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Volunteers of America- Chesapeake and Carolinas, proposes the planning, development, and implementation of activities to meet CCBHC operational criteria within its VOA-DC Hope Center, a behavioral health clinic in Washington, DC. The proposed project will serve individuals and families in all wards of Washington, DC, including adults with severe mental illness (SMI), individuals with substance use disorders (SUD), children/adolescents with serious emotional disturbance (SED), and individuals with co-occurring disorders (COD), while serving pregnant women and their families and veterans as subpopulations of focus. The overarching goals and objectives of the program are to (1) Increase, deepen, and strengthen programming of the VOA-DC Hope Center to meet CCBHC operational criteria, which will include formalizing processes to offer Targeted Case Management, expanding crisis stabilization programming to include mobile operations, and formalizing partnerships with DCOs to provide primary care; (2) Identify, address, and reduce barriers that affect accessibility to and outcomes of behavioral health treatment through such mechanisms as a comprehensive needs assessment, reducing spatial barriers to treatment through telehealth and more convenient office space; and (3) Increase awareness and address the impact mental health/ substance use has on the adults, mothers, children, families, and veterans of the District of Columbia by establishing a Behavioral Health Council of key informants, developing an anti-stigma campaign, and conducting targeted outreach for subpopulations of focus through the formation of strategic partnerships (i.e. family/accountability courts, veterans orgs). Through the CCBHC model, consumers will have access to a rich menu of programming that includes prevention, early intervention (i.e. anti stigma campaign), treatment (MAT, family, group, and individual therapy, ACT), and continuing care/recovery supports (peer support/navigation, employment and job training, housing support). The proposed CCBHC will serve 1100 unduplicated individuals within Washington DC over the course of the grant period: 200 in Year 1, 250 in Year 2, 300 in Year 3, and 350 in Year 4. Washington, D.C., a diverse urban area of 690,000 residents, 25,514 of which are veterans. The catchment area is 43% Black, 42% White, and 12% Hispanic/Latinx. There are slightly more females (53%) than males (47%). Though the poverty rate is only slightly higher in DC than the national average at 15%, stark disparities exist. For example, the median income for white households in DC is $160,000; for Black households it is only $53,000. With an average home value of $897,000, many families face housing and financial instability that can affect mental health. There are 63,000 households in Washington DC with children; nearly 10,000 of them live under the federal poverty level. Washington, D.C. lags behind the nation in effectively addressing the effect of substance use and mental health disorders on its residents. According to The District of Columbia Community Health Needs Assessment, the District has a higher percentage of residents reporting use of illicit drugs in the past month, 20.4 versus 11.2 nationally among adults and 11.2% versus 7.8% among adolescents. Pregnant, postpartum, and parenting women and their families face unique barriers to accessing behavioral health care services with the catchment area. Stigmatization of SUD, particularly during pregnancy, can prevent mothers from seeking obstetric care and affect the health of both the mother and child. Caregiving responsibilities, fear of incarceration, and potential custody loss all affect a woman's ability and willingness to seek treatment for SUD. Pregnant women and veterans, though often prioritized in public health initiatives, face also face barriers such as lack of knowledge of resources of available and disparate systems.

Cherry Health's proposed project, Implementing a Certified Community Behavioral Health Clinic in Kent County will ensure that comprehensive, high-quality behavioral health care will be available to adults with severe and persistent mental illness (SPMI), children with a serious emotional disturbance (SED), adults and children with substance use disorder (SUD) or co-occurring disorder, veterans, and underserved populations. Adults and children with mild to moderate behavioral health issues are identified as subpopulations of focus within the projects geographic catchment area of Kent County, Michigan. In particular, Cherry Health's Certified Community Behavioral Health Clinic (CCBHC) will strive to reach the 24% of Kent County's Medicaid population who are identified as persons living with any mental illness and even more specifically, the 47% of this population that goes without treatment. Cherry Health anticipates serving 2,865 patients annually through the life of this project. Cherry Health is well positioned to implement a CCBHC. Its present organizational structure as a Federally Qualified Health Center, integrated primary care and behavioral health services, patient population, payment policies, and current community partnerships already meet a majority of the CCBHC criteria. Cherry Health is poised to expand and enhance its service delivery model by hiring additional staff to increase the capacity to serve more patients with SPMI/SED/SUD needs. Cherry Health will develop partnerships with hospitals, veteran organizations, schools, jails, and other community organizations to increase referrals to Cherry Health so that the unmet need in the community can be addressed. Additionally, this project will focus on enhancing care pathways and screening procedures to ensure patients are receiving the right care at the right time, and that natural supports are included in treatment planning at a greater rate. With its robust continuous quality improvement system, Cherry Health will be able to efficiently incorporate CCBHC metrics into this process so that project metrics are tracked and monitored to ensure goals and objectives are met. Through the use of evidence-based practices such as Cognitive Behavioral Therapy, Motivational Interviewing, Solutions Focused Therapy, and more, Cherry Health will provide the nine core services of the CCBHC model in order to improve mental health and substance use outcomes, as well as support improved functioning in all life domains, such as housing and employment. Cherry Health anticipates increased referrals and an increased number of patients seen for CCBHC services. This project is poised to fill a gap in care for individuals currently unable to access these important services.

Sun River Health, Inc. (dba Hudson River HealthCare) is seeking to provide comprehensive, coordinated behavioral health care by establishing a new Certified Community Behavioral Health Clinic (CCBHC) program with its primary service location in Shirley, NY. Project Title: Sun River Health CCBHC Planning, Development and Implementation, Shirley, NY. Populations to be Served: The target population includes those living in the community surrounding Sun River Health's Shirley Health Center in Suffolk County, New York, with a special focus on individuals recovering from Substance Use Disorder (SUD) and those with cooccurring mental and substance use disorders (COD), those with serious mental illness (SMI), and children and adolescents with serious emotional disturbance (SED). Strategies/Interventions: Sun River Health will conduct a planning and development process to implement a new CCBHC that meets SAMHSA CCHBC Certification criteria. To do this Sun River Health will provide a comprehensive ranger of outreach, screening, treatment, care coordination, and recovery supports aligned with CCBHC Certification Criteria. Services also include PHQ9 depression screening, Columbia Suicide Severity Scale, GAD-7 anxiety screening, Modified Simple Screening Instrument for Substance Abuse (MSSI-SA), Alcohol Use Disorders Identification Test (AUDIT), and Rapid Opioid Dependence Screen (RODS), as well as comprehensive psychosocial assessments and psychiatric evaluations. Project Goals and Objectives: Through the project, Sun River Health will: develop and implement a sustainable CCBHC service delivery model that is responsive to the mental health and substance use needs of the community and those most at risk for behavioral health disparities; improve access to comprehensive behavioral health care, treatment, and supports for members of the target population through the full implementation of the nine (9) core CCBHC services; develop, implement, and maintain effective CCHBC-wide data-driven continuous quality improvement (CQI) plan for clinical services and clinical management to ensure services delivered through the CCBHC program are of the highest quality; and achieve compliance with all CCBHC Criteria.

Maryville, Inc. serves approximately 5,000 unduplicated consumers with substance use and mental health disorders throughout the state of New Jersey, the majority of whom reside in counties to be served through the Maryville CCBHC -- Camden, Gloucester, Cumberland, Salem, Burlington, and Atlantic Counties. These individuals have diagnosable Substance Use Disorders (SUD), mental health, and/or gambling disorders, typically accompanied by physical health issues. Individuals with severe and persistent mental illness live approximately 25 years less than individuals without mental illness. This may be due to the myriad of medical conditions that may be undiagnosed/unmanaged by someone with mental health issues and/or chronic substance use. Those living in poverty, uninsured, unemployed, and/or homeless are typically not tending to their physical health. All six of the counties to be served have higher unemployment, disability and drug overdose rates than the rest of the nation, and all are equal to or greater than the state and nation in the area of frequent mental distress. According to each county's 2020 Needs Assessment, the areas of need are in the areas of housing, employment, primary, behavioral and mental health treatment access, and transportation. The data illustrates the need for enhanced mental health services and highlights the impacts of physical health in relation to treatment and overall wellbeing. The targeted populations identify common primary health concerns that disproportionally impact minority populations and put additional stress on behavioral health, prompting a focus to support enhancement of crisis management services and expanding the organizations outreach to promote support and resources for those with SUD and mental health concerns. With SAMHSA grant funding, Maryville will look to advance services for substance use disorder and mental health to improve outreach and accessibility, and will improve integrated services provided for those with Serious Mental Illness (SMI), Serious Emotional Disturbance (SED), Substance Use Disorders (SUD) and Co-Occurring Mental Health and Substance Use Disorders (COD) in an effort to reduce high-risk behaviors related to mental illness, substance use disorder and physical illness that may contribute to poor overall health outcomes. Improvements in housing stability, employment, education, family and social supports, food security and other social determinants of health. The overarching theme of project activities will focus on providing comprehensive, integrated, coordinated and person-centered services that are culturally competent and equitable to all populations while meeting CCBHC Certification Criteria. Specific expansion of services to be provided through grant funding includes implementing 24/7 crisis mental health services, psych rehab services, outpatient delivery of primary care screening and monitoring of key health indicators, intensive, community based mental health for members of the armed forces, veterans, the elderly, LGBTQ+ and criminal justice affiliated subpopulations. This proposed CCBHC project will also further educate Maryville staff on supporting the consumer population and advancing the delivery of care through Maryville and partner agencies. Project evaluation will be successful through support from the Innovations Collaborative for program assessment, development and monitoring, and reporting. To meet the project objectives, Maryville will also work alongside SAMHSA to collect, monitor, analyze and report clinical quality measures to understand the outcomes of the project and overall impact on the community. Additionally, Maryville will work with state and local agencies to properly monitor clinical and demographic data, enhance social determinant of health tracking and resource connection, and meet the needs of each consumer within the community.

Certified Community Behavioral Health Clinic (CCBHC) Planning, Development, and Implementation Grant Niagara County Department of Mental Health and Substance Abuse Services Niagara County Department of Mental Health (NCDMH) will build upon and transform its existing trauma-informed, licensed outpatient clinic and community services to create Niagara County Comprehensive Counseling and Wellness (NCCWC), a CCBHC serving adults with Serious Mental Illness (SMI) and children/youth with Serious Emotional Disturbance (SED) across Niagara. Individuals served will have improved health, wellness, and quality of life. The two sites for this project are New York State (NYS) Licensed Integrated Mental Health (MH) and Substance Use Disorder (SUD) clinics located at 1001 11th Street, 2nd Floor, Niagara Falls and 5467 Upper Mountain Rd, Lockport. NCDMH serves over 1900 individuals annually through the outpatient clinics and 2300 through its crisis and community programs. The Population of Focus (POF) served through NCDMH is high risk, compared to our county, region and NYS on key health indicators, including 12-month rates of inpatient hospital and emergency room visits related to MH, SUD, and medical conditions. 60% of persons served have a co-occurring MH/SUD and 30% do not have an active relationship with a Primary Care Provider (PCP). Persons served are disproportionally low income, BIPOC, LGBTQ, Veterans, and trauma victims in comparison with the local community, thus are disproportionately impacted by health disparities, having less access to quality care, increased barriers due to lack of transportation, and increased fear/stigma associated with seeking help. Additionally, there is a critical shortage of services for children in our community. The project will facilitate consumer engagement in services and create better outcomes related to social determinants of health by incorporating peer specialists, expanding targeted case management (TCM), and furthering access to Psychiatric Rehabilitation Services (PRS). The project will increase the number of people who have access to high-quality care and who experience improved health and well-being by hiring additional licensed masters level clinical as well as medical staff (LPN, family nurse practitioner) and will train all direct service staff in a range of evidence-based treatment. The additional clinical staff will have a particular focus on expanding the availability of services for children. Finally, the project will develop its health data and infrastructure technology, including the implementation of an advanced Electronic Health Record system in order to assure effective coordination of consumer care and to create an effective, sustainable CQI/program development process that will utilize data tracking, collection and analytics to assess and improve outcomes at the program, population and sub-population levels. The project will serve a total of 745 individuals with SMI/SED in Niagara County over the 4 years of the project, including 125 in year 1, 175 in year 2, 210 in year 3, and 235 in year 4.

With a mission to change lives by offering help, hope, and opportunity to the most vulnerable in our community, The Bridge provides housing and behavioral health services to 4,000 New Yorkers annually. With SAMHSA funding, The Bridge will strengthen its community-based BH services in the targeted New York City boroughs (Manhattan and the Bronx) and neighborhoods by creating a CCBHC that provides 24/7/365 person-centered integrative services to 180-200 people each year, reaching an unduplicated total of 755 in 4 years. The Bridge aims to improve access and decrease barriers to BH care among high-need individuals through a comprehensive range of outreach, screening, assessment, treatment, care coordination, and recovery supports (Goal 1) through the following objectives: Within 6 months of contract start, increase response time to less than 3 hours for those in need of BH care by developing and implementing a 24/7 crisis intervention, risk assessment, and treatment response system for high-need individuals; and Within 12 months of contract start, increase utilization of BH services (scheduled appointments, maintained appointments, medication adherence) by strengthening social supports among high-need individuals by utilizing a Certified Peer with lived experience. The Bridge will improve the efficiency and effectiveness of integrated BH and physical health care among high-need individuals through case management, health screening, monitoring, and partnerships with health providers (Goal 2) through the following objectives: Within 12 months of contract start, increase the number of high-need individuals who manage their wellbeing by providing onsite and community-based health screenings, health education, and health promotion activities to 180-200 individuals annually; and By the end of the grant period, increase the number of high-need individuals who receive physical health care from 25% to 65% of the total population served by providing facilitated referrals and support making and attending appointments. The Bridge will improve the delivery of culturally competent, evidence-based BH care through workforce development and training (Goal 3) through the following outcomes: Each year throughout the four-year grant period, review and improve diversity, equity, and inclusion policies and practices to address disparities in MH outcomes; and within three months of contract start, recruit and hire a Fidelity Trainer/QA Specialist to build the capacity of at least 100 employees to deliver culturally competent, evidence-based care to 180-200 individuals each year The Bridge is currently implementing all required CCBHC activities, including crisis mental health services; screening, assessment, and diagnosis; patient-centered treatment planning; outpatient mental health and substance use disorder services; outpatient primary care screening and monitoring of key health indicators and health risks; targeted case management; psychiatric rehabilitation services; peer support; and services for veterans. Program enhancements will include formalizing an after-hours on-call schedule system; strengthening bi-directional referral relationships with local hospitals; building evidence-based practices; strengthening youth services; expanding peer supports; and improving diversity, equity, and inclusion policies and practices to address disparities in MH outcomes.

Guidance/Care Center's proposal to be a Certified Community Behavioral Health Clinic (CCBHC) will serve 415 clients by the end of the grant period in Monroe County, Florida (50 YR1, 150 YR2 and YR3, 65 YR4). With the proposed CCBHC funding, G/CC will undergo a system transformation that will bring fragmented services together to deliver them in a coordinated manner across multiple disciplines, including primary care, behavioral health, mental health, and psychiatry. G/CC has identified the population of focus as any individual with a mental health or substance use disorder (SUD) who seeks care, including those with a serious mental illness (SMI) or an opioid use disorder (OUD); children and adolescents with serious emotional disturbance (SED); individuals with co-occurring mental health and substance use disorders (COD); and individuals experiencing a mental health or substance use-related crisis. Goal 1: Increase the availability of and access to high-quality mental health and SUD services in Monroe County, FL. Objective 1.1: By September 2026, provide high-quality, integrated outpatient mental health and SUD services to 415 children, adolescents, and adults (Y1=45; Y2, 3=150; Y4=65). Objective 1.2: By September 2026, 85% of clients will receive primary care screening and monitoring for BMI, blood pressure, HIV/VH, and tobacco use. Objective 1.3: By September 2026, 85% of clients with trauma symptoms will receive Seeking Safety. Objective 1.4: By September 2026, 85% of clients with an SUD will receive Relapse Prevention Therapy. Objective 1.5: By September 2026, 70% of clients will complete treatment successfully. Goal 2: Improve the behavioral, mental health, and social functioning of children, adolescents, and adults with mental health and substance use disorders residing in Monroe County, FL. Objective 2.1: By September 2026, 80% of clients with an SUD will eliminate or reduce substance use within 6 months, and 70% will maintain improvements at discharge measured by the NOMs. Objective 2.2: By September 2026, 80% of clients will exhibit fewer mental health symptoms within 6 months, and 70% will maintain improvements at discharge measured by the PCL-5, CFARS/FARS, and NOMs. Objective 2.3: By September 2026, 80% of clients completing services and not having stable living arrangements at intake will have stable living arrangements at discharge measured by the NOMs. Objective 2.4: By September 2026, 80% of clients completing services will be in an educational/vocational program or employed at discharge measured by the NOMs. Objective 2.5: By September 2026, 75% of clients with hypertension or presenting as under/overweight will fall within normal limits at 6 months, and 65% will maintain the improvements at discharge measured by blood pressure and BMI.

Memorial Healthcare System proposes to expand and improve the behavioral health care continuum in the South Florida geographic catchment area by becoming a Certified Community Behavioral Health Clinic. (CCBHC) with the implementation of the Solutions and Opportunities for Uplifting Lives (SOUL) Program. This initiative will allow Memorial to implement and hardwire care coordination efforts as a pivotal feature within the CCBHC. Memorial proposes to serve 1,650 unduplicated consumers over the course of 4 years. The populations of focus comprise children, adolescents and adults in Broward County, Florida (a non-Medicaid expansion State) with mental health disorders, who are uninsured or from under-resourced communities and vulnerable to health disparities. Their conditions impair routine functioning in everyday activities and can include serious mental illness, serious emotional disturbance, those susceptible to suicide risk, overdose and individuals with co-occurring mental and substance use disorders. The participants reflect the demographic diversity of the service area and include consumers with special needs, veterans, those identifying as LGBTQ+ and/or those at risk for suicide and overdose, vulnerability to homelessness and socioeconomic disparities that hinder access to health resources. A prevailing population characteristic is that they cannot afford services and/or co-pays and are uninsured or underinsured. Care Coordination is the lynchpin of the CCBHC model and is currently the weakest link in the catchment areas continuum of care. Whether services are provided directly by staff or through collaboration with service providers through Designated Collaborating Organizations (DCO) agreements, communication and coordination to navigate the consumer between providers is essential to address the consumers needs, preferences and barriers. Since the fragmented mental health system presents challenges for consumers as they transition from one care setting to another, Memorial will hire and train a team of six (6) Care Coordinators to work with both adults and children/adolescents to ensure consumer-friendly warm handoffs to and from DCO partner agencies for clinical care and to address the consumers social determinants of health (SDOH). To support the Care Coordination teams efforts to use measurement-based care (MBC) into program implementation to drive clinical decision making Memorial will also enhance the organizations infrastructure. Enhancements to the electronic health record system will build capacity to collect, record, monitor, track, analyze and report on key data points resulting from evidence-based practices and interventions employed in the treatment of consumers. An Advisory Council will also provide input to help consumers access care and reduce disparities while complying with HIPAA guidelines and improving the SOUL Program services to be consumer-centered and outcome-based mental health care. The goals and objectives are to establish and meet all requirements to become a CCBHC by Month 12 by increasing the quality of behavioral health services and increasing Care Coordination for consumers in Broward County. An Evaluator will analyze clinic-level quality measures on services received and data on retention in program services including Care Coordination, Mental Health Services, Substance Use Treatment, Primary Care and Support Services to monitor individual progress towards positive health outcomes including mental health functioning, stability (e.g., no overdose), suicidal thoughts or actions, and other successes (e.g., improvements in employment, housing status, decreases in criminal justice involvement, physical health indicators, increases in social support). Data towards training and enrollment goals will be analyzed monthly to address Infrastructure, Prevention and Promotion (IPP) and National Outcome Measures (NOMs) goals with special attention to enrollment per the Disparities Impact Statement.

Access: Supports for Living Inc. (Access) intends to provide CCBHC services to New York's Ulster County through a Behavioral Health/Substance Use Disorder (SUD) Urgent Care (BHUC) model that can combine walk0in and telehealth same-day services with the full scope of CCBHC services, including same-day access to psychiatry, therapy, Medication Assisted Treatment (MAT), care management, peer services, nursing, and integrated physical health services. Access intends to serve those in poverty and uninsured and underinsured individuals in Ulster County, focusing on the diverse subpopulations within the county. While the demographic make-up of the county is predominantly white, Access already serves a higher percentage of individuals identifying as African American or Hispanic. The population of focus also includes 11% of county residents who report poor mental health for two weeks or more over the last month and 13% of residents who did not seek care because of cost. In operating the BHUC, Access intends to make care more accessible to all individuals in the county and remove some of the stigma of receiving mental health and SUD care. Individuals will be greeted in a "living room" type of experience, allowing someone to get comfortable with seeking care as the first step in care. Once the individual is comfortable, Access provides the full spectrum of CCBHC services to meet the individual's needs including on-site psychiatric services and MAT inductions, as indicated. Access also provides all of the routine and follow-up care a person may need to be successful in treatment. Further, Access intends to address key Social Determinants of Health by providing employment housing, and food security supports to individuals who need it. In the first year of the project, Access intends to serve 250 individuals, growing to 2, 250 individuals over the four-year life of the project.

Hospital Menonita CIMA (CIMA), the largest non-profit specialty mental health organization in Puerto Rico (PR) and an operating division of Mennonite General Hospital, Inc. (MGHPR), the largest non-profit organization in PR, will plan, develop, and implement a Certified Community Behavioral Clinic (CCBHC) to serve 2,000 individuals over four years in 11 municipalities in PR. The CIMA CCBHC Program will provide comprehensive and coordinated behavioral health services for adults with serious mental illness (SMI), substance use disorder (SUD), including opioid use; children and adolescents with serious emotional disturbance (SED); individuals with co-occurring mental and substance disorders (COD); and individuals experiencing a mental health or substance use-related crisis. These 11 municipalities, which experience some of the poorest social, economic, and health conditions in PR, are Aibonito, Arroyo, Barranquitas, Coamo, Comerio, Guayama, Maunabo, Orocovis, Patillas, Santa Isabel, and Salinas. Overall, 99% of the population is Hispanic and primarily Spanish-speaking. HRSA classifies the entire zone as medically underserved and a Health Professional Shortage Area for mental health care providers. Over the four-year program, CIMA will achieve the following: Objective 1: Within 150 days, complete a need assessment in the catchment area that addresses cultural, linguistic, treatment, culture, staffing needs, transportation, income, and other barriers to be served by the CCBHC. Objective 2: Within 60 days, complete a readiness review using the CCBHC Certification Criteria with an external organization. Objective 3: Within six months, comply with 100% of the CCBHC Certification Criteria. Objective 4: By the end of the program, comply with a 100% annual readiness review using the CCBHC Certification Criteria. Objective 5: By the end of the program, reduce by 15% the suicides in the catchment area (from baseline). Objective 6: By the end of the program, increase by 25% the number of consumers initiated medication-assisted treatment (MAT) (from baseline). Objective 7: By the end of the program, increase the number of consumers who initiated the SUD youth program by 25% (from baseline). Objective 8: By the end of the program, increase the number of consumers receiving primary care screening by 20% (from baseline). Objective 9: By the end of the program, increase the number of consumers who receive vocational counseling by 15% (from baseline). Objective 10: By the end of the program, CIMA expects to reduce hospital utilization of high-utilizer individuals with SMI and COD by 25% (from the baseline). Objective 11: By the end of the program, CIMA anticipates an increase of 15% in the referrals to the first psychosis episode program (from the baseline). The program will enroll 400 clients in Year 1, 500 Year 2, 550 Year 3, and 550 Year 4.

Project Abstract Summary Comprehensive Healthcare (CHC), a Community Mental Health Center in Walla Walla County, Washington since 2013, will engage in planning, development, and implementation of a CCBHC that meets the CCBHC Certification Criteria. Comprehensive Healthcare seeks to improve access to community-based mental health and substance use disorder treatment and support, including 24/7 crisis services, to anyone in the Walla Walla County who needs support, regardless of their ability to pay or place of residence. As a CCBHC, CHC will focus on serving any individual with a mental health or substance use disorder who seeks care, including those with serious mental illness (SMI), substance use disorder (SUD) including opioid use; children and adolescents with serious emotional disturbance (SED); individuals with co-occurring mental health and substance disorders (COD); and individuals experiencing a mental health or substance use-related crisis. CHC strives to address health disparities and provides services to individuals regardless of race, ethnicity, sex, sexual orientation, gender identity, age, and/or socioeconomic status. Over the course of this four-year grant CHC will serve a total of 750 unduplicated individuals: 100 in Year One, 150 in Year Two, 200 in Year Three, and 300 in Year Four. Strategies and interventions will include system and service transformation to ensure timely access to treatment, transformation of service structures in improve engagement in ongoing treatment services, services and supports to minimize psychiatric inpatient admissions and recidivism, outreach and education to decrease unnecessary emergency department utilization, and training to increase practitioner skills and competencies. Goals and objectives will be achieved by improving service delivery structures through the hiring of a consultant, the formation of a Transformation Committee, increasing outreach and engagement, and ensuring timely access by hiring staff to increase service delivery capacity and hiring of bilingual staff and/or representatives of marginalized populations to support services to underserved populations. CHC will also increase the competencies of staff as they continue to respond to the effects of the COVID pandemic on the mental health and substance use patterns of Walla Walla County residents.

As a CCBHC-PDI grant awardee, Westchester Jewish Community Services (WJCS) will expand and enhance outreach, engagement, and integrated behavioral health and trauma treatment for individuals with substance use disorder (SUD) and youth ages 5-18 with BH conditions such as serious emotional disorder (SED) who have experienced trauma, with a particular focus on black and Latinx communities and LGBTQ+ youth. WJCS project goals are to: (1) Increase the number of children and adolescents served, including black, Latinx, and LGBTQ+ youth; (2) Increase the number of individuals with SUD or co-occurring disorders (COD) served; (3) Increase the number of clients screened for health-related social needs (HRSN); (4) Train staff to implement EBPs that address the needs of our populations of focus; (5) Improve EBP fidelity maintenance QI process; and (6) Enhance the inclusiveness of our services for LGBTQ+, Black, and Latinx clients. We plan to address these goals by establishing solid referral relationships with local VAs, FQHCs, and other partners and by strategically and proactively outreaching and engaging youth through our school-based satellite clinics and Center Lane program for LGBTQ+ youth to conduct a brief social-emotional wellness screening. We will also: (1) leverage our training infrastructure to increase the number of staff trained in Encompass and Community Reinforcement And Family Training (CRAFT) by 60%, EBPs that focus on youth and adults with SUD or COD; (2) increase staff trained in LGBTQ+ sensitivity by 90%; (3) increase the share of staff who are black and Latinx in both sites by 50% to ensure our staff are representative of the populations we are serving; (4) complete a health review form in our EHR for 90% of new clients; (5) reduce PHQ-9 scores of 70% of clients with a positive PHQ-9 score of 10 or greater; (6) maintain a No-Show Rate at or below 10%; and (7) support attendance for at least 4 treatment sessions for 50% of new clients. We will improve our client assessment process by implementing our HRSN screening for all clients. During the grant period, 70% of new clients will have a change in food security, job, or housing status. To improve EBP fidelity, we will enhance our Utilization Review process to review 25% of all client charts annually to check for appropriate assessments, quality of documentation, and ensure that we are providing the highest standard of care to our clients. We will also improve the process for maintenance of EBP fidelity by conducting an annual chart review on a random sample of 20% of clients receiving dialectical behavior therapy (DBT) to ensure fidelity to the model and by verifying that 85% of staff providing EBPs such as DBT or TF-CBT have undergone intensive training and receive weekly supervision on the model. We will collaborate with Sun River FQHC and Mount Vernon Neighborhood Health Center to provide primary care services, including ongoing monitoring of health needs, vaccinations, HIV, and HEP screenings and care and to refer clients to our CCBHC sites when they identify individuals who need more support for their BH needs. We will also partner with the Guidance Center for ACT services and the Human Development Services of Westchester to provide social support opportunities. During the grant period, we will seek to increase the number of children/adolescents served by 25%, and black, Latinx, and LGBTQ+ youth by 50%, and individuals who receive SUD services by 20%. The project will serve 250 unduplicated individuals in the first year of the project and 1,200 individuals over the course of the project.

Elizabeth Layton Center (ELC) is a community mental health center (CMHC) in eastern Kansas that proposes to pursue certification as a community behavioral health clinic (CCBHC). This will allow the agency to expand and enhance access to comprehensive, coordinated behavioral health services for individuals with serious mental illness (SMI), serious emotional disturbance (SED), substance use disorder (SUD), or a co-occurring disorder (COD) in and around Franklin and Miami counties. This project also seeks to address health disparities experienced by individuals who are uninsured and under-insured. As a licensed CMHC and outpatient SUD service provider in the state of Kansas, ELC provides many of the required CCBHC services, though there is a need to expand these services to more individuals and provide whole-person integrated and coordinated care. ELC proposes to enhance existing services and add additional services to meet CCBHC criteria by focusing on workforce development, by training staff on and implementing evidence-based practices (EBPs) relevant to the target population, and by expanding access to intakes and mobile crisis response. Population to Be Served: ELC serves individuals with SMI, SED, SUD, and COD in two counties in eastern Kansas. While both Franklin and Miami counties post poverty rates that are less than the state average (10.6%), a far greater proportion of our clients experience poverty. Among Franklin County residents, nearly half (48%) of clients reported incomes below the federal poverty level (FPL) last year. For Miami County clients, this rate was 42%. These clients experience significant barriers to accessing the services they need. This project will emphasize reaching and serving individuals who are uninsured or underinsured, a growing subpopulation among ELC clients that includes individuals from low-income households, those experiencing homelessness, and those returning from incarceration. Serving these clients often results in a financial burden that challenges organizational capacity, including ELC's ability to recruit and maintain high-quality staff. Strategies/Interventions: This funding will support the expansion of services offered and the use of evidence-based practices, such as Assertive Community Treatment (ACT), Medication-Assisted Treatment (MAT), and Individual Placement and Support (IPS). Most significantly, ELC will expand and enhance its existing crisis services and increase access to individuals regardless of their place of residence. ELC will build staff teams that enable an enhanced, multidisciplinary approach to crisis response. This will also improve service accessibility, creating a bridge for individuals who need entry into ELC's community-based services. Goals and Objectives: The goals of the ELC CCBHC project are to increase workforce and organizational capacity to deliver and track high-quality CCBHC services; to increase CCBHC service penetration into the population of focus and provide high-quality, targeted services for individuals who are uninsured or underinsured; and to enhance access to care through expanded access to intakes and enhanced mobile crisis response services to individuals in our geographic area of focus. ELC proposes to serve a total of 4,002 unduplicated individuals throughout the four-year period of performance.

Project Summary: Bienestar Human Services (BIENESTAR) is applying for CCBHC-PDI funding as there is greater demand for acute behavioral healthcare care in East Los Angeles than can be provided by existing resources. This service gap, specifically for the treatment of low-income populations with SMI, SED, SUD, and/or COD, can be reduced with our proposed CCBHC. Geographic Catchment Area: Los Angeles County's Service Planning Area (SPA) 7. Project Name: Bienestar CCBHC for Latinx/LGBTQ Populations of East Los Angeles Populations to be served: Low-income Latinx LGBTQ residents of Los Angeles County Service Planning Area (SPA) 7, including persons with SMI, SED, SUD, or COD. SPA 7 has higher rates of poverty, a larger percent of the population that is Latinx, and a larger percent of the population that is LGBTQ than Los Angeles County as a whole. Number to be served: Year 1: 75; Year 2: 75; Year 3: 75 Year 4: 75; Life of project: 300 Project strategies/interventions: BIENESTAR will use a combination of several evidence-based- interventions, including Cognitive Behavioral Therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR), Medicated-Assisted Treatment (MAT) and Motivational Interviewing (MI). These interventions and screenings will be provided in English and Spanish. Project goals and measurable objectives: Our goals include a reduction in the risk for suicide, prevention of death by suicide; reduction in problem use of alcohol and/or opiates; and an increase in access to MH services, including improving awareness of services. Measurable objectives are as follows: (1) For each year, screen 400 clients, using the Columbia-Suicide Severity Rating Scale (C-SSRS) at Clinica Bienestar and the CCBHC; (2) For each year, those assessed to be at-risk for psychological distress or suicide will be referred to CCBHC for treatment; 100% will develop a crisis plan; (3) For each grant year, 65% of CCBHC patients will have reduced risk for psychological distress and reduced risk for suicide by improvements in K10 and C-SSRS scores between assessments; (4) For each year, 100.0% of those screened at-risk for SUD, will receive a referral for CCBHC services; of those referred, 75% will yield an attended appointment; (5) For each year, 65% of CCBHC patients with problem alcohol use will have reduced frequency of use as demonstrated by improvement between assessments; (6) For each year, 30% of CCBHC patients determined to have problem use of opiates will have reduced frequency of use as demonstrated by improvement between assessments; (7) For each year, screen 400 clients, using the Kessler Psychological Distress Scale (K10) at Clinica Bienestar and the CCBHC; (8) Each year, 100% of clients with a high-risk K10 screening, will be provided a C-SSRS screening and referral to the CCBHC; (9) Each year, 100% of clients with an at-risk K10 screening, will be provided a referral for CCBHC services; of those referred, 75% will yield an attended appointment; and (10) For each year, we will reach 500 individuals via social media, regarding availability of CCBHC services and for language appropriate health education.

The VHCS CCBHC-PCI Initiative initiates planning, development & implementation of a CCBHC meeting the CCBHC Certification Criteria in Monongalia, Marion, Taylor & Preston Counties in West Virginia, which suffer from high overdose rates, poor mental/physical health & child welfare which are exacerbated by lack of healthcare providers, COVID & poor social health determinants. The Initiative serves 7,100 clients (1,600-Y1/1,700-Y2/1,800-Y3/2K-Y4). Project goals (interventions/strategies) include: (1) Increase access to and availability of services that are responsive to community needs by establishing the Initiative by (A) Hiring the Project Director to lead the program & Advisory Board; (B) completing the Needs Assessment; (C) Implementing the needs assessment staffing & service plans; (D) Completing the required attestation demonstrating CCBHC Criteria compliance; (E) Subscribing to an interpretation service; and (F) Expanding non-traditional hours. (2) Support recovery from mental health and SUD via achieving the nine Core CCBHC Criteria by (A) Developing current crisis services in response to the needs assessment; (B) Developing EBP screening, assessment & diagnosis, including a risk assessment by leveraging the needs assessment to identify screens for children/veterans & hiring an Intake Specialist; (C) Hiring Case Managers to develop capacity to provide universal crisis plans; (D) Developing outpatient mental health/SUD services to include more child/adult services; (E) Expanding medical services to rural Preston/Taylor by purchasing equipment to enable staff to complete full telehealth physicals; (F) Developing targeted case management services by hiring additional adult, children/family & adolescent Case Managers; (G) Expanding day treatment services to Marion County; (H) Developing peer services to include a mental health peer; (I) Developing Counselor services by increasing Counselor licensing and expanding Therapy services; (J) Developing family services by adding a Family Therapist & Family/Child Case Manager; and (K) Developing veteran services to include a Peer, more partnerships & increased ability to bill for veterans services. (3) Use evidence-based practices that address community needs by implementing the Needs Assessment-driven training plan. (4) Continually work to measure and improve the quality of CCBHC Initiative services by (A) Developing capacity to measure/improve service quality by hiring an Evaluation Specialist & Quality Assurance staff; (B) Purchasing a new EHR to support collecting required CCBHC outcomes; (C) Serving 7,100 clients; (D) Measuring DLA-20 outcomes; (E) Clients experiencing significant improvement in NOMs mental health outcomes at 6-months; (F) 30% of clients improving in 1 physical health indicator by discharge; (G) Clients reducing illicit substance use by 10% at 6-months; (H) 80% of clients remaining in treatment for at least 6-months; (I) Monitoring disparity groups to ensure equal use/access/outcomes; (J) Designing/implementing CQI plan; (K) Leveraging needs assessment to identify ways to improve HIE, HIT & MBC; and (L) Maintaining/expanding partnerships in response to the needs assessment. (5) Meaningfully involve clients & family members in their own care and in the broader governance of the Initiative by (A) Ensuring 51% of the Advisory Board are clients/family members/caregivers; (B) Involving clients, family members, and caregivers in the design and implementation of the Needs Assessment; (C) Leveraging the advisory board to re-designing agency satisfaction surveys; and (D) Initiating client-led focus groups & an alumni group for SUD clients. (6) Sustain the Initiative by (A) obtaining state certification; (B) Creating a sustainability plan; (C) Working to negotiate a federal indirect cost; and (D) Ensuring that agency policies, procedures, protocols, credentialing, licensure, and accreditation align with CCBHC requirements.

Project Summary: Hill Country is a multi-service, non-profit community health center with Federally Qualified Health Center (FQHC) operating in rural, mountainous, northern California. We are applying for CCBHC-PDI funding for our site in Redding, as there is greater demand for acute behavioral healthcare care in Shasta County than can be provided by existing resources. This service gap can be reduced, through expansion of services, including access to 24-hour crisis intervention, and access to timely assessment, for low-income and uninsured adults and children with serious MH and SUD conditions. Geographic Catchment Area: Shasta County, California, north of the Sacramento Valley Project Name: Shasta County CCBHC to serve rural residents with SMI, SED, SUD, and COD Populations to be served: Low-income and uninsured adults and children of Shasta County with a behavioral health diagnosis, with emphasis on those with SMI, SED, SUD, and COD. Number to be served: Year 1: 150; Year 2: 175; Year 3: 175 Year 4: 200; Life of project: 700 Project strategies/interventions: Hill Country will use several of evidence-based- practices, including Cognitive Behavioral Therapy, Motivational Interviewing, Seeking Safety, Wellness Recovery Action Plan, and Medication Assisted Treatment (MAT) for opioid use disorder. All services will be conducted through a patient-centered approach, and be will be delivered in a manner that is compassionate, culturally sensitive, and linguistically appropriate. Project goals and measurable objectives: Our goals include: Reduce suicide risk and prevent death by suicide; Increase access to SUD services and prevent overdose deaths; Increase access to MH services to those who may need services along w/ medication; and increase access to care by improving awareness of services. Measurable objectives are as follows: (1) Each year, screen 500 individuals across all departments, for depression; (2) Each year, 100% of those at-risk for major depression will be referred to the CCBHC for treatment; (3) Each year, screen 100% of CCBHC patients for suicide risk; (4) Each year, 100% of those at-risk for suicide or major depression will develop a crisis plan; (5) Each year, 65% of CCBHC patients will have reduced risk for suicide, and reduced risk- for depression as indicated by improvements in scores between assessments; (6) Each year, 65% of individuals who screen positive for drug and/or alcohol issues during intake, will attend their referral appointment; (7) Each year, 100% of individuals who screen positive for drug and/or alcohol use during intake, will be referred to SUD groups; (8) Within 6 months of award, we will hire a Peer Support Specialist and a Substance Abuse Counselor; (9) Each year, the CCBHC will conduct in-reach using our EHR, to identify and refer patients prescribed psychotropic medication, but are not engaged in MH care; and (10) Each year, will reach 1,000 individuals through a social media campaign to raise awareness of MH and SUD services at the CCBHC, provided regardless of ability to pay, insurance status, or any other factor, and with a commitment to reducing transportation as a barrier to care.

SummitStone Health Partners (SHP) will establish a CCBHC to expand quality-driven, data-informed, community-based health and primary care for individuals across the lifespan who have or are at risk for a mental illness or substance abuse disorder or co-occurring disorders in Larimer County. To reduce health inequities, SHP will focus on people discharging from its crisis stabilization services; veterans/members of the armed forces; and BIPOC communities. The project will address the most pressing needs of our community, which has experienced dramatic increases in serious mental illness, overdose deaths, and suicide in recent years. SHP's clinical division reports that up to 75% of clients who leave crisis services do not transition into ongoing treatment. To support clients' ongoing stabilization and recovery, SHP will expand its Street Medicine and Addiction Rapid Transition Team (SMARTT), which will reduce return utilizations of crisis services by providing community-based, flexible services that build therapeutic alliances and, crucially, center on providing clients with the right care at the right place at the right time. SHP will also provide additional supports for youth aged 12-18 experiencing mental health crises, including obtaining licensure for five-day crisis stabilization unit stays and the addition of a crisis transitions family peer specialist. In collaboration with the Cheyenne VA Health Care System, SHP will provide outpatient/intensive outpatient SUD and medication-assisted treatment (MAT) to veterans and members of the armed forces. Through formal DCO relationships and current programming, SHP will ensure that all clients receive expert primary care screening, referral, and evidence-based intervention as well of provision of recommended vaccinations within 12 months of award. Equitable and representative care, an existing agency priority, will be further advanced through ongoing opportunities for education and self-reflection at every level of the organization, including the Board of Directors, allowing SHP to keep apace of Larimer County's quickly changing racial and ethnolinguistic landscape and adjust services as needed to guarantee that anyone can access care regardless of their background. Finally, SHP will expand its current capacity for continuous quality improvement as part of the agency's ongoing commitment to providing the highest quality and equitable care. Funds will be used to hire a program evaluation specialist; launch a Continuous Quality Improvement Committee and implement a performance measurement and management plan. Additionally, SHP will make investments in EHR updates; data connectors to support data sharing with DCOs and other referral sources; and the integration of NOMs data and building automated reassessment alerts into the EHR. SHP will serve 150 individuals in Year 1; 180 in Year 2; 216 in Year 3; and 259 in Year 4 for a total of 805 individuals. Goal 1 is to raise SHP's standard of care by achieving 100% of the CCBHC standards for staffing, access, care coordination, scope of services, quality and other reporting, and governance and accreditation. Goal 2 is to build SHP's capacity to reduce health disparities by providing evidence-based, trauma-informed care to the population of focus through outreach, service expansion, and infrastructure investments. Goal 3 is to develop and sustain SHP's capacity for continuous quality improvement to increase efficiencies and reduce health disparities.

The OhioGuidestone Cleveland, Ohio CCBHC will expand and enhance behavioral health services for adults with SMI, children and youth with SED, and youth and adults with SUD/COD. OGS proposes to expand access for transitional youth and homeless experiencing SUD, COD co-morbid physical health conditions, or an elevated risk or need for crisis services in the Cleveland area of Cuyahoga County Ohio. OGS will also expand services for pregnant and parenting women. The Ohio State Health Improvement Plan has designated Maternal and Infant health as a priority. The OGS Cuyahoga County CCBHC will serve 400 individuals in year one and 600 in year 3 and 4 respectively. The National Survey on Drug Use and Health, 2017-2018 and American Community Survey, 2018 estimated 34,425 adults 18 and older had SMI and an estimated 14,241 adults had co-occurring Major Depressive Episode (MDE) and SUD in the past year in the past year in Cuyahoga County, OH. Within the catchment area an average of 11% unemployment rate and 21.8% of residents live at less than 100% FPL (Federal Poverty Level), There are 73,455 single parent households and 9,500 women were pregnant or gave birth in the previous year. The demand for highly responsive community-based care is high, and per the most recent CHNA, there are limited services for mothers who have children and/or who may be pregnant. The coordinated, integrated and evidence-based local interventions critical to effectively engaging and supporting transition age youth were also identified as a significant barrier in Cleveland. According to the United Way of Cleveland 2019 Needs Assessment more than 1/3 of people who were homeless in Cuyahoga County suffered from chronic substance use disorder, and more than a 1/3 suffered from SMI. Additionally, individuals suffering from SMI can cost taxpayers more than $40,000 per year while homeless. In the wake of the pandemic, rates of homelessness are rising in Cleveland. Adults, families, and youth who are homeless require accessible, integrated, and trauma informed care. OGS proposes the following goals should we be a CCBHC Grant awardee. Goal 1: Increase capacity and targeted services to families and caregivers in the targeted geographic area. Estimated 10 percent of participant siblings who are eligible and choose to engage; 20 percent caregivers of participants who are eligible and choose to engage. Goal 2: Improve integrated referrals and care coordination with physical health partners to achieve better BH and physical health outcomes for SED and SMI population. Goal 3: Expand Substance Use and Co-occurring Disorder Treatment for Transitional Age. Goal 4: Monitor and increase service delivery of co-occurring mental health and substance use disorder diagnoses and co-morbid physical health conditions or an elevated risk or need for crisis services or chronically homeless. Goal 5: Expand internal capacity and elevate staff competency for BH services for under resourced pregnant or parenting women to positively impact health disparities.

Project Abstract Summary of Project: As a qualified local government behavioral health authority with 46 years of proven expertise serving the populations of focus, Region 8 Mental Health Services and DCOs will implement the Greater8 CCBHC to transform community behavioral health systems in Rankin County and expand access to quality care by strengthening infrastructure and advancing trauma-informed, culturally relevant integrated care, delivering comprehensive person and family-centered coordinated behavioral health services. Name: Greater8 CCBHC-PDI. Populations of focus: Adults with a mental or substance use disorder, including those with SMI, SUD, including opioid use; children/adolescents with SED; adults and adolescents with COD; and adults, children/adolescents experiencing a mental health and/or substance use-related crisis, including members of the armed forces, veterans, and families. Prioritized access to address existing behavioral health disparities: 62% Female; 37% Male; 1% Transgender; 20% African American; 1% Multiracial; 2% Hispanic/Latinx; 2% veterans/armed forces; 2% HIV/Hepatitis+; 45% COD. Strategies: 1) Planning, development, and implementation of a CCBHC model meeting CCBHC Certification Criteria, 2) Providing in-person and telehealth videoconferencing trauma-informed integrated care, including targeted outreach, crisis response planning, screening, assessment, outpatient MH/SUD/COD treatment, care coordination, and recovery supports based on the needs assessment aligned with CCBHC services; 3) Improving access and expanding wraparound recovery-oriented peer supports for SMI/SED/SUD/COD consumers. EBPs: MI, Team Solutions, Solutions for Wellness, S-BIRT, CBT, TF-CBT, Rx for Change: Clinician-Assisted Tobacco Cessation, EMDR, ACT, Disease Management, Long Acting Injectables and Medical Evaluation/Management, Peer Support, The Mandt System, WRAP, MHFA and Measurement-Based Care. Goals: 1) Plan, develop and implement CCBHC services increasing access to and availability of high-quality services responsive to emerging needs in Rankin County; 2) Support recovery from mental health and substance use disorder challenges via comprehensive community-based mental and substance use disorder treatment and peer recovery supports partnering with DCOs to promote whole-person wellness and recovery; 3) Use trauma-informed, evidence-based practices and team-based care coordination to holistically address person-centered treatment; 4) Facilitate CQI strategies to proactively measure, monitor and improve the quality of services that inform treatment, clinical decision-making, evaluation and sustainability; 5) Involve consumers/family in their own care and the governance of the CCBHC; 6) Improve integrated care outcomes and address health-related disparities. Measurable Objectives: 1) 100% timely submission of BHDIS/CCBHC Attestation; 2) Increase DCOs by 10% annually; 3) 100% accurate diagnosis and access to person-centered treatment planning; 4) 80% consumers report high perception of care; 5) 51% consumer/family governance; 6a)100% will receive physical health measurements, appropriate lab testing and physical examination; 6b) 65% will improve mental health functioning; 6c) 80% will reduce substance use; 6d); 6) 65% will improve employment status; 6e) 65% will improve housing stability. #Served: 75 (Year 1) 10 children/adolescents; 65 adults; (Years 2-4); 175 adults; 25 children/adolescents = 600 total.

CORE Health, a 501(c)(3) non-profit since 2017, proposes to become a Certified Community Behavioral Health Center (CCBHC) serving Cowlitz and Lewis County. CORE will increase the access and availability to quality health care, both primary care and behavioral, to low-income Medicaid-eligible and uninsured children, youth, and adults and Medicare-eligible adults with mental health, substance use and co-occurring disorders. Our targeted focus is on (1) adults with opioid use disorder (OUD), (2) children and adolescents with severe emotional disturbance (SED), (3) local veterans with mental health and/or substance use disorders, (4) individuals with a dual diagnosis of mental health and substance abuse, (5) adolescents with substance use disorder, (6) individuals experiencing homelessness and (7) limited English speaking residents. The need for outpatient mental health and substance use, psychiatric medication management, peer support, supported housing and employment has grown astronomically over the past two years. CORE Health provided outpatient services to 1,574 in 2021 and 2,216 in the first four months of 2022 equating to an 322% increase from the first four months of 2021 to the first four months of 2022. Over the 4-year grant period, our goal is to provide comprehensive integrated services to 4,000 new unduplicated lives. The Health Resources and Services Administration (HRSA) has designated Cowlitz County a Health Professional Shortage Area for both primary care and mental health specific to the low-income population. For Lewis County, HRSA has designated a Health Professional Shortage area for the low-income homeless migrant farmworker population in regard to primary care and for mental health they have designated all of Lewis County as a high needs geographic. Goal 1: Hire an addiction psychiatrist, LICSW, LMHC, Master level therapists, medical assistant and/or registered nurse to increase accessibility and availability of person-centered, trauma-informed, and culturally competent services to help meet the needs of our communities. Goal 2: Establish agreements with our community partners to increase care coordination for primary care, judicial, food and housing insecurity, FACT, WISe, Withdrawal Management, Crisis Stabilization, domestic violence, and transportation. Goal 3: Decrease youth substance abuse, SED, and anxiety by implementing school-based programs within each school district. Goal 4: Implement health screenings as part of each clients evaluation/assessment and monitor progress. Goal 5: Create a MAT program to address prescription/opioid use disorder/overdoses. Goal 6: Enhance treatment services through specialized trainings of evidence-based practices for our targeted population. Goal 7: Increase data collection and measurable objectives via software which will provide accurate data on client outcomes, gaps in care, identify social determinants of health so that we deliver value-based care. Every individual we serve deserves to have treatment barriers removed (including the inability to pay for services) and to engage in all facets of care designed to enhance their quality of life.

The Volunteer Behavioral Health (VBH) Certified Community Behavioral Health Clinic (CCBHC) intends to provide a comprehensive and integrated behavioral health service array to the Upper Cumberland, Tennessee area through high-quality coordinated services in response to the needs of the community, clients, and family members while involving consumer voice and choice in the decision-making of the CCBHC and their own care in a meaningful way. The population of focus is individuals in this primarily rural region who are uninsured or underinsured with low incomes, and have or are or at risk for mental illness and/or substance use disorders (SUD) including opioid use, those with serious mental illness (SMI); children and adolescents with serious emotional disturbance (SED); individuals with co-occurring mental and substance disorders (COD); and individuals experiencing a mental health or substance use-related crisis. Person-centered, family-centered, recovery-focused, and trauma-informed services will be provided regardless of an individuals ability to pay to 1,035 people over a 4-year period (135 in year 1, and 300 per year for years 2-4) at VBH's Cookeville Community Mental Health Center in Putnam county. VBH's CCBHC will increase access and elevate care for clients through a full-continuum of crisis stabilization intervention, mobile crisis services, walk-in center, and outpatient services including therapy, Care Coordination, and medication management. Additionally, a 5-member Multidisciplinary Connector Team (MCT) will be implemented to enhance service quality and meet clients where they are. This location provides a central access point to neighboring counties in Central Appalachia (Clay, Cumberland, Dekalb, Fentress, Jackson, Macon, Overton, Pickett, Smith, Van Buren, Warren, and White) that are under-resourced in treatment and recovery services. VBH will increase access and availability of these services, particularly to subpopulations that show health disparities following a needs assessment at 6 months, by supporting long-term recovery from mental health challenges, SUDs, and CODs through comprehensive and whole-person treatment leading to reaching ones full potential.

Easterseals Michigan CCBHC Macomb Grant [SM-22-002] will improve comprehensive coordinated integrated behavioral health care by establishing new programs and services in Macomb County, MI through multidisciplinary team-based care and pathways for people in crisis, depression, using substances or tobacco, comorbid conditions related to chronic health conditions, at high risk for suicide, and/or trauma. Investments in infrastructure will facilitate care coordination, population health analytics and monitoring, increased access and engagement into services through targeted interventions to address health disparities and social determinants of health. Evidence-based treatment and training, coupled with expanded staff, will increase community behavioral health services to 932 over four years (Y1 125, Y2 216, Y3 216, Y4 375). Outreach efforts and a no wrong door approach for individuals seeking services increases the volume and effectiveness of screening, assessment, and care coordination for complex, co-morbid cases. Populations of focus are adults, youth, families, and armed services/veterans who are uninsured, and/or underinsured. ESM will be focusing on special populations within schools. Project goals derive from Macomb County (MO) community needs assessments and target vulnerable populations including youth at risk for suicide, depression and anxiety; armed services/veterans and individuals and families with substance and tobacco use and/or trauma. The goals are: 1) Increase service capacity and access for children, adults and veterans through workforce expansion, screening, and outreach activities. 2) Reduce suicides by implementing Zero Suicide Care Pathway and Evidenced Based Practices that address trauma, high suicide, and depression risk. 3) Implement Complex Care delivery approaches to reduce health disparities by expanding care coordination for individuals with complex comorbid conditions. 4) Implement crisis service delivery system focusing on a decrease of utilization of inpatient services by increasing access to care centered around reduced wait times for engagement. 5) Decrease youth substance use and mental health symptoms by increasing youth resiliency in the community by implementing evidenced based programs (EBPs. 6) Enhance behavioral health, substance use, and trauma services for armed services/veterans. MC citizens identify as 83% Caucasian, 13% African American, and 4% Asian. Five percent (5%) as armed services/veterans and two percent (2%) identify as Hispanic or Latino. MC is 51% female and 49% male. Youth are 21% of the population. MC has an overall 9% poverty rate, cities such as Warren and Roseville have poverty rates above 13%. Tobacco users are 30% of the population, which is nearly double the adult smoking rate of 18.7% for the state of Michigan. In 2020-21, 62% of residents reported having anxiety, depression, and other mental health disorders. In MC, Opioid and Narcotic misuse is 35% of the population and suicide is a risk for 22%. Almost 20% (19.7%) of adults in MC reported they have not received the treatment they need due to access barriers which included no insurance and limited coverage of services, shortfall in medical providers, and a lack of available treatment. Anticipated outcomes include: enhanced outreach, by phone or in person, to 95% of high-risk individuals, clinical pathways for high-risk conditions that are culturally competent and linked with health disparity data, 11 BHC staff trained in EBP EMDR, MI, CBITS, ASIST, PET, TFCBT, Star BH Tiered training, clinical pathways for high-risk conditions that are culturally competent and linked with health disparity data, team-based care model to support care coordination with primary care partner, diversion of 15% individuals from hospitalizations, school-based colocation and referral pathways with 3 Macomb school districts to serve up to 50 children and adolescents with EBPs; and 6 outreach/educational presentations a year.

Tarzana Treatment Centers, Inc. (TTC) will plan, develop, and implement a Certified Community Behavioral Health Clinic (CCBHC) in the San Fernando Valley or Service Planning Areas (SPA) 2, situated in northern Los Angeles County (LAC). The overall purpose of TTC's project is to create a CCBHC that: 1) increases access to and availability of high-quality mental health and SUD treatment services and supports that are responsive to the needs of the community; 2) utilizes evidence-based practices that address the needs of the individuals served; 3) continually measures and improves the quality of services; and 4) meaningfully involves consumers and family members in their own care and the broader governance of the CCBHC. TTC's CCBHC will provide person- and family-centered integrated behavioral health services, including behavioral health screening, assessment, and diagnosis, patient-centered treatment planning, outpatient mental health and substance use disorder (SUD) treatment services, primary care screening and monitoring, care coordination, psychiatric rehabilitation services, peer support/counseling and family support services, veteran-specific services, and crisis management services, all in accordance with CCBHC Certification Criteria. TTC's target population for CCBHC services will be any individuals in the catchment area with behavioral health needs with a special focus on population groups facing health disparities, including individuals with serious mental illness (SMI), SUD including opioid use disorder (OUD), or co-occurring mental and substance use disorders (COD), children and adolescents with serious emotional disturbance (SED), and individuals experience a behavioral health crisis. As a provider of integrated health services for 50 years, TTC already provides most CCBHC core services. Thus, TTC's initial efforts will be focused on enhancing services and undertaking several capacity development activities to ensure compliance with all CCBHC Certification Criteria within one (1) year of award. Specific activities will include: 1) adapting its Enhanced Case Management policies and procedures to create cross-disciplinary treatment teams; 2) creating CCBHC Care Coordinator positions to lead these treatment teams and provide targeted case management services; 3) enhancing crisis management services, including providing 24-hour phone service and improving coordination with LAC crisis mobile response teams; 4) planning, developing, and implementing a Health Information Technology (HIT) system to merge data from TTC's two (2) electronic health records (EHRs), one for behavioral health and one for primary care; 5) enhancing services for veterans in collaboration with the Veterans Health Administration (VHA); and 6) developing and implementing enhanced cultural competency training for CCBHC staff inclusive of veterans, American Indian/Alaska Native, and other identified sub-populations. In addition to conducting a community needs assessment (CNA) by the end of month 6, TTC will also conduct the following required activities: 1) Develop a plan for staffing, training, and delivery of all required CCBHC services by month 8; 2) Provide at least five (5) of the nine (9) core CCBHC services by month 6; 3) Develop or strengthen formal agreements with other community providers to strengthen care coordination; 4) Involve consumers and family members in designing, implementing and evaluating CCBHC services; and 5) implementing all nine (9) core CCBHC services and demonstrating compliance with all Certification Criteria by the end of Year 1. TTC's CCBHC will serve 75 unduplicated patients in Year 1 and 150 unduplicated patients annually in Years 2-4 for a total of 525 unduplicated patients served during the 4-year project.

Across the U.S., almost a quarter (22.3%) of all adults with a mental illness reported that they were not able to receive the treatment they needed. In NH, this number is 28.8%, putting it at number 50 among the states for access to critically needed services. In addition, 2020 statistics show the opioid overdose rate in NH was the second highest in the country- nearly 3 times the national average. Community Council of Nashua, N.H., better known as Greater Nashua Mental Health (GNMH), has applied for a funding opportunity from the Department of Health and Human Services and Substance Abuse and Mental Health Services Administration (SAMHSA) with the goal of becoming a Certified Community Behavioral Health Clinic (CCBHC) in order to enhance and increase its capacity to provide evidence-based mental health and substance use disorder services to the residents of Southern Hillsborough County. The majority of clients served by GNMH live in the towns of Amherst, Brookline, Hollis, Hudson, Litchfield, Mason, Merrimack, Milford, Mont Vernon and the city of Nashua, although our Deaf and Hard of Hearing Services team provides services statewide. Clients are individuals of all ages, who receive specialized services tailored to all stages of the life cycle. The majority of GNMH clients have complex mental health and substance use disorder needs, many of whom have co-occurring diagnoses, and therefore require more than one service as well as a variety of supports. The goals of the project include increasing access to and availability of high-quality care by implementing intentional and innovative strategies within the agency; working continuously to measure and improve the quality of services and access to high-quality mental health and substance use disorder services, regardless of an individuals ability to pay; and to meaningfully involve consumers and family members in their own care as well as in the broader governance of the Certified Community Behavioral Health Clinic. GNMH intends to serve a total of 6,500 unique clients between October of 2022 and September of 2026, the proposed dates for the project, if awarded funding.

Dirne Health Centers, Inc. d/b/a Heritage Health submits this application to establish a Certified Community Behavioral Health Clinic (CCBHC) program serving Kootenai and Shoshone Counties in the Northern Panhandle region of Idaho. The two-county region is home to nearly 200,000 residents in a mix of urban and rural settings and suffers from a dire lack of behavioral health services, as indicated through a mental health provider to population ratio that is 42% less than the statewide average in Idaho and less than half the provider to population ratio U.S. states with the highest levels of access (Community Health Rankings 2021). The region also lacks sufficient crisis services, including 24/7 access to mobile crisis services and crisis stabilization services responsive to the youth and adolescent population. This lack of resources results in disproportionate rates of behavioral health disparities, including higher rates of suicide incidence and risk, and untreated substance use disorder (Community Health Rankings, 2021). By establishing the proposed CCBHC program, Heritage Health aims to expand integrated behavioral health care in Kootenai and Shoshone County with a particular focus on those who need services the most; individuals with high needs, including adults with Serious Mental Illness (SMI) and children with Severe Emotional Disturbance (SED) and those with co-occurring illness, and sub-populations that frequently experience heightened barriers to accessing care those who are living in poverty and who are under/uninsured. Key strategies that Heritage Health will implement to expand access to needed behavioral health care services include (1) strengthening the Idaho Region I (including Kootenai and Shoshone County) crisis continuum of care to de-escalate mental health and substance use crisis and divert unnecessary inpatient or Emergency Department usage by connecting users to outpatient care; (2) expanding access to integrated behavioral health services for underserved populations through increasing mental health and substance use disorder treatment providers who are trained in providing care to marginalized populations; and, (3) enhancing HIT infrastructure and staffing to provide care coordination for CCBHC consumers across mental health, SUD, medical, and social support needs with a variety of partners within the Northern Idaho communities served. Heritage anticipates serving 450 unique individuals in Year 1; 600 unique individuals in Year 2; 750 unique individuals in Year 3; and 900 unique individuals in Year 4, for a total of 2,700 patients served across the lifetime of the grant. Heritage is well-positioned to establish a fully-compliant CCBHC program within one year of award and already provides a significant array of integrated medical, dental, and behavioral health services. Heritage has served the communities in Northern Idaho since 1985 and is an NCQA Level III Patient-Centered Medical Home.