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The Bridge of Central Massachusetts, Inc., DBA Open Sky Community Services (Open Sky) proposes to improve and advance our CCBHC service delivery called the Open Sky Rapid Response HUB (OSRRH) which provides real time access to integrated behavioral health treatment services and rehabilitative supports. Currently these services are accessible 24/7 and delivered by an interdisciplinary team. Service delivery is not bound to the four walls of the clinic and is delivered flexibly in a variety of settings. We utilize practices that include Trauma Informed Care and Housing First principles as vehicles for stabilization and engagement in CCBHC services. Open Sky is the primary CCBHC agency working in partnership with Designated Collaborative Organizations (DCO): Family Health Center of Worcester, Edward M. Kennedy Community Health Center, You, Inc., Riverside Community Care, Community Healthlink Inc., and Spectrum Health Systems, that will provide primary care, specialized services for youth and families, state-sanctioned crisis services and substance use treatment, as indicated, for those engaged in Open Sky’s CCBHC. Open Sky RRH serves individuals throughout Worcester County (pop. 862,11, US Census), providing office based in the City of Worcester or through mobile outreach. According to the US Census, 37% of Worcester residents speak a language other than English in their home (2017-2021 average), 23.9% are Hispanic or Latino, and 19.3% are in poverty. Other providers offer mental health and substance use services but without the array of housing and other services designed to address health related social needs offered by Open Sky. During each year of the grant, the OSRRH will serve 150 unduplicated individuals and families (600 throughout the lifetime of the project) with known and chronic conditions (SMI, SED, SUD, COD) as well as those whose wellbeing has been negatively impacted by the COVID-19 pandemic. Populations of focus will include the homeless, justice-involved, veterans, LGBTQIA+ youth and young adults, and seniors. Worcester County is one of the MA counties hardest hit by the opioid epidemic, accounting for over 12% of MA overdoses in 2021 (www.mass.gov). Among the County’s justice-involved and homeless populations there is high prevalence of mental health conditions and overdose, as well as lack of follow-up care following an overdose (UMASS Medical, 2020). In 2023, undomiciled Worcester County residents totaled 963, 45% of whom are Hispanic/Latinx and 58% BIPOC (2023 PIT Count). Open Sky’s mission aligns with that of SAMHSA’s and reads: Blending best practices with the power of community, we partner with individuals and families to see beyond and live beyond perceived limitations to pursue fulfilling lives. We have identified three overarching outcomes for the individuals and families we support that are tied to the Open Sky approach: Wellness, Opportunities, and Relationships. The goals of the OSRRH are to empower individuals and families to achieve wellness, build relationships, and realize opportunity. Wellness objectives involve expanding open access and outreach models for delivering evidence-based clinical interventions that equip participants with the skills to improve their near and long-term behavioral and physical health. By adding capacity for integrated peer services, the OSRRH will continue to create connections, natural supports, and recovery capital that will lead to lasting relationships. To enable participants to realize opportunity, the OSRRH will integrate housing, education, employment, and case management services into person-centered care plans, opening pathways to self-determination and self-sufficiency.

SCHARP Crenshaw CCBHC Improvement & Advancement bolsters existing behavioral health services to reduce recidivism, opioid related death and return to homelessness. Black Angelenos, who represent over 70% of Crenshaw & Leimert Park residents, are at exponentially higher risk. Southern California Health and Rehabilitation Program, a Black-led organization, will close these health disparities for 450 clients experiencing serious mental illness and substance use disorders. SCHARP has been a continuous provider of Behavioral Health (BH) and related services to adults and children in Los Angeles County since 1994. The Population of Focus is unhoused and/or justice involved Black adults and young adults in South Los Angeles with serious mental illness (SMI) or substance use disorders (SUD), including veterans. Children/adolescents with serious emotional disorders (SED) are also included, and those with co-occurring disorders (COD) and a general SMI/ SUD/SED/COD population. Strategies and interventions include process improvements to enhance delivery of the nine CCBHC Core Services (Crisis mental health services; Screening, assessment, diagnosis, and risk assessment; Patient-centered treatment planning; Outpatient mental health and substance use services; Primary care screening; Targeted Case Management or TCM; Psychiatric rehabilitation; Peer support; Intensive, community-based mental health care veterans). Interventions also include Evidence Based Practices: Motivational Interviewing; Seeking Safety; Cognitive Behavioral Therapy; Assertive Community Treatment (ACT). Goal 1 is to reduce risk of opioid related deaths in POF through onsite, same day MAT/MOUD treatment. Related objectives are to train all staff in MAT/MOUD and Targeted Case Management for SUD, ensure at least one MAT prescriber is scheduled daily for walk-in treatment, establish a trigger and same-day referral in internal workflow for OUD risk, as well as quality assurance program to ensure 42 CFR Part 2 documentation. Goal 2 is to Reduce POF risk of returning to homelessness by increasing access to Targeted Case Management & Assertive Community Treatment, an Evidence Based Practice. Related objectives are to establish risk assessment for return to homelessness, 100% enrollment in of those at risk in TCM and ACT, and engage population health strategies to stratify risk and focus team efforts. Goal 3 is to reduce recidivism through peer support by ensuring 100% of clients with recent incarceration are paired with peer with lived experience of justice involvement. Target minimum number of clients served are as follows: 75 in Year 1; 125 each year for Years 2 through Year 4 (Total 450 over four years).

Southeast Healthcare (SE) provides a comprehensive range of community-based integrated behavioral and physical health care services as a CCBHC-E grantee in eight diverse Ohio counties (Franklin, Delaware, Morrow, Belmont, Harrison, Monroe, Tuscarawas & Carroll). Through the Southeast CCBHC IA project, SE intends to improve and advance the CCBHC model throughout the organization and service area, with specific enhancements in care coordination, accessibility, trauma-informed care, and suicide risk response. SE primarily serves those living with severe mental illness (SMI), and/or substance use disorders (SUD) with low socioeconomic status and facing health disparities. The population of focus covers the lifespan, from children and youth with severe emotional disturbances through older adults with SMI, and/or SUD with a specific focus on the homeless population, those involved with the criminal justice system, and the Appalachian population in the service area. SE intends to address disparities and other barriers typically faced by these populations. SE will serve 1,500 individuals total during the four-year period (350 in years 1 and 4, and 400 in years 2 and 3).Goal 1: Enhance access to and availability of services to members of historically underserved subgroups and to those most urgently in need of care. Objectives: 1.1- 25% of enrollees will represent one or more of the four target populations. 1.2- Take immediate action on behalf of 100% of individuals who identify an emergency need, and provide services within 1 day for individuals who identify an urgent need, within 10 days for individuals who identify routine needs. Goal 2: Increase integration of comprehensive PH, BH and adjunct service delivery. Objectives: 2.1- Attendant to domains 1 (screening, referral, and follow-up) and 7 (linkages with community and social services) of the Comprehensive Healthcare Integration (CHI ) Framework, 80% of individuals in each annual enrollment cohort will be screened for SDoH. 2.2- Attendant to domains 1 and 7 of the CHI Framework, 75% of individuals who screen positive for an SDoH will receive a timely referral and follow-up. 2.3- Attendant to domain 4 (self-management support) of the CHI Framework, 45% of individuals will report increased self-efficacy to manage chronic healthcare conditions. 2.4- Attendant to domain 5 (multidisciplinary teams) of the CHI Framework, 100% of SE staff requests for multidisciplinary care conferences will be fulfilled by CCBHC staff. Goal 3: Expand and advance care coordination to achieve improved health outcomes. Objectives: 3.1- Launch a risk-stratification system to improve alignment between individual needs and care coordination services. 3.2- Implement organization-wide Case-to-Care Training for case managers and team leaders/supervisors in collaboration with a trainer affiliated with the National Council CCBHC success center. 3.3- 100% of individuals discharged from inpatient acute-care hospitals will have a contact attempt documented within 24 hours of discharge. 3.4- 100% of all individuals hospitalized for a suicide attempt will have a multi-disciplinary care team meeting within 7 days of discharge, led by an independently licensed staff member to produce an enhanced care plan. 3.5- 50% of individuals in the annual enrollment cohort will demonstrate improvement in self-reported BH symptoms, overall health and/or clinic measured PH indicators. Goal 4: Strengthen the organizational climate for integrated, wholistic, person-centered, trauma-informed care. Objectives: 4.1- SE will conduct at least one organization-wide EBP/promising practice training, which addresses one or more core IHC element and which includes an experiential component and follow-up. 4.2- During the course of each EBP/promising practice training, SE and project leadership will identify staff champions to provide in situ support and reinforcement to staff engaged in delivering the focal EBP/promising practice.

Berrien Mental Health Authority dba Riverwood Center (RWC) CCBHC Improvement and Advancement Project proposes to expand its services to residents who experience or are at risk of developing severe mental illness, severe emotional disturbance and/or substance use disorders. In addition to these populations of focus, RWC intends to expand current services offered to the mild and moderate mentally ill population. Project aims include enhancing our comprehensive healthcare approach through improving coordination with local primary care providers; expanding access and engagement to our array of substance use services; increasing trauma-informed treatment practices; and implementing new evidenced-based practices (EBP) to improve care for those who experience an acute behavioral health (BH) crisis. This grant will aim to serve 460 individuals in year one, 210 in year two, 230 in year three and 250 in year four, for a total of 1,150 Berrien County residents over the next four years, with additional broad community impacts. Berrien County’s population is 80% White, 14% Black/African American, 2% Asian, 1% American Indian, 0.1% Native Hawaiian and Other Pacific Islander. 3% of residents are of two or more races and 6% are Hispanic/Latino. English is the predominant language spoken. 22% of the county population is under 18, and 21% are over 65 years of age. 51% of county residents are female and 49% are male; 17% of middle schoolers and 19% of high schoolers in Berrien County identify as LGBTQ2 and 0.4% of people in Berrien County live with a same sex partner3. There are approximately 8,400 veterans in Berrien County1. RWC service population mirrors this demographic make-up, though serves a higher percentage of consumers identified as Black/African American (28%). RWC currently serves approximately 4,800 consumers annually; many of these consumers suffer from preventable and/or treatable medical conditions such as cardiovascular, pulmonary, and infectious diseases. As an expansion of current efforts, RWC consumers will receive increased screening and, when warranted, intervention and monitoring of a broad range of health risk behaviors and conditions. Integral to this effort will be improving the exchange of health information (HIE) among community providers, as evidenced by communication with external providers and an improvement to post-ER follow-up. RWC will leverage grant funds to expand and improve services to individuals who experience acute BH conditions via a multipronged approach, including: increased screening and treatment for RWC consumers with substance use disorders, increased coordination with local hospitals through enhanced Health Information Exchange, and enhanced evidence-based trauma-informed treatment practices. Expanding access and increasing engagement rates are additional key population health issues that will be addressed by targeting the increasing rates of suicide and substance use (including opioid use). Increasing screening and treatment for individuals with SUD will be targeted and measured through the use of standardized screening for IDDT, tracking referrals and engagement in MAT services, and consistent screening for unhealthy alcohol using the AUDIT.

Population of focus for SMA Healthcare’s CCBHC services includes consumers of all ages with serious mental illness (SMI), substance use disorders (SUD), including opioid disorders; children and adolescents with serious emotional disturbance (SED); individuals with co-occurring disorders (COD); and individuals in need of primary care services living in Volusia County Florida. Project goals and objectives include: Goal #1- SMA’s CCBHC will operate in compliance with the most recent CCBHC Certification Criteria by July 1st, 2024 and be in compliance throughout the project period: Objective #1a & b. CCBHC program will begin and provide all nine core CCBHC services within four months after grant award. Objective #1c- CCBHC services funded by this grant award will serve 450 consumers annually in years 1-4. (total unduplicated number served over 4 years will be 1,000). Objective #1d & e - Provide medical case management services to 75 consumers and case management to 50 or more unduplicated non-insured consumers enrolled in psychiatric medication management outpatient services each year. Objective #1f- Implement psychiatric rehabilitation services for 50 unduplicated consumers annually. Objective #1h- Provide 250 consumers CCBHC evidence-based mental health-related services (IPP Measure). Goal #2- Conduct at least one Community Needs Assessment: Objective #2a- By the end of 2024, SMA Healthcare will conduct a Community Needs Assessment that includes input from consumers and family members. Objective #2b- By June 30, 2025, SMA will submit an attestation that it has met the CCBHC Certification Criteria. Goal #3- Implement infrastructure development activities needed to address operational activities needed to continue meeting the certification criteria and improve the quality and effectiveness of CCBHC services: Objective #3a- Continue to provide and engage in third party support SMA’s electronic Health Information Technology. Objective #3b- SMA will engage in data sharing through electronic health information exchange. Objective #3c- Care Coordination Agreements (CCA) will be executed within the first three months of grant award and annually. Goal #4- Meaningfully involve consumers and family members in designing, providing, monitoring, evaluating services, and participating or providing input to the CCBHC board: Objective #4a- SMA will recruit annually at least one member who is a consumer or consumer’s family member to the advisory board. Objective #4b- At least 4 or 50% of advisory board members will be consumers or family members. Goal #5- Within one year of award, SMA will develop and implement a sustainability plan that is updated annually to support delivery of services once federal funding ends: Objective #5a- SMA CCBHC will complete and submit to SAMHSA a Sustainability Plan within a year of grant award and annually thereafter. Goal #6- Participate in SAMHSA provided CCBHC Technical Assistance Center activities. Objective #6a- SMA’s CCBHC will participate in TAC activities that promote adherence to the CCBHC model, certification, sustainability, and processes that support access to care and evidence-based practices throughout the period of grant award. CCBHC services funded by this grant award will serve 450 consumers annually in years 1-4. The total unduplicated number served over 4 years will be 1,000.

CASES will improve and advance the Nathaniel CCBHC (NCCBHC), located on the 125th Street corridor in Central Harlem. The NCCBHC will provide rapid access, high-fidelity integrated care for Central Harlem residents, who experience some of NYC's highest rates of psychiatric and substance use-related hospitalization, and people involved in NYC's criminal justice (CJ) system who are in the community under Court supervision and experience high rates of SMI, SED, SUD, and homelessness. The NCCBHC will provide services to people not connected to care, including 1) residents of Central Harlem--a majority Black (55%) and Latino (22%) community in which 25% live below the poverty line--who in addition to some of NYC's highest rates of psychiatric and substance use-related hospitalization experience the highest citywide rate of resident incarceration, and 2) people involved in NYC's CJ system, including who are recruited and connected to NCCBHC from CASES' co-located Pretrial and Alternative-to-Incarceration (ATI) Programs. These Pretrial and ATI Programs annually divert more than 6,000 youth and adults from New York County (Manhattan) Family, Criminal, and Supreme Courts, among whom the highest concentration citywide reside in Harlem. Consistent with the intersection of racial, ethnic, socioeconomic, and health disparities with involvement in the CJ system, the people served by NCCBHC are predominantly Black (68%), Latino (36%), male (62%), and young (48% ages 18-34), with 38% female, 10% LGBTQI+, 4% ages 13-17 (33% with SED) 20% ages 35-44, and 26% ages 45+. More than one in three (35%) are Harlem residents, 68% have CJ involvement, 69% have SMI, 25% have SUD, and 18% are homeless. Nearly one in three (31%) are CJ-involved Black men. With a CCBHC-IA grant, NCCBHC will strengthen model implementation by expanding peer support, targeted case management, and SU services including to support three core improvements: 1) achieving same-day access for initial evaluation for all people new to the clinic seeking walk-in services regardless of level of need; 2) decreasing wait times for initial evaluation for people seeking non-crisis services; and 3) increasing treatment utilization among the focus population of CJ-involved New Yorkers including CJ-involved Black men. These improvements will promote recovery for 1,400 people engaged in NCCBHC over the four-year grant (300 in Year 1, 360 in Year 2, 360 in Year 3, and 380 in Year 4). The targeted enhancements related to increased access and engagement--and improved health--correlate with successful completion of Court supervision requirements for CJ-involved people with SMI and/or SUD in the community with open cases. While 50% of participants with SMI and/or SUD successfully complete CASES Pretrial Services--thereby completing Court supervision-90% of Pretrial participants with SMI and/or SUD co-enrolled in NCCBHC treatment services successfully complete Court supervision and thus avoid jail detention.

The applicant, AMHC, will implement CCBHC-IA to provide services to 808 unduplicated individuals with serious mental illness (SMI), serious emotional disturbance (SED), or co-occurring SMI/SED and substance use disorder (COD) in 3 northern Maine counties (Yr 1: 175; Yr 2: 193; Yr 3: 211; Yr 4: 229). AMHC will enhance the current CCBHC’s comprehensive and coordinated behavioral health care by improving outreach, screening, assessment, treatment, care coordination, and recovery supports for those with SMI, SED, and/or COD. Within the catchment area of Aroostook, Hancock, and Washington counties, Maine, the focus population comprises estimated 5% (6,570) who have an SMI, 17% (4,826) who have an SED, and 4% (6,570) who have a COD. Among AMHC’s focus population, 50% are male, 50% are female, 93% are white, 1% are Black, 1% are Asian, 2% are Hispanic, and 2% are Native American. AMHC subpopulations include the 8% who are Veterans and 8% who are minorities. SAMHSA’s Certified Behavioral Health Clinics (CCBHCs) model will guide AMHC’s implementation of evidence-based interventions/models, including Motivational Interviewing, Cognitive Behavioral Therapy (CBT), Trauma-Informed CBT, Positive Parenting Program, Modular Approach to Therapy, Peer Recovery Support Services, Psychiatric Collaborative Care Model, Psychosocial Rehabilitation Model, and Zero Suicide. AMHC will implement all 9 core CCBHC model services including screenings/assessments and diagnosis; patient-centered planning; outpatient, mental health, and SUD services, targeted case management, outpatient clinic primary care screening/monitoring, community-based mental health care for Veterans, peer, family support, and counselor services, and psychiatric rehabilitation services. Other program components include linkages to primary/specialty care and dissemination of comprehensive evaluation. The AMHC Board of directors comprising stakeholders and focus population members will serve as the Advisory Board and support AMHC’s goals, which include enhancing/ expanding capacity to provide accessible, coordinated, and evidence-based treatment and recovery support services; developing/expanding the infrastructure/capacity of an integrated community service system; improving client health status and outcomes; and developing/disseminating a replicable service model. Measurable objectives include: outreach to 950 individuals with an SMI, SED, and/or COD; complete a minimum of 1 community needs assessment; stakeholder outreach/ engagement/education to strengthen collaborative relationships; reduce substance use, mental health/trauma symptomatology, and feelings of loneliness/isolation; reduce use of emergency department for behavioral health among participants; reduced criminal justice involvement; increased treatment access and recovery capital; and increased Social Determinants of Health. Since 1964, the applicant, AMHC, has been a continuous provider of behavioral health and related services to adults and children in the catchment area and has grown to encompass Behavioral Health service provision and support for every level of care across a variety of settings. AMHC operates a successful CCBHC in the catchment area that is fully certified. AMHC referral services are available for Medication Assisted Treatment, Matrix Intensive OP Treatment, or other higher levels of clinical care. In addition, partnering organizations will serve as AMHC’s linkage/referral sources, collaborate in service provision, participate in training, and take part in Advisory Board/evaluation activities. AMHC partners are rooted in the focus population’s culture/languages and have demonstrated experience/familiarity with the catchment area culture. Partnering community health providers and hospitals will receive linkage to all CCBHC services. AMHC staff will focus efforts on expanding partnerships with Veteran serving organizations and the Youth Peer Support Statewide Network.