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SM-20-012 Individual Grant Awards
|Award Number||Organization||Grantee State Sort descending||City||Funding amount|
|1 H79 SM083203-01||
Project name: JAMHI CCBHC Expansion Populations to be served: Adult residents of the City and Borough of Juneau, Alaska catchment area with SMI, SUD, or COD; and children and adolescents with SED, SUD, or COD. Number of people to be served: Year 1: 200, Year 2: 300, Over life of project: 500. Project summary: Through the CCBHC Expansion Grant, JAMHI will serve adults with Serious Mental Illness (SMI), children with Serious Emotional Disturbance (SED), adults and children with substance use disorder (SUD), and adults and children with co-occurring mental illness and SUD (COD), in the City and Borough of Juneau catchment area, which has a population of 32,434. Project goals and measurable objectives: Goal 1: Clients can access appointments during convenient hours. Objectives: (1a) By month 4, JAMHI will add staffing to expand operating hours. (1b) By month 4, JAMHI will offer expanded hours. (1c) By month 8, 200 people will access JAMHI’s expanded hours. Goal 2: JAMHI will begin Assertive Community Treatment (ACT). Objectives: (2a) By month 2, half of the ACT team will be in place. (2b) By month 4, ACT services will start. (2c) By month 9, the full ACT team will be in place. (2d) By month 18, the ACT team will be serving 100 people. Goal 3: JAMHI will offer services for children/youth with SED/SUD/COD and their families. Objectives: (3a) By month 3, JAMHI will hire and train 2.0 FTEs for this service. (3b) By month 4, JAMHI will begin services. (3c) By month 4, JAMHI will be providing 24-hour crisis intervention services for youth and their families. (3d) By month 12, 50 children/adolescents will receive services. Goal 4: JAMHI will provide expanded psychiatric rehabilitation services. Objectives: (4a) By month 3, JAMHI will hire and train a 1.0 FTE Employment Specialist. (4b) By month 4, JAMHI will offer the EBP of IPS. (4c) By month 12, 15 individuals will receive these services. Goal 5: Service members and veterans can access culturally relevant CCBHC services. Objectives: (5a) By month 2, JAMHI will incorporate military culture considerations into their cultural competency plan. (5b) By month 3, 100% of JAMHI staff will receive training in military culture. (5c) By month 6, 100% of staff will be approved to provide services to both active service members and veterans. Goal 6: JAMHI will conduct a comprehensive compensation study. Objectives: (6a) By month 6, JAMHI will engage a consultant to conduct the study and provide recommendations. (6b) By month 12, JAMHI will incorporate recommendations into a recruitment and retention plan. Strategies/interventions will include EMDR, Motivational Interviewing, Dialectical Behavioral Therapy (DBT), Prolonged Exposure Therapy, Narrative Exposure Therapy, Cognitive Behavioral Therapy, Twelve Step Facilitation Therapy, SBIRT, Assertive Community Treatment (ACT), Individual Placement & Support (IPS), Positive Youth Development (PYD), Transition to Independence Process (TIP), and Medication Assisted Treatment (MAT).
|1 H79 SM083286-01||
Certified Community Behavioral Health Clinic, ACMHS Abstract: Anchorage Community Mental Health Services seeks SAMHSA support to become a Certified Community Behavioral Health Clinic (CCBHC) providing comprehensive services to children, youth and adults experiencing severe emotional disturbance (SED), severe mental illness (SMI), substance use disorders (SUD) and co-occurring disorders (COD.) Services will reduce symptoms, improve functioning and improve health outcomes. As a CCBHC, ACMHS will serve Alaska’s metropolitan area as defined by the U.S. Census Bureau, 2019: the Anchorage Municipality and Fairbanks/North Star Borough. This catchment area is 9,042 square miles (larger than New Jersey) and has a population of 390,509 (US Census Bureau estimate, 2018). 53.4% of Alaska’s population resides within this catchment area. Data identify critical shortages of services for children, transition age youth and adults who experience SED, SMI, SUD and COD, with acute shortages in available SUD and COD treatment. ACMHS will improve outcomes (symptom reduction, functional improvement, improved health outcomes) for children and youth who experience SED by improving access to services and expanding wrap around services. ACMHS will improve outcomes for adults experiencing SMI (symptom reduction, functional improvement, physical health improvement, maintain population in community setting) by improving access to services and implementing and expanding available evidence-based practices. ACMHS will improve outcomes (symptom reduction, substance use reduction, functional improvement) for transition age youth and adults experiencing SUD and (COD), expanding treatment capacity at ACMHS by training providers in SUD and COD treatment. ACMHS will improve client health outcomes by integrating primary care and by implementing best practices in psychiatric medical care. ACMHS will expand and develop the current workforce to support the above activities and obtain certification as a CCBHC. ACMHS will use four strategies, make improvements and expand existing services, develop services to address the acute shortage of SUD and COD services, expand and develop our workforce, and implement improvements in primary care integration and psychiatric medical practices. Unduplicated to be served using grant funds: Year 1 (8/30/2020-8/29/2021) 500 SED children and youth unduplicated, 2,200 SMI/SUD/COD adults unduplicated. Year 2 (8/30/2021-8/29/2021) 600 SED children and youth 2,400 SMI/SUD/COD adult unduplicated. Total to be served during project, unduplicated, current served plus new admissions: 4,300 SMI/SUD/COD adults, 1,360 SED/SUD/COD children and youth.
|1 H79 SM083195-01||
Ouachita Behavioral Health and Wellness [OBHAW], comprehensive behavioral health provider, will use CCBHC expansion funds to implement a Service Expansion Project, a recovery-oriented rural network of crisis outreach, integrated treatment, and health monitoring, ACT and recovery support with multiple contact points for adults, families, and children/youth with significant behavioral health needs in five rural counties in South Central Arkansas. The Project will serve adults with SMIO, COD, SUD, and OUD and children/youth with SED. The area has very high rates of opioid prescriptions and suicide, and rates of depression and diabetes are significantly higher than national rates. The total area population is 174,513, county populations range from 72-92% white, < 1 to 24% African-American, and 3 to 7% Hispanic. Strategies and interventions include Mobile Crisis Outreach, an ACT Team, Outreach Case managers for care transitions, coordination of care with primary providers, clinical monitoring of chronic disease indicators multiple EBPs for the populations of focus, telehealth, use of Enhances Illness Management and Recovery tools and the MyStrengths mobile/internet platform. Project goals are: 1) Improve the capacity of rural Arkansas adults with SMI and COD and youth with SED to achieve recovery from behavioral disorders and community stability through a team-based, "no wrong door model" of comprehensive, integrated, evidence-based treatments; and 2) Persons with SMI, COD, SUD, or SED and chronic health conditions will improve self-management of co-occurring conditions and increase access to community support systems through the delivery of care coordination, Assertive Community Treatment, case management, and peer support. Objectives include: 90% of CCBHC clients and families involved in a face-to-face psychiatric or substance-related crisis incident will have at least 2 contacts with outreach staff in the week following the incident; 80% of children/youth with SED will demonstrate a 30% or greater reduction in traumatic stress symptoms, as measured by Trauma Symptom Checklist for Children; 70% of clients enrolled in integrated treatment for COD/SMI will demonstrate a 20% or better improvement in psychosocial functioning after a 6 months of enrollment; 50% of clients engaged in SUD and OUD treatment will indicate no past 30-day substance use related to the specific SUD after 6 months of outpatient treatment; 90% of enrolled CCBHC clients with chronic health conditions will have a care coordination plan with identified DCO primary care providers completed within 3 weeks of project enrollment; 95% of CCBHC clients with SMI or COD will receive clinical health monitoring by medically trained staff at 3-month intervals; 80% of persons with SMI and COD enrolled in ACT services will have received a weekly minimum of 90 minutes of face-to-face contact with team members; 80% of clients linked with community support services will receive at least 2 contacts from case managers or peer support staff in community settings within 3 months of engagement. The project will enroll 415 new unduplicated adults and children/youth in Year 1, 620 in year 2 and 1035 for the Project.
|1 H79 SM083302-01||
Funding support from SAMHSA through CCBHC Expansion Grant will allow Western Arkansas Counseling & Guidance Center, a private, non-profit CMHC providing services for over 48 years, to become a Certified Community Behavioral Health Clinic to advance primary-behavioral health integration, meet service gap needs and use evidence-based practices to increase services to 2,000 new children and adults in 6 Arkansas counties with mental and/or behavioral health disorders, including opioid disorders. (Y1: 900; Y2: 1,100). The catchment area is the 6 most western counties in Arkansas: Crawford, Franklin, Logan, Polk, Scott, and Sebastian. The majority of the geographic area is extremely rural with the urbanization concentrated in Fort Smith. The 6 counties are HRSA-designated Medically Underserved Areas and Health Professional Shortage Areas in primary and behavioral health domains. The target population: children (0+) with Serious Emotional Disturbance (SED) and persons of all ages who have or are at risk for: 1) Serious Mental Illness (SMI) 2) Substance Use Disorders (SUD), including opioid disorders 3) Co-occurring mental health and SUD (COD). WACGC serves 8087 current active clients. The catchment area is approximately 83% White, 14% Hispanic, 7% Black or African American, 5% Asian, and 2% Native American. Funding issues in Arkansas have resulted in recent closures of behavioral health agencies, 3 in our direct service area. WACGC provides the only comprehensive behavioral healthcare system in the western region. The community has identified the need to provide seamless integrated care to persons at risk/or justice involved who are in a cycle of jail, crisis, or treatment. At risk/or youth in detention centers receive no services when detained. The entire population with SMI, SUD, SED, COD, and other complex issues such as trauma, foster care, LGBTQ, or Veteran status will all benefit from access to integrated care on one campus with telemed capabilities. Goal 1: Raise the standard of care by meeting all CCBHC criteria (first 4 months YI). Objective 1.1: Expand the scope of services; staffing; accessibility; and care coordination Goal 2: Increase the provision and scope of services offered by 25% to the target population. Objective 2.1: Enhance the workforce to persons at-risk or detained with behavioral health and/or SUD. 2.2: Provide additional EBP training, including SUD treatment, to all clinical staff involved in the care of the target population. 2.3: Multidisciplinary Treatment teams, law enforcement, medical providers, and other pertinent stakeholders will work with identified clients within the community setting, to implement Assertive Community Treatment (ACT). 2.4: Develop and implement a vaping/smoking cessation outdoor challenge program for youth Goal 3: Increase availability and timely access to integrated care to the target populations across the lifespan Objective 3.1: Enhance the workforce and office space for integrated care and care coordination 3.2: Provide staff with training on integrated care for persons with behavioral health and/or COD issues using the SAMHSA four quadrant integration model. 3.3: Create a mobile mental health team that will take mental health services to the target population through the use of an adapted recreational vehicle.
|1 H79 SM083041-01||
Mid-South Health Systems' CCBHC Project will focus on individuals with serious mental illnesses, substance use disorders; children and adolescents with serious emotional disturbances; and individuals with co-occurring mental illness and substance use disorders. MSHS is the Community Mental Health Center servicing 20 Counties in Eastern Arkansas. The Catchment area is inclusive of the Mississippi Delta Region, an area plagued with many problems such as abject poverty, high crime, poor health and myriad issues related to substance use and mental illness. For the purposes of the current project, efforts will focus primarily on 3 counties within MSHS' Catchment Area- Craighead, Crittenden and Mississippi Counties. MSHS' CCBHC Project goas are to expand access to comprehensive behavioral health services that meet the criteria for CCBHCs to individuals with SMIs, SEDs, SUDs and CODs in Craighead, Crittenden and Mississippi Counties, Arkansas. Secondly, to expand the array of behavioral health services and support offered in the CCBHC's Catchment Area. It is also our goal to deliver integrated care for behavioral health and physical health risks and needs; and finally to ensure sustainability of the CCBHC Project Services in the target area. Over the course of the project it is anticipated that 185 individuals will be served annually and 370 individuals over the lifetime of the project.
|1 H79 SM083280-01||
Prototypes, a program of HealthRIGHT 360 (HR360), provides a comprehensive range of mental health and substance use disorder treatment to people in Southern California, with a focus on pregnant/parenting women. Project Enhancing Access to Comprehensive Healthcare (EACH) will improve integration between behavioral and primary health services for our client population by partnering with Parktree Community Health Center, which is our designated collaborating organization for this project. Women, particularly pregnant and parenting women, have unique behavioral and primary health needs that the Prototypes CCBHC will address. We will utilize a variety of evidence-based interventions to increase client wellbeing, including parent child therapies (Parent Child Interaction Therapy and Child Parent Psychotherapy) that are demonstrated effective at improving familial relationships. We will also utilize the Full Service Partnership evidence based model, which is based on Assertive Community Treatment. FSP programs, which Prototypes already provides, offer intensive, individualized care coordination to high need individuals with severe behavioral health issues. Other evidence based interventions to be used include CBT, DBT, and Motivational Interviewing. The goal of the Prototypes CCBHC expansion is to integrate primary care and behavioral health services for behavioral health clients receiving services at Prototypes Pomona Family Campus. The following outcomes are to be achieved: 100% of clients will be offered screening for HIV and Hepatitis A, B, and C upon intake; program leadership will establish care coordination procedures, hire staff, and acquire the necessary equipment to provide transportation between the Prototypes and Parktree by December 30, 2020; program leadership will create and implement (by December 30, 2020) an in depth physical health questionnaire to be provided to 100% of new clients during intake by December 30, 2020; and 100% of clients with unmet primary healthcare needs, as identified in the physical health questionnaire, will be referred to Parktree and offered transportation. With the CCBHC Expansion grant funds, Prototypes will serve 512 unduplicated clients annually and 1024 unduplicated clients over the entire project period of 2 years.
|1 H79 SM083044-01||
As a consortium, Uplift Family Services (UFS) and designated collaborating agencies, School Health Center of Santa Clara (SHC) and Pacific Clinics (PC) are seeking to become a Certified Community Behavioral Heath Clinic for the purpose of increasing access to and improving the quality of community mental and substance use disorder treatment by integrating services with physical health. The target population is unrepresented and under represented low-income families through Santa Clara County, with focus on individuals that live in the Washington Clinic neighborhood whereby most residents are Hispanic, Lantinx and non-English speakers. While operating as separate entities, services will be delivered in an integrate manner within a single clinic in San Jose, California to allow for more comprehensive assessment and treatment of physical, mental health, and substance use disorders in a manner that is less likely to be stigmatizing, more consistent with the target community's help-seeking behaviors, and relatively seamless in care. UFS behavioral personnel will be integrated with SHC physical health personnel. Experts in adult behavioral health, Pacific Clinics will provide telepsychiatry, training, and consultation. We expect to serve 2000 unduplicated clients over the two years. Our goals are: Goal 1. Increase access to outpatient community mental health and substance use disorder treatment for un/underrepresented communities through outreach and engagement and insurance enrollment assistance so that they can access needed behavioral health treatments. 1A. To increase access for the uninsured population. 1B. To increase the number of insured children and adolescents receiving mental health treatment. 1C. To increase the number of insured adults receiving mental health treatment. 1D. To increase access to behavioral therapy for adults receiving MAT. Goal 2. Increase the availability of high-quality behavioral health services by implementing evidence-based treatment to decrease symptoms that impact daily functioning. 2A. To increase the use of evidence-based treatment for children and adolescents with trauma. 2B. To increase use of evidence-based practices for mental disorders among adults. 2C. To increase substance use prevention and treatment among children/adolescents. 2D. To increase the use of behavioral therapy for individuals receiving MAT. Goal 3. Provide an array of behavioral health services in a single location to improve access and minimize barriers for unrepresented and underrepresented, hard-to-reach population. 3A. To increase integration of physical health and behavioral health services by providing more comprehensive assessments at each visit. 3B. To increase integration of physical health and behavioral health treatment by improving coordination between primary care physicians and behavioral health treatment teams to improve client outcomes and increase client satisfaction. 3C. To develop a continuum of outpatient behavioral health services for children and adolescents in the catchment area. 3D. To develop a continuum of outpatient behavioral health services for adults in the catchment area.
|1 H79 SM083234-01||
La Maestra’s Certified Community Behavioral Health Clinic (CCBHC) will serve low-income, uninsured and underinsured individuals in central, east and south San Diego County, California. The overall goal of this project is to stabilize people in crisis by increasing access to comprehensive behavioral health services including substance use disorder services (SUDS) by working with the existing established county-wide network to provide: 24/7 crisis intervention services for individuals with serious mental illness (SMI) or SUD patients, including opioid use disorders; children and adolescents with serious emotional disturbance (SED); and individuals with co-occurring mental and substance disorders (COD). La Maestra expects to achieve this goal by reaching the following objectives: 1) screen a minimum of 8,000 patients annually for SUD and/or COD using evidence based screening tools or 16,000 patients during the two year project period; 2) provide comprehensive outpatient mental health and SUD to 2,000 individuals annually or 4,000 over the two year project period; 3) conduct at least 3,000 HIV and viral hepatitis screenings annually; 4) provide onsite MAT services for a minimum of 150 adult patients annually; and 5) offer and provide onsite primary care, behavioral health, and social services to 80% of all patients served at the CCBHC through comprehensive case management. In 2019, La Maestra served 45,716 patients. According to 2019 clinic data, 84% of patients served are living at or below 200% of the federal poverty level, 26% of patients are uninsured and 68% are underinsured. In addition, 58% of patients are Hispanic/Latino and 60% prefer to be spoken to in a language other than English. According to the 2018 California Health Interview Survey (CHIS), 24.6% of adults in the service area reported needing help for self-reported mental, emotional and/or alcohol or drug use and did not receive treatment. Additionally, 40.8% of teens reported needing help for mental health problems, a 21.8% increase since the last survey done in 2016. Furthermore, 174,000 people out of 1,072,000 surveyed reported seriously thinking about committing suicide in 2018. This suggests a need for increased access to comprehensive behavioral health and SUDS to stabilize people and respond to health and wellness needs in the service area. La Maestra will adhere to current Evidence Based Practices (EBP) and expand its Family Wellness Unit and Wellness Supportive Services departments to become a CCBHC within 120 days of grant award. La Maestra has a proven track record of opening new clinic sites and obtaining certifications including patient centered medical home (PCHM) Level III, the highest level of PCMH recognition. Additionally, all performance assessments and evaluations for this program will be conducted by Dr. Andrew Sarkin, Ph.D., an independent, third party evaluator from the University of San Diego’s Health Services Research Center (HSRC). HSRC is a comprehensive research unit that was established in 1991. Dr. Sarkin has over two decades of evaluation experience in behavioral health and clinical psychology.
|1 H79 SM083242-01||
San Ysidro Health (SYHealth) proposes to deliver comprehensive mental health and substance use disorder services (SUD) for San Diego County’s low-income populations. As San Diego County’s potentially first dual Federally Qualified Health Center (FQHC) and CCHBC (Certified Community Behavioral Health Clinic) entity, SYHealth will serve residents regardless of their ability to pay, with CCBHC services prioritized for patients experiencing Serious Mental Illness (SMI). Priority will be expanded as SYHealth’s CCBHC operations grow. As a dual FQHC-CCBHC entity, SYHealth will be uniquely positioned to provide seamless care to patients of all levels of illness by: (1) prioritizing patients with highest needs (SMI patients) for SYHealth’s new CCBHC system of care; and (2) serving mild-to-moderate patients via SYHealth’s existing FQHC Behavioral Health Services infrastructure, as well as its existing FQHC primary care services via collaboration of its behavioral health and medical providers. CCBHC patients who have stabilized and are no longer in need of SMI clinic services will be moved to SYHealth’s FQHC Behavioral Health clinics, thus allowing for ongoing capacity to serve other patients in need of more intensive care. SYHealth’s goal is to increase access to behavioral health and SUD services by operating a sustainable FQHC-CCBHC entity in San Diego County, thereby providing a healthcare home to residents with complex mental health and SUD needs. To achieve this goal, SYHealth proposes the following objectives: 1. By December 31, 2020, SYHealth will obtain CCBHC certification from California Department of Health Care Services (DHCS). 2. By August 29, 2022, SYHealth will serve a total of 400 CCBHC patients (~200 unduplicated per year). 3. By August 29, 2022, 80% of CCBHC patients presenting a need for medical and/or oral health care will be referred to SYHealth’s FQHC primary care program. 4. By August 29, 2022, 90% of CCBHC patients who are at risk for and/or living with HIV will be referred to SYHealth’s HIV Services Program. 5. By August 29, 2022, 90% of low income CCBHC patients with complex healthcare needs will be referred to SYHealth’s DHCS care management programs.
|1 H79 SM083082-01||
Chinatown Service Center (CSC) is seeking to expand our organization to establish the first CCBHC in California. CSC's proposed CCBHC site is located in Alhambra, at 320 S. Garfield Avenue. Our population of focus will be adults and children with a behavioral health diagnosis, including Severe Mental Illness, Severe Emotional Disturbance, and Substance Use Disorders. Los Angeles (LA) County is organizing eight Service Planning Areas (SPA); our proposed catchment area is SPA 3, also the location of our CCBHD site. In SPA 3, the primary racial groups are Hispanics (46.0%), followed by Asians (29.0%). Clinical characteristics of SPA 3 demonstrate the need for the CCBHC: a) 46.1% with SED/SMI did not utilize mental health services; b) 36.0% of adults who tried to access mental health, reported it was difficult to access care; c) the prevalence of Asians with SED/SMI is two to ten times higher than all other LA County SPAs; d)11.4% Medicaid enrolled individuals are estimated to have SED/SMI; e) 11.0% adults are at-risk for major depression; and f) 30.0% of those incarcerated in the LA County jail system have mental illness, nearly twice the U.S. estimate (16.9%). CSC proposes to serve 10,500 unduplicated patients each year, with a total of 21,000 patients projected to be served over the two-year grant period. Based upon the demonstrated need for expanded behavioral health care in SPA 3, CSC has developed the following CCBHC program goals, which are in addition to and separate from other performance measures required by the CCBHC criteria. Program objectives include: 1) By the end of grant, conduct outreach within 8 locations to reach 150 SED youth, with 75% becoming CCBHC patients; 2) By the end of the grant, conduct outreach within 8 locations to reach 200 patients with SMI, with 75% becoming CCBHC patients; 3) Within 6 months, develop a resource guide addressing emotional and social support/resources with SPA 3, distribute 80,000 resource guides by the end of the grant; 4) By the end of the grant, provide depression screenings for 2,000 patients, referring positive screenings, with 75% of referrals yielding an appointment; 5) For each grant year, provide transportation to 300 patients, with 75% of patients receiving vouchers attending scheduled appointments; 6) For each grant year, conduct community outreach at 8 fairs or events to raise awareness of the CCBHD program, reaching 3,500 individuals by the end of the grant; 7) Within six months of award, provide cultural competency training to 90.0% of CSC providers and selected DCO and partner staff; and 8) By the end of the grant, identify 200 individuals with mental health or SUD disorders, previously incarcerated and/or soon to be released, and refer to CSC's CCBHC, with 75% of referrals yielding an appointment. CSC is a long-established, multi-service agency with Federally Qualified Health Center (FQHC) designation; we already meet much of the criteria to become a CCBHC. Further, CSC has ample experience serving patients within the population of focus. We are confident that our proposed approach/timeline will allow for CCBHC certification within four months of award.
|1 H79 SM083312-01||
Project Name and Summary: Mental Health Partners' (MHP) Certified Community Behavioral Health Clinic Expansion Growth Initiative will 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. MHP will increase access to care, add workforce capacity, and implement new Intensive Outpatient Programs. Population to Be Served: Individuals of all ages who have or are at risk of a mental illness or substance use disorder, including those with co-occurring disorders. Focus on three key underserved populations to reduce disparities in access to care and health outcomes: Hispanic/Latinx individuals and families, low income families, and military service members/veterans and their families. CCBHC Expansion will enable MHP to expand services to a total of 1,450 individuals annually via increased care coordination, primary care/behavioral health integration, and Intensive Outpatient Programs, for a total of 2,900 over the 2-year project. MHP serves an annual average of 14,500 throughout all clinical programs, all of whom will benefit from the quality improvements facilitated by CCBHC support. Strategies/Interventions: Certified Community Behavioral Health Clinic required services will be delivered through MHP's Behavioral Health Home and specialized outpatient model of care to deliver a comprehensive spectrum of mental health, addictions, crisis, 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. Project Goals and Objectives: Goal 1: Grow the direct service workforce to enhance service availability and interoperability, and to improve access to care specifically for target population and identified subpopulations. Goal 2: Implement new clinical services targeting the highest behavioral health needs for the target population and subpopulations of focus by adding new Intensive Outpatient Programs, adding integrated care models along the IPAT spectrum, and increasing standard and complex care coordination to address growth and complexity of co-occurring conditions. Goal 3: Strengthen health information technology (HIT) to facilitate client engagement, expert clinical decision-making, and demonstration of effectiveness of services to payers by achieving CMS Promoting Interoperability Programs 2020 objectives and measures, improving data management and analysis processes, and enhancing program evaluation capability. Goal 4: Improve cost analysis and reporting methodology by capitalizing on Colorado's already-strong cost reporting processes to review and shift MHP's and the State's ability to inform alternative payment systems and cost reporting requirements for CCBHC.
|1 H79 SM083190-01||
Project Name and Summary: Aurora Community Mental Health Center, d/b/a Aurora Mental Health Center (AuMHC) proposes to become a Certified Community Behavioral Health Clinic to increase access to coordinated mental health, substance use, medical, recovery supports and intensive services for individuals who have or at risk of a behavioral health condition, as well as building staff expertise and capacity for population health management. Population to be Served: individuals who have or are at risk for a mental illness or addictions disorder, including individuals with co-occurring disorders. We will focus on three key underserved subpopulations to reduce disparities in behavioral healthcare access and outcomes: refugees, aslyees and immigrants; individuals experiencing homelessness; and members of the Armed Forces and Veterans. Strategies/Interventions: We will integrate best practices for high risk populations to elevate our standard of care, building our staff expertise, evidence-based treatment modalities, and population health management capacity to become a trauma center of excellence. Key activities include: integrating CCBHC standards into all aspects of operations; investment in technology solutions and infrastructure to increase system functionality; staff training to improve clinical competency and culturally-responsive and person-centered care; building capacity for data-driven performance monitoring and improvement activities; centralizing client access to care, and creating an Advisory Workgroup and other feedback mechanisms to improve client experience of care. Project Goals and Measureable Objectives: Goal 1 is to elevate standard of care by achieving CCBHC standards, as measured by updating and operationalizing policies and workflows, increasing Program Analyst, Training, Information Systems, and Quality staff, and establishing a Quality Improvement Plan. Goal 2 is to improve client experience of care by increasing client feedback mechanisms and implementing strategic initiatives to address client-identified barriers to care, as measured by completing a community needs assessment, establishing a centralized contact center, administering client satisfaction surveys, providing staff training in customer service, and establishing an Advisory Workgroup. Goal 3 is to increase capacity to effectively treat clients through training and population health management, as measured by training staff in evidence-based practices and addictions counseling, establishing logic models and key outcomes for clinical programs, and developing data dashboards for population health monitoring. Goal 4 is to increase capacity to conduct data-driven performance improvement activities by increasing use of technology, staff data literacy, and technology functionality, as measured by building interoperability between electronic health record, human resources information system, general ledger and training management platforms, and completing technical enhancements to the electronic health record and training management systems.
|1 H79 SM083209-01||
BHcare, the Local Mental Health Authority for the Lower Naugatuck Valley and the Shoreline regions of Connecticut, proposes to establish CCBHC locations in Branford and Ansonia that are focused on providing coordinated primary and behavioral healthcare, integrated behavioral health services for children and their families, and comprehensive mobile crisis services that are available to our community 24x7x365, all while systematically improving the quality of our care. We intend to grow our clinics' capacity to 2,750 unique individuals in year one, and 3,000 in year two of the grant period. Our proposal has five goals, 1) to fully implement the required services within the CCBHC model, 2) to integrate behavioral health and medical services in both our clinic sites, 3) to offer behavioral health services to children as part of comprehensive service provisions to the entire family. 4) to increase the availability of crisis services, and 5) to increase care quality through measured-based care and training improvements. We intend for our CCBHC to collaborate with leading health and behavioral health organizations in the region including Clifford Beers, CommuniCare, Fair Haven Community Health Center, Griffin Hospital, and Stonington Institute in order to offer comprehensive, coordinated, and integrated care. To do this, we intend to hire two children's behavioral health clinicians, four Registered Nurses, two Medical Assistant, three clinicians to provider Assertive Community Treatment, one Project Evaluator, and one data analyst. We propose to enhance the training of our staff in order to offer four evidence-based models of car. Primary Care Access, Referral, and Evaluation (PCARE) will facilitate the integration of our behavioral health and primary care services. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) will enable us to prove short-term, family-centered treatment for children. We will implement the Columbia-Suicide Severity Rating Scale (C-SSRS) Risk Assessment and Safety Planning model in all of our crisis services. And throughout our services, we will implement Measurement-Based Treatment (MBT) to Target, so that all of our clients received care that is driven by their achievement of their personal goals. In addition, all of our staff will receive annual training in military cultural competency in order to ensure that Veterans feel comfortable, welcome, and cared for in BHcare's service system. BHcare has been moving for many years in the direction of the comprehensive, coordinated, integrated model that CCBHC represents, and we look forward to becoming CCBHC certified within four month of grant award.
|1 H79 SM083106-01||
Critical support from SAMHSA, through a CCBHC Expansion Grant, will allow CHR, Connecticut's most comprehensive, non-profit behavioral healthcare agency and the only agency to meet all CCBHC criteria, to immediately enhance its existing services for children, families, and adults with mental illness, substance use disorders, opioid use disorders, and serious emotional problems. CHR's proposal, called CT Now, builds on the groundbreaking work CHR started with SAMHSA in 2018 to expand 24/7 crisis care; enhance engagement strategies to help individuals connect with life-saving addiction services; add new behavioral health resources for veterans and their families; and launch a Family Medicine clinic for CHR clients. CT Now takes those initiatives a step further, adds more integrated care services for children and families, and fosters sustainability planning for all of these life-saving programs. The population to be served includes adults with serious mental illness, substance use disorders (including opioid use disorders) and co-occurring disorders, as well as youth with serious emotional disorders in 20 towns in central Connecticut. This is an area that has been hard hit by the opioid use crisis, with 89 overdose deaths in 2019. About 30% of households earn less than the basic cost of living and data indicates critical gaps in care for youth and adults with unmet mental health and integrated care needs. To expand services in the region, goals, strategies and interventions will include expanding crisis stabilization services to mitigate high risk behaviors; sustaining and expanding integrated care services for people of all ages; enhancing recruitment and retention efforts of clinical staff so CT Now goals are met; and expanding access to evidence-based wellness programming for people of all ages. Measurable objectives will include providing same-day access to MAT for OUD referrals by month 5; providing same-day access to Psychiatric Evaluation with and MD or APRN for individuals with acute symptoms of SMI; using peer staff to increase engagement by 75% with individuals who had a recent hospitalization or crisis assessment; expanding Saturday business hours by month 4 in 2 locations; providing vaping education to youth; screening for HIV and viral hepatitis (A, B, and C) in individuals with SUD and high-risk behaviors and linking 75% of newly diagnosed to infectious disease specialist by month 3; expanding CHR Family Medicine from 20 to 40 hours a week by month 3; implementing EBP Collaborative Care Model (CoCM) uniformly across CHR sites; leveraging the work of a dedicated CHR HR recruiter to help recruit strategically-needed clinical staff and working with the Associate Medical Director to enhance retention through mentoring, CEU reimbursement and more; and expanding access to EBP wellness programming. We expect to serve approximately 450 unique clients of all ages annually through CT Now and 575 through the two-year period.
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Recovery Network of Programs, Inc. (RNP) and its three Designated Collaborating Organizations (DCOs)—the Child & Family Guidance Center, Inc. (CFGC); Greater Bridgeport Community Mental Health Center, Inc. (GBCMHC); and Optimus Health Care, Inc. (Optimus)—propose the RNP Certified Community Behavioral Health Clinic (CCBHC), which will expand access to quality treatment for substance use disorders (SUD), SUD prevention, serious mental illness (SMI), and co-occurring mental and substance use disorders (COD) by licensed providers. The RNP CCBHC will deliver its services to residents of Bridgeport, Connecticut, and the surrounding area. RNP will focus on serving men and women with COD, their partners who have COD, and their children who have been affected by their parent(s)’ illness(es). RNP’s innovation will be the creation of comprehensive and fully integrated primary care, SUD, SMI, and COD prevention and treatment services using artificial intelligence to facilitate population health management, effectively enabling RNP CCBHC to access the databases of all four Partners. Combined with RNP’s existing tele-health capacity, RNP and its partners will be able to more effectively collaborate on treatment planning and address crises and other untoward events together with all of the practitioners involved in a POF member’s treatment. Specifically, the RNP CCBHC will bring these services to 375 POF members in Year 1 and 425 in Year 2 (800 total). To reach that total, RNP and its DCOs anticipate screening 500 individuals each year who are not currently connected to treatment. The goals of the proposed Project are as follows: expand the number of POF members that receive comprehensive SUD/SMI/COD treatment by 800 over the two-year project period, improve the efficacy of treatment and prevention services, reduce substance use among the POF, reduce the severity of symptoms and improve adherence and compliance with treatment, reduce relapses requiring hospitalization, increase the subjective sense of participants’ well-being, and improve their quality of life. RNP’s CCBHC will focus outreach and engagement efforts on members of the POF that appear to have the most serious needs, or have reached the point where they are ready to make positive changes in their lives, but do not know where to turn. The proposed project will significantly reduce hospital admissions, length of stay, and emergency department (ED) visits by POF members over their use of inpatient and ED services in the prior year. The RNP CCBHC also anticipates working with child welfare to reduce out-of-home placements by helping POF members to be better parents. In addition, the project will result in fewer babies born with Neonatal Abstinence Syndrome and/or low birth weight. Finally, because of early intervention and improved adherence to treatment, RNP anticipates year-over-year improvements in these statistics within the two-year project period, as well as when measured against prior years. These outcomes are made possible by using the predictive power of the project’s software to plan interventions that are both timely and effective with the POF.
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Through Project Connect, Bridges plans to implement a comprehensive and innovative continuum of care that enhances access to vital mental health and substance abuse services, physical health screenings and primary care in Milford, West Haven, Stratford, and Orange, CT and beyond. Bridges enhanced access targets the most difficult to engage and high-risk individuals who often present with polysubstance abuse and severe mental health issues. An ACT service delivery model will be implemented at a new clinical site in West Haven. This model will focus on recovery and rehabilitation through the range of services offered by Bridges, including case management, care coordination, crisis intervention and stabilization, peer support, medication management, clinical services that are supported by evidence-based practice and access to vocational and social rehabilitation services. Bridges also plans to expand its mobile medication assisted treatment program to include physical health screenings, testing for HIV and hepatitis and primary care services. The expanded mobile van will travel to designated areas in West Haven and Milford where clients can access peer recovery support and induction for Suboxone. Through strengthened partnerships among community stakeholders, Bridges is launching a school-based health center with Optimus Healthcare (a federally qualified health center) at West Haven High School in April 2020 to provide both primary care and behavioral health services. This partnership along with the service expansion under Project Connect will create a continuum of services in West Haven, where many of the most vulnerable and clinically complex clients can access comprehensive services. Bridges will also be working toward providing pediatric primary care at its main site located in Milford, where integrated adult primary care is currently offered by Optimus. Outpatient clinical services will be expanded to Stratford to provide an access point to CCBHC services in that area. Bridges aims to serve a total of 2,150 unduplicated adults and children in year one and 2,300 unduplicated adults and children in year two. Physical health screenings will be provided to 200 people accessing the mobile primary care/medication assisted treatment services. 75% of those seeking medication assisted treatment on the mobile clinic will be tested for HIV and Hepatitis and 100% of those will be referred to a specialty clinic for referral if they test positive. Primary care will be provided to 100 children at the Milford location.
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Through SAMHSA’s Certified Behavioral Health Clinic Grant Program (CCBHC), Community Mental Health Affiliates, Inc. (CMHA), will increase access to and improve the quality of community mental health, substance disorder, and co-occurring treatment services among adults, youth, and families in Central CT. The CCBHC will provide 24 hour/7-day access to community-based mental health, substance abuse, and co-occurring disorder treatment integrated with an on-site Federally Qualified Health Center. The CCBHC service population includes adolescents and adults with serious mental illness (SMI), substance abuse disorder (SUD), and co-occurring disorders (COD), as well as children with serious emotional disorders (SED) in CMHA’s Central CT service area: Berlin, Bristol, Burlington, Kensington, New Britain, Plainville, Plymouth, Southington, and Terryville. US Census/agency data shows a target population of 238,618: 194, 180 ages 18+, 19,759 ages 12-17 and 24,679 ages 4-11. CMHA is the only Central CT provider which offers the full array of CCBHC services to a population of primarily indigent children and adults. In Fiscal Year 2019, CMHA served 4,050 clients - 3,770 adults over age 18 and 280 children ages 4-18; (70%) are from New Britain; 43% are Caucasian, 39% are Latino (a majority Puerto Rican), 12% are African-American, 6% are other/unknown. 95% fall at/below 200% of the Federal Poverty Level, with 77% on Medicaid, 19% on Medicare; 14% and .8% have a primary language of Spanish and Polish, respectively. Agency and community data indicates need for more Open Access hours, Medication Assisted Treatment (MAT), Veteran/Military services, Targeted Case Management (TCM), Assertive Community Treatment (ACTT), and treatment for Autism Spectrum Disorder (ASD) youth. CCBHC Goals include: 1) To equip CCBHC staff with the skills and knowledge of evidence-based practice (EBP) by providing EBP model staff training (Motivational Interviewing/ Cognitive Behavioral Therapy (MI/CBT), Trauma, Recovery and Empowerment Model (TREM), Seeking Safety, Trauma-Focused Cognitive Behavioral Therapy, Modular Approach to Therapy (MATCH); 2) To reduce the incidence of death by drug overdose, suicide, and self-harm by increasing the availability 24/7 Mobile Crisis Teams and Open Access Clinic hours. 3) To reduce high risk behaviors, substance abuse, trauma symptoms, and improve behavioral health and daily living skills among target adults by expanding outpatient, telehealth, Assertive Community Treatment and Targeted Case Management. 4) To reduce behavioral and trauma symptoms and improve child/adolescent functioning by expanding EBPs for children/adolescents with SED/ASD. 5) To reduce chronic disease and premature death among adults and children by embedding the Community Health Center (CHC) into the CCBHC and further integrating primary and behavioral health care. 6) To reduce smoking and promote wellness and recovery by providing care management and recovery support groups. 7) To meet CCBHC goals/objectives by creating project management/governance structures. The CCBHC will serve a total of 2,510 unduplicated consumers.
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InterCommunity Health Care (IC) is seeking to expand its integrated whole-person primary care, mental and behavioral health, and substance use disorder recovery services through the Certified Community Behavioral Health Clinic (CCBHC) Expansion Grant to children, adolescents, adults, veterans, individuals experiencing homelessness, individuals who were formerly incarcerated, and individuals at-risk for HIV/HCV who have serious mental illness (SMI), substance use disorders (SUDs), opioid use disorders (OUDs), serious emotional disturbance (SED), and mental health and SUD comorbidities within IC’s 16-town catchment area in Connecticut’s Greater Hartford region. IC will become certified as a CCBHC at our 3 major health centers in Hartford, East Hartford, and South Windsor, Connecticut. IC currently provides comprehensive behavioral health services at its longstanding East Hartford service site and will expand these comprehensive, co-located, whole-person services into its Hartford and South Windsor locations, in addition to expanding agency-wide crisis services to 24/7. IC will use expand the use of evidence-based treatment that comprises of Medication Assisted Treatment (MAT) as a primary EBP and will use integral EBPs in conjunction with MAT that includes Cognitive Behavioral Therapy. IC will provide services for 550 unduplicated persons in year 1 of the grant period and in will serve 800 unduplicated persons year 2 of the grant period. To address critical needs and improve access to integrated healthcare for low-income, underserved populations in IC’s catchment area, the following goals and subsequent measurable objectives will be achieved: (1) Increase IC’s capacity to provide integrated primary care, mental health, and SUD services in our expanded Hartford and South Windsor service sites to improve health outcomes and decrease health disparities, (2) Enhance care coordination model and population health management within IC’s spectrum of integrated services to increase linkages throughout IC’s continuum of care that will promote financial sustainability of IC’s programs and improve client engagement; (3) Improve IC’s standard of integrated healthcare by meeting 100% of the CCBHC criteria for Staffing, Availability and Access, Care Coordination, Scope of Services, Quality and Other Reporting, and Organizational Authority, Governance and Accreditation.
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The Village requests $3,663,642 to implement “The CCBHC @ The Village: Enhancing Mental Health and Addiction Care Access and Quality for CT’s Capitol Region.” The project catchment area includes Hartford (state Capitol) and 5 surrounding towns with a collective population of 265,000 and will serve 900 unduplicated individuals in 3 priority populations. Populations are: 1) Child or adolescent Emergency Department psychiatric admissions; 2) Adults with substance or alcohol use disorders; and 3) Patients who exit treatment early. Project goals include: 1) Achieve and maintain CCBHC certification to increase access, quality, and availability of community mental health and substance use disorder treatment for individuals in Greater Hartford; 2) Decrease substance use/abuse through expanded access to EBP/treatment for underserved populations; 3) Reduce ED admissions and discharge delays for children and youth with psychiatric conditions; 4) Achieve greater equity, efficiency, continuity of care, and overall treatment outcomes; and 5) Reduce incidence of depression, anxiety, and substance use disorders in older adults. The project will serve an estimated 350 unduplicated individuals in year one, and 550 in year two. The project will add 12.613 FTE staff positions, and build capacity to meet a subset of CCBHC requirements during months 1 to 4 of the project period. The proposed project will: a) enhance primary care integration and monitoring for adverse effects of medication through CCBHC-funded Care Coordinators, Case Managers, and Medical Assistants; b) enhance use of care coordination protocols and EHR integration with designated collaborating organizations (DCOs) connected to CCBHC priority populations; c) enhance psychiatric rehabilitation and social support opportunities (3.0 FTE Peer Recovery Specialists), and integrate these activities into existing comprehensive community recovery support offerings available at the Village and/or DCOs; d) enhance specialized services for Veterans (0.25 FTE Clinician); e) offer Assertive Community Treatment enhancements; f) better serve existing judicial/officials/court systems, child protective service agencies, and school systems through CCBHC expansions to priority populations; and g) introduce enhancements to methods for input from patients and family members. The project leadership team (and DCOs) will use data from the PQI Plan and evaluation to analyze costs and benefits, and to develop a road map for sustainability. Project funding will support a full-time, independent evaluator. The formative evaluation activities will document capacity building milestones such as the development of DCO relationships, professional development training, data collection, and fidelity of EBP implementation. Annual evaluation reports will document implementation milestones, process measures (e.g., service utilization, reach across priority populations), clinical outcomes (e.g., treatment completion, follow-up), and lessons learned. Evaluation activities will align to support compliance with all grant reporting requirements to SAMHSA SPARS.
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SMA Healthcare’s Certified Community Behavioral Health Clinic (CCBHC) will increase access to and improve the quality of community mental health and substance use disorder treatment in Volusia County, Florida. Access to a full continuum of service lines to treat addiction and serious mental illness is a well-documented, overwhelming need in the community. In response, SMA will enhance and expand its services to include the necessary staffing, availability and accessibility of services, care coordination, scope of services, quality and other reporting, and organizational authority required to operate as a CCBHC. The population of focus includes consumers with serious mental illness (SMI) or substance use disorders (SUD), including opioid use disorders; children and adolescents with serious emotional disturbance (SED) and individuals with co-occurring mental and substance disorders (COD). CCBHC project goals include: expanded access to existing behavioral health services for the population of focus; implementation of new required CCBHC services, demonstrate improved consumer outcomes, and utilize community relationships to provide certain CCBHC services and improve care coordination. CCBHC will serve 765 individuals during Year 1 and 714 individuals Year 2 with an anticipated total of 1,183 unduplicated individuals by end of Year 2. The CCBHC will provide a comprehensive set of integrated primary and behavioral health care services, including 24/7 mobile crisis and both voluntary and involuntary inpatient crisis stabilization; inpatient and outpatient detoxification; behavioral health screening, assessment, and diagnosis; outpatient primary care screening/monitoring of key health indicators; patient-centered, integrated treatment planning; medication assisted treatment; psychotropic medication management; and comprehensive, trauma-informed, evidence-based, outpatient mental health and substance use services including therapy, psychiatric rehabilitation, Assertive Community Treatment, and peer/community social support, provided in office and through telehealth. The CCBHC’s designated collaborating organizations (DCO), including Halifax Health, Family Health Source, Mental Health America, Volusia County Schools, Florida Department of Juvenile Justice, Community Partnership for Children, Volusia-Flagler County Coalition for the Homeless, and the Daytona Beach Housing Authority will provide children’s inpatient crisis stabilization, veteran’s services, drop-in services and care coordination services as described in PAMA Section 223 (a)(2)(C). CCBHC’s evidence-based practices include Motivational Interviewing, Cognitive Behavioral Therapy, Community Reinforcement Approach, Dialectical Behavior Therapy, and Eye Movement Desensitization and Reprocessing. Related evidence based program models to be utilized include : Peer Emergency Department Intervention, Feedback Informed Treatment, Integrated Dual Disorder Treatment, Medication Management, Medication Assisted Treatment, Assertive Community Treatment, Assisted Outpatient Treatment, Targeted Case Management, Seeking Safety, Wellness Recovery Action Plan, COR-12 for Opioid Use Disorder treatment, and Moral Reconation Therapy. Program evaluation will be ongoing. Evaluation activities will ensure full and continuous compliance with the 162 criteria required for a CCBHC and designated collaborative organizations. CCBHC will also collect and report GPRA and NOMS data to SAMHSA. In addition, CCBHC will collect and report on the 21 data and quality measures described in the “Quality Measures and Other Reporting Requirements” found in Appendix A of the “Criteria for the Demonstration Program to Improve Community Mental Health Centers and to Establish CCBHC’s.”
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The Henderson Behavioral Health CCBHC Initiative will provide a continuum of coordinated behavioral health, substance use, primary care, and wellness promotion on-site to underserved and disenfranchised children, adolescents, adults and families who reside in Broward County, Florida. Primary focus will be placed on serving four (4) population groups (1) adults with a serious mental illness or substance use disorder with an emphasis on the opioid crisis; (2) Veterans and active military personnel: (3) individuals with co-occurring mental and substance use disorders and (4) children and adolescents with serious trauma and/or emotional disturbance. The Initiative will deliver integrated services by providing rapid-response 24/7 crisis management; screening, assessment, diagnosis and treatment of behavioral health, substance use and physical health needs; patient-centered and family-centered treatment planning; active and veteran military support; case management and care coordination; clinical outpatient and psychiatric rehabilitation; peer and family support. Through the CCBHC Initiative, Henderson Behavioral Health will support the goals of increased availability and accessibility to integrated, cost-effective, high-quality community-based treatment services; improved quality of integrated treatment services by the continual inclusion of evidenced-based practices in routine care; positive health outcomes, wellness, and resiliency of residents by increasing awareness through effective public education of the prevalence of different illnesses, risk and preventive factors, and promoting screening, early intervention, treatment and prevention strategies; and decreased hospital readmission rates by engaging individuals in treatment upon discharge from an inpatient stay. Objectives accomplished through the Initiative will result in the revision or writing of policies and procedures to reflect EBPs by January 2021; 250 Broward residents trained in Mental Health First Aid by the end of year two of the Initiative; 100% of new clients identifying routine needs were provided an initial evaluation within 10 business days; 60% of persons served received 2 or more services within 3 months of initial assessment; 80% of persons served received follow-up within 1 business day of discharge following hospitalization for mental illness or substance use; and 95% of individuals and families served rate their participation in treatment as positive. The program will serve a minimum of 500 persons in the 1st year of operation, 600 persons in the 2nd year, for a total of 1,100 individuals served with CCBHC funding by grant conclusion.
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Centerstone's Certified Community Behavioral Health Clinic (C-CCBHC) project will establish Centerstone’s Bradenton clinic as a CCBHC, improving access to/quality of community behavioral health services for individuals with serious mental illness (SMI), substance use disorders (SUD), opioid use disorders (OUD), co-occurring disorders (COD), and/or youth with serious emotional disturbance (SED). C-CCBHC will serve 1,000 unduplicated clients from among the 6,100 served at the clinic yearly (Yr 1: 375; Yr 2: 625/yr). C-CCBHC’s target population is expected to mirror those of the catchment area, comprising DeSoto, Hillsborough, Manatee, and Sarasota counties in Florida. Children/adolescents will comprise 51% male, 49% female, 45% white, 18% African American, and 31% Hispanic/Latino individuals; adults will comprise 48% male, 52% female, 64% white, 12% African American, and 20% Hispanic/Latino individuals. Of the catchment area’s population of 2,155,000, nearly 66,570 area adults have SMI; 88% did not receive mental health services. Nearly 114,020 area adults have SUD; 63,157 with COD; 13,656, OUD. Of adults with illicit drug use, 144,494 needed, but did not receive specialized treatment. An estimated 44,820 area children/adolescents meet criteria for SED, and 6,420 (ages 12-17) have SUD. An expected 56,560 area Veterans have a mental health/SUD diagnosis, including 19,210 in rural areas. Among the estimated 7,810 Vets with SMI, 2,340 are expected to also have post-traumatic stress disorder. From 2016-2018, the area had 1,563 cases of Hepatitis B; 7,853, Hepatitis C; 1,164, HIV; and 196 deaths due to HIV/AIDS. C-CCBHC will provide an array of integrated primary/behavioral health care services (e.g., crisis care; mental health screening, assessment, and diagnosis; primary care screening and monitoring of key health indicators; HIV/Viral Hepatitis screening and Hepatitis A/C vaccinations; integrated treatment planning; Medication Assisted Treatment and medication management; and telehealth). C-CCBHC’s evidence-based interventions are numerous and include Cognitive Behavioral Therapy, Motivational Interviewing, Assertive Community treatment, Illness Management and Recovery, Integrated Dual Disorder Treatment, and more. C-CCBHC will accomplish the following goals: 1) Continue delivery of comprehensive community-based mental and substance use disorder services for the target population, meeting all CCBHC criteria; 2) Enhance infrastructure/capacity for a full continuum of coordinated care; 3) Ensure access to/availability of timely services for the target population; 4) Improve health status and outcomes for C-CCBHC consumers engaged in treatment; and 5) Apply a CQI approach to drive outcome improvement and ensure ongoing service delivery. To support these goals, C-CCBHC will achieve the following measurable objectives: Decrease mental health symptomatology by 45%; Decrease substance use by 45%; Achieve 50% reported compliance with medication; Deliver personalized treatment plans for 100%; and Achieve 80% consumer/family 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.
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DACCO Behavioral Health, Inc. (DACCO) is seeking a Certified Community Behavioral Health Clinic (CCBHC) Expansion Grant (FOA No. SM-20-012) entitled Certified Clinic Expansion Project (CCEP). The CCEP will strategically build on the agency’s existing strengths and combine the strengths of selected community partners to establish a CCBHC in Hillsborough County Florida, in order to increase access to and improve the quality of community mental health and substance use disorder treatment for its residents. The CCEP will identify and engage vulnerable residents who have not typically participated voluntarily in behavioral health treatment, by reducing their barriers to engaging using technology and innovative measures to improve ease of access to care and supporting their motivation to engage in treatment by providing peer support. Through our collaboration with our local partners, the agency will bridge the gap between treatment availability and improve our community’s engagement in behavioral health treatment, increasing the numbers served and providing quality evidence based care. DACCO will complete all criteria to meet the standards for a CCBHC within the initial four months of the funding period. Through the establishment of the CCEP 2,000 new patients will be identified in our community, 75% (1,500) of whom will be screened and then 65% (975) of those screened will engage in treatment. Adults and youth will be screened and offered behavioral health assessment and treatment. This grant will allow DACCO to shift the treatment paradigm from serving individuals in crisis to engaging individuals in a holistic system of care in which resources can be maximized. Proposed strategies include: use of targeted web-based marketing for engaging voluntary participants before they enter they system of care in crisis, 24/7 access to appointments and linkage to assessments using technological approaches including a behavioral health call center, website and Telehealth technology, and use of certified Recovery Peers for recovery coaching and motivation throughout the process of treatment. Once engaged in treatment, DACCO will facilitate a variety of evidence based strategies including but not limited to Motivational Interviewing, Cognitive Behavioral Therapy, trauma-informed strategies including Acceleration Resolution Therapy; and Peer Recovery Support, and will engage with community partners to ensure that patients are provided with the care that meets their needs. DACCO has served residents of Hillsborough County since 1973 and has established strong community partnerships with both treatment providers and the local University of South Florida whose Florida Mental Health Institute will provide oversight and evaluation of the project. Through the years of collaboration with these stakeholders the agency has demonstrated the ability to identify and maintain grant partnerships, and has achieved a reputation for excellence in the field of behavioral health in general and substance abuse treatment in particular. Examples of recent awards include SAMHSA’s 2013 Science and Service Award and the 2013 iAward for Innovation in Behavioral Health Services national awards for Comprehensive Coordinated Care for opiate-addicted pregnant women. With a solid foundation in the provision of excellent behavioral health care DACCO looks forward to using this grant opportunity to move our community towards greater efficiency and improved behavioral health outcomes.
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Recovery Consultants of Atlanta, Inc., (RCA) proposes to increase access and improve the quality of mental health and substance use disorder treatment services through a CCBHC expansion project, RCA—CCBHC for integrated healthcare. RCA will serve underserved adults with chronic health diseases, serious mental illness (SMI), substance use disorders (SUD), including opioid use disorders; individuals with co-occurring mental and substance disorders (COD). Within the population of focus are ethnic minorities, homeless veterans, and persons at risk for human immunodeficiency virus (HIV) and transmission. Atlanta’s DeKalb (pop.736,066) and Fulton (pop. 1,010,420) counties, the catchment area, are federally designated as areas among those hardest hit by the HIV epidemic; and, medically underserved with health professional shortages in primary care and behavioral health. The large African American populations (DeKalb-54.9%, Fulton-44.4%) struggle with higher poverty rates (DeKalb-24.6%, Fulton-20.3%) compared to the county rates (DeKalb -17.6%, Fulton-14.8%). Unemployment intensifies financial instability with unemployment rates at 5.9% for DeKalb county and 7.7% for Fulton county. Of all Georgia’s behavioral health treatment compensation, 52.7% was paid in part by private insurance and 89.7% with a method of self-pay—unrealistic for a population plagued with financial hardship. RCA aims to remedy access to holistic healthcare with its credentialed, licensed professionals who will (1) expand integrated patient-centered mental health and primary care services and (1a) serve 1,000 (400=year 1 + 600=year 2) clients during the grant period; (2) assess/monitor clients health indicators to improve physical health outcomes and (2a) establish baselines for systolic/diastolic blood pressure, body mass index, Hemoglobin A1c, HIV and Hepatitis A/B/C; (3) assess, diagnose and develop treatment plans for SMI, SUD, CODs and (3a) monitor adherence to antipsychotic medication, use evidence-based assessments and therapeutic interventions for recovery and deliver intensive case management for social supports and care coordination. RCA will apply person-centered treatment planning that considers clients’ strengths and preferences and always involves the clients in the process and decisions for recovery strategies. Clinicians will draw from evidence-based practices such as integrated dual disorder treatment, Motivational Interviewing, Cognitive Behavioral Therapy, Trauma-Informed Care, Medication-Assisted Treatment and Medication Reconciliation; Illness Management and Recovery and Tobacco Recovery Across the Continuum. RCA will collaborate with mental health crisis services sanctioned by the Georgia Department of Behavioral Health/Department of Community Health Medicaid Office to provide intervention services for a psychiatric or substance use crisis including (1) 24-hour mobile crisis teams (ACT), (2) emergency crisis intervention services, (3) crisis stabilization, (4) suicide crisis response, (5) substance abuse crisis and intoxication, including ambulatory and medical detoxification services.
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Eyerly Ball Community Mental Health Services (CMHS) will enhance the continuum of behavioral health care services through its proposed CCBHC project entitled, “Increasing Access to Mental Health and Substance Use Treatment Services, Improving Coordination Between Healthcare Providers, and Enhancing Availability of Crisis and Suicide Prevention Services.” This project’s population of focus includes children and adults with mental illness (MI), serious mental illness (SMI), serious emotional disturbance (SED), substance use disorders (SUD), and co-occurring disorders (COD). In order to most effectively serve this identified population, Eyerly Ball CMHS will be utilizing the following evidence-based practices: Assertive Community Treatment (ACT), First Episode Program (FEP), Intensive Psychiatric Rehabilitation (IPR), Motivational Interviewing, Peer and Family Support Specialists, and Medication Assisted Treatment (MAT). Specifically within our outpatient clinics, psychotherapeutic interventions such as Cognitive Behavioral Therapy (CBT), Mindfulness, and Eye Movement Desensitization and Reprocessing (EMDR) Therapy are tailored based on an individual’s developmental phase in life. With project funding, Eyerly Ball CMHS is proposing the following goals: increase engagement in behavioral health services by improving access to care and creating a presence in area hospital systems, decrease hospital and emergency department utilization by increasing availability and awareness of crisis and suicide prevention services, and increase continuity of care through comprehensive screening activities to ensure individuals have access to the resources needed to maintain their physical and mental health and well-being. Specific, measurable, achievable, realistic, and time-bound objectives have been developed for each goal, including expanding the Eyerly Ball Enrollment Team by hiring ten new Navigators, Behavioral Health Coordinators, and Access Coordinators; decreasing consumer emergency department utilization by 15% by making use of appropriate crisis services; and increasing the number of referrals to a PCP as indicated through age-appropriate screenings for key health indicators and health risks, as well as diabetes, metabolic and cardiovascular risk factors. Eyerly Ball CMHS will serve 2,000 unduplicated consumers during the first year and 3,800 unduplicated consumers over the project period of two years.
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Hillcrest Family Services proposes to develop a CCBHC project for Dubuque and Jackson Counties, Iowa for the purpose of increasing access to and improving the quality and coordination of community mental health and substance use disorder treatment. The populations of focus include adults with serious mental illness (SMI), youth with serious emotional disturbance (SED), individuals with substance use disorders (SUD), and individuals with co-occurring mental health and substance use disorders (COD). Specific focus areas include children up to age 17, African American, Native Hawaiian/Pacific Islander, and Hispanic/Latino populations, veterans, uninsured, underinsured, and underserved, individuals with commercial insurance but inability to pay, individuals and families living in poverty, and households without vehicle access. The proposed two-year project requests $2,000,000 per year to enhance and improve services to target populations for a total of at least 2,584 individuals over the span of the project. Evidence-based, comprehensive outpatient mental health and substance use services, including medication management (including medication-assisted treatment), a continuum of crisis services, intensive psychiatric rehabilitation, primary care services, ACT, peer and family supports, HIV/Hepatitis screening, and case management will be delivered with a person centered and family-centered focus. Hillcrest Family Services will leverage existing behavioral health services through community mental health centers in Dubuque and Jackson Counties. In FY 2019, Hillcrest provided services to 8,639 individuals including therapy, medication management, mobile crisis outreach, HIV and Hepatitis, crisis residential, intensive psychiatric rehabilitation, integrated health homes, peer support and assertive community treatment. When overlaying data from the National Association of Mental Health (NAMI) with census data from the targeted counties, it is estimated that there are 22,477 adults with SMI, 2671 children with SED, 14,918 with co-occurring mental health and substance use issues, 12,532 individuals living in poverty, 5,304 uninsured, and 7,795 veterans. Hillcrest Family Services will utilize evidence-based practices such as Dialectical Behavioral Therapy (DBT), Eye Movement Desensitization and Reprocessing Therapy (EMDR), Multidimensional Family Therapy (MFT), Theraplay, Motivational Interviewing, Acceptance and commitment Therapy, Trauma-Focused Cognitive Behavioral Therapy, Medication Assisted Treatment, ACT, and IPR to facilitate achieving the goals of the project. Major goals of the project include Goal 1: Decrease the unnecessary use of emergency resources by diverting participants with behavioral health conditions, SUD, or COD from ERs and/or Law Enforcement encounters by providing crisis response; Goal 2: 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 3: Reduce all causes of hospitalization readmissions by increasing follow-up after hospitalization for mental illness, SUD or COD. Goal 4: Increase comprehensive screening activities to identify individuals in need and to link to appropriate services and supports. Strategies that will support the achievement of goals include standardized screening and assessment, meeting all CCBHS certification requirements by 4 months post award, enhancing an existing advisory group, building additional infrastructure around electronic health record software, increasing capacity for population health data management, and further enhancement of continuous quality improvement methodologies to support and enhance the project.
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The North Central Iowa Mental Health Center, Inc. dba Berryhill Center in Fort Dodge, Iowa is a not for profit entity associated with UnityPoint Health and located in rural Webster County, Iowa. Through federal CCBHC grant funding, we seek to expand existing mental health services thereby addressing mental health needs of our community. It is our goal to increase treatment accessibility, improve pathways to mental health services and expand crisis intervention services. The Berryhill CCBHC Expansion Project will be available to all persons with mental health needs in Webster County (population 36,277) which is located in rural North Central Iowa. Berryhill served 8.7% (3,158) Webster County Residents in 2019, and is the primary safety-net mental health services provider in the region. It is estimated that in year one of our project 3,393 individuals will be served and in year two that number will increase to 3,628 individuals, for a total of 7,021 persons served over the lifetime of the project. To reach our overarching goal of improvement and expansion of mental health services in our region, we have used local data to identify three key areas and related goals with measurable objectives to achieve the most impactful outcomes. Goal #1: To reduce by a measurable amount the inappropriate usage of the emergency room by CCBHC patients as a pathway to care. This goal will be achieved through the use of carefully implemented and monitored continuing care plans for CCBHC patients deemed to be frequent users of the ED and prolific data sharing with other area safety net providers. Success will be measured by an actual reduction in usage by identified patients. Goal #2: To provide a unified community system for patients in crisis situations. This goal will be achieved through the CCBHC acting as coordinator and in collaboration with other area safety net providers to provide a comprehensive and targeted system of care for patients in crisis. Data will be used to determine community needs and pinpoint areas of crisis intervention opportunity. This data will also indicate improvements made in care delivery over time. Goal #3: To provide a more direct pathway for appropriate care for individuals with mental health issues that present to the emergency department, thereby avoiding inappropriate or over usage of the ED. This goal will be achieved through the provision of a Behavioral Health Consultant to work directly in the ED for care integration of patients with mental health concerns. Success will be measured through utilization and documented encounters with the Behavioral Health Consultant.
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Project Name: Seasons CCBHC Enhancement Project Applicant: Northwest Iowa Mental Health Center dba Seasons Center for Behavioral Health Project Summary: To increase access to and improve the quality of community behavioral health services and care though the expansion of CCBHC services in nine rural counties in northwest Iowa. Target Population to be Served: The target population for the proposed project is adults with a serious mental illness, children with a serious emotional disturbance, and individuals with co-occurring disorders. The project will target subpopulations: infants and young children; youth in foster care, out of home placement, kinship care or adopted; and veterans and military families. Demographic and Clinical Characteristics of Target Population: The geographic service area for the project encompasses 9 counties in rural northwest Iowa: Buena Vista, Clay, Dickinson, Emmet, Lyon, O’Brien, Osceola, Palo Alto, and Sioux. The 9 county region has a population of 137,943 residents (Census 2018 Estimates). Seasons provided behavioral health services to 4,382 individuals in 2019, including 1,729 children within this service area. Evidence-Based Strategies and Interventions: Assertive Community Treatment (ACT), Intensive Psychiatric Rehabilitation (IPR), Medication Assisted Treatment (MAT), Matrix Model, Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Seeking Safety (SS), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Parent Child Interactive Therapy (PCIT), Eye Movement Desensitization and Reprocessing (EMDR), and Theraplay. Project Goals and Measurable Objectives: The goals of the project are: Goal I: To equip mental health professionals with skills, knowledge, and resources to provide high quality, evidence-based, trauma-informed, and culturally responsive CCBHC services. Goal II: Conduct data collection and evaluation activities as required by SAMHSA, to monitor and report on project effectiveness, and evaluate outcomes for use with expansion and sustainability as a CCBHC. Goal III: To ensure families are able to easily obtain behavioral health services, resources, and supports, along a continuum of prevention, early intervention, and treatment, within their local communities. Goal IV: To create the organizational capacity to lead and champion a sustained, high-quality CCBHC within a rural geographic service area. Number to be Served Annually and Throughout Lifetime of Project: The targeted number of individuals to be served over the two-year project period is 1,150, and to maintain at least 80% of the individuals throughout the course of the project.
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In Linn County, IA, Abbe Center CCBHC Project will implement strategies to engage individuals who over-utilize or are "at-risk" for presenting at the emergency department (ED) instead of utilizing more cost-effective community-based services due to lack of engagement, timely access to services and/or understanding how to navigate the service system. Current populations served are children and adults with mental illness, serious mental illness, serious emotional disturbance, substance use disorders & co-occurring disorders. In 2019, Abbe Center served 7,144 individuals in these categories. It is estimated that 15% of these individuals will be determined "at-risk." The population of focus for this grant is "at-risk" individuals as determined by the following criteria: 1) being recently discharged from the ED or inpatient unit after a behavioral health visit; 2) utilizing a mobile crisis or crisis stabilization service; 3) having an interaction with law enforcement due to a behavioral health reason; or 4) having an urgent social determinant of health need. Abbe Center CCBHC will serve 1,072 unduplicated individuals determined to be "at-risk" each year (1,608 unduplicated over the 2-year grant project period). Project Goal 1: Decrease ED utilization by CCBHC clients by 20% by providing timely access to services and enhancing care coordination to individuals identified as "at-risk". Objective A: Engage "at-risk" individuals and coordinate behavioral health services. 1. By January 1,2021, Implement a "One Step" referral process for quick engagement of clients from the ED to Abbe. 75% of the people referred from the ED will engage by having a service with Abbe. 2. By August 29, 2021, 60% of individuals "at-risk" will receive outreach/care coordination. Objective B: Provide timely access to services through urgent care services and Access Center. 1.By April 30, 2021, Abbe Center will expand an established urgent care track to include 20 hours per week availability of Prescriber services. 2. By August 29, 2021, increase by 50% law enforcement "drop-offs" at an Access Center. Project Goal 2: Integrate the management of physical health and behavioral health by creating and implementing care pathways for clients with diabetes, smoking, and cardiovascular disease. Objective A: Increase the number of clients who are actively engaged with their PCP. 1. By July 1, 2021, implement tracking of primary care visits and work with clients identified as "at-risk" to ensure at least 70% have had at least one primary care visit with in the last year. 2. By April 1, 2021, Abbe will co-locate a primary care provider within the CMHC setting and develop an integrated workflow to co-manage healthcare needs.
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Plains Area Mental Health, Inc. CCBHC target population is adults with a serious mental illness (SMI), children with a serious emotional disturbance (SED), adults with long term and chronic substance use disorders including opiate addiction, and individuals with co-morbid mental health and/or substance use disorder (SUD). The geographic focus area for CCBHC will concentrate on thirteen counties in Northwest Iowa. The population is 206,995 across 7,790 square miles. All of the identified counties in the target area are designated by Health Resources and Services Administration (HRSA) as Medically Underserved Areas/Populations (MUA/P) and Health Professional Shortage Areas (HPSAs) for mental health, primary care, and dental. According to the American Foundation for Suicide Prevention, suicide was the 9th leading cause of death for the overall population in Iowa, and the 2nd leading cause of death among youth aged 13–19. Iowa has the 5th highest rate of binge alcohol drinking in the U.S. according to the National Survey on Drug Use & Health, 2015-2016. According to Your Life Iowa, a resource hub and call center, there are only 5 MAT providers in our targeted area and located in 3 of the 13 counties. Last year a longstanding SUD provider suddenly closed their doors leaving a significant void of SUD services in 8 Northwest Iowa counties, including five of the counties in our targeted service area. The proposed targeted service area and population lacks access to coordinated care for co-occurring disorders, physical healthcare, and social determinants of health such as housing, employment, transportation, and nutrition. There is a lack of coordinated care between and among the SUD and Mental Health providers resulting in a siloed service system, barriers to access and missing the synergistic impact of co-occurring disorder treatment and higher costs of care. The 2018 Rural Health Forum, A Summary to Promote Action, a joint report by the Iowa Department of Public Health and the Iowa Healthcare Collaborative, stated access to care is one of the biggest challenges affecting rural health and rural communities along with lack of core specialty services, including behavioral health, and lack of capacity to address social determinants of health. Plains Area Mental health CCBHC will increase access to coordinated mental health, substance abuse disorder (SUD), and physical healthcare to 1500 new individuals by increasing service capacity, cultural competency for service to veterans, and expansion of evidenced based services to adults and children.
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The Elevate Housing Foundation (EHF) proposes to increase the access and availability of high quality, integrated primary care, mental health (MH), and substance use disorders (SUDs) treatment and recovery support services to adults ages 18+ in Waterloo, Iowa and nearby rural areas who suffer from one or more behavioral health conditions. Iowa is marked as one of the worst states in the USA for treatment for mental health needs. It has lower ratios than 44 other US states in psychiatrists and mental health workforce availability. EHF’s CCBHC will deliver all required CCBHC components in its mental health and substance use disorder services. The project will serve 650 adults and veterans in Year 1 and 800 adults and veterans in Year 2, totaling 1,450 clients over the grant period. All individuals approaching the facility will receive treatment until funds the facility has reached capacity. Proposed strategies and evidence-based services include: Medication Assisted Treatment, Motivational Interviewing, Motivational Incentives, mobile and in house crisis services, screening, assessment & diagnosis; whole-person treatment planning; integrated primary care screening and services; targeted case management; psychiatric rehabilitation; care coordination and a full continuum of addiction treatment with peer supports; Comprehensive outreach; HIV/HCV testing. The Goals for the program are (1) to increase access of behavioral treatment, service and resource options to young adults, adults and seniors that will improve mental health and overall wellness; (2) Provision of coordinated care with existing resources to provide a customized treatment option to adults and seniors that will decrease emergent situations and achieve long-term health outcomes; (3) Provision of customized services for individuals with co-occurring disorders.
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The Robert Young Center - Certified Community Behavioral Health Clinic” (“RYC-CCHBC”) will increase access to and improve the quality of community mental health and substance use disorder treatment services for individuals with serious mental illness (SMI) or substance use disorders (SUD); children/adolescents with serious emotional disturbance (SED); and individuals with co-occurring mental and substance use disorders (COD). RYC-CCBHC expects to serve 15,000 individuals over the two-year grant period: (Year 1: 6,750; Year 2: 8,250) living in Rock Island and Mercer counties in Illinois and Scott and Muscatine counties in Iowa. RYC-CCBHC’s population of focus is comprised of 12,500 adults with SMI (60% of whom has a COD) and 2,300 children/adolescents with SED. The demographic of the population is predominately White (82%), followed by African American (12%), and Hispanic/Latino (4%). More than 17% of local adults experience “fair/poor” mental health (vs. 13% in the U.S.), and 35% rate the ease of obtaining mental health services as “fair/poor.” Expanded Care Coordination will be the linchpin of the RYC-CCBHC project to provide evidence-based strategies and interventions for the population of focus. Interventions will include crisis mental health services; screening, assessment, and diagnosis; consumer-centered treatment planning; comprehensive outpatient mental health and substance use services; screening for HIV and Hepatitis; primary care screening; social supports and community recovery supports; intensive services for military and Veterans; and Assertive Community Treatment. RYC-CCBHC will partner with Trinity Medical Center, Community Health Care (FQHC), UnityPoint Clinics, Rock Island and Mercer county public health departments, Community Veterans Engagement Board, and other community-based social service organizations. RYC-CCBHC goals and objectives include: 1) Establish RYC as a certified CCBHC, enhancing availability and connectivity to whole health treatment, and enhancing technology to monitor consumer outcomes; 2) Improve key health outcomes for the population of focus, including enrolling 2,000 “high-risk” individuals in care coordination, decreasing utilization of high-cost services (e.g., ED visits; hospitalizations), linking consumers to primary care, improving social domains and social determinant of health (e.g., employment, housing), and engaging consumers in alcohol and other substance use treatment programs; and 3) Build capacity and infrastructure to sustain RYC-CCBHC, including establishing a consumer-focused Advisory Work Group, offering to enroll 100% of eligible consumers in health insurance/benefits, and developing/implementing a sustainability plan. RYC is an established, 50-year-old, non-profit Community Mental Health Center that serves over 20,000 individuals with behavioral health needs annually.
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Centerstone's Certified Community Behavioral Health Clinic (C-CCBHC) will support continued/expanded implementation of Centerstone's CCBHC in Alton, Illinois, improving access to/quality of community behavioral health services for individuals with serious mental illness (SMI), substance use disorders (SUD), opioid use disorders (OUD), co-occurring disorders (COD), and/or youth with serious emotional disturbance (SED). C-CCBHC will serve 1,000 unduplicated individuals from among the 5,900 that the clinic serves yearly (Yr 1 & 2: 500/yr). C-CCBHC’s target population is expected to mirror those of the catchment area, comprising Calhoun, Greene, Jackson, Jersey, Macoupin, Madison, St. Clair, & Williamson counties in Illinois. Those ages 17 and under are expected to comprise 51% male, 49% female, 66% White, 19% African American, and 5% Hispanic/Latino individuals. Those 18+ are expected to comprise 48% male, 52% female, 80% white, 14% African American, and 3% Hispanic/Latino individuals. Of the catchment area’s population of 744,000, 4% (23,100) of adults are expected to have SMI, and 16,610 children/youth ages 6-18, SED. Roughly 8% (46,195) of adults and 4% of adolescents 12-17 have SUD, and 0.7% (4,042) of adults and 0.4% of adolescents 12-17 have OUD. An estimated 33% of the 63,518 area Veterans are expected to have a mental health diagnosis. An estimated 14,780 (64%) adults with SMI and 11,630 (70%) youth ages 12-17 with SED have not received appropriate supports. An estimated 36,300 adults and 5,370 adolescents with SUD remain untreated. Without integrated care, 23,860 individuals with COD are at increased risk of physical illness, homelessness, incarceration; 52,840 individuals with SUD are more vulnerable to heart disease and cancer; and those with SMI are expected to die up to 30 years prematurely. C-CCBHC will provide an array of integrated primary/behavioral health care services (e.g., crisis care; mental health screening, assessment, and diagnosis; primary care screening and monitoring of key health indicators; HIV/Viral Hepatitis screening and Hepatitis A/C vaccinations; integrated treatment planning; Medication Assisted Treatment and medication management; and telehealth). C-CCBHC’s evidence-based interventions are numerous and include Cognitive Behavioral Therapy, Motivational Interviewing, Assertive Community treatment, Illness Management and Recovery, Integrated Dual Disorder Treatment, and more. C-CCBHC will accomplish the following goals: 1) Continue delivery of comprehensive community-based mental and substance use disorder services for the target population, meeting all CCBHC criteria; 2) Enhance infrastructure/capacity for a full continuum of coordinated care; 3) Ensure access to/availability of timely services for the target population; 4) Improve health status and outcomes for C-CCBHC consumers engaged in treatment; and 5) Apply a CQI approach to drive outcome improvement and ensure ongoing service delivery. To support these goals, C-CCBHC will achieve the following measurable objectives: Decrease mental health symptomatology by 45%; Decrease substance use by 45%; Achieve 50% reported compliance with medication; Deliver personalized treatment plans for 100%; and Achieve 80% consumer/family reported satisfaction with their experience of care. Key C-CCBHC strategies include updating a full needs assessment and meeting all CCBHC certification requirements immediately upon award; expanding/enhancing access/services; convening the 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.
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The overarching goals of our project are to meet all CCBHC criteria, develop the full continuum of care needed for the populations of focus (POF), build on our existing federally qualified health center (FQHC) and community mental health center (CMHC) capacities to achieve full integration of services, and develop population health management capacities that include continuous quality improvement. Through this process, we will be able to provide greater access to evidence-based interventions that engage the POF in meaningful steps toward recovery. At present, Chestnut Health Systems (Chestnut) serves 10,000 unduplicated clients per year. We will use CCBHC funds to build an even greater service capacity for those in the POF with the most complex conditions by bridging the gap between primary care and behavioral health care. CCBHC funds will allow us to serve by year two an additional 700 clients per year. From the end of month four of the project through the end of year one we will serve an additional 465 clients with CCBHC certified services, approximately 7,132 for the entire period. In year two of the project, we will serve 700 additional clients and 10,700 for the entire year. For the entire two-year project, we will serve 1,165 additional unduplicated individuals from the POF, 17,132 in total, all with CCBHC certified services. Our project is called Chestnut Health Systems CCBHC. The POF include adults with serious mental illnesses (SMI), youth with serious emotional disturbances (SED) and people with co-occurring substance use disorders (COD) residing in Madison and St. Clair Counties in Illinois. Chestnut uses evidence-based practices (EBP) to treat behavioral health conditions. Our goals and their objectives include but are not limited to the following: Goal 1: By month 4, implement all remaining CCBHC criteria that are not already being met: Obj. 1: Recruit and hire all additional staff needed to implement CCBHC requirements. Obj. 2: Convert existing community support services and personnel to an ACT team. Obj. 3: Establish a CCBHC advisory work group comprising adults, children/youth, and caregivers served by the CCBHC. Goal 2: Ensure access to primary care and continuity of care across CCBHC service: Obj. 1: 100% of CCBHC enrollees will be connected with primary care services and a designated care coordinator within one month of enrollment. Obj. 2: Beginning in month 4, monitor enrollment and engagement in CCBHC services for 100% of CCBHC enrollees. Obj. 3: Ensure 90% CCBHC enrollees receive annual wellness visits by month 4 and through the duration of the project. Goal 3: Increase the number of unduplicated clients served by CCBHC services: Obj.1: By month 12, educate at least 100 community key stakeholders about the CCBHC project and services, and increase community referrals to Chestnut by 25%. Obj. 2: Serve an additional 1,175 unduplicated clients with CCBHC-certified services by month 12, and serve a total of 17,840 by the end of month 24 of the project. Chestnut is requesting $4 million for the two year project.
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Egyptian Health Department’s (EHD’s) CCBHC will ensure people living with SMI/ SED/ SUD/COD in Gallatin, Saline, and White counties have access to comprehensive, evidence-based behavioral health (BH) and primary care (PC) services needed to attain recovery and well-being. The CCBHC will increase access to a comprehensive array of evidence-based practices (EBPs) to address the needs of the rural community. EHD will serve 2,500 clients annually with CCBHC-required screenings and coordination with primary care. Over the two-year grant, EHD will expand intensive services to 800 clients with complex needs (600 adults and 200 youth). The intensive service array will include ACT, IPS, Supported Education, High-Fidelity Wraparound, integrated care coordination for complex BH/physical health (PH) conditions, case management and AOT for court-ordered individuals, crisis follow-up and stabilization for adults, targeted veteran services, and telehealth for clients discharged from psychiatric hospitals. EHD’s primary goals and highlighted objectives include: 1) Implement CCBHC criteria: a) By month 4, hire a psychiatric nurse practitioner and establish an ACT team; recruit, hire, and train all other project staff; b) Establish an advisory work group comprised of at least 51% CCBHC enrollees and family members. 2) Universally screen and monitor health: a) Screen and monitor health indicators for 100% of enrollees; b) Screen and monitor prevalence and risk of diabetes for 100% of enrollees on psychotropic medications; c) Document that 100% of enrollees receive routine follow-up. 3) Ensure access to PC and continuity of care: a) 100% of enrollees with complex BH/PH needs will have a designated care coordinator; b) All existing clients will have a designated PC provider within 4 months; c) Pilot telehealth services to follow hospital discharge by month 4, and provide integrated telehealth to at least 50 people post-discharge by year 2. 4) Provide coordinated care for clients with complex BH needs: Identify and enroll 100% of eligible adults in ACT or Community Support; b) Provide or ensure referral to Wraparound services for 100% of eligible children. 5) Expand psychosocial rehabilitation services: a) Refer and enroll at least 5 adult clients into IPS and 5 youth clients into supported education each month in year 1; b) At least 25% of participants receiving IPS will obtain employment after 1 year of participation and at least 40% will have obtained employment after 2 years; c) Enroll 75% of court-ordered individuals into case management and AOT. 6) Increase services to veterans: Serve at least 100 Veterans with SMI/SUD by year 2. 7) Decrease health risk: 50% of enrollees with elevated health indicators at enrollment will experience a clinical improvement after 12 months. 8) Decrease substance use: a) Refer 100% of enrollees who screen positive for tobacco or substance abuse to intervention or treatment; b) 75% will participate in intervention or treatment within 30 days; c) 40% of enrollees with SUDs at baseline will reduce substance use after 12 months. 9) Decrease use of restrictive settings: Monitor and develop QI plans to address the use of restrictive settings, and reduce high utilization by month 21.
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Hamilton Center, Inc. (HCI) will establish a CCBHC at its Vigo County outpatient clinic, improving access to evidence-based community behavioral health and integrated primary care services for individuals who live and seek services in Vigo County, Indiana. According to “The State of Mental Health in America 2020” from Mental Health America, 1.04 million, or 21% of the population in Indiana, suffer from mental illness, but 272,000, or about 25.2%, are unable to receive treatment, ranking Indiana 7th-highest among states. Several factors contribute to this, including a shortage of psychiatrists, lack of insurance, and lack of treatment sites/options. Indiana ranks 9th-worst for the ratio of mental health providers to patients. Challenges in Vigo County are similar, with limited access to psychiatric beds, lack of a mobile crisis unit, limited access to intensive services, and limited opportunities for short-term crisis stabilization. Vigo County is also designated as a Low-Income Population HPSA. With this project, HCI proposes to help address some of these unmet needs by focusing services on adults and children in Vigo County, Indiana, with serious mental illness (SMI) or substance use disorders (SUD); children and adolescents with serious emotional disturbance (SED); individuals with co-occurring disorders (COD); and individuals with chronic physical health needs. HCI proposes to serve 150 individuals in the first grant year, and an additional 325 in year two, for an unduplicated count of 475 individuals. HCI has three goals with this project: 1) Increase access and coordination of crisis stabilizations services for adults and children by implementing evidence-based practices within the 24-hour crisis service model, 2) Improve access and coordination to intensive community based services for adults with SMI, SUD or COD, and 3) Improve coordination of care by increasing primary care screenings, monitoring and referrals for individuals within the targeted populations. HCI is well positioned to achieve CCBHC certification within four months of award. HCI has been a state-certified as a community mental health center since inception in 1971. It has grown to become a regional behavioral health organization in central and west central Indiana. Services offered include trauma-informed behavioral health and substance abuse services to children, adolescents and adults with specific programs designed for the most intensive consumers - those with serious mental illnesses, substance use disorders (including medication assisted treatment programs), serious emotional disturbances, those with co-occurring disorders and those with chronic health conditions. In addition, HCI is a certified Integrated Care Entity by the State of Indiana and has a designated community health center site (primary care and behavioral healthcare) working towards an FQHC look alike designation.
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Community Mental Health Center Inc.-CMHC-will be expanding existing services and creating new service lines to meet criteria to become a Certified Community Behavioral Health Center-CCBHC. This transformation will increase access to healthcare to the population we serve in Dearborn, Ohio, Switzerland, Ripley, and Franklin counties in Indiana with the intent to improve patient health outcomes and reduce healthcare costs by eliminating unneeded services. The Board of Directors will be comprised of at least 51 percent consumers or family members who have been consumers of behavioral health services within the first 4 months of the grant award. Additionally, population-specific Advisory Groups will be developed in this time frame. Needs assessments will be reviewed and conducted in order to identify specific service needs and barriers will be conducted in the first 4 months as well. Efforts to identify advanced wishes of patients will be completed. Project goals with a completion date of 4 months include expansion of emergency crisis services to include mobile crisis services on a 24-7 basis to cover the 5-county area list above provided by a licensed therapist and case manager. 80 percent local law enforcement agencies will be trained to assist with the mobile crisis service. Expanded integrated primary care services will be added in new locations for improved access to our population to get their physical healthcare needs met. This entails the hiring of a Family Nurse Practitioner and support staff. Tobacco screening and cessation services will be expanded as well. Medication Assisted Treatment -MAT- will be expanded through the addition of a certified practitioner onsite for induction and monitoring as well as a partnership with a DCO to provide additional MAT services. The MAT clinic will serve at least 20 patients by the 4-month mark. An Assertive Community Treatment -ACT- team will be developed to provide more intensive services to those who have co-occurring Serious Mental Illness -SMI- and substance use disorder -SUD- diagnoses and will be serving up to 10 patients by the end of the first 4 months. By the end of the grant, a detoxification service will be implemented on the crisis intervention unit. 80 percent therapists will be trained in specialized evidence-based practices by the end of the grant period. The CMHC service area is rural with a predominantly white, lower socioeconomic population. The population has a high incidence of trauma and other risk factors for developing mental health and physical health issues. It is anticipated that CMHC will serve 5,000 patients the first year and 6,000 individuals through the life of the grant, comprised of all age groups. CMHC provides the full-continuum of care either directly or through agreement with a designated collaborating organization-DCO, such as Highpoint Health, Margaret Mary Health, East Indiana Comprehensive Treatment Center, NAMI of Southeastern Indiana, Southeast Indiana Economic Opportunity Corporation, and the Dearborn County Health Department.
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Good Samaritan (GS) Comprehensive Health System is requesting $4 million over a two year period ($2 million annually) to expand CCBHC care and support services for a high-need, multi-state project service area with a population of over 242,000 persons. Headquartered in Vincennes, Indiana, the project will benefit citizens residing in the Indiana 8th and Illinois 15th Congressional districts. It will serve 11 high need counties, including the seven Indiana counties of Knox, Daviess, Pike, Gibson, Sullivan, Greene and Martin, and the four Illinois counties of Lawrence, Richland, Crawford and Wabash. Over 90 percent of these counties have received DHHS, HRSA Medically Underserved Area or Medically Underserved Population designations. The project will serve an estimated 2,200 persons. The service area Congressional leadership strongly supports the project due to the compelling behavioral health needs in the region, especially the exploding demand for treatment needs caused by the exploding demand for substance use treatment due to the impacts that opioid use has inflicted on the region. The following Indiana and Illinois members of Congress are formally supporting the project: Senators Young and Braun of Indiana, Congressman Bucshon, MD (IN-08) and Congressman Shimkus (IL-15). GS, in collaboration with numerous community partners, will provide integrated behavioral and primary care, along with any required human and social service supports. The project will use evidence based practices (EBPs) to deliver both person and family centered integrated behavioral and primary care services that will include on call crisis intervention services for the following priority populations 1) persons with serious mental illness (SMI), 2) persons with, or who are at risk for, substance use disorders (SUDs), 3) persons having, or are at risk for, opioid use disorder (OUD), 4) children and youth with a serious emotional disturbance (SED), 5) persons with cooccurring mental and substance disorders (CODs), 6) disadvantaged persons with a disorder who reside in a rural area and face significant barriers to accessing care (transportation, etc.), and, 7) underserved and minority populations. As the state designated Community Mental Health Center (CMHC), the GS's Samaritan Center (both a previous and current SAMHSA grantee) will provide comprehensive access to community based mental and SUD services, treatment of those disorders and integrated primary care in a single location. The project will be integrated within the GSH comprehensive system of care and will provide 1) Crisis Mental Health Services, 2) Screening, Assessment and Diagnosis, 3) Person Centered Treatment Planning, 4) Outpatient Mental Health, 5) SUD Treatment and Recovery, 6) Health Screening and Monitoring, 7) Case Management, 8) Peer and Family Supports, 9) Psychiatric Rehabilitation, 10) Assertive Community Treatment, 11) Home Based Health, and, 12) Medication Assisted Treatment. The project will place special emphasis on implementing innovations and best practices to expand integrated care and services for underserved rural areas and rural populations. It is expected to generate numerous community benefits and outcomes, including improvements in: 1) the number of individuals impacted, screened and assessed using the CCBHC model; 2) the number and types of CCBHC services provided; 3) individual diagnoses; 4) physical health outcomes; 5) behavioral health outcomes; 6) employment status; 7) substance use characteristics; and, 8) housing status.
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CCBHC Expansion Grants, FOA No. SM-20-012 Porter-Starke Services Inc. Project Name: Healthy Together - The primary goal of Healthy Together is to improve healthcare outcomes for individuals with serious mental illness, children and adolescents with serious emotional disturbance, those with substance use disorders, opioid use disorders and co-occurring disorders for Porter and Starke counties in Indiana. The minimum expected unduplicated client numbers annually are 1,000 in Year 1 and 1,500 in Year 2 for a total of 3,500. There are high rates of under diagnosis of these conditions and even after diagnosis, difficulty accessing the needed care. A repercussion is that these individuals often also have inadequate medical care as well leading to early mortality and chronic illness. This project will integrate medical and behavioral health care and improve access to care that is specific to need. Through an Advisory Work Group individuals with these disorders and their families will ensure that service design and delivery are most effective and responsive to the needs of the individuals affected. Operating as Certified Community Behavioral Health Clinics, specific goals are to improve screening for medical and behavioral health issues (including HIV and Hepatitis A, B and C), assess and treat issues identified through screening, improve behavioral health functioning of participants, improve care coordination and access to other needed services (e.g. medical care, vaccinations), reduce overdoses, establish systems to work with the courts to avoid hospitalization for psychiatric reasons, expand access to/enrollment in wellness based programs, and decrease barriers to care. Services to be provided includes Medication Assisted Treatment, psychiatry, outpatient therapies, intensive outpatient addictions treatment, care management/coordination, tobacco cessation, wellness/recovery coaching, peer recovery supports and community health worker services.
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Four County Comprehensive Community Mental Health Center’s CCBHC project, Expanding North Central Indiana Access, Coordination, and Treatment (ENACT), will serve 4 rural counties in Indiana: Cass, Fulton, Miami, and Pulaski. Focus populations are adults with Serious Mental Illness, Substance Abuse Disorder, and Co-Occurring Disorders and youth with Severe Emotional Disturbance. Veterans and justice-involved individuals are priority populations. ENACT will serve a total of 5,775 new unduplicated admissions over the 2-year period, 2750 in Year 1 and 3,025 in Year 2. Trauma-informed care, no wrong door, and suicide prevention is the contextual framework for ENACT and several EBPs, which will be delivered with fidelity, have been identified for populations to be served. For all consumers served, the overarching goal is to decrease symptomology, enhanced recovery, and increased functional outcomes in daily life, so consumers perceive improvement in their quality of life. Project goals and measurable objectives include the following: Goal 1: Establish comprehensive community-based behavioral health services for the focus population that meets all CCBHC criteria. • Establish an Advisory Work Group that will report to and inform the Board of Directors. • Review/revise training and quality improvement plans as need to meet CCBHC requirement. Goal 2: Increase timely access to behavioral health services in the 4C service area. • Offer same day access intakes for 100% of service referrals. • Attempt personal contact within 24 hours with consumers with behavioral health presentation released from the emergency departments and county jails. • Establish mobile crisis teams to respond to 100% of consumers who require in-person contact in the community within 1 hour of contact by referring agency. • Establish an intensive, community-based behavioral health program for veterans. Goal 3: Increase effectiveness of behavioral health services in the 4C service area. • Reduce readmission inpatient psychiatric admissions by 10% and 20% in years 1 and 2, respectively. • Provide care coordination to 100% of high risk/high utilization consumers within 24 hours of identification. • Expand peer support services to help coordinate services in the continuum of care. • 80% of consumers will experience improved health outcomes through standardized tools that measure symptom reduction and improvement in daily functioning. • 85% of consumers will rate satisfaction with services received as “high” or “very high”.
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Centerstone's Certified Community Behavioral Health Clinic (C-CCBHC) will support continued/expanded implementation of the agency’s CCBHC in Bloomington, Indiana, improving access to/quality of community behavioral health services for individuals with serious mental illness (SMI), substance use disorders (SUD), opioid use disorders (OUD), co-occurring disorders (COD), and/or youth with serious emotional disturbance (SED). C-CCBHC will serve 2,000 unduplicated clients from among the 6,100 served at the clinic yearly (Yrs 1-2: 1,000/yr). C-CCBHC’s target population is expected to mirror those of the catchment area, comprising Bartholomew, Brown, Greene Lawrence, Monroe, Morgan, and Owen counties in Indiana. Children/adolescents will comprise 51% male, 49% female, 86% white, 2% African American, and 6% Hispanic/Latino individuals; adults will comprise 49% male, 51% female, 90% white, 2% African American, and 3% Hispanic/Latino individuals. Of the catchment area’s population of 409,000, nearly 17,125 adults have SMI; 83% did not receive mental health services. Roughly 24,060 catchment area adults have SUD; 12,046, COD; and 2,605, OUD. Of adults reporting illicit drug use, 29,112 needed, but did not receive treatment. Roughly 8,349 catchment area children/adolescents meet criteria for SED, and 1,008 (ages 12-17) have SUD. An expected 8,300 area Vets have a mental health/SUD diagnosis, including 2,615 in rural areas, and about 1,250 have SMI. About 374 area Veterans with SMI are expected to also have PTSD. Since 2017, there have been 273 confirmed Hepatitis A cases. From 2016-2018, there were 168 Hepatitis B and 1,561 Hepatitis C catchment area cases. Roughly 9.3% of the area’s 433 persons with HIV were co-infected with Hepatitis C; 54% of those also reported injection drug use. Immediately upon award, C-CCBHC will provide an array of integrated primary/behavioral health care services (e.g., crisis care; mental health screening, assessment, and diagnosis; primary care screening and monitoring of key health indicators; HIV/Viral Hepatitis screening; integrated treatment planning; Medication Assisted Treatment and medication management; and telehealth). Medical detoxification and vaccination services will be provided by project DCOs. C-CCBHC’s evidence-based interventions are numerous and include Cognitive Behavioral Therapy, Motivational Interviewing, Assertive Community treatment, Illness Management and Recovery, Integrated Dual Disorder Treatment, and more. C-CCBHC will accomplish the following goals: 1) Continue delivery of comprehensive community-based mental and substance use disorder services for the target population, meeting all CCBHC criteria; 2) Enhance infrastructure/capacity for a full continuum of coordinated care; 3) Ensure access to/availability of timely services for the target population; 4) Improve health status and outcomes for C-CCBHC consumers engaged in treatment; and 5) Apply a CQI approach to drive outcome improvement and ensure ongoing service delivery. To support these goals, C-CCBHC will achieve the following measurable objectives: Decrease mental health symptomatology by 45%; Decrease substance use by 45%; Achieve 50% reported compliance with medication; Deliver personalized treatment plans for 100%; and Achieve 80% consumer/family reported satisfaction with their experience of care. Key C-CCBHC strategies include expanding/enhancing access/services; convening the exiting 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.
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Four County Mental Health Center, Inc. proposes to strengthen and expand current behavioral health services and collaborate with physical healthcare providers to create a comprehensive and integrated healthcare model across Chautauqua, Cowley, Elk, Montgomery, and Wilson Counties in Southeast and South Central Kansas. This highly rural area is home to an estimated population base of 81,820. The region has an estimated 17.2% of persons living in poverty and an average median annual household income of $43,330. There are widespread risk factors for the area including intergenerational behavioral health conditions, social norms favorable to substance use, early onset drinking and use of substances, high rates of depression, and death by suicide rates that are 3% higher than the national average. The area is considered a Health Professional Shortage Area and citizens of the region must seek care outside the geographical boundaries for many critical services and supports. The project will serve an estimated 6,575 unduplicated individuals in Year 1 and 6,970 individuals in Year 2. The CCBHC will serve everyone, regardless of their ability to pay or their county of residence. The primary target population for services will be individuals with mental health conditions, substance abuse disorders, or co-occurring disorders who lack health insurance coverage, are underinsured, or health insurance has been formally deemed unaffordable. There will also be concerted care coordination efforts placed on the Service Member, Veteran, and their Families (SMVF) priority population. The goals of the project are 1) to increase population penetration for integrated healthcare services through the CCBHC model of care which involves service expansion and collaborative efforts with area healthcare providers, and 2) increase human resource capacities to promote the attraction and retention of qualified personnel through increased wages and strategic recruiting efforts. Year 1 Objectives for Goal 1 include: increasing the number of patients served; providing care coordination services to at least 100 SMVF; having at least 50% of CCBHC patients with a Primary Care Provider listed in their electronic health record; providing Assertive Community Treatment to at least 50 individuals; tracking and quarterly reporting on key health indicators of at least 75% of enrolled patients; hiring of additional treatment staff to serve unmet needs; and creating more culturally-sensitive practices for the SMVF population through PsychArmor training. Year 1 Objectives for Goal 2 include: increasing social media recruiting efforts by 30%; fostering relationships with schools and key statewide job placement organizations to increase recruiting opportunities by 30%; broadening opportunities for referral bonuses and increase the bonus amounts by at least 30%; create more competitive salary and benefit packages to reduce the number of open positions by 30%; and reducing employee turnover attributed to low salaries by 30%.
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“Centerstone Certified Community Behavioral Health Clinic – Kentucky” (C-CCBHC) will strengthen an existing 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 2,400 individuals (Y1: 1,200; Y2: 1,200) with substance use disorders (SUD) or co-occurring disorders (COD), as well as adults with serious mental illness (SMI) and children/ adolescents with severe emotional disturbance (SED). C-CCBHC's catchment area (Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer, and Trimble counties, Kentucky) is home to nearly 783,000 adults, comprising 49% male, 51% female, 77% white, 18% African American, and 5% Hispanic/Latino individuals. Approximately 8% of adults are unemployed, 14% live below poverty, and 10% lack a high school diploma/equivalent. Nearly 6% of adults are Veterans. Approximately 227,000 are under age 18 and comprise 51% male, 49% female, 65% white, 23% African American, and 8% Hispanic/Latino individuals. Among this population, 14% experience poverty, and 4% of those ages 16-19 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, 45% of adults experience SMI; 56% of children/adolescents, SED; and 30% of adults and 5% of children/adolescents, COD. 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 services/interventions, including crisis care; complete mental health screening; outpatient primary care screening/monitoring of key health indicators; patient-and family-centered integrated treatment planning; MAT and medication management; and comprehensive, trauma-informed, evidence-based, outpatient mental health and substance use services. A partnering Centerstone of Kentucky (CKY) clinic will provide psychiatric rehabilitation services and CKY has an established well-developed 10-touch ACT Team available to all clients in the catchment area who meet criteria. Other project goals include enhanced infrastructure/capacity; increased access to/availability to services; improved health status/outcomes and improved systems and consumer care. Project strategies support goal achievement of enhancing the existing array of EBP interventions offered; expanding the consumer voice in the Advisory Council; increasing collaboration with community providers; utilizing an experienced evaluation team; and applying continuous quality improvement. C-CCBHC’s goals will result in decrease in mental health symptomatology by 25%; decrease in substance use by 25%; decrease in smoking by 25%; increase in daily life functioning by 50%; 90% consumer-reported satisfaction; and 90% of family members’ satisfaction.
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Project Abstract for New Vista’s CCBHC Expansion: New Vista is a leading provider of behavioral health services in Central Kentucky. The CCBHC expansion grant allows the expansion of behavioral health and physical health services in Fayette county. Additionally, the grant provides for the development of a new expanded service center in Madison county. The New Vista Health Centers offer person-centered, integrated services. The comprehensive array of services includes community-based outpatient behavioral health and substance use services, primary care services, 24/7 crisis center services, psychiatric rehabilitation and recovery support services in one location to serve both urban and rural populations. New Vista has already developed a pioneering approach to care in Central Kentucky, by opening a New Vista Health Center (NVHC) in Fayette County. A similar NVHC will be developed in Madison and serve Madison plus the surrounding counties of Clark, Estill and Powell. The NVHC's comprehensive array of services will ensure that individuals are receiving coordinated treatment. Some of the additional services that will be offered are Intensive Outpatient Program, Peer run Drop-in Center, Therapeutic Rehabilitation Program (TRP), Assertive Community Treatment (ACT), and engagement/outreach team. The populations of focus for the CCBHC project include individuals with a Co-Occurring Disorder (COD), Severe Emotional Disturbance (SED), Serious Mental Illness (SMI), and Substance Use Disorder (SUD in a five-county implementation area. The implementation area will include Clark, Estill, Fayette, Madison, and Powell counties. The target populations have a demographic makeup consistent with the five-county region (about 85% White and 10% African American). The populations also include uninsured and underinsured individuals, and veterans. One of the project goals is to expand low barrier services to increase access to behavioral health and primary health care for individuals with a COD, SED, SMI or SUD diagnosis. Common barriers to treatment include transportation, income, benefits and time as individuals navigate multiple systems of care. The CCBHC expansion grant will allow New Vista to improve access and coordination of behavioral health and physical health care services. The project is expected to increase the number of unduplicated clients served. Last fiscal year New Vista served 7,500 unique individuals in the five-county implementation area. We project our expanded services will allow us to serve at least 9,375 (25% more) unique individuals year one and 10,312 (an additional 10%) year two.
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As of result of the 2015-2018 MAPP Survey in the Green River region of western Kentucky, RiverValley Behavioral Health (RVBH) will provide expanded CCBHC services for the non-metro rural areas to 300 individuals per grant year who have been identified as SMI, SED, SUD, and/or COD. Due to barriers of living in rural areas, lack of transportation and limited access to substance abuse treatment, crisis intervention, and physical and mental health services, these individuals will receive services in the areas of integrated behavioral-physical health; substance abuse treatment; crisis intervention including mobile crisis; care coordination, smoking cessation, peer support and recovery; Medication Assisted Treatment; Assisted Outpatient Treatment (AOT) or Assertive Community Treatment (ACT). This project has six major goals which include: increasing the capacity for access to treatment in the rural non-metro areas of Western Kentucky by reducing wait lists and utilizing peer support specialists; increasing mobile crisis capacity to rural areas and reduce burden and reliance on law enforcement personnel; increasing capacity of physical-mental health integration; reducing the number of readmissions within 30 days and first-time admissions to acute hospitalization; expanding public health efforts for the target population by utilizing evidence-based practices; and expanding addiction and SUD/COD treatment and recovery efforts, particularly with methamphetamine and opioid addictions in the rural non-metro counties in the catchment area.
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NorthKey Community Care is an historic behavioral health center serving the eight most northern Kentucky counties adjacent to greater Cincinnati. NorthKey is among the oldest community mental health centers formed by the 1963 CMHC act. Accredited by the Joint Commission, NorthKey will serve an additional 1,246 severely ill children, adults, addicted persons including veterans, and people with chronic physical health conditions with funding from this grant. Populations to be served: The Kentucky Counties of Boone, Campbell, Carroll, Kenton, Gallatin, Grant, Owen, and Pendleton have a total population of 438,647. Persons residing in these counties are the primary persons served, but all persons will be served regardless of need, origin, or ability to pay. Service expansion will emphasize minorities, LGBTQ, Veterans, and School children. Clinical Characteristics: Primary clinical targets are persons in crisis, the severely mentally ill, seriously emotionally disturbed children, and those with substance use disorders. The opioid epidemic in the greater Cincinnati area places new demands on an already stressed system. Strategies/Interventions: NorthKey uses a special array of evidence-based practices to serve a complicated urban, suburban, and rural area fraught with poverty and social upheaval. Project Goals and Measurable Objectives: Goal 1: Verify all CCBHC components in first four months of operations and renew in all NorthKey areas needing improvements. Objective 1.1 Increase CCBHC trained staff by 40 FTE's to implement six CCBHC areas: 1)staffing; 2) service availability and access; 3) care coordination; 4) scope of services; 5) quality reports; and 6) governance. Objective 1.2 Increase services in areas of diagnostic, geographical, racial, age, and gender disparities based on analysis. Goal 2: Expand seven clinical behavioral health services to underserved target populations as revealed by needs assessment within four months of grant award. Objective 2.1 Address service delivery disparities by increasing access and services by 12.4% to minorities, veterans, youth, SMI,SED, SUD, persons in Crisis. Objective 2.2 Increase access and availability of services to 1,246 persons by rolling out new service array to underserved areas. Goal 3: Work with Advisory Group, Governing Board, and Community Partners to increase access and availability of service delivery systems to improve CCBHC compliance to SMI/SED/SUD. Objective 3.1 Train and support Advisory Group of clients and family members on CCBHC components to monitor and recommend changes to services. Objective 3.2 Establish regular meeting cycle with community partners to examine CCBHC components for system changes. Goal 4: Measure and Report the 21 required CCBHC performance measures to improves services. Objective 4.1 monitor and report all CCBHC quality and performance measures using Credible Software. Objective 4.2 Improve all NorthKey operations using monthly quality reports in Leadership Team, Advisory Group and Governing meetings to change policies and goals. Number served annually and throughout project: Approximately 600 new persons served each year and 1,246 persons throughout project resulting in a 15% expansion in persons served.
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Mountain Comprehensive Care Center will increase access to and quality of community mental and substance use disorder treatment along with integrated physical healthcare for persons with serious mental illness, substance use disorders (including opioid use), children and adolescents with serious emotional disturbance, and persons with co-occurring mental and substance disorders through the Eastern KY CCBHC Expansion across Floyd, Johnson, Pike, Magoffin, Martin, Lawrence, Carter, Bourbon, Clark, Harrison, Letcher, and Perry counties, KY. Population: MCCC will serve persons of all ages in the targeted eastern KY region with mental and substance use disorders, including those with the most serious and complex issues. The targeted area experiences significant economic and behavioral health care disparities including among the highest regions in the state and country for mental health, SMI, SED, SUD/OUD and COD. It is anticipated that some clients may also have co-morbid medical issues. Interventions: MCCC will provide a comprehensive collection of services that creates access, stabilizes people in crisis, and provides the needed treatment and recovery support services for those with the most serious and complex mental and substance use disorders. MCCC will integrate additional services through agency and community resources to ensure an approach to health care that emphasizes recovery, wellness, trauma-informed care, and physical/behavioral health integration. Key EBPs include Motivational Interviewing, Cognitive Behavioral Therapy, Medication Assisted Treatment, Illness Management & Recovery, and trauma-informed care. Goals & Objectives: MCCC will serve 300 unduplicated persons in Year 1 and 600 in Year 2 for a total of 900 over the project period. Goals are to: Increase the health of persons with mental health and SUD (including serious/complex) in the targeted service area by expanding access to evidence-based community behavioral health services; Improve stability by providing and/or coordinating access to comprehensive recovery support services; and Improve the agency’s infrastructure to provide high-quality community behavioral health services by providing staff training, resources, and CQI. Objectives include: by the end of each year MCCC staff will have: provided evidence-based outpatient behavioral healthcare so that 60% of clients of the targeted population served will show improvement in their mental health functioning and/or a decrease in use of alcohol/illicit substances; provided and/or coordinated: housing resources so that 60% of clients of the targeted population served who are homeless or precariously housed will improve their housing status, wellness and recovery supports so that 60% will participate in some type of recovery and/or peer support service, and wraparound services so that 50% will improve their education/employment status and/or access to benefits; and infrastructure supports include at least 200 agency staff will have received training; the agency will obtain CCBHC certification by Month 4; and the Project Director will expand and meet quarterly with an Advisory Work Group. Morehead State University will conduct the evaluation and participate in cross-site evaluation, as required.
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ServiceNet's Community Behavioral Health Clinic (SCBHC) meets critical public need for substance use disorder and serious mental illness treatment by increasing access, providing, and coordinating comprehensive and integrated medical, substance use, and psychiatric care. SCBHC is committed to community-based person and family-centered, trauma-informed treatment, and working with key area healthcare providers to achieve better health outcomes. SCBHC serves the predominantly rural counties of western Massachusetts. Our focus of care are individuals with serious mental illness (SMI), those with substance use disorder (SUD), and high-risk individuals such as the homeless. Clients come from diverse socio-economic backgrounds, but due to economic need or disability, a high percentage receive public benefits, MassHealth, and Medicare. Our goals are; increased and timely access, a reduction in negative impacts of SMI and SUD on client functioning, and better integration of care. To achieve these goals, we will hire more staff, raise the level of coordination with healthcare via Designated Collaborating Organizations (DCO), and maintain a rigorous evaluation program. SCBHC will serve an additional 300 people a year with SMI, SUD, and Co-Occurring Disorders (COD). Nursing staff and supervised case managers are vital to screening and monitoring key health indicators and referring clients to our primary care DCOs for needed healthcare. Psychiatric staff and nurses will work with primary care DCOs to screen for clinical adverse effects of medication including metabolic syndromes. These efforts will also be important in determining individuals at high risk for HIV, Hepatitis A, B, & C, and other health impacts that may co-occur with SUD or SMI. Teams will work with our DCO, Tapestry Health, for help with screening and prevention strategies like PrEP, syringe access and disposal, access to Narcan, and emergency contraception. We will work with Clinical Support Options (CSO) to provide 24/7 crisis service. Case Managers/Recovery Navigators will assist clients in obtaining benefits and support client engagement, utilization, and adherence to treatment. Our internal DCO, Adult Clinical Community Services (ACCS), will provide psychiatric rehabilitation services and social support opportunities. Our program will have a comprehensive community component bolstered by our long and positive community relationships with veteran services, local law enforcement and jails, housing authorities, recovery support services, and local offices of state agencies. Our multi-disciplinary Assertive Community Treatment (ACT) team will serve people with SMI, SUD, and those with COD. Community recovery support will be enhanced with case management, peer support, counseling, family support, and the development of psycho-educational groups for families, illness management, and recovery. The SCBHC Advisory Committee made up of people with lived experience and families will inform and guide our services. SCBHC will expand services, strengthen coordination, enhance evaluation, and increase contract and 3rd party revenue to sustain the program.
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The Gandara (GC) CCBHC Expansion Project will target CCBHC resources to effectively serve Spanish speaking individuals & family members, in Springfield/ Holyoke, MA, with a Serious Mental Illness, Substance Use Disorder and/or SED. It will enhance care coordination and provide integrated services by a multidisciplinary Care Coordination team, and improve functioning, behavioral health, and social/economic well-being to 1200 new/existing clients. Gandara serves an average of 5000 individuals annually at its two adjoining outpatient clinics, (2155 Main Street and 85 St. George Road in Springfield), where it provides a full array of mental and behavioral health, addictions, care management and, SAMHSA funded, Primary and Behavioral Health Care and Minority HIV-Service Integration programs. Current BH records at GC’s OP clinics found 87% of clients have SMI or co-occurring disorders and 13% have SUD. Ninety percent (90%) are Hispanic/ Latino; 45% lack a high school or GED diploma; 28% are between ages 16-34 years 32% have co-occurring SMI and SUD. Clients in this sample also have a high no-show rate, with 37% of reporting multiple treatment barriers, including lack of transportation, forgetting appointments, and anxiety in the waiting area. Nearly 25% of “no-shows” missed 3+ appointments. These data demonstrate the need for new interventions and intensive services in order to retain clients in treatment and attain better health outcomes. CCBHC Expansion activities will be based within Gandara’s Springfield clinical campus. GC developed its Cooperative Care Team (CCT) model, as part of its SAMHSA PCBHI & MASI grants, to provide integrated primary, mental health, and substance use disorder (SUD) services for individuals assessed with SMI/DD/SUD and chronic health conditions. The project uses the Integrated Dual Disorders Treatment (IDDT) and Motivational Interviewing EBP’s, with systems-wide trauma informed care and an integrated bio-psychosocial and ecological approach. The CCT will expand in both clinic sites and outreach treatment locations to engage individuals with high risk of SMI/SED/DD and SUD. The team will include a psychiatrist, nurse prescribers, clinicians, medical assistants, and case managers. Activities will include: 1) Expand timely service provision services through Level of Care assessment, assignment to appropriate treatment for all clinic and outreach clients, and increased access to Medication Assisted Treatment, through expanded hours and increased staffing, 2) Improve engagement and positive outcomes for CCT clients through expanded EBP training, Assertive Community Treatment (ACT), twice weekly CCT meetings. 3) pilot a telemedicine program so CCT team members can participate remotely in meetings deploy case managers to outreach, home and community settings to support remote client participation in CCT services; hire new staff CCT utilizing Telemedicine in an effort to address the recruitment challenges in the service area. 4) Expand outreach services aimed at Hispanic/Latinx, African American, & LGBTQ Youth/ Young Adults (YYA) at high risk of BH disorders. 5) Strengthen clinic systems and processes to provide real time/actionable client outcome data. Numbers Served: 2 Yr. total=1200 individuals: Y1=350 new & 150 existing clients; Y2- 450 new & 250 existing clients. 10 individuals served by ACT over 2 years.
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Project name: CCBHC Expansion Strategies/interventions: Clinical and Support Options (CSO), a large behavioral health organization already certified as a CCBHC, will provide residents of all ages with services to address serious mental illness, serious emotional disturbance, substance use disorder and co-occurring disorders by meeting all 16 required services in six sites, adding three new sites under this grant, which will be geographically distributed across Western and Central Massachusetts in 5 counties. Population to be served: Based on 2015 SAMHSA estimates, there are a total of 17,000 adults with SMI (persistent and severe) or COD (86%, n=14,260) or youth/children who have SED (14%, n=2,380) in the service area. There are over 32,000 veterans in the new service area; 25% were in active military service after 2001. Number of people to be served: The CCBHC program will serve an estimated 1,000 unduplicated participants in each of Year 1 and 2 for a total of 2,000 people for the total grant period. Project goals: Goal 1: CSO will deliver all 16 services required by CCBHC, directly or through DCO partnership; Goal 2: CSO will create maximum access to services for those with SMI/SED in the 5-county service area and Goal 3: CSO will establish an integrated care coordination capacity and access to services available to 100% of CCBHC clients. Measurable objectives: Objective 1.a: CSO will provide all 16 required services delivered by appropriately credentialed/experienced staff upon contract start date, expanding nursing, primary care screening, care coordination and wellness supports to 3 additional locations within 60 days of the contract start date. Objective 1.b: 100% of CCBHC staff will trained in relevant EBPs to their role within the first 6 months of contract start date, in use by CCBHC and other practices specific to CCBHC. Objective 2.a: There will be same day, walk-in access at all 6 sites for 100% of those seeking to enroll. 2.b. CSO services will conduct intake, assessment and enrollment for 100% of participants within 24 hours of referral or immediately on arrival for walk-ins. Objective 3.a.: CSO will track 100% of CCBHC participants in its EHR for CCBHC service utilization internally, in DCOs and community organizations to which clients are referred. Objective 3.b. CCBHC participants will average a 10% improvement in measures of psychological distress and social connectedness as measured by the GPRA survey.