The purpose of the proposed “Integrated Health Macomb” (IHM) project is to expand and enhance targeted protocols, services, rate and ease of access, and community capacity consistent with the CCBHC requirements for all residents living in Macomb County, Michigan (population 874,759), which is the intended catchment area. IHM will provide CCBHC required services, including integrated behavioral and primary health care services to uninsured and under-insured Adults with Serious Mental Illness (SMI), Children with Severe Emotional Disturbance (SED) and persons with co-occurring Mental Illness and Substance Use Disorder. IHM goals will focus on increasing ease of access, expanded use integrated care and proven Evidence-Based Practice (EBP) treatment and support models. Primary health care screening and monitoring services will be provided in coordination with an FQHC community partner. IHM will expand informed trauma competency within the IHM system,with Designated Collaborating Organizations and other community stakeholders. IMH will demonstrate improved system performance in access to services, engagement with persons served and retention in treatment. Finally, IHM will apply quality improvement practices to collect, monitor and report on data to show program impact and create improvement strategies. IHM expects to provide services to approximately 1,500 persons annually, 3,000 over the two year grant period.
With SAMHSA CCBHC Expansion funds, Advocates proposes to create the Advocates Community Counseling (ACC) CCBHC to bolster its existing 24/7 behavioral health (BH) service continuum, targeting un/underinsured people of all ages with complex BH and physical health needs in 5 communities in the MetroWest (MW) region of Massachusetts (MA), (total pop. 166,183), an area not covered by any CCBHC in MA. Population to be served: Framingham, our proposed CCBHC location, is the largest community in MW (pop 71,232) and the most diverse, with ~35% of its residents from communities of color and 38% speaking a language other than English. The city has the largest Portuguese-speaking Brazilian population in MA and a higher percentage of uninsured residents (7%) compared to the region/state (3%), many of whom are immigrants. MW has higher rates than state averages of hospitalizations related to mental health or heroin abuse. ACC will service those most at risk - people with serious mental illness (SMI), substance use disorders (SUD), co-occurring mental health and substance use disorders (COD), co-occurring complex medical conditions, and serious emotional disturbances (SED) - some of whom are uninsured and/or non-English speaking. Strategies/interventions: We will improve the accessibility and quality of community BH services in the MW region through the creation of the ACC CCBHC, operating an integrated, team-based approach to providing comprehensive, accessible, and responsive “whole-person” care across a continuum of complexity and need, providing the right care, in the right place, at the right time. The proposed approach draws on proven delivery models and Evidence Based Practices (EBP) and creates strong linkages with strategic community partnerships, particularly primary care and SUD providers and those that address social determinants of health. Goals and Objectives: ACC CCBHC will serve 400 people in year 1 and 400 in year 2, reaching an unduplicated total of 800 in 2 years. Goal 1- Decrease barriers to care by expanding access to 24/7 BH services for people with SMI/SUD/COD/SED who have experienced stigma, lack of insurance, or scarcity of culturally/linguistically appropriate services, by implementing a ‘no wrong door’ approach regardless of their ability to pay or place of residence; offering multilingual and culturally competent care to Portuguese and Spanish-speaking residents; and embedding peer support throughout our services. Goal 2- Improve efficiency and effectiveness of BH services by creating service delivery models to better assess needs, coordinate care, and integrate BH and physical healthcare through integrated treatment teams; conducting preventative primary care services; and implementing care coordination to provide continuity of care. Goal 3- Increase access to services that meet the unique BH needs of target populations by expanding EBPs through an addiction recovery and medication-assisted treatment (MAT) team; first-episode psychosis team based on Coordinated Specialty Care and Open Dialogue; and youth and family team using the Adolescent Community Reinforcement Approach (A-CRA).
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.
Through the CCBHC Expansion Grant Mercy Life Center Corporation (MLCC), a PA CCBHC awardee and a CCBHC Expansion Grant awardee will further increase access and capacity and enhance and expand services for individuals with SMI, SUD, SED and COD within Allegheny County PA, by utilizing collaborative partnerships, enhanced clinical treatment teams and complex care coordination. The proposed services include expansion and refinement of care management services resulting in increased linkage to all nine core services with a special emphasis on expanded coordination of and linkage to primary care screening and monitoring and increased access to psychiatric services through tele-health portals. The creation of a data driven quality measurement process will inform care. Expanding on a high fidelity CCBHC program, these proposed comprehensive population focused services 1) effectively screen, assess and coordinate care through a Complex Care Management Model, 2) provide increased access to MH, SUD & COD treatment, 3) institutes a safety net for community providers to coordinate and access care across systems, 4) provides access to telepsychiatry and teleconsultation services to address gaps in care related to readiness to engage, social disparities and provider shortage areas. Throughout the life of the grant 5000 individuals will be served. The project will utilize the Evidence-Based Practices Illness Management and Recovery (IMR), Motivational Interviewing (MI), Harm Reduction, and trauma informed approaches and interventions, in engaging and maintaining individuals in service. MLCC, building upon the CCBHC model, will expand capacity and sustain a program with the following objectives: (1) Outreach and engage individuals with mental health and substance use disorders and screen and enroll 600 individuals, (200) in YR1 and (400) in YR2 that are dually served in MLCC’s CCBHC and in MLCCs specialized primary care with 85% continued engagement beyond 6 months. (2) Increase the number of internal connections (linkage) to the nine core services a CCBHC participant, risk stratified as high risk has, by 10% year one and 30% over the life of the grant. On average 2 contacts per person, risk stratified as high risk, will be increased to 5 per person over the lifetime of the grant. This will impact 600 individuals, (200) in YR1 and (400) in YR2. (3) Linkage with community partners will increase by 10% year one and by 50% over the lifetime of the grant. On average 2 contacts per person with community partners will be increased to 4 per person over the lifetime of the grant. This will impact 600 individuals, (200) in YR1 and (400) in YR2. (4) Create a data driven quality measurement process to track, evaluate and inform utilization and effectiveness of EBPs as measured by reduction in tobacco use and obesity, stabilization of/reduction in psychiatric and SUD symptoms and improvement in quality of life. This will impact 5000 individuals over the life of the grant (2000) in year 1 and (3000) in year 2.
Care Plus NJ's "Expansion Continuation" program will build upon the current CCBHC Expansion program to increase access to and improve the quality of community behavioral health services in Bergen and surrounding counties in NJ. It will continue to offer comprehensive and coordinated care to individuals with SMI, SUD's, COD's, and SED, but with expanded family systems, community outreach, and perinatal behavioral healthcare capacities. It is estimated that 56.9% of individuals with mental illness and 89.2% of individuals with SUD's do not receive treatment (NIMH, 2018; SAMHSA, 2015). Untreated SMI, COD's, SED, and SUD's (especially for pregnant and postpartum women) can increase the risk of premature death, chronic medical conditions, homelessness, incarceration, suicide, and more. In 2018, Bergen County had significantly higher rates of inpatient hospitalization for behavioral health diagnoses compared to NJ overall and the highest growth of children's crisis intervention responses since 2011 in the State. NJ's maternal mortality rate is almost double the national average and a higher number of mothers in NJ have postpartum depression compared to the national average. Specifically, 60% of serious perinatal mood disorders goes undetected, and 40% of those detected go untreated. Each project year, 500 unduplicated individuals in the population of focus will be served, for a total of 1,000 unduplicated individuals served over the project period. Goal 1: Improve access and the quality of behavioral health services through the expansion of the CCBHC program. Objective 1.1: By the end of the project period, 70% of participants will report maintenance or a decrease in behavioral health symptom severity as demonstrated through evidence-based assessment measures. Objective 1.2: By the end of the project period, 100% of enrolled expecting and parenting families will be screened for perinatal mood disorders, SUD's, and COD's, and referred to services as needed. Objective 1.3: By the end of the project period, 400 hours of care coordination will be provided for enrolled individuals to improve physical and behavioral health. Goal 2: Implement plans for sustainability to ensure delivery of services once federal funding ends. Objective 2.1: By the end of the project period, 500 physicians, health workers, and other community stakeholders will be trained in screening, intervention, and available resources for the population of focus, including for expectant and parenting families. Objective 2.2: 100% of individuals and families will be referred to appropriate services upon conclusion of the project. Objective 2.3: By the end of the project period, 100 organizations will collaborate, coordinate, and share resources to integrate service systems as a result of this grant. Fully integrated mental healthcare, substance abuse treatment, and physical healthcare will be provided to support individuals and families with the highest needs throughout their lifespan. Care Plus NJ has the infrastructure, intersystem relationships, and clinical expertise to successfully continue our CCBHC Expansion services into the next grant period.
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.
“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.
Horizon Health Services (HHS) with its affiliate, Horizon Village (HV), proposes to expand and enhance its Certified Community Behavioral Health Clinic (CCBHC) services to persons with serious mental illness (SMI), substance use disorders (SUD), children/adolescents with serious emotional disturbance (SED), and persons with co-occurring disorders (COD) through several initiatives targeted to improve patient engagement, care access and treatment outcomes. HHS is committed to providing services to the indigent and those with SMI or SUD, including opioids. 74% of our more than 15,000 patients are uninsured or on Medicaid. HHS is a recipient of a CCBHC Expansion Grant (SM-18-019). We have successfully implemented the full range of the required treatment services, and have conformed to all required services, activities and reporting. Our intent is to continue the operation of our CCBHC due to the ongoing prevalence of SMI and SUD in our region, and to build on our comprehensive service model, which includes inpatient detoxification and intensive residential rehabilitation treatment programs that go beyond the CCBHC requirements, to serve an expanded market need. This will be accomplished through: implementing HIV and Viral Hepatitis screening; applying our telepractice capacity to serve patients with treatment access challenges including residents of two (2) additional underserved counties - our patients shared with medical practices; increasing the number of clinicians with the capacity to serve persons with co-occurring disorders; improving patient adherence to psychotropic medications and medical screening and linkage to medical care; reducing wait time for initial appointments; expanding our vocational/educational rehabilitation programs; and implementing processes to avert crises for at-risk patients in transitions between levels of care and who are pregnant/post-partum. We will measure our performance on a range of treatment engagement/outcome measures including: access time and attendance of initial appointments for all patients (including post-inpatient), psychiatric services and Medication Assisted Treatment; cardiovascular disease and diabetes screening and care linkage; patient adherence to anti-psychotic and anti-depressant medications; and hospitalization, re-hospitalizations and emergency room visits. As indicated, our main focus is to increase our CCBHC participation, care coordination and patient access/engagement. We intend to expand the number of clients served annually across all age categories, and anticipate serving annually an additional 1,476 (10% increase) unserved patients by the end of the contract period. Our current patients reside largely in northern Erie, Niagara and Genesee Counties in Western NY, and we plan to make our services available to the 170,029 residents of Orleans and Chautauqua Counties through our telepractice initiative.
As Missouri's second largest Certified Community Behavioral Health Clinic (CCBHC), Burrell, Inc. is requesting $4,000,000 over two years to continue to expand its successful, cost effective CCBHC model that benefitted from CCBHC-E FY2018 funding. Burrell's CCBHC has improved access and quality of services, integrated primary care, and supportive human and social services. With this funding, an estimated 1,600 person will be served in an area whose population exceeds 890,000. All 17 counties are designated by DHHS as Mental Health and Primary Care Professional Shortage Areas, and 82% are designated as Medically Underserved Areas. Over 98,000 (11%) adults and children are without insurance in these counties and may not have access to healthcare services they need. The project will use evidence-based practices to expand access for individuals with: 1) serious mental illness; 2) substance use disorders, focusing on opioid disorders; 3) children and youth with serious emotional disturbances; and 4) individuals with co-occurring behavioral health disorders. Subpopulations such as those experiencing homelessness, the LGBTQ+ population, African American and Hispanic Communities will be targeted populations for services. Examples of services provided by the comprehensive system of care include: Crisis Mental Health Services; Screening, Assessment and diagnosis; Person Centered Treatment Planning; Outpatient Mental Health; SUD Treatment and Recovery; Health Screening. Monitoring; Case Management; Peer and Family Supports; Psychiatric Rehabilitation; Assertive Community Treatment; Home-Based Health; and, MAT (opioids). The project will place special emphasis on access to crisis help in a wide variety of locations (schools, emergency rooms, primary care facilities, home, etc.) Over the last two years, with help from FY2018 funding, Burrell has transformed access to care into an understandable, easy, stress free experience through extensive telehealth scheduling advances, workforce development and the opening of Burrell's Connection Center. Expected FY2020 outcomes include improvements in: number of individuals impacted, screened and assessed; number of types of services; individual diagnoses; physical and mental health; employment; substance use; housing; and, 21 additional SAMHSA CCBHC measures. Community and Congressional leaders strongly support the project due to compelling local behavioral health and SUD needs. In 2019, an estimated 925,000 Missouri adults over the age of 18 experienced some form of mental illness, of these, 226,000(24%) experienced an SMI that substantially limited their life activities (DMH,2019). SAMHSA NOMS data shows Missouri's incidence of co-occurring mental health/substance disorders is triple the national median for children (9% vs 3%), and more than double the national median for adults (57% vs. 22%). Opioid and SUD will be an area of focus because there is a strong connection between mental health and substance use, as evident in the regions co-occurring disorder rates. CARF accredited with over 1,600 staff, 26,000 persons served and $125 million annually in revenues, Burrell has over 42 years experience as a State designated CMHC. It is a current SAMHSA funding recipient (CCBHC-E, PBHCI, PATH, TREE, SOC) and is a SAMHSA Science and Service Award winner. Its staff have decades of experience in community based treatment along with management and oversight experience for continued CCBHC-E success.
Certified Community behavioral Health Clinic-Amelia (CCBHC-A) CCBHC-A is a collaboration between Greater Cincinnati Behavioral Health Services (GCB), a regional behavioral health agency and 2 organizations-The HealthCare Connection, a Federally Qualified Health Center and GCB's primary care partner and Child Focus, Inc.- a licensed crisis services provider. This partnership will increase access to/improve the quality of community mental health and substance use disorder treatment in Clermont County, OH (CC), a rural, Appalachian county. GCB expanded to CC in 2014 to address health disparities in a county with limited services. It has elements to establish a CCBHC but needs funding to address access issues and strengthen services. Primary gaps include a mismatch between service demand and funding for uninsured clients; workforce shortages; limited access to crisis and youth mental health services; lack of integration between mental health/primary care and substance use disorder treatment; and insufficient care coordination. CCBHC-A will be established to address these issues. GCB meets most CCBHC requirements and will obtain technical assistance from the National Council for Behavioral Health to ensure it meets certification requirements by 12/30/2020. Once certified, CCBHC-A will provide integrated services to 1,000 new clients over 2 years-400 in year 1 and 600 in year 2. Goals/Objectives include: 1) Establish CCBHC-A to increase access to integrated services via certification and expansion of clinic hours; 2) Increase access to crisis services to reduce suicide via expansion of mobile crisis to 24/7, establishment of emergency crisis services, access to crisis support beds, and adoption of Critical Time Intervention; 3) Integrate SUD treatment to increase service access via workforce expansion, development of treatment protocols, and integration of a SUD module into the EHR; 4) Expand youth counseling and psychiatry to serve more children/adolescents; 5) Expand primary care and care coordination to improve health via workforce expansion, improvements in EHR population health, and development of a technology-based care coordination plan; and 6) Develop sustainability strategies to include participation in state-level crisis planning, development of a sustainability plan, and expansion of value-based contracts with managed care organizations. Key interventions include Critical Time Intervention, Medication-Assisted Treatment, Assertive Community Treatment, Cognitive Behavioral Therapy, and Integrated Dual Diagnosis Treatment. The focus population is youth and adults, to include persons with serious mental illness, substance use disorders, youth with serious emotional disturbance, and persons with co-occurring disorders. 94% are White; 54% female. Average age is 40. Top diagnoses are major depressive disorder and bi-polar disorder. 21% are uninsured. GCB spent 6 years building the infrastructure and services to establish the foundation for a CCBHC with the help of 2 SAMHSA grants. SAMHSA funding will allow GCB to finalize integration efforts and expand its workforce to meet the demands of a disparate population in a disparate region.
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.
The St. Clair County Community Mental Health (CMH) Improving Community Health CCBHC Initiative will focus on increasing access to high-quality, evidence-based community behavioral health and substance use disorder services. The program will serve adults with Serious Mental Illness (SMI), adults and youth with co-occurring disorders (COD), youth with serious emotional disturbances (SED), and adults and youth with substance use disorders (SUD). Services and supports provided will be person and family-centered, recovery focused, and trauma informed with a focus on integrated healthcare that supports each person’s unique individual needs. Project outcomes will include improved mental and physical health among adults and children served, increased access to services, and furthering community-based education and prevention programming to improve the health and wellness of individuals in St. Clair County.CMH is planning up to a 15% increase in persons served, which amounts to an additional unduplicated 338 adults with SMI or COD and 129 youth with SED. A 50% increase in SUD treatment is expected, which amounts to an additional 44 people served. Standardized and validated assessment tools are used to identify level of care and monitor individual progress. Services provided include: Crisis mental health services, including a 24-hour mobile crisis team; screening, assessment, and diagnosis; patient-centered treatment planning; comprehensive outpatient mental health and substance use disorder services; screening for HIV and viral Hepatitis A, B and C; Outpatient primary care screening and monitoring of key health indicators; clinical medication monitoring; case management; psychiatric rehabilitation services; social support opportunities; comprehensive community recovery supports; intensive community-based mental health care for members of the armed forces and Veterans; and Assertive Community Treatment. The project includes five goals: to improve mental and physical health of individuals receiving services; to enhance service provision; to improve the mental and physical health of community members; to attract and retain qualified, competent, and confident staff; and to plan for CCBHC sustainability. These goals will be achieved through staff training, provision of evidence-based services, increasing integrated healthcare efforts, workflow re-design, technology enhancements, outreach and prevention efforts, school-based mental and physical health clinic implementation, and formal development and implementation of a staff recruitment and employee wellness plan.
This proposal, titled Community Mental Health Authority of Clinton, Eaton & Ingham (CMHA-CEI), Certified Community Behavioral Health Clinic (CCBHC) Expansion Project, is being submitted in response to Funding Announcement (FOA) No. SM-20-012 for the FY2020 Certified Community Behavioral Health Clinic Expansion Grants. CMHA-CEI serves the tri-county capital region located in central Michigan which consists of both urban and rural communities (based on the USDA definition of rural) and has a population of almost 500,000 people. Within the CMHA-CEI catchment area, there is a 27% (13,500) gap in mental health services and an 89% (19,700) for substance abuse services (Altarum, 2019). CMHA-CEI is requesting $2,000,000 per year to expand services to 2,500 unduplicated individuals over the two-year funding period. The target populations are: individuals who have Medicaid or are uninsured, underinsured, or have commercial insurance and diagnoses of Serious Mental Illness (SMI), Serious Emotional Disturbance (SED), Substance Use Disorder (SUD), and/or co-occurring disorders (COD). Services will be provided by Nurse Care Managers, Mental Health Therapists, and Peer Recovery Coaches; as well as Ingham County Health Center, IRIS Telehealth, and Hope Network who are Designated Collaborating Organizations (DCO). The DCOs will provide tele-psychiatry services, medication-assisted treatment, and medical oversight for withdrawal management within the CMHA-CEI detox facility. The Ingham County Health Center is also a key partner with providing behavioral and primary health care integration. The goals for the project are: Goal 1: Increase capacity for Mental Health and Substance Use Disorder Services to serve more consumers who have a diagnosis of SMI, SED, and/or SUD to improve consumer access; Goal 2: Increase care coordination of behavioral and physical health needs for consumers who have a diagnosis of SMI, SED, and/or SUD and a co-occurring chronic health condition in order to improve health outcomes; Goal 3: Increase the use of Evidence-Based Practices with consumers who have a diagnosis of SMI, SED, and/or SUD to improve their quality of care; and Goal 4: Improve organizational systems and processes to maximize efficiencies in services, professional development, and reimbursements.
Deschutes County Health Services (DCHS) is the most rapidly growing county in Oregon, a CCBHC Planning Grant state. The DCHS Certified Community Behavioral Health Expansion Project will focus on increasing access to collaborative, integrated services for individuals with serious mental illness (SMI), substance use disorders (SUD) and Co-occurring disorders (COD), and children/youth with serious emotional disturbance (SED), with an additional focus on enhanced services to homeless, incarcerated, limited English proficiency (LEP) and rural members of the target population. Overarching project goals are: individuals served will experience improved behavioral and physical health and functioning and clinical competencies will be maximized in the behavioral health workforce. By August 29, 2022, the number of clients screened for any mental illness who then receive care at an integrated site will increase by 26%, for an annual increase of 870 additional participants and a two-year total of 1,740 additional, unduplicated individuals served. Additional measurable objectives are: * By August 29, 2022, the number of homeless clients that receive services will increase by 25%, up from 209 clients in 2019, for a two-year increase of 104 clients and a two-year total of 520 homeless individuals served. * By August 29, 2022, DCHS will increase # of individuals that receive follow up within seven (7) days of an ED visit for an SUD condition from 30% to 70%. * By August 29, 2022, DCHS will increase # of individuals that receive follow up within seven (7) days of an ED visit for a MH condition from 72% to 85%. * New Stabilization Center will help reduce ED utilization among DCHS clients by 10%. * By August 29, 2022, 300 individuals having received 6 months or greater of service will show an average increase of 5 points in their Daily Living Activities (DLA)-20 score. * By August 29, 2022, 70% of individuals with a diagnosis of depression, who score positive for depression on the PHQ-9, will show an average decrease of 4 in PHQ-9 score six months post entering services. * By August 29, 2022, 90% of individuals served will have a primary care provider and 95% of individuals served, with a primary care provider will have at least one care coordination service involving their primary care provider documented in the clinical record. * By December 31, 2020, 100% of staff responsible for treatment will receive training in language access best practices and interpretation and translation resources. * By August 29, 2022, 100% of LEP clients will have client facing documents provided to them in their language. * 100% of project clinical staff will receive training on EBPs for integrated care, including 80% clinical staff attendance to National Council on Behavioral Health Conference.
Summary: Community Healthcore proposes to expand and enhance its current delivery of coordinated, integrated primary and behavioral health care to better Bowie, Cass, Gregg, Harrison, Marion, Panola, Red River, Rusk and Upshur counties. This unique area, which borders Oklahoma, Arkansas and Louisiana, has been challenged by insufficient health care resources for generations, causing residents to relocate to access care, or do without. Project Name: Northeast Texas CCBHC Network Population to Be Served: Uninsured, low income children and adults diagnosed with serious mental illness, serious emotional disturbance, or co-occurring mental illness and substance abuse disorders who have co-morbid physical health conditions and chronic diseases. Healthcore estimates that at least 30,000 residents of the nine counties meet this definition, and African Americans and Hispanics are over-represented in comparison to regional demographics. Strategies/Interventions: Healthcore is a state-certified CCBHC provider. Healthcore proposes to continue operating an integrated care clinic in Longview, and add three additional CCBHC-certified clinics (located in Red River, Harrison and Bowie counties) over the project period. The primary intent is to implement a networked model of care with the capacity to improve consumer health, enhance the consumer experience of care, control the cost of care. Care management will be a key implementation strategy; multi-disciplinary care management teams in each of the four CCBHC clinics will provide or arrange comprehensive, individualized primary and behavioral health care services and recovery supports, guided by an integrated health care plan. Project Goals and Measurable Objectives: Goal: Provide quality-focused, patient-centered, recovery-oriented, trauma-informed, integrated physical and behavioral health care and treatment in four integrated care clinics. Objectives: 1. Hire, prepare and assign four care teams to the integrated care clinics. 2. Use evidenced-based screening and assessment tools to diagnose physical and behavioral health conditions and provide indicated primary care and behavioral health treatment to 8,500 consumers. 3. Follow an outside the 4-walls service philosophy that features peer leadership and increases consumer capacity for effective self-management. Outcomes: 8,500 children and adults receive integrated physical and behavioral health care; 250 veterans have their immediate physical and behavioral health care needs met and are connected to specialized continuity care resources in the region; 8,500 adults and children receive case management; and, 5,000 adults and children receive social support services, recovery support, peer support, and/or employment or housing connections. Number to Be Served: 3,500 unduplicated adults and children in 2020-21, and 5,000 unduplicated children and adults in 2021-22, for a project total of 8,500.
BestSelf Behavioral Health is requesting funding in the amount of $2,000,000 per year for 2 years to sustain and expand its current New York State Certified Community Behavioral Health Clinic (CCBHC) and the initial SAMHSA CCBHC Expansion Grant Project. Funding will sustain services currently provided through the initial expansion grant, expand capacity of the CCBHC Assertive Community Treatment (ACT) Team, and support implementation of an additional clubhouse located in southern Erie County. The population of focus for the proposed project includes individuals with serious mental illness (SMI) or a substance use disorder (SUD); children and adolescents with serious emotional disturbance (SED); and individuals with co-occurring disorders (COD) residing in Erie County, New York. By project end, BestSelf 2020 CCBHC Services Expansion will provide direct services to 1,525 clients (763 annually) who will receive these additional services, reduce all-cause hospitalizations, and improve medication adherence rates. Goals and objectives for the proposed project include providing access to: the social support activities provided through two clubhouse locations to 650 clients annually; CCBHC ACT services to a 75 client case load; and comprehensive services for 75 transition age youth who may be at risk of suicide, homelessness and serious substance use, annually. These CCBHC expansion services will supplement current activities and continue to enable BestSelf to provide comprehensive community-based mental health and substance use disorder services in an approach that emphasizes recovery, wellness, trauma-informed care, and physical-behavioral health integration.
Thrive Behavioral Health, Inc.'s CCBHC Expansion Project seeks to enhance and expand evidence based practices to adults with serious mental illness (SMI) and serious and persistent mental illness (SPMI), children and adolescents with serious emotional disturbances (SED), young adults with emerging SMI, and chronically homeless adults with SMI. Thrive received its CCBHC certification in May of 2019. It is a DCO of a current CCBHC grant. With three collaborators (Newport County Community Mental Health Center, Community Care Alliance and CODAC Behavioral Health), Thrive will provide expanded and enhanced CCBHC services to 9,000 people across the State of Rhode Island in the first year of the project. A total of 10,000 (non-duplicated) people will be served over two years. The project will expand evidence based behavioral health practices to over 300 adults, children and families who currently do not have access to these services in the first year and over 675 over the two year grant period. Covering an area of 1,212 square miles and a population of 1,059,639 (72.5% White, 15.5% Hispanic, 8.2% Black and 7.7% Other), Rhode Island has the highest adult rate of mental illness nationally (24%) and 34% of Rhode Island children who needed mental health treatment or counseling in the past 12 months did not receive it. Older adults are admitted to mental health and substance abuse facilities at much higher rates than the national average. Psychiatric hospitalization rates for children and adults exceed those for other New England states and the needs assessment indicates a serious lack of availability of intensive in-home behavioral healthcare. Rates of attempted suicide and opioid overdose are above the national average.Young adults with first episode serious mental illness have had limited early access to research based treatment to increase recovery and reduce disability. The three main goals of Thrive's CCBHC project include: 1) Enhancement of existing CCBHC services it provides as a DCO of a current CCBHC project of which Newport County Community Mental Health Center is the lead agency. These include four evidence based practices (EBP): Assertive Community Treatment, Individual Placement Services (Supportive Employment), Consolidated Specialty Care/Healthy Transitions, and Positive Parenting Program (Triple P). 2) Implement three additional EBPs will be added: Integrated Health Homes, Permanent Supportive Housing, and Dialectical Behavioral Therapy. 3) Implementation of infrastructure enhancements to improve the overall quality and coordination of care. Enhancements include workforce development (training for 200 staff in recovery/person-centered care, Motivational Interviewing, and CLAS standards), and a recovery-oriented, person-centered electronic health record (EHR) with a measurement-based care component and a language line.
Services for the UnderServed, Inc. (S:US) will continue our one year of experience operating a Certified Community Behavioral Health Clinic (CCBHC) at Wellness Works, formerly known as Comprehensive Treatment Institute (CTI), located at 177 E. 122nd Street in East Harlem with a satellite location at 1366 Inwood Avenue in the Highbridge area of the Bronx. These neighborhoods have some of the highest rates of serious mental illness, substance use disorder, and serious emotional disturbance in NYC. S:US has long served these individuals and will continue to serve them for this project. We will continue to use EBPs such as Motivational Interviewing, Intentional Peer Support, and Medication Assisted Treatment to provide services including individual and group counseling for SUD, targeted case management, psychiatric evaluations and counseling, medical assessments, medication monitoring, and peer-led recovery and support groups for individuals with SMI, SUD, COD, or SED. We will provide these services to 600 individuals per year (1,200 over the two-year program). Our partner, Union Community Health Center, will provide integrated medical care at S:US’ Wellness Works. In our first year of operating Wellness Works as a CCBHC, 1 in 4 clients had an opioid use disorder (OUD). Based on community statistics and characteristics of the population Wellness Works currently serves, we predict an increase of individuals with OUD at Wellness Works. In the past year, we created an outreach team in Harlem consisting of Peer Specialists who help engage people with OUD and connect them to counseling and MAT services at Wellness Works. S:US will continue outreach and to engage individuals with OUD, expanding the team to the Bronx, a part of the city with high need for these services. The majority (70%) of the people we serve are transitioning from hospitals, long-term residential treatment, and incarceration. Not only are they in need of clinical services to sustain and strengthen their recovery, comprehensive case management and peer support are essential for successful reintegration into their communities. Based on current referrals to Wellness Works, we estimate that that the majority (75%) will identify as male, 20% as female, and 5% as transgender. The majority (46%) will identify as African American or Black, Latino or Hispanic (29%), and White (16%). Nearly half (45%) will not have a high school education, and 80-85% will be unemployed when they first engage in services at S:US. Program goals include: 1) Increasing access to and improve the quality of community behavioral health services in Manhattan and the Bronx: 2) Increase access to CCBHC services through comprehensive assessment for new consumers: 3) Increase staff capacity to provide culturally competent patient-centered services: 4) Integrate primary care and behavioral health care to improve health outcomes for individuals with SMI, SUD, COD, or SED: 5) Increase capacity for sustainable CCBHC services.
NHCC proposes to expand its CCBHC services to include its Valley Stream clinic in Nassau County, NY. The focus will address unmet needs of the county, specifically co-occurring substance use disorders with complex care needs leading to increased psych and medical hospitalizations and ED visits. The services of CASACS, Peers, Nurses, Case Managers, and Psych Rehab Specialists are essential to sustained recovery and wellness. Goal 1: Decrease psychiatric and medical hospitalizations for clients with behavioral health and/or substance use disorder by engaging them in CCBHC services that will lead to improved treatment engagement and outcomes including addressing the underlying and resultant trauma, challenges to physical well-being and life conditions through the CCBHC’s integrated, collaborative and multidisciplinary approach to treatment, wellness and sustained recovery. Obj 1: By the end of year one of the project, the CCBHC will demonstrate a 25% decline in both psychiatric and medical hospitalizations and emergency department visits by improving the application of BH, SUD, Suicide and Risk assessments and evidence-based practices, including MAT, and access to enhanced 24/7 Crisis Intervention Services including a 24 hour mobile crisis team, emergency crisis intervention services, and crisis stabilization. By the end of year two of the project, the Valley Stream CCBHC will demonstrate a 50% decline in both psychiatric and medical hospitalizations and emergency department visits through continued trainings and engagement. Goal 2: Improve the identification and engagement of SUD services of CCBHC clients with COD (BH/SUD) and new referrals through the clinical team’s utilization of additional substance use and behavioral health screening tools and the provision of integrated and collaborative support and services of the CCBHC psychiatrists, clinicians, CASACs, nurses, TCMs, PRSs and Peers. Obj 2: By the end of year one of the project, the CCBHC will have successfully implemented same day/next day access and “no turn away” policies via outreach and engagement of 50% of its existing and newly identified COD clients into its integrated BH and SUD services and Primary Care Monitoring through psycho-education, evidence-based practices, screenings and the integrated services of prescribers, therapists, CASACS, medical/nursing staff, TCMs, PRSs and Peers. By the end of year two of the project, the CCBHC will have successfully engaged 75% of its newly referred and identified COD clients into its integrated BH and SUD services through the implementation of interactive text, email and secure web-based applications in order to promote interactive treatment, improve outreach and decrease no-shows. Goal 3: Increase community awareness of and access to CCBHC services for individuals with behavioral health and/or substance use disorders including those who would additionally benefit from outpatient Medication Assisted Treatment, primary care monitoring, case management services, psych rehab services, crisis intervention, peer supports, ACT services, Clubhouse, and/or VA services in order to support stability and recovery. Obj 3: By the end of year 1 of the project, the CCBHC will receive a 25% increase in new referrals that will have or be at risk of a co-occurring BH/SUD, a SUD-only diagnosis or opioid use through the development and expansion of the clinic’s service relationships with County health departments, hospitals, BH/SUD treatment centers, community-based health, primary care and social services organizations, advocacy groups, academic institutions, cultural and religious centers, insurance providers, law enforcement and first responders, local municipalities and VA services. By the end of year two of the project, the CCBHC will continue to develop and expand its community relationships and awareness, leading to a 40% increase in new referrals that will have or be at risk of a co-occurring BH/SUD, a SUD-only diagnosis or opioid use.
Oklahoma City CCBHC provider, NorthCare, will improve access to care individuals in Oklahoma and Logan Counties through the two year 2020 Expansion Grant funded by the Substance Abuse and Mental Health Services Administration. Target populations for the grant will include adults with Serious Mental Illness and individuals in crisis. The grant will provide enhanced services for an estimated 750 persons who need intensive levels of service. In addition to this broad focus, the grant will provide support enhanced crisis intervention and suicide prevention teams, outreach and engagement of persons who experience homelessness or housing instability, outreach and engagement among persons in the criminal justice system, and assisting clients to access core mental health and substance abuse treatment, secure benefits, housing, and employment. Goal 1: Increase access to and improve quality of behavioral health services to reduce suicidality and prevent hospital readmission. Objectives: 80% of clients with suicide risk experience reduced risk of suicidality; 80% of clients will report reduced depressive symptomology and 10% or fewer of those with an episode of inpatient psych hospitalization will be readmitted to psychiatric hospital within 180 days. Goal 2: Increase access to and improve quality of behavioral health services to improve and maintain client housing stability for those that are experiencing homelessness or insecure housing. Objectives: 95% of clients with history of insecure housing that are in stable housing will maintain stable housing; 60% of previously housing insecure clients attain housing stability. Goal 3: Increase access to and improve quality of behavioral health services to achieve client income stability. Objectives: 90% of clients currently employed maintain employment; 40% of previously income unstable clients attain employment, improve employment status (PT to FT); number of Medicaid eligible clients increases by 50%.
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).
Wayne County, Michigan (WC) is the most populous county in the state of Michigan. As of 2018, the U.S. Census Bureau estimated its population as 1,753,893 making it the 19th populous county in the U.S. According to Detroit Wayne Mental Health Authority 2017-2018 Annual Report, prevalence rated for SUD 7,879 (10.7%); SMI 39,398 (53.53%), and SED 12, 274(16.6%). Over 414,000 out of 1.74 million persons are living in poverty with WC. The three most impoverished communities average above the national average for poverty: Detroit 39.8%, Highland Park 40.9%, and Hamtramck 50.9%. Within these high-risk communities and in other WC areas many individuals have limited or no access to a comprehensive, integrated array of behavioral and physical health services due to a lack of or inadequate health care coverage. MDHHS Care Connect 360 data identified that over 4% of the individuals served by ESM have a chronic comorbid condition and 40% have five or more. This equates to approximately 3,500 individuals requiring more comprehensive integrated care coordination. Other subpopulations at risk including veterans and youth suicide, as identified by the Detroit Wayne Mental Health Authority, with 25.4% seriously considering attempting suicide and 18.6% committing suicide based on the Michigan Profile Health Youth 2016-2017 survey. DRP is the only peer-led, peer-ran, peer-driven organization in WC that is contracted, licensed and currently providing a full CCBHC continuum services to all target (SMI, SED, CA, COD, Recovery Services) populations. The exception is crisis behavioral health services, which is provided by the state sanctioned crisis behavioral health system. Detroit Recovery Project proposes to address the underserved mental health (MH) needs of high-risk individuals and families within Wayne County, Michigan. DRP will expand and enhance our continuum of care to increase our service capacity to fully provide person/family centered, integrated health services to all individuals within our community and to meet and achieve Certified Behavioral Health Clinic Certification within the first four months of the award. DRP will serve an additional 735 new CCBHC consumers in service delivery by the end of the Year One and 815 by Year Two, serving a total of 1,550 individuals total. Our goals are to: 1) Increase capacity and access to outpatient and behavioral health services for the COD, SUD and SED populations in the target catchment area of Detroit, Michigan; 2). Expand complex care delivery and care coordination for individuals with physical health needs (BP, HIV/AIDS, obesity, etc.); 3) Implement Evidence Based Practices (EBPs) for the target populations; 4) Implement specialty services for youth ages 7-17 at risk of suicide or depression; 5) Expand behavioral health and wraparound services for service members, veterans and their families.
HealthWest’s CCBHC Expansion Grant will expand the continuum of behavioral health care for residents of all ages in Muskegon County. This project will address unmet needs in the community which include lack of Integrated Health for Children with SED; lack of vaping screening and education: limited Telehealth capacity; need for video remote interpretation: and lack of adequate staffing for delivery of EBPs. Another strong area of need includes lack of access to behavioral health services including Mobile Crisis Response; MAT services; integrated health for SUD/COD population; and disparity in care for Native Americans, Veterans and rural communities. Specific service enhancements will include increased mobile crisis response, increased capacity for delivery of MAT and increased integrated primary care services for children under 15 and adults with SUD or COD, and EBPs for Trauma. Through this project, HealthWest is committed to serving a total of 625 individuals per year (for a total of 1,256 over the two year period) using CCBHC award funds. Goal 1: Increase capacity of the Mobile Response unit to improve access to timely trauma informed supports and evidence based treatment for individuals experiencing mental health crises. 1a: By the end of year two, provide 95% of MRSS requests within 1 hour urban and 2 hour rural. Goal 2 : Increase integration of substance use disorder, behavioral health and primary care by expanding service population and treatment offerings within the Integrated Health Clinic. 2a: By the end of quarter two of year 1, increase MAT treatment capacity by one full time provider in the IHC. 2b: By the end of year two, begin providing integrated services via multidisciplinary treatment teams to children ages 018 years of age, including vaccinations and a focus on care coordination around the needs of youth with Diabetes Mellitus and Hypertension 2c: Once per quarter, screening and education related to tobacco use including smoking, vaping, and chewing will be completed with 80% of individuals receiving services. 2d: By the end of year one, enroll an additional 130 adults with co-occurring disorders (COD) or Substance use disorders into IHC services, which includes immunization, HIV and viral Hepatitis screenings and education. Goal 3: Reduce health disparities by reducing barriers and providing increased treatment to underserved populations Muskegon County. 3a: By the end of year 1, implement tele-health service delivery with at least ten individuals, focusing on rural and veteran populations 3b: By the end of year 1, implement video remote interpretation (VRI) to provide increased translation, interpretation, and American Sign language for at least 20 individuals who speak ESL 3c: By the end of year 2, partner with Little River Band of Ottawa Indians to increase service utilization by members of this tribe by 10%. Goal 4: Increase the array of EBPs for individuals who have experienced trauma 4a: By the end of year 2, HealthWest will implement plan which will increase the number of staff equipped to deliver EBPs for trauma treatment by 20% 4b: Two additional staff will be trained in EMDR (Eye Movement Desensitization and Reprocessing by the end of year one.
Interborough Developmental & Consultation Center, Inc. IDCC will provide a fully integrated continuum of behavioral health and care coordination of chronic physical health conditions for high risk, underserved residents of Coney Island (CI), Brooklyn, New York. The Project will serve Adults with SMI, COD, SUD and OUD, the majority of whom will have one or more chronic physical illnesses that elevate risk, as well as serve children/youth with SED, their caregivers, and family members. CI has a population of 106,459; 53% are foreign-born, 43% report limited English proficiency, 56% white, 16% Latino, 14% Asian, and 12% black, and the greatest proportion of persons over 65 in NYC. The poverty rate is 24%, with unemployment of 11%. Veterans make up 2.1% of the population. CI has the highest NYC rates of congestive heart failure and diabetes risk in the Medicaid population, as well as high rates of SMI and depression. The Project will co-locate and coordinate mental health and psychiatric services, substance abuse including MAT, and primary health care, and provide Mobile Crisis Outreach, extensive care coordination, management of transitions to and from in-patient care, a Veterans’ Outreach Coordinator, and peer recovery support in community and home locations. IDCC will use the evidence-based practices, screening and assessment tools, and core CCBHC principles endorsed by New York State, which is a CCHBC expansion site. Project goals are: 1) Deliver a continuum of crisis response and integrated treatment, and care coordination for Coney Island residents in the CCBHC populations of focus; 2) Establish comprehensive care coordination and clinical monitoring for high risk Coney Island residents in the populations of focus; 3) Increase community awareness of the availability of mobile crisis, integrated treatment, and care coordination services in Coney Island. Objectives include: Provide 200 face-to-face mobile crisis visits Year 1 and 520 visits in Year 2; 60% of clients enrolled in integrated COD treatment for COD will reduce symptoms of traumatic stress; 50% of clients in SUD treatment will achieve no past 30-day use of their drug of choice after 6 months of treatment; 70% of children in comprehensive trauma support services decrease in trauma related symptoms; 80% of clients with chronic health conditions enrolled IDCC primary health care will demonstrate at least a 20% improvement in 1 or more key health indicators; 70% of CCBHC clients engaged in MAT for OUD will demonstrate no past-30-day use of opioids within 3 months of induction.; 100 home-bound persons will receive care coordination and integrated COD treatment per year; Provide presentations on how to access CCBHC services (5 presentations per year for each of 2 years), in the languages used by the CI populations of focus (English, Spanish, Cantonese, and Russian); Provide outreach/engagement visits to 250 persons involved in the criminal justice and homeless services systems. The Project will serve 450 unduplicated clients in Year 1, and 770 in year 2, for a total of 1,220 over the two years. SAE-BHE, a firm with considerable experience evaluating SAMHSA Projects, will conduct the performance assessment.
Northwest Essex Community Healthcare Network (Northwest Essex) CCBHC Expansion Grant will increase access to CCBHC services in Essex County to serve expanded populations with serious mental illness (SMI), substance use disorders (SUD), co-occurring disorders (COD) and to children and adolescents with serious emotional disturbances (SED) and Veterans. Northwest Essex will further develop and expand our services, focusing on the use of Evidence-Based Practices, to address key areas of need within Essex County. Our service hours will be expanded to seven days a week, including evenings, and include all CCBHC services with increased case management, Ambulatory Withdrawal Management (AWM), SUD services for adolescents and adults, Medication Assisted Treatment (MAT) and Tobacco Cessation, crisis intervention/stabilization services and primary care screenings. Our 24/7 crisis services will be enhanced to utilize the Living Room Model, providing an environment with supportive staff to address issues that may place consumers at risk for hospitalization. Additional nursing staff will support clinical monitoring for adverse effects of medications and expanded screenings for HIV and Hepatitis, followed by linkage to appropriate care by our medical staff. We will be able to connect more individuals to specialized care as needed through additional hours for medical staff to provide primary care screenings, vaccinations, and monitoring of key health indicators and health risk, and ensure positive outcomes through implementing coordination and follow-up protocols. Case managers will provide services to obtain entitlements, housing, and access to transportation and community supports. We will emphasize hiring bilingual staff whose language and culture is representative of the community we serve. All treatment will be provided through our integrated model of care as is the case with our current provision of CCBHC services, and through collaboration with four Designated Collaborating Organizations (DCOs) in Essex County: Clara Maass Medical Center, Mental Health Association of Essex County, CSP-NJ and Bridgeway Rehabilitation Services, as well as with other Essex County agencies which we have long time partnerships for referrals. Northwest Essex will measure our success monthly upon project implementation, supported by Rutgers University, using clearly defined performance measures to ensure we are meeting our goals: 1) Increase access to behavioral health and primary healthcare for SMI, SUD, COD and SED populations; 2) Improve the quality of treatment by expanding and developing services; 3) Enhance our integrated healthcare model to better coordinate care for target populations across mental health, SUD and physical health services systems; and 4) Improve consumers’ behavioral and physical health outcomes. Northwest Essex will provide these services to 2,200 consumers with grant funds throughout the project period (1,000 additional consumers in Year 1 and 1,200 additional consumers in Year 2).
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.
Richard Hall Community Mental Health Center CCBHC The Richard Hall Community Mental Health Center Certified Community Behavioral Health Clinic Expansion Program will increase services in Somerset County by partnering with DCO's to create a single system to meet the complex needs of clients with behavioral health problems lacking access to quality, co- located, integrated care. Increased use of telehealth, 24/7 support and crisis services and evidence based practices will ease access to care. We will reduce disparities among clients who are cost burdened, uninsured or medicaid/ medicare recipients by integrating recovery supports, case management, 24/7 crisis intervention and stabilization and telehealth into community based settings which will improve the outcomes for adults with a mental illness, co-occurring disorders, and substance use disorders including opioid use disorders and veterans/armed forces members. Expansion services also support children with serious emotional disturbances and their families. Our Richard Hall mission is to provide wellness and recovery oriented services and trauma informed care to clients who experience barriers to receiving care. We will provide person and family-centered, co-occurring capable, trauma-informed and recovery-oriented care by using evidence-based practices. A focus on nicotine/vaping dependence; anxiety; depression; family systems and parenting; trauma/post-traumatic stress disorder; MAT and medication management; and screening for co-morbid physical/dental health problems will be incorporated into the expansion. Richard Hall will implement alternative, non-tradition approaches for specialty populations including: Addiction-Comprehensive Health Enhancement Support System; Equine Assisted Therapy; Trauma Releasing Exercises Yoga; and Multidimensional Family Therapy. The clients recovery will be enhanced through the use of culturally and linguistically competent care and efforts will be made to improve the affordability, accessibility and availability of care in Somerset County. We will provide services to 300 clients in year one and 425 clients in year two. A Peer Recovery Specialist and Case Manager will be assigned to clients at first contact to screen for immediate needs including housing, food insecurity and medical needs, to name a few. We have developed a comprehensive plan to collect and report data using the capabilities in our EHR. Under the direction of the project evaluator, quality and performance data will be collected, analyzed, measured and reported quarterly. Analyzed data will inform the development of our sustainability plan which will be developed and continuously reviewed throughout the life of the grant to improve the quality and outcome of services being delivered. The Richard Hall Community Mental Health Center Certified Community Behavioral Health Clinic Expansion Program is necessary due to the unprecedented demand for integrated service as the population has outgrown current available services.
The Center for Alternative Sentencing and Employment Services (CASES) will implement the Nathaniel CCBHC, a forensic-specialist CCBHC in Central Harlem serving a focus population of criminal justice-involved youth and adults who have mental illness and co-occurring disorders (CODs). Over the life of the grant term, Nathaniel CCBHC will serve 1,375 clients: 650 in Year 1 and 725 in Year 2, about 80% male, 80% Black or Multiracial, and 35% Latinx, consistent with disparities in criminal justice (CJ) involvement. The focus population includes: 49% with serious mental illness, 55% with high-severity PTSD, 33% with severe substance use disorder, 72% at risk body mass index (BMI), 34% at risk regular smokers, 57% with incarceration experience, 45% with open legal cases in Criminal and Supreme Courts, and 31% homeless. Central Harlem experiences significant disparities in residents' CJ involvement and public health. The neighborhood ranks first in NYC for new HIV diagnoses, and its residents experience high rates of non-fatal assault, psychiatric, and avoidable hospitalization.The Nathaniel CCBHC responds to the risks for premature treatment dropout and poor treatment engagement and other prevalent outcomes among CJ-involved populations with CODs. Co-located in Central Harlem with high-volume Pretrial and Alternative-to-Incarceration (ATI) programs, the CCBHC will provide comprehensive, CJ-specialist outpatient interventions. Targeting CJ-involved persons at elevated risk for poor health and recovery outcomes, the CCBHC will engage consumers in a culturally-competent, risk-responsive, and trauma-informed approach that incorporates mobile, care coordination, and rehabilitation services--addressing a critical community need. The CCBHC envisions the integration of mental health and primary care and the addition of robust substance use disorder (SUD) treatment, mobile 24/7 crisis and outreach services, peer support, case management, and care coordination--guided by CASES' CJ-specialist approach. The program will a) provide rapid access and engagement in comprehensive integrated care for CJ-involved youth and adults, b) improve health and wellness, c) support improvements in social determinants of health including homelessness and CJ outcomes by reducing recidivism, and d) support improvements in the treatment engagement of juvenile justice youth and their families. Unique program features include transitional supports from correctional and/or inpatient hospital settings, leveraging the CCBHC's mobile outreach capacity, peer supports, telehealth, and care managers.
MHMR of Tarrant County proposes to enhance our comprehensive system of care through an integrated service delivery framework and improve homeless individuals’ experience through care coordination and promote overall health and wellbeing through the Mobile Outreach and Treatment Services for Homeless Individuals (MOTSHI). Research indicates that providers in the Tarrant County area identify substance use services and mental health/behavioral health care as the most challenging to access for homeless and/or low-income individuals. During the 2019 Tarrant County Homeless Point in Time count, 2,028 persons were experiencing homelessness – a 0.6% increase from 2018. This often mobile population has had negative experiences with mental health care and programs, and is determined not to accept further treatment. For these reasons, individuals can be slow in receiving services and ambulatory treatment is preferred in most cases. Therefore, MHMR will expand its Care Coordination model of services to improve primary and behavioral health outcomes for this population. The purpose of MOTSHI is to provide robust outreach and mobile services to increase the accessibility to behavioral and primary health care to homeless individuals living in Tarrant County. The MOTSHI team will include a Project Director, a RN Practice Manager, a RN Community Wellness Nurse, four Outreach Specialists, a Licensed Therapist, a Prescriber, two Wellness Navigators, a Transportation Navigator, an AOT Personal Service Coordinator, a Peer Support Specialist, a Veteran Mental Health Peer Specialist, and a Substance Use Counselor. MHMR will also contract with Acclaim to provide a mid-level Physical Assistant and Medical Assistant to provide medical services in the field. This team will provide services to address primary and behavioral health issues, including linkage to internal and outside resources, follow up to referrals, and nonclinical support from Peers. The MOTSHI Team will place staff in the designated sites to provide assessment for behavioral health diagnoses and indicators of medical risk, and they will provide linkage to clinics. The RN Practice Manager will work with the Outreach Specialists and RN Community Wellness Nurse to make appropriate linkages to treat identified concerns, within the agency or externally if specialized services are required. Staff will provide ongoing support and follow up for people in services to facilitate access to care and to ensure continuity across all involved providers of services. Peers will also provide appropriate support and linkage to community resources. All people linked to MHMR integrated services will receive care using evidence-based practices, and their needs will be assessed as needed to determine the most appropriate type of care. As certified CCBHC and the largest provider of behavioral health care in Tarrant County, MHMR has an established ability to effectively provide care for behavioral health, SUD, or primary health care needs. Though the agency will work with its community partners, no Designated Care Organizations will be used to provide services. Through this opportunity, MHMR plans to expand access to 300 unduplicated individuals, age 16 and over, by the end of the grant.
Preferred Family Healthcare’s (PFH) Health Pathways Plus project will focus on youth and adults aged 12+ with a substance use disorder (SUD), who experience a multitude of service gaps, barriers, and disparities related to treatment access, residing in the rural and economically disadvantaged 18 counties in north central and northeast Missouri. The project will expand SUD and mental health services to 160 adults and 40 adolescent youth clients annually. The target population will be non-Medicaid eligible, with no other source of funding for treatment and medically and clinically appropriate for mental health/ SUD treatment. Significant barriers to service access exist due to rurality: lack of public/affordable transportation, distance/ travel to treatment sites; lack of/minimal recovery support services (e.g. recovery/transitional housing, community-based recovery groups, peer support); and lack of/limited wraparound support services (e.g. benefits assistance; job training/vocational support; affordable/available housing; child care; lack of culturally/ linguistically responsive programs; pervasive stigma related to substance use; and health professional shortages). The goal and measurable objectives of Health Pathways Plus will improve access and increase the number of clients engaged and retained in CCBHC services. Goal 1: Expand CCBHC services to uninsured individuals who are in excess of the current funding available. Obj. 1.1 Enroll at least 160 adults and 40 youth clients into the program in Y1 & Y2; Obj. 1.2 All clients receive a comprehensive assessment; Obj. 1.3 Health Navigator will assist 90% of clients with accessing health care coverage; Obj. 1.4 90% of the clients will demonstrate engagement by participating in at least 4 visits during the first 60 days of treatment. Goal 2: Provide integrated healthcare, including addressing needs of individuals with co-occurring disorders (COD) and opioid use disorders (OUD). Obj. 2.1 80% of individuals with OUD will be referred to a DATA-waivered physician to assess for medication assisted treatment; Obj. 2.2 90% of the SUD clients with COD will receive co-occurring individual therapy; Obj. 2.3 100% of clients admitted into the program will be screened for tobacco use; Obj. 2.4 80% of the clients reporting tobacco at intake will receive a tobacco cessation intervention; Obj. 2.5 100% of adult clients will be screened for HIV/viral Hepatitis; Obj. 2.6 90% of clients who identify as past/current members of the armed services will be referred to the Veterans Specialist; Obj. 2.7 65% of adult SUD clients will report participation in recovery/community support at follow up; Obj. 2.8 70% of participants will report they are healthy overall at follow up; Obj. 2.9 85% of adult SUD clients will report abstinence or a reduction in use at follow up. Goal 3: Improve education and/or employment status of those participating in the program. Obj. 3.1 90% of clients 17 or under who have not graduated from high school (or equivalent) will remain enrolled in school; Obj. 3.2 90% of clients who report seeking employment will receive assistance from Job Coach; Obj. 3.3 50% of clients unemployed at intake will be employed at follow up.
Team Wellness Center, a provider of bidirectional behavioral and primary care in inner-city Detroit, will increase the total number of Wayne County adults and children, struggling with serious mental illness and substance use disorders, who have access to and utilize person-centered treatment. The two-year project will particularly target complex subpopulations, such as justice-involved, precariously housed, and super-utilizer populations. The proposed project will annually serve 9,000 unduplicated people and 12,000 during the project’s two-year period. The project will enhance Team Wellness Center’s capacity to deliver comprehensive, integrated treatment in the community, during non-business hours, and as an alternative to episodic treatment at hospital emergency departments. The project features the following innovations: • Specialized peer outreach with 500 returning citizens with SMI and SUD • Expanded clinical capacity at Team Wellness Center’s Psychiatric Urgent Care unit to assist 7,000 individuals with SMI and SUD • A behavioral and primary care mobile unit that annually reaches 2,000 individuals with SMI and SUD in neighborhoods with historically poor connections to behavioral and primary care • Additional permanent housing placement and retention resources using a Housing First model that will assist 150 homeless individuals with SMI and SUD • Evidence-based chronic disease and chronic pain self-management education for 25 peer support professionals to, in turn, educate 500 individuals with complex SMI and SUD The proposed project will implement all of the CCBHC required activities at the scope and standards outlined in the CCBHC Criteria Compliance Checklist.
The Mental Health Association of Westchester(MHA) proposed project is "Mental Health Association of Westchester Certified Community Behavioral Health Clinic Expansion Project 2020." The project will serve individuals experiencing serious mental illness, SUD, and co-occurring mental health/substance use disorders, as well as children and adolescents with serious emotional disturbance and military/veterans and their families. The Counties are designated as Medicaid mental health professional Medically Underserved Populations and include 37,963 veterans and many active military personnel. Over 25% of children in the area live below the poverty line and 8.2% of residents (81,145), including 3% of children (9,508) lack medical insurance. In the past year, an estimated 22.45% of young adult (18-25) and 14.65% of other adult Metro North residents were diagnosed with a mental illness and 7% of residents used an illegal substance or prescription medication for non-medical reasons. Rockland County Teen (15-19 years) suicide mortality was 4.1 per 100,000 in 2016. In Westchester County, 12% of residents used illicit drugs in the past year and provider surveys identify substance overdose, suicide and youth vaping as emerging issues. Project goals: (1) serve 4,840 individuals in Year 1, increasing to 5,566 in Year 2; (2) screen, assess and confirm the diagnosis of at least 400 unduplicated individuals suspected to have a SUD (3) initiate treatment within 14 days for at least 60% of individuals with a confirmed SUD diagnosis (current rate in the region is 54%); (4) serve at least 250 individuals in active MAT (increase from original grant's target of 60); (5) at least 90% of individuals in mental health and/or SUD treatment will have outpatient primary care screening and monitoring of key health indicators and health risks within two months of MHA enrollment; (6) initiate mobile treatment services in Rockland County and serve 50 children and adolescents; (7) initiate telehealth to expand 24/7 crisis intervention; (8) engage at least 50 military personnel, veterans and their family members in mental health and/or SUD services; (9) annual Hepatitis A, B and C screenings with 40% of individuals with SUD; (10) have follow-up outpatient behavioral health evaluation within 7 days for 60% of MHA individuals discharged from a psychiatric hospital; (11) annual metabolic testing of at least 50% of individuals with ongoing antipsychotic use. Client satisfaction results will be reviewed quarterly and used to adjust operations. Strategies: add a psychiatrist via telehealth for crisis response; continue services and add staff including Credential Alcoholism and Substance Abuse Counselor for screening, assessment, diagnosis; develop mobile capacity for children in Rockland Co. needing mental health/SUD care; support HIV/Hepatitis screening and work with DCO in lab and on site; hire nurse navigator to monitor workflows; expand care management in Rockland County to support individuals ineligible for care management; implement tobacco cessation program including myStrength; and move part-time employment counselor to full-time. MHA meets all CCBHC requirements and will utilize continuous monitoring to ensure ongoing compliance. MHA has 2018 expansion grant to integrate SUD services and serve un/uninsured and veterans, through which we have begun the work that this grant would expand in both scope and populations.
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.
Calhoun County CCBHC is a project of the Calhoun County Community Mental Health Authority (CCCMHA), hereafter referred to as Summit Pointe, to improve the health of individuals in the county while advancing integration of behavioral health and physical health care, increasing use of evidence-based practices, and expanding capacity, access, and availability to high quality care. The population of focus is Adults with Serious Mental Illness (SMI), Adults with Substance Use Disorders (SUD), Children/Adolescents with Serious Emotional Disturbance (SED), and Youth and Adults with co-occurring Substance Use Disorders (COD). Calhoun County’s population is 133,952 with 30,478 youth under the age of 18 and 9,976 veterans. Demographic make-up shows 79.88% Caucasian, 10.99% African American, 2.84% Asian, .68% American Indian, .04% Native Hawaiian. Hispanic/Latino is 5.33% of the total population. Gender make-up is 48.93% male; 51.07% female. Summit Pointe’s strategy will provide crisis mental health services, screening, assessment and diagnosis, patient centered treatment planning, risk assessment and crisis planning, outpatient behavioral health services, outpatient primary care screening and monitoring of health indicators and risks, clinical monitoring for adverse effects of medications, targeted case management, psychiatric rehabilitation services social rehabilitation programming, peer recovery supports, veterans’ behavioral health services, and Assertive Community Treatment. Evidence based practices include: SBIRT, Motivational Interviewing, and Seeking Safety. Goal 1. Increase access to behavioral health services for population of focus. Objective 1a) Summit Pointe and DCO outreach staff will provide contacts to 800 people in the community by end of year 2. Objective 1b) 1200 individuals by end of Year 2. Goal 2. Deliver comprehensive and coordinated care that provides access to effective evidence based interventions for individuals with complex needs. Objective 2a) Provide evidence based treatment for 100% CCBHC enrolled individuals. Objective 2b) Provide care coordination for 100% CCBHC enrolled individuals. Objective 2c) Increase number of individuals receiving SUD services from implementation baseline by 100% by end of year 2. Goal 3. Deliver integrated care for behavioral health and physical health risks and needs. Objective 3a) 95% or more of enrolled individuals will receive primary care screening and monitoring of health indicators and risks as identified in CCBHC Quality Measures. Objective 3b) Nurse Care Coordinators will be assigned to 100% individuals identified with high behavioral and health risks as determined by screenings completed. All individuals with SMI/SED/SUD/COD served by Summit Pointe will be eligible to participate with the CCBHC. Individuals enrolled in the grant portion of the CCBHC will be those who consent to the evaluation including new individuals entering care and current individuals eligible for CCBHC services. Project will serve 250 individuals Year 1, 250 individuals Year 2, for a total of 500 unduplicated individuals.
The purpose of Andrews Center's Certified Community Behavioral Health Clinic (CCBHC) expansion project is to increase access to coordinated, integrated and quality community mental health and substance use disorder treatment for children, adolescents and adults who are experiencing serious mental illness, substance use disorder, co-occurring mental and substance disorders and/or serious emotional disturbances. Increased availability and accessibility of needed services in conjunction with a strategic staffing plan, Andrews Center's CCBHC will target the following goals and objectives: increase access to evidence-based outpatient behavioral health care for children, adolescents, and adults who are experiencing serious mental illness, serious emotional disturbances and/or co-occurring mental and substance use disorders to reduce consequences of non-treatment; increase our scope of services to include evidence-based outpatient treatment for adults who are experiencing substance use disorders to reduce consequences of addiction; expand access to evidence-based crisis services for children, adolescents and adults who are experiencing serious mental illness, serious emotional disturbances and/or co-occurring mental and substance use disorders to reduce effects of non-treatment; increase our scope of practice to include care coordination activities to improve health outcomes. Andrews Center will serve 3,000 unduplicated individuals in the first year with an additional 3,000 new people in the second totaling 6,000 unduplicated individuals during the life of the project with an anticipated ongoing increase beyond the two-year funding opportunity.
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.
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.
Flushing Hospital Medical Center will implement the Flushing Hospital CCBHC project to expand access to comprehensive behavioral health services for adults, adolescents, and children in Queens, New York with a serious mental illness or substance use disorder, co-occurring disorders, or a serious emotional disturbance. The CCBHC, which will be certified by December 31, 2020, will serve 250 people in year 1 and 500 throughout the life of the project. Among the hospital’s racially and ethnically diverse urban service area population (769,666), many adults with psychiatric problems are not receiving counseling or medication treatment; chronic physical conditions commonly occur with mental and substance use disorders; admissions for substance use disorders remains high, particularly for opioid use disorders; and multiple barriers to seeking treatment exist, including poverty, lack of health insurance, poor English-speaking skills, and cultural stigma. The goals of the Flushing Hospital CBHC are to: (1) provide access to comprehensive 24/7 community-based services, treatment of co-occurring disorders, and physical health care; (2) improve treatment compliance and follow-up for patients with substance use disorders; (3) expand primary care services and enhance physical health outcomes with patients having a serious mental illness or substance use disorder who are at increased risk for co-occurring physical disorders; and (4) improve prevention services for patients at risk for opioid use disorder, improve access to opioid use disorder treatment services, and improve treatment outcomes for patients with opioid use disorder. Its objectives are to reduce the number of patients that leave against medical advice and increase the number of patients receiving inpatient rehabilitation and Medication Assisted Treatment and screened for diabetes and tobacco use. In addition, it will establish an Ancillary Withdrawal Management Program and expand primary care services in its outpatient mental health and addictions services clinics, screening for HIV and viral hepatitis, and providing hepatitis vaccinations. The Flushing Hospital CCBHC will hire additional staff to support the expansion of treatment services and provide the necessary clinical and administrative supports, including an evaluator, program coordinator, family nurse practitioner, CASAC, QA/PI coordinator, patient navigator, peer advocate, and data entry clerk. Jamaica Hospital Medical Center’s Comprehensive Psychiatric Emergency Program, licensed under New York State’s network of crisis mental health services, will provide mobile crisis services to adults and children. The clinic will work with designated collaborating organizations to provide inpatient rehabilitation, Assisted Community Treatment, case management, care coordination, Assisted Outpatient Treatment, child/adolescent, and veterans’ services, and other social support opportunities.
Helio Health Integrated Outpatient Clinic Expansion plans to focus on the following populations: individuals experiencing a mental health crisis and substance use disorder, adults with severe mental health or co-occurring illnesses, members of the armed forces and veterans, and those with chronic health conditions living in six Central NY counties. The project will build capacity to expand services within the largely rural service area encompassing the population centers of Syracuse and Utica. The population is predominantly white, non-Hispanic with significant racial/ethnic minority groups within the region. Hospital and ED data reflects the leading conditions at admission for Medicaid beneficiaries as depression, hypertension, drug abuse, diabetes, asthma, chronic stress and anxiety diagnoses, schizophrenia, and chronic alcohol abuse. Approximately 31% of the population lives in poverty or is low-income. We intend to 1) increase access to on-demand care, mobile services, and MAT for individuals in mental health crisis or with substance use disorder; 2) improve the well-being and functioning of adults with severe mental health or co-occurring illnesses by addressing social barriers and increasing autonomy; 3) improve the well-being of members of the armed forces, veterans and their families by providing evidence-based programs and services tailored to their needs; and 4) increase screening for people with chronic health conditions and provide or refer them for treatment in order to improve health outcomes. The project will expand the capability of current staff and add new staff over the project period to: expand MAT access 24/7; provide live contact and increase same day provider assessments to 95% for those in our open access and community outreach programs; train all psychiatric rehabilitation specialists in evidence-based practices; ensure 75% of adults with SMI participate in at least one PRS session; ensure that 46% of adults with SMI seeking employment receive at least one supported employment session; provide 40% more sessions for those seeking PRS services and work to decrease PRS no-show rates by 10%; increase the number of individuals linked to community supports by 37%; train 20 counselors in Cognitive Processing Therapy and prepare them for Clinical Military Counselor Certificate; provide Cognitive Processing Therapy for 75% and individual or group therapy sessions to 85% of armed forces members or veterans with PTSD in the program; provide services for an additional 55 members of the armed forces or veterans; screen 90% of admitted individuals for chronic health conditions and adverse effects of medication; screen 90% of high risk individuals for HIV/AIDS; train 5 peer specialists to become certified in HIV/AID peer supports; train all infectious disease staff to provide evidence-based Hepatitis C treatment; and treat or refer for treatment all patients with positive HIV or viral hepatitis test results. We expect to serve 1,630 individuals annually and 3,260 individuals over the lifetime of the expansion project.
Monarch's CCBHC Expansion Project will increase the depth and breadth of mental health and substance use disorder services in rural North Carolina. As part of the project, Monarch will become CCBHC-certified within four months of award notification and will implement evidence-based interventions, case management/care coordination services, physical healthcare support, and peer/family support services in Stanly County, N.C. Project Name: Monarch's CCBHC Expansion Project FY2020 Population Served: Target population includes adults with serious mental illness (SMI), children with serious emotional disorders (SED), adults with substance use disorders (SUD), adults with co-occurring disorders (COD). Number Served: Monarch projects will serve 1,550 unique individuals in year 1; 1,600 unique individuals in year 2; and a total of 2,305 unduplicated individuals during the lifetime of this two-year CCBHC expansion. Strategies/Interventions: Monarch will provide comprehensive, integrated care that directly addresses behavioral health issues; chronic health conditions (e.g. diabetes and heart disease); and adverse social determinants of health like hunger, poverty, lack of transportation and homelessness which impact treatment, recovery and health. Project Goals/Measurable Objectives: 1) Monarch will implement strategies and services that contribute to mental and physical health and wellness; 2) Monarch will use evidence-based screenings, assessments and surveys to determine patient risk and coordinate appropriate support; 3) Monarch will address the critical behavioral health needs of Stanly County residents by expanding community education, outreach and partnerships; 4) Monarch will complete technology-based enhancements to support care delivery and care coordination; Objectives include: 1) Expand post-hospitalization services to provide patient follow up by Nurse Care Manager or Peer Support; 2) Launch Substance Abuse Intensive Outpatient (SAIOP) service to support Medication-Assisted Treatment patients; 3) Incorporate Occupational Therapy services specific to supporting patients with SMI and SUD; 4) Establish a high-risk patient registry to identify patients for whom HIV, Hepatitis A, B and C screening and/or vaccinations are appropriate and coordinate care; 5) Use Social Determinants of Health surveys to identify patients experiencing barriers to treatment and enroll identified patients into Targeted Case Management Services; 6) Educate community members on mental health and substance use disorder-related topics through community events; 7) Expand community outreach to the general population, and to specific, targeted populations including veterans, the Hispanic community, and the LGBTQ population; 8) Establish cooperative relationships with a variety of physical health providers and local social services organizations to facilitate care coordination/referrals for people served; 9) Launch an electronic health record mobile application to allow for secure, real-time documentation by clinicians and care management team members in the field; 10) Integrate electronic health record and information with 24-hour Mobile Crisis Services provider.
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”.
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.
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.
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.
Centerstone's Certified Community Behavioral Health Clinic (C-CCBHC) project will establish Centerstone's Harriet Cohn Clinic in Clarksville 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 individuals from among the 5,300 that the clinic services yearly (Y1: 375; Y2: 625). C-CCBHC’s target population is expected to mirror those of the catchment area, comprising counties Cheatham, Houston, Montgomery, Stewart, and Robertson in Tennessee. Those ages 17 and under are expected to comprise 51% male, 49% female, 67% White, 15% African American, and 11% Hispanic/Latino individuals. Those 18+ are expected to comprise 49% male, 51% female, 76% white, 13% African American, and 6% Hispanic/Latino individuals. Of the catchment area’s population of 322,000, 4.9% (11,711) of adults are expected to have SMI, 3,362 children/youth ages 6-18, SED. Roughly 7% (16,730) of adults and 3.9% of adolescents 12-17 have SUD, and 0.7% (1,673) of adults and 0.4% of adolescents 12-17 have OUD. Nearly 33% of the 33,459 area Veterans are expected to have a mental health diagnosis. An estimated 7,495 (64%) adults with SMI and 5,800 (70%) youth ages 12-17 with SED have not received appropriate supports. An estimated 15,060 adults and 2,980 adolescents with SUD remain untreated. Without integrated care, 10,085 individuals with COD are at increased risk of physical illness/homelessness/incarcerations; 19,960 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.
Certified Community Behavioral Health Clinic (CCBHC) Expansion: This project will increase access to integrated mental health/addiction-related treatment to serve more: (1) adults with serious mental illness, (2) adults with substance use disorders, (3) children and adolescents with serious emotional disturbance, and (4) individuals with co-occurring mental and substance use disorders living in the most health-challenged localities across Nassau County, NY. Compared to the county’s general population, our target population disproportionately comprises Black and Latinx individuals and persons of lower income, less education, and less housing stability, including many Veterans. They also face the highest needs with regard to educational, vocational, and social determinants of health and are disproportionately un/under-insured. Providing SAME-DAY access and using a MOBILE outreach fleet, while co-locating with Federally Qualified Health Centers (primary care) in Hempstead, Freeport, New Cassel, and Elmont, plus other venues frequented by the target population such as The INN soup kitchen (Hempstead) and the Nassau County Department of Social Services, we will fill gaps in mental health and substance use services that leave people here often waiting weeks and months for needed services. In a coordinated way, this project will deploy (at least) the following 9 Evidence-Based Practices in behavioral health, well suited for our target population: (1) Medication Assisted Treatment/ therapy (MAT); (2) Peer Support; (3) Motivational Interviewing; (4) Integrated Treatment for Co-Occurring Disorders; (5) Cognitive Behavioral Therapy (CBT); (6) Family Psychoeducation; (7) Wellness Management & Recovery (WMR); (8) Individual Placement and Support; and (9) Trauma-Informed Care (including, the evidence-based Seeking Safety coping skills therapy model). Strategies/interventions encompass 24-hour mobile crisis response, along with screening, assessment, diagnosis, and patient-centered treatment. Our interventions meet all 21 metrics of New York State’s rigorous CCBHC checklist as well as SAMHSA’s robust 20-page CCBHC Compliance checklist, including provision of Assertive Community Treatment (ACT) and HIV/Hepatitis A, B, and C testing and linkage to treatment. This project will reach 1,400 individuals total (525 in Year 1 and 875 in Year 2). The main goal is to increase local access to and improve the quality of community mental and substance use disorder treatment. A small sampling of the measurable objectives we include in our plan are: conducting 700 behavioral health screenings/assessments using evidence-supported protocols; providing ACT services to 50 new individuals who are not presently covered by State-supported ACT services; and seeing 40% of served individuals who were initially identified as presenting moderate or high risk of depression and/or suicidality ultimately showing reduced symptoms of each, respectively, measured via evidence-based tools at follow-up.
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.
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.
CCBHC Expansion Project Abstract Summary: Utilizing the 2-year CCBHC funding, CNS Healthcare (CNS) provides comprehensive outpatient services to 3,000 children, adolescents, adults and older adults with Serious Mental Illness and Substance Use Disorders who are uninsured, underinsured, and underserved in Southeast Michigan. Additionally, services focus on outreach to Veterans, Native Americans, and LGBTQIA+ community. All strategies, interventions, goals, and measurable objectives meet criteria for the Medicare and Medicaid programs. CNS is a CARF International accredited health home, and a community mental health provider with over 25 years of experience of providing mental health and substance use services in Oakland and Wayne Counties, Michigan. Each year, CNS provides services to over 5,400 individuals, in 9 locations, including five outpatient clinics, two clubhouses, and two drop-in centers. CNS is a recipient of a SAMHSA Primary and Behavioral Healthcare Integration (PBHCI) grant (2015-2019) and has a co-located Federally Qualified Health Center (FQHC). CNS embraces the full implementation of consumerism, and ensure that individuals, we serve are involved in the design, delivery and evaluation of the mental health services. Additionally, CNS is home to an award-winning Anti-Stigma Team, composed of individuals with lived experience of mental illness and substance use disorders, who work locally and nationally, to educate the public. CNS has an active community outreach program, presenting to schools, places of worship, law enforcement, civic organizations, and the public. As CNS expand access to current Community Mental Health services, the agency will pursue the goals of advancing Medicaid Meaningful Use, and Medicare Merit-Based Incentive Payment System (MIPS) with the following Clinical Quality Measures (CQM): antidepressant medication management, suicide risk assessment, controlling high blood pressure, diabetes control and initiation of alcohol and drug dependence treatment, documentation of medications in the medical record, children and adolescent major depressive disorder, preventive care, screening and follow-up for clinical depression, Body Mass Index (BMI), tobacco use cessation intervention and weight assessment counseling for children and adolescents. The following services will be provided: screening assessment and diagnosis, patient centered treatment planning including risk assessment and crisis planning. In partnership with the state-sanctioned crisis center, CNS provides crisis services. Additionally, CNS provides outpatient primary care screening and monitoring of key indicators and health risks, clinical monitoring for adverse effects of medications including monitoring for metabolic syndrome, target case management, psychiatric rehabilitation services, clubhouses, peer support services, and assertive community treatment. Additionally, CNS will increase over baseline the provision of the following services medication assisted treatment, telemedicine/telehealth, evaluation and management, enhanced vital signs, health education, case management, peer support services, individual and group therapy.
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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