure development, expand promising elements of the project to the DCF system and providers statewide. Key objectives includes (1) Partnerships through a local governance board, statewide infrastructure and community engagement. (2) Local services: Using an innovative Family Partner/Clinician service model along with a newly created Review Board to monitor and improve access to services, in partnership with Children’s Services of Roxbury and DCF, over the project period Boston SOC will provide a full-range of behavioral health engagement, assessment, treatment, family support and referral services to at least 210 children in Boston ages 0-48 months with or at risk of SED, and their families, who are involved with the child welfare system. (3) Statewide infrastructure and dissemination: With the support of the project’s statewide Partnership for ECMH, by Year 2 Month 5, develop and disseminate an interim report that provides information on project activities and results; and by Year 4 Month 5, produce a final report on project activities, results, challenges, insights, and recommendations for scaling promising elements of the model across the child welfare system. The unduplicated number of individuals to be served is: Year 1:30 children/60 caregivers, Year 2 60/120, Year 3 60/120, Year 4 60/120. Over the project period, we will serve 630 unduplicated individuals.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082196-01 BOSTON PUBLIC HEALTH COMMISSION BOSTON MA MOULIN CHRISTINA $1,000,000

The Prince George's County Health Department in partnership with the Prince George's County Department of Social Services (DSS) seeks to establish a System of Care for transition aged (16-24) youth with a particular focus on youth who are experiencing homelessness. We will build on the County's currently expanded network of community-based providers to include Mobile Response and Stabilization Services (MRSS) with an Intensive Family Intervention Team providing in-home or identified locations identified by youth experiencing homeless, for up to six weeks with the option of referral for community-based services as needed. Additional support will be provided by the Prince George's County Schools Network which places a DSS staff person (referred to as a Community Resource Advocate [CRA] and a behavioral health provider in 40 schools across the County. Services to youth with severe and/or escalating behavioral health needs will involve creating alternatives to using foster care to meet these needs. An additional focus of the TAY SOC will be the creation of the infrastructure-interagency agreements, human and other resources to support quality data collection on the needs and numbers of TAY in our County.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082207-01 PRINCE GEORGE'S COUNTY UPPER MARLBORO MD DUVAL-HARVEY JACQUELYN $1,000,000

Title: System of Care St. Louis Summary: The proposed System of Care Expansion will provide an Integrated Family Treatment Model to juvenile justice involved youth ages 12-18 with an SED and those with signs and symptoms of Serious Mental Illness and their families. Families will receive care navigation support from Family Support Partners and clinical services from community mental health providers that can deliver evidence based services to meet the needs of youth and address the unmet mental health needs of parents/caregivers. The geographic area served will be the St. Louis Promise Zone, a Federally designated are characterized by high levels of poverty, poor health outcomes, and lack of access to mental health services. The 2017 Youth Behavioral Health Needs Assessment identified system navigation, increasing youth accessibility to services, and investment in family systems approaches as top priorities and emphasized that behavioral health needs of youth do not stand in isolation from the needs of the family. In addition, a key focus will be on providing family advocacy and peer support services delivered by trained family advocates with lived experience to help families navigate the mental health service delivery system within the juvenile justice space and within the community. The proposed work will focus on eliminating barriers and building bridges between domains of care, specifically between Youth Behavioral Health and Adult Behavioral Health, to create an Integrated Family Treatment Model. The goals of the project are as follows: (1) Strengthen and enhance current infrastructure to connect juvenile justice involved youth and families with mental health service providers that implement the Integrated Family Treatment Model; (2) Connect juvenile justice involved youth and families with Family Support Partners; and (3) Create an Integrated Family Treatment Model for juvenile justice involved youth and families.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082197-01 CITY OF SAINT LOUIS MENTAL HEALTH BOARD ST. LOUIS MO MUHAMMAD SERENA $999,897

The proposed Golden Triangle Region System of Care will serve seven rural North East Mississippi Counties (Lowndes, Oktibbeha, Noxubee, Clay, Webster, Choctaw and Winston) to support the implementation, expansion, and integration of the SOC approach by creating sustainable infrastructure and services. The SOC will improve mental health outcomes for children and youth, birth through age 21, children and youth with serious emotional disturbance (SED) and those with early signs and symptoms of serious mental illness (SMI), including first episode psychosis (FEP) and their families by focusing on mental health and related recovery support services, sustainable financing, cross-agency collaboration, evidence-based practices (TF-CBT), SPARCS, Moral Recognition Therapy (MRT), Family Intervention Suicide Prevention (FISP), Coping and Support Training (CAST), Illness, Management and Recovery (IMR), ARISE Life Skills Curricula, Second Step Program, Motivational Interviewing (MI), Skills Streaming and The Prepare Curriculum, and enhanced policy and infrastructure with youth-guided and family driven peer leadership.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082188-01 COMMUNITY COUNSELING SERVICES, INC. WEST POINT MS TAYLOR STEPHANIE $999,995

Project Abstract Summary Summary. The proposed four-year NFusion IV System of Care will serve five rural North Mississippi counties, and will build upon the existing system of care foundation in DeSoto County and expand and enhance system of care services in Alcorn, Prentiss, Tippah and Tishomingo counties. Through EBPs, TF-CBT, Wraparound (MYPAC), A-CRA the expanded system of care will improve mental health outcomes for children and youth, birth through age 21, children and youth with serious emotional disturbance (SED) and those with early signs and symptoms of serious mental illness (SMI), including first episode psychosis (FEP) and their families by focusing on sustainable financing, cross-agency collaboration in Region IV through implementing enhanced policy and infrastructure and youth-guided and family driven peer leadership. The proposed 4-year system of care will result in comprehensive system of care services ensuring effective cross-agency expansion and the provision of mental health and recovery supports. Project Name: NFusion IV System of Care. Populations served: Birth to 21 years of age; 15% African American; 5% Hispanic; 2% Multi-racial. Strategies: NFusion IV System of Care seeks to expand trauma-informed, cultural and linguistically appropriate system of care EBPs, supports and policies with a cross-agency approach of coordinated service delivery and integration of mental health services, ensuring effective cross-agency expansion and the provision of mental health and related recovery support services to participants with SED and those with early signs of SMI, including FEP to include an array of non-mental health supports, i.e. vocational counseling, education services, health-related services, substance abuse prevention, stable housing, independent living skills and advocacy. Each participant will work with a care team that facilitates the identification and implementation of an individualized service plan in partnership with the child/youth, family, natural supports and professional supports to achieve their personal goals. NFusion IV System of Care will develop a cross-agency infrastructure through an integrated system of care and ensure national and local evaluation of performance assessments are conducted. Goals: (1 Expand Region IV cross-agency collaboration to serve SED individuals and those with early signs and symptoms of SMI, including FEP; 2) Provide a broad array of accessible and coordinated services/supports; 3) Ensure individualized, managed care; Plan, deliver, and evaluate these services with the full participation of families and youth in a culturally and linguistically sensitive manner; and 4) Facilitate broad-based, sustainable systemic support for the population of focus. Objectives: Annually and over four-years: 1) 90% of participants will improve diagnosis; 2) 80% of participants improved mental illness symptomatology; 3) 80% of participants will improve employment/education; 4) 80% of participants will reduce criminal justice involvement; 5) 80% of participants will improve stability in housing; 6) 80% of participants will reduce readmission to psychiatric hospitals; 7) 80% of participants will improve social support/social connectedness; and 8) 85% of participants will report a high client perception of care. # served: 75 Year(s) 1-4, totaling 300 in four years.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082193-01 TIMBER HILLS REGION IV MENTAL HEALTH MENTAL RETARDATION COMMISSION INC CORINTH MS HUMPHREY TRACY $999,664

The purpose of North Dakota's System of Care Expansion and Sustainability grant is to improve the mental health outcomes for children and youth, birth through age 21, with serious emotional disturbance (SED), and their families. The system of care will be implemented in two regions in the state: Lake Region Human Service Center - LRHSC, Region III; and West Central Human Service Center - WSHSC, Region VII. LRHSC serves a six-county area that includes Benson, Cavalier, Eddy, Ramsey, Rolette, and Towner counties; and the Turtle Mountain Reservation and Spirit Lake Reservation. This 6,756 square mile area is home to about 43,168 people. WCHSC serves a ten-county area that includes Burleigh, Emmons, Grant, Kidder, McLean, Mercer, Morton, Oliver, Sheridan, and Sioux counties, the Standing Rock Indian Reservation, and part of the Fort Berthold Indian Reservation. This 14,452 square mile area is home to approximately 130,000 people. In 2018, LRHSC served approximately 430 children with SED. WCHSC served approximately 1300 clients in 2018, 790 of which were children with SED. The first goal is to develop a sustainable infrastructure to support the system of care approach for North Dakota children with SED and their families. The following, summarized, objectives were identified to achieve this goal: 1. enhance existing data and monitoring systems; 2. enhance workforce development; 3. establish a statewide leadership structure; 4. develop and improve coordination of an integrated payment structure; and 5. increase family and youth voice. The second goal is to increase access of high-quality and culturally appropriate services and supports available to children with SED and their families in the identified regions. The following, summarized, objectives were identified to achieve this goal: 1. improve the quality of existing services and supports; 2. create new services and supports; and 3. enhance culturally responsive services and supports. An estimated 1,200 children and their families will be served each year - with the exception of year 1 which will likely be closer to 600 - for a total of approximately 2,800 un-duplicated children and their families over the course of the grant period.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082202-01 NORTH DAKOTA STATE DEPARTMENT OF HUMAN SERVICES BISMARCK ND ANDERSON LAURA $3,000,000

The Santee Sioux Nation Nebraska Native Trauma and Research Consortium will to improve the mental health outcomes for American Indian children and youth, birth through age 21, with serious emotional disturbance (SED), and their familie throughout Nebraska. This program will support the implementation, expansion, and integration of the System of Care approach by creating sustainable infrastructure and services. The Nebraska Native Trauma and Research Consortium is an inter-tribal initiative building upon the Santee Sioux Nation's documented success in meeting the needs of reservation, urban, rural, and frontier American Indians through strong ongoing collaborative working relationships. Primary goals are: (1) Collaboration with state, tribal, and other entities; (2) Deliver culturally competent behavioral health care to children with a SED; (3) Utilize resources at the tribal systems and community levels; (4) Implement services, supports, and mechanisms to promote and sustain youth and family participation that engage and involve families and youth; (5) Enhance the decision-making governance structure; and (6) Develop and implement a strategic financing plan

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082206-01 SANTEE SIOUX TRIBE OF NEBRASKA NIOBRARA NE DONOVAN GREG $1,000,000

The City of Manchester Health Department (MHD) has identified Manchester, NH as the geographic catchment area for the proposed Manchester System of Care (MSOC) initiative. Manchester is the largest city in NH and the most populous city in northern New England with a total population of 111,196 ; more than 12,000 Manchester residents are children ages 0-8 . MHD will target children 0-8 with a serious emotional disturbance, and their families. MSOC will adapt the NH Wraparound Practice Model to fidelity to address the unmet mental health needs among young children requiring additional services and supports. MSOC will build an infrastructure to screen for, assess, and address the growing needs of infants, toddlers, and younger children experiencing socio-emotional, behavioral, or mental health disorders. MSOC will partner with the NH Department of Health and Human Services (DHHS), Bureau for Children’s Behavioral Health to ensure alignment with statewide strategies previously funded by a System of Care grant, with modifications for the population of focus.Given that Manchester is home to a sizeable and growing group of traumatized and highly vulnerable young children and families, there is a need for more coordinated interventions geared for this young age group such as that proposed through MSOC. MSOC aims to improve mental health outcomes for infants, toddlers, and children birth through age 8 with serious emotional disturbances, and their families, by adapting the NH Wraparound Practice Model for this age cohort, enhancing the framework and the service delivery system to ensure the youngest children are cared for, and their families are supported. In particular, MSOC will adapt and expand the age continuum currently served by the state’s System of Care model by ensuring community-based supports meet the growing mental health needs of infants, toddlers, and young children. Given the disparate number of children in Manchester impacted by the opioid crisis and, in turn, involved in the child welfare system, MSOC will ensure its coordinated network considers these unique and growing challenges presented by traumatized children and their families. By breaking down silos and braiding services and funding sources, MSOC will result in at least 20 children being identified early and served more effectively and efficiently, and with enhanced services. To achieve the necessary systems-change required, the Manchester-based partnership will 1) Develop the MSOC infrastructure and capacity; 2) Implement high-fidelity wraparound care coordination for young children and their families; and 3) Improve MSOC functioning, efficiency, and sustainability. MSOC will transform the current system of care that includes fragmented service delivery and categorical programs and funding into a care management model that provides a locus of accountability to better coordinate services and supports across child-serving systems and ensure a family-driven approach at every level. Within a coordinated service array, MSOC will address the clinical and functional needs of young children and families by creating a family-driven plan that draws upon a community-based team to help the family AND by developing and monitoring a plan of care that builds on family strengths and addresses their identified priorities.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082210-01 MANCHESTER, CITY OF MANCHESTER NH HOEBEKE JAIME $730,006

PROMISING PATH TO SUCCESS 2.0

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082200-01 NJ STATE DEPT OF CHILDREN AND FAMILIES TRENTON NJ REH STACY $3,000,000

New Mexico’s Children, Youth, and Families Department Behavioral Health Services (CYFD BHS) is ideally positioned to expand the infrastructure and capacity built through previous Systems of Care (SOC) grants in New Mexico in the New Mexico Systems of Care III (NMSOC III) program. NMSOC III will serve children and youth (ages 0-21) with a serious emotional disturbance (SED) by providing Mobile Crisis Response, High Fidelity Wraparound, Trauma-Informed Care, and Family Peer Support Services in a comprehensive SOC approach. In addition to strengthening the infrastructure of statewide behavioral health (BH) service system, NMSOC III will serve children and youth in Sandoval, Chaves, and Valencia Counties. These counties were selected because of the rural population and they have not been served in previous SOC grants in NM. The goals of NMSOC III are to 1) Enhance the BH workforce, 2) Engage youth, family and community members and ensure meaningful voice, 3) Improve interagency collaboration, 4) Expand the service array for children and youth, and 5) Utilize ongoing Continuous Quality Improvement framework. To achieve these goals, CYFD BHS will collaborate with other state agencies and managed care organizations to create policies and procedures that support children and youth with SED to remain in their communities with strong supports. NMSOC III will achieve goals through active state and local governance teams that will identify areas of need and activities to support these families, including addressing financial barriers and improving communication and collaboration across systems. NMSOC III will enhance the BH workforce by providing training to professionals on screening and assessment, Mobile Crisis Response, Wraparound, Family Peer Support Services, and the Nurtured Heart Approach. Local sites will be fully trained and staffed in the High Fidelity Wraparound Approach. The CYFD SOC Statewide Youth Coordinator and Family Engagement Specialist will engage youth and families by inviting them to participate in the Youth MOVE NM Chapters and to be on the governance teams. Children/Youth referred to NMSOC III services will be screened for SED, trauma history, and fit for Wraparound and other Support Services. Enrolled youth will have access to a full array of SOC services, such as Wraparound, Peer Services, Respite Care, and Crisis Mobile Response. Local communities will work with CYFD BHS to align funding streams with existing initiatives to maximize sustainability of services. For quality improvement, fidelity assessments will be conducted to ensure high quality services. Local sites will implement Quality Services Reviews to have a better understanding of the impact of the grant program in the community. Quality improvement reports will be shared with the governance teams and state agencies to impact policies and procedures that enhance services to children and youth in the BH system. NMSOC III is expected to enroll 600 children and youth in services over the life of the grant, with 60 enrolled in year 1 and 180 each year for years 2-4.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082287-01 NEW MEXICO ST DEPT/CHILDREN/YOUTH/FAM SANTA FE NM PITTENGER BRYCE $3,000,000

The Nevada System of Care (SOC) aims to sustain and build upon the successful foundation and progress achieved under the 2015-2019 SOC implementation grant while expanding evidence-based services and supports for children/youth (ages birth to 21) who experience (or are at risk of) SED and their families. Nevada intends to expand and enhance services in Northern and Southern Nevada and expand services to additional rural and frontier areas of the state. The family-run organization, Nevada Parents Encouraging Parents (PEP) and the youth-run organization, Youth M.O.V.E. Nevada, are authentically engaged in all aspects of the SOC. Representatives of these organizations will continue to participate in strategic and finance planning, implementation, and in the continuous quality improvement of the SOC. Under the current implementation grant, in FY 2017 Wraparound In Nevada (WIN) served 696 children/youth and served an additional 365 children/youth in FY 2018 statewide. Under this expansion grant, we propose that the unduplicated number of individuals served annually will be 1,788 and the unduplicated number of individuals served over the lifetime of the grant period will be 5,964. Our outcomes will be measured not only by tracking the total number of children/youth served, but also by several more specific measures. For example, we will assess the quality, fidelity, and appropriateness of the services (e.g., WFI-EZ, DART, and FOCUS fidelity benchmarks and checklists); assess the improvement experienced by the children/youth and their families in key outcomes (e.g., CIS, CANS, and CGSQ); and measure our success rates at serving the targeted subpopulations. Within the main target population, we have identified a need to better serve children/youth with early signs and symptoms of serious mental illness, including those who have experienced their first episode of psychosis. Three subpopulations have been identified as particularly in need of services, including early childhood (ages 0-6), transitional age youth (14-21), and children/youth with dual diagnosis SED and ID/DD. Based on priorities that emerged from the current SOC implementation grant, Nevada is proposing the following expansions: (1) Increase capacity to provide family-driven, youth-guided, and culturally and linguistically appropriate services to a greater number of children/youth in the state. (2) Increase access to mental health services through a “single point of entry” system. (3) Improve care coordination and services at the appropriate intensity level that matches youth and family needs. (4) Increase access to evidence-based mental health interventions by expanding the service array. (5) Increase capacity of services to special target populations, such as early childhood (ages 0-6), transitional age youth (14-21), and youth with dual diagnosis (SED & ID/DD).

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082235-01 DIVISION OF CHILD AND FAMILY SERVICES CARSON CITY NV ROOSE KATHRYN $3,000,000

Tapestry's Resilience Initiative's overarching goal will be to develop a replicable rural multi-generational model weaving together the current system partners with best practice opportunities to build a sustainable, cohesive and comprehensive system of care. The Tapestry Resilience Initiative will improve the mental health outcomes in the impoverished, rural county of Chautauqua, in southwestern NYS by supporting expansion of required services, targeted evidenced-based practices and continuous evaluation. The best predictor of future success. SAMHSA's investment in Tapestry to date has impacted locally, statewide, and nationally. Tapestry Resilience Initiative is poised to have an impact particularly in NYS that will influence the direction of children's policies and services for years to come. Systems of Care experience has given us a qualified lens with which our community partners have identified two sub-groups who are most vulnerable and yet who hold immense potential. Objectives for young children include: community mapping; and enhanced Children's Single Point of Access; High Fidelity Wraparound; evidenced-based Parents As Teachers, evidenced-based parent education; Pyramid Model framework to embed programs and policies in schools/childcare/community; childcare provider training; Rapid Skills training; and Healthy Steps. Objectives will equip caregivers, integrate behavioral health into pediatric /primary care practices, and expand evidenced based practices. Strategies for college students include behavioral health screenings, resiliency training, suicide prevention workgroups on campus, establishment of a satellite clinic on campus, self-help technology, and awareness/education effort. Tapestry will implement culturally appropriate evidenced-based programs/practices to support children, youth and families with diagnostic and evaluation services;outpatient clinical services and professional consultation; 24-hour services; intensive home-based services; intensive day treatment; respite care; therapeutic foster care; services for transition to adulthood; recovery services; reporting and monitoring; engaging youth and families; an expanded governance board that includes family and youth voice to make programmatic and policy changes based on decisions informed by the realist evaluation approach; and develop a strategic financing plan. The Tapestry Resilience Initiative will serve 8200 individuals over the grant period.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082275-01 CHAUTAUQUA COUNTY DEPARTMENT OF MENTAL HYGIENE MAYVILLE NY LUDWIG RACHEL $1,000,000

A three-pronged approach was developed by the county and multiple stakeholders to strengthen and enhance the current system of care in Herkimer County: 1. DESSA (Devereaux Student Strengths Assessment software) will be purchased for 6 corridor school districts, covering K-12. The DESSA software tracks multiple student markers in order to derive a psychometrically-sound measure of social and emotional competence among individual children and groups of children. This will allow the schools to identify early children with SED or those who are at risk of SED. The software interfaces with the current student management system, SchoolTool, to provide intervention management capabilities and progress monitoring. 2. 5 Family School Navigators will also be provided to those schools (one district already utilizes a navigator). These navigators will create relationships with the families in each district These navigators will be charged with identifying families who have just given birth and reaching out to begin forging a positive, strength-based connection with the school from day one that persists though the child’s elementary career. These ongoing relationships between the navigators and the families position the navigators in such a way allowing them to observe the family in their homes, and identify any emergent needs or changes in the family environment which may pose a risk to the children in the home (toddler age and up) of developing an SED. The FSNs will also make themselves available to assist families with everything from basic to more complex needs, to refer to any appropriate programs or services that could stabilize or strengthen the family/child, and to support the families in ways tailored to match their individualized need(s). FSNs, therefore, act as a referral source and supportive intervention to increase early identification of children with SED, or at-risk of SED, and their families and to connect them as quickly as possible with appropriate school-based and community resources. To fully accomplish this, FSNs also work closely with school personnel including teachers, counselors and social workers, as part of a child-focused care team. Therefore, in addition to these children undergoing assessments via the DESSA software, the FSNs will also be able to monitor the child and alert the school to anything the DESSA might not capture, acting as a secondary identification system. 3. A resource inventory of mental, behavioral, and supportive services available in the community will be created by the county and distributed to the schools. This inventory will allow schools to easily and quickly match the needs of a child/family with the appropriate program to address the issue(s). In addition, the Human Resources Planning team (the SOC oversight body) in conjunction with the schools and family advocates will ascertain which programming is the most impactful. This information will then be cross-referenced against needs of the children and families in the community and the capacity of the current programs to determine which program/service would benefit from enhancement and increased capacity.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082388-01 COUNTY OF HERKIMER HERKIMER NY CAIN CHRISTINA $989,447

The overall goal of the OnCare Transition Age Youth System of Care is to support the healthy transition of high risk youth ages 6-21 into adulthood by establishing a systemic infrastructure to identity and intervene with emerging and at-risk SED for transition age youth; tailoring mental health and related services to meet their needs; and developing a bridge from the children's mental health system to the adult system that includes educational, employment and career. While Onondaga County's prior System of Care efforts have focused on the full age population and have led to sustainable infrastructure changes and improved mental health outcomes for the targeted populations, we have not been able to build the infrastructure needed to specifically engage high risk TAY. Onondaga County has a total population of 465.398 (77.1% being White non-Hispanic) and 21.8% of all children live below the poverty line. The City of Syracuse is the urban center of the County and a total population of 143,396 (44.7% are non-white). The City of Syracuse has the 23rd highest poverty rate in the country and the nation's highest rate of extreme poverty concentrated among Blacks and Hispanics. Of the population of ages 16-19, 36.7% of Black and 38.2% of Hispanic youth are not in the labor force. From January to October 15, 2018, 37 people 19 years old of younger had been stabbed or shot in the city, including the tragic shooting death of a 12 year old. Over 1,000 TAY within the Syracuse City School District attend school less than 25% of the time. Onondaga County Black youth are almost 14 times more likely to be arrested than white youth and 58 times more likely to be detained and Hispanic youth are almost 16 times more likely to be detained than White youth. One in five of youth aging out of foster care will become homeless after turning 18; only half will obtain employment by 24; over 70 percent of female foster youth will become pregnant by 21, and one in four former foster youth will experience PTSD. Specifically, the project goals will be accomplished through the following: development of a universal identification, assessment, referral and linkage process for mental health and substance use challenges; adaption/enhancement of behavioral health services to specifically engage and treat the effects of living in traumatizing environments and the criminogenic behavior high risk youth exhibit; development of culturally competent engagement and treatment practices that provide services through the credible messenger approach, adaption/enhancement of the educational and work-readiness support systems to individually engage and support the needs of high risk youth; and expansion of sustainable infrastructure and services to meet the needs of the identified population. The Project will implement the Transition to Independence Process Model through a credible messenger approach. In addition, by year 4 the goals is that 150 Transition Age Youth will be referred for behavioral health and other supportive services while supporting 75 youth annually.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082204-01 ONONDAGA COUNTY MENTAL HEALTH DEPARTMENT SYRACUSE NY THOMAS NEAL TASHIA $1,000,000

The Mosaic Project outlined in this proposal will make available a core benefits package of behavioral health services to all children and youth ages 0-18 plus youth in transition in Union County through culturally competent, accessible service coordination and services. The core benefits package is designed to fulfill the Institute of Medicine’s behavioral health intervention spectrum (IOM, 2009) from universal prevention through intensive treatment and recovery supports. This application is unique in that it starts with a sustainable financing plan that links child serving systems, providers and public/private payers including Medicaid and establishes universal social, emotional, and behavioral screening for every child in the County. The Mosaic Project provides the infrastructure of care management and service coordination to ensure that all children receive access to programs and services necessary to promote well-being, intervene early, treat behavioral health conditions, and give ongoing support for children and families. Partners committed to the Mosaic Project include the (applicant) Mental Health and Recovery Board of Union County (MHRBUC), the behavioral health planning and funding authority (political subdivision) for Union County; The Union County Council for Families, a statutory body charged with service coordination for multisystem youth; Partners for Kids (PFK) an Accountable Care Organization (ACO) for four of the five Ohio Medicaid Managed Care plans; and CareSource - the fifth and largest of Ohio’s Medicaid MCOs. It will be the responsibility of the Mosaic Project to engage families via Central Intake and to help the family select the correct mix and amount of services from the complete IOM Continuum and then utilize all available benefits – private insurance, Medicaid, MH Block Grant, SAPT Block Grant, state GRF funds, funds from juvenile justice and child protection, education funding, and local levy dollars to provide the service plan seamlessly to the family. Under the direction of the Mosaic Project governance board representing families with lived experience, providers, stakeholders, and payers, the project will: Establish SOC infrastructure to improve prevention, early identification, and referral for children with or at risk of developing SED; Identify and remove barriers to access, engagement, awareness of and service delivery for SOC; Establish and expand evidence-based mental health interventions to fulfill the required activities and ensure network adequacy for delivery of SOC services; and Identify and/or create community and natural supports for children/youth with SED and their families to support effective treatment and provide natural transition from services. The Mosaic Project will serve 250 youth with/at risk for SED annually, with a project total of approximately 400 unduplicated youth. An additional 800 youth/families per year (3,200 for the project) will be served through lower level engagements including prevention, problem identification, and referral.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082260-01 MENTAL HEALTH AND RECOVERY BOARD OF UNION COUNTY MARYSVILLE OH IRVING CARMEN $970,345

Cherokee Nation’s Helping Everyone Reach Out (HERO)Project will build on previous system of care successes with the creation of Project I-tsu-la: Working together to provide comprehensive mental health services to tribal children, youth, and families. HERO Project aims to serve American Indian youth ages 0-21 residing within the Cherokee Nation reservation, spanning 6,950 square miles in the state of Oklahoma. Project I-tsu-la goals include building upon on previous SOC efforts by improving capacity, coordination, and expansion of service delivery for American Indian children and youth with serious emotional disturbances and their families, as well as developing a comprehensive system of care, advancing policies, community outreach and culturally appropriate services to address mental health through prevention, intervention, and continued care for American Indian children and their families. HERO Project plans to expand on previous awarded grant activities through Project I-tsu-la by training clinical providers and project staff in evidence-based interventions such as, Eye Movement Desensitization and Reprocessing, Trust-Based Relational Intervention, and Dialectical Behavioral Therapy. In addition to training in child/youth specific interventions, HERO will expand clinical services to serve Cherokee Nation’s outlying health centers by implementing a therapeutic home visiting model in four clinics: Red Bird Health, Three Rivers, A-Mo, and Sam Hider Health Centers. A clinician and family care manager will be housed full-time in the remaining four clinics: Mankiller, Will Rogers, Cooweescoowee, and Vinita Health Centers. Measurable objectives include service delivery of evidence-based interventions and community level interventions, such as the creation of a social marketing plan and partnering with Cherokee Nation’s Youth Motivating Others through Voices of Experiences (Youth M.O.V.E). Chapter to create a youth/elder summit to be held annually. Finally, workforce development activities will be completed by project staff with parents, caregivers, and community stakeholders around children’s mental health. The project will serve 285 individuals annually, totaling 1,140 unduplicated individuals served over the duration of the grant.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082300-01 CHEROKEE NATION TAHLEQUAH OK SKINNER JULI $990,567

Abstract The BHARP System of Care Expansion and Sustainability project will implement focused, System of Care strategies through a network of twenty-three counties in rural Pennsylvania to enhance the service delivery system for children and youth age 0-21 with serious emotional disturbance and their families enrolled, or eligible to be enrolled in the public mental health services system. The specific goals of the project are to create or enhance county stakeholder involvement in service delivery system development, implement family-systems trauma-focused interventions in Behavioral Health Rehabilitation Services (BHRS), improve treatment outcomes and level of functioning in the population of focus, and increase engagement in treatment by the population of focus and their families. Objectives focus on specific county stakeholder development, improvements in level of functioning scores as measured by required SAMHSA evaluation tools, and practice change by assessing treatment plan content and successful completion of treatment in the evidenced based practice. The project will use a tiered approach to implementation, with fourteen primary county programs, known as Tier 1, participating at the highest level, developing complete System of Care infrastructure and development of clinical and support services. The other nine BHARP counties will benefit from training on trauma systems and support for basic system of care infrastructure development, preparing them for future system of care implementation. BHRS providers in the twelve Tier 1 counties will receive training in an evidence-based practice that focuses on trauma informed structural family therapy called Parenting with Love and Limits. Specific engagement and trauma informed strategies in the evidence-based practice will be implemented in other levels of care to create a consistent experience for children and their families. County leadership teams will be created or enhanced in the counties to support family and youth engagement through the creation of family and youth networks and organizations. Four hundred children and their families will be served throughout the lifetime of the project with the goals of policy and practice development to sustain and expand the practice throughout the BHARP region. Forty will be served in year one and one hundred twenty in the remaining three years.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082194-01 CMSU BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES DANVILLE PA BEACH RICHARD $1,000,000

In continuing this critical process of System of Care (SOC) development, Philadelphia DBHIDS will use highly effective strategies to bring about system transformation and improvement, including: developing infrastructure; building capacity; partnering with families and community stakeholders; creating avenues for collaboration across agencies; leveraging fiscal resources; and solidifying change through policy. Over the past four years, Philadelphia has made significant changes to its children’s behavioral health care system. DBHIDS has strengthened family/youth partnerships, implemented High Fidelity Wraparound (HFW) as an approach to youth-driven planning, supported the launch of an authentic family-run organization, and began developing the family peer support workforce. Although Philadelphia upholds System of Care (SOC) values and principles in children's behavioral health services, DBHIDS currently faces three important system development issues: 1) lack of coordinated infrastructure and capacity for intensive community-based alternatives and supports for multisystem youth with SED and their families; 2) lack of integration across child-serving systems and community partners for youth at-risk for out-of-home placement; and 3) the need for innovative fiscal strategy and policy to support the sustainability of the expanded SOC over time. Specifically, we propose to address the five following goals to bring about systems change. Goal 1: Transform and expand a coordinated array of intensive community-based services alternatives to out-of-home treatments for multisystem youth with SED within a family-driven, youth-guided, and culturally-competent system of care. Goal 2: Collaborate with DHS, Community Umbrella Agencies (CUAs), providers, and community organizations to increase behavioral healthcare care integration across systems. Goal 3: Expand family and youth partnerships in all levels of SOC implementation (i.e., direct services through governance). Goal 4: Create and embed sustainable training and technical assistance strategies to facilitate ongoing learning, coaching, and practice improvement according to the SOC approach. Goal 5: Sustain SOC implementation through coordinated fiscal strategy and policy. Through intensive cross-system services provided through this grant, Philadelphia Healthy & HOME will serve 100 youth/yr in Years 1&2 and 200 youth/yr in Years 3&4 for a total of 600 youth with SED. Philadelphia has demonstrated its ability to change effectively and successfully sustaining key components of all SAMHSA grants. By establishing infrastructure, increasing access, and leveraging funding this grant will enable Philadelphia to expand SOC and improve outcomes for culturally-diverse children and youth with SED and their families.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082199-01 DEPARTMENT OF BEHAVIORAL HEALTH AND INTELLECTUAL DISABILITIES SERVICES PHILADELPHIA PA BRACALIELLO CATHERINE $1,000,000

Wraparound Shelby is proposed by Shelby County government to create the service delivery infrastructure needed for improved access to mental health services and supports for youth under 18 with SED and their families. The goal is to serve 400 families over the 4-year grant funded period using high fidelity wraparound as the primary intervention. Care coordinators and family support specialists will work in teams to develop individualized service plans and connect families with natural community supports to provide the resources needed for children to thrive in their home, school and community. The purpose of the program is to improve mental health outcomes for the children with SED and their families to be served by supporting implementation, expansion, and integration of the SOC approach. Shelby County has a poverty rate for children under 18 of 30%, with 2/3 on TennCare. There is no local entity providing coordinated planning and continuous leadership to support children’s MH services and Shelby County will work with UTHSC to create this local locus of accountability and coordination for children’s MH services. All project providers are part of the provider network collaborative and services will be accessible county-wide. Wraparound Shelby is based on the foundation established in managing the past SOC program in Shelby County and the BSB-TN Statewide ACEs Initiative grant by UTHSC Center for Health in Justice Involved Youth (Center). Children with SED are at high risk of chronic absence from school, disciplinary actions in school, or entering juvenile justice/child welfare systems indicating a significant need for coordinated MH services for youth exiting the juvenile justice and child welfare systems. The program will include training and technical assistance for the professional community in trauma informed and culturally responsive care and measurable goals include improved school attendance and performance, decreased contact with the juvenile justice system, and parent/caregiver satisfaction with child functioning. Community engagement and participation in the implementation, evaluation and sustainability planning will be included through a community governance structure that is an integral component of the SOC model. In addition to service provider partners, key stakeholder participants include local CMHCs, Shelby County Schools, and Department of Children’s Services. Data collection and reporting will be the responsibility of UTHSC, as well as the general management and oversight of all services provided related to this project. A community advisory board structure will be developed to assure maximum involvement of community stakeholders in the planning, implementation and evaluation of the project. The Center has led many similar collaborative efforts over the past 4 years and maintains the needed community relationships to support success of all these efforts.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082390-01 MEMPHIS SHELBY COUNTY HEALTH DEPARTMENT MEMPHIS TN GRIFFIN DORCAS $999,724

The City of Houston’s Mayor’s Office of Education in collaboration with Baylor College of Medicine are proposing a four-year initiative to develop integrated systems of care for youth with serious emotional disturbances (SED), “Be Well Be Connected.” This initiative aims to provide a stepped level of care for youth in partnership with independent school districts through (a) cloud-based screening protocols for at-risk youth, (b) crisis tele-health assessments, (c) connection to appropriate level of care within the community based on these screenings and assessments and importantly, (d) building additional clinical capacity for in-home intensive services for youth with first episode psychosis or bipolar disorder. This project will enhance ongoing collaborative efforts across schools, departments, community agencies and family-led organizations to identify those students at risk for SED and provide evidence informed intensive care management and multi-agency treatment planning. At the same time, this initiative will triage students with mild to moderate needs who can be effectively treated within routine outpatient settings to prevent worsening needs. The project seeks to a) increase the number of youth being assessed for SED and other significant mental health conditions, b) increase formal collaboration and planning across departments and community mental health teams, c) enhance the ability of local schools to respond in a evidence informed and culturally sensitive to mental health crises and the needs of youth with SED more broadly, d) reduce barriers and improve attitudes towards youth presenting with SED on school campuses, within family-led organizations and across community partners, e) develop a comprehensive monitoring process for youth designated at high risk, f) increase family involvement and engagement for youth with SED, g) improve the quality and quantity of professional assessments of youth through tele-health platforms, and h) increase the number of referral and successful treatment linkages for all youth with significant mental health needs in schools. The proposal aims to annually screen at least 500 youth, provide tele-health assessments to at least 150 youth with a connection to an appropriate mental health referral, and provide intensive in-home therapies to at least 40 youth with first episode psychosis or bipolar disorder.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082256-01 HOUSTON, CITY OF HOUSTON TX WILLIAMS LAUREL $1,000,000

The Milwaukee County Behavioral Health Division (BHD) Wraparound Milwaukee (WM) submits this application for 3,998,092 (over 4 years) to support the redesign and implementation of the psychiatric crisis service system of care (SOC) for youth and young adults by expanding early intervention, prevention, response, and postevention services, while also working to enhance the crisis SOC for youth and their caregivers through infrastructure development. With the impending outsourcing of BHD’s inpatient services and the scheduled closure of the county’s Mental Health Complex in June 2021 (including Psychiatric Crisis Services (PCS), BHD’s psychiatric emergency department), the population to be impacted are youth and young adults, ages 4-18, and their caregivers accessing crisis services through PCS, in addition to the ongoing and future needs of this population of youth and young adults. Services will be delivered in Milwaukee County as the geographic catchment area, with an urban population of 952,085. Based on enrolling new youth and families in the WM SOC following PCS admission, the projected number of unique consumers to be served through direct service delivery are: Year 1, 67; Year 2; Year 3; and Year 4, 90; 337 consumers throughout the project lifetime. Strategies and interventions include implementing a PCS-based Youth Clinical Resource and Referral Coordinator; enhancing evidence-based youth and caregiver screening and assessment tools in PCS and WM SOC enrollment; initiating Youth Team Connect (clinician and peer/parent peer specialists) for post-PCS follow-up; expanding crisis response services such as Youth Crisis Assessment Response Teams and a 23-hour stabilization unit; and the development and implementation of early intervention, prevention, and postvention community-based strategies. Project goals are to expand the system of crisis care through service delivery for youth and young adults currently accessing crisis services through PCS; and to enhance and sustain the system of crisis care through infrastructure development prior to and beyond PCS closure. Measurable objectives are to: (1) facilitate access to crisis response services and supports for youth and young adults admitted to PCS; (2) provide evidence-based and evidence-informed mental health services and related recovery support services for youth and caregivers newly enrolled in WM SOC; (3) implement additional community-based crisis response services through multi-system collaboration; (4) better understand the needs, system gaps, and experiences of youth and young adults and their caregivers accessing crisis services; (5) develop the workforce capacity and competence of SOC crisis services partners; (6) practice data-informed decision-making to guide strategies in building, and transitioning to, a community-based crisis SOC continuum for youth and young adults and caregivers; (7) improve the SOC linkages and coordination with other child serving systems; and (8) apply the strategic financing plan to community-based crisis services. The proposed project focuses on building stronger system partnerships between law enforcement, education, healthcare, and county programs for youth with significant behavioral health challenges.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082192-01 MILWAUKEE COUNTY DHS-BEHAVIORAL HEALTH DIVISION MILWAUKEE WI DELSART LEANNE $999,501

The West Virginia System of Care (SOC) grant will enhance the state's system for children and youths aged 0-21 with serious emotional disturbance (SED) or serious mental illness (SMI) and their families. Specifically, the grant will connect existing foundational services (e.g., Children's Mental Health Wraparound and Children's Mobile Crisis Response and Stabilization) with emerging services under the planned SED 1915(c) waiver and the Family First Prevention Services Act. It will also add regional Family Coordinators and respite services for families not eligible for Medicaid. The SOC approach will be implemented in all six regions of the W.Va. Bureau for Behavioral Health (BBH) and linked by a statewide crisis line connecting families with needed services. The grant will also fund a pilot youth drop-in center in Cabell and Wayne Counties that, if successful, will be a model for youth drop-in center expansion around the state.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM082205-01 WEST VIRGINIA STATE DEPT HLTH/HUMAN RSCS CHARLESTON WV TENNIS NIKKI $3,000,000