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HHSC's proposed TDR20 project aligns with the Center for Disease Control and Prevention (CDC) best practices for public health emergency response to support the provision of non-intrusive and culturally sensitive behavioral health services to approximately 8,200 school-aged youth and adults impacted by Tropical Storm Imelda and severe flooding in the Rio Grande Valley. HHSC TDR20 project proposes a comprehensive plan that includes access to immediate 24-hour mental health and substance use disorder (SUD) services including screening, assessment, referral, evidence-based treatment, crisis counseling, recovery support, and follow-up in Texas (HHS) Regions 5, 6, and 11. The plan will support positive healthcare outcomes for school-aged youth, adults, and families affected by Tropical Storm Imelda and severe flooding in the Rio Grande Valley. Additionally, funds will be used to implement a Responding to Crisis Learning Community using the Project ECHO model (Extension of Community Healthcare Outcomes), a professional peer tele-mentorship program aimed at establishing relationships with local businesses, families, and community groups thereby broadening and linking community resources. The plan is also inclusive of workforce development training designed to increase the ability of individuals in the community to recognize the signs and symptoms of mental illness and SUD in school-aged youth and adults impacted by a disaster and link them to appropriate services. Texas TDR20 will leverage and extend several existing infrastructure components. Infrastructure components and formal partnerships already in place include community training initiatives, school-based mental health promotion and coordination, and virtual direct mental health and substance use screening, assessment, referral, treatment, and recovery support services. Given the existing collaborative infrastructure, the comprehensive plan rapidly scales critical emergency response services using a central navigation hub and call center providing a 24-hour virtual crisis intervention service. The plan will deliver treatment that is both telehealth and technology-based and provide virtual and/or telephonic recovery support while simultaneously building workforce competencies and community capacity for increased identification and linkage to care. This will be achieved using the emergency response rapid scale and spread model used by the project team deploying the hub to accomplish the statewide buprenorphine waiver training and treatment model (www.GetWaiveredTX.com) funded through a CDC emergency response grant awarded to the Texas Department of State Health Services. The project team will also leverage existing workforce development training activities implemented through the SAMHSA Emergency Response Grant (SERG) and Project AWARE (Advancing Wellness and Resilience in Education), a multi-dimensional school-based mental health promotion and care coordination project funded by SAMHSA.

In 2019, the counties of Greene, Miami, and Montgomery, Ohio, were devastated by an unprecedented 18 EF4 tornadoes. The Ohio Disaster Response Project (ODRP) will address the mental health, addiction, and wraparound needs of both youth and adults in these communities through evidence-based screening, diagnostic, crisis, and treatment services, as well as a comprehensive workforce development plan, serving a total of 69,000 unduplicated individuals. Youth will be served via school-based universal screenings using the SBIRT model and Panorama Social Emotional Learning Assessment. High risk young people will be referred to a Student Resiliency Coordinator who will provide care coordination and linkages to a continuum of services that include prevention, screenings, diagnostic assessments, mental health therapy, case management, and psychiatric services. School districts will also have access to crisis support and a crisis debriefing intervention team as part of their emergency preparedness planning. Evidence-based treatment services for youth will include Cognitive Behavioral Therapy (CBT), Trauma-Focused-CBT, as well as family, group, and play therapies. Adults will be served via the network of behavioral healthcare providers who will integrate trauma questions into their standardized intake forms. As clinically appropriate, evidence-based treatment services for adults will include CBT, Cognitive Processing Therapy, Eye Movement Desensitization and Reprocessing, Community Psychiatric Supportive Treatment, Withdrawal Management, Medication Assisted Treatment, Integrated Dual Disorder Treatment, and Assertive Community Treatment services. Telehealth services will be available in tech-enabled spaces where individuals may meet privately with a remote clinician. All individuals will be assisted with transportation and access to community vocational services. A Mobile Crisis Outreach Team will be deployed for any youth or adult that is deemed to be in imminent danger. Workforce development opportunities will include Youth and Adult Mental Health First Aid, Trauma Informed Approaches, Social Resilience Model, Stewards of Children, Threat Assessment, Crisis Intervention Planning, De-Escalation, NOVA trainings, and several evidence-based treatment modalities. A comprehensive marketing plan will ensure individuals have knowledge of, and access to, community resources via the GetHelpNow software application. Lastly, these communities will come together for planning purposes via the ODRP Community Resilience Committee that will utilize the Adverse Community Experiences and Resilience and the THRIVE models as frameworks for addressing and preventing community trauma. By September 2021: 1) 162 new instructors will be trained in new training curriculum, 2) 2,500 people will be trained, 3) 9 providers will implement treatment EBPs, 4) 5 schools will implement SBIRT, 5) 9 schools will implement SEL assessments, 6) 135 new members will join the Ohio Crisis Response Team, and 7) the Ohio Disaster Response Community Resilience Committee will have met a minimum of six times.

Under the FY2020 Disaster Response State Grant Program, the state of Missouri will address the long-term behavioral health effects that the 2019 floods and tornadoes had on adults and children in the affected areas. The multiple rounds of natural disasters have traumatized many lives. Therefore, it is imperative that we provide each one of the communities impacted with the resources they need to rebuild and to support their health and wellness. Selected Certified Community Behavioral Health Organizations (CCBHOs) and one Community Mental Health Center (CMCH) will work with the Missouri Department of Mental Health Division of Behavioral Health (DBH) to identify evidence-based practices that will benefit the communities and population of focus. The identified community behavioral health treatment providers are local agencies that understand the unique cultural nuances that exist within each of the proposed communities to be served. Their system of care is well positioned to create impactful and sustainable change in the lives of Missourians who have been adversely affected by the 2019 natural disasters. The behavioral health treatment providers will provide direct treatment services in schools via the use of behavioral health professionals, behavioral health aides, peers, and other related professionals. The service provision will be dependent on the identified school's need. The behavioral health treatment providers will connect adults who may have behavioral health issues (including serious mental illness, substance use disorders, or co-occurring disorders), and their families to needed services, and provide direct treatment services. Developed screening and assessment instruments will be employed to all grant supported activities, which will help address the treatment needs of those in need of support, resources and clinical services. For any evidence-based practices implemented by the agency, each practice will follow fidelity to ensure optimal results and outcomes for each participating client. Mental Health First Aid (MHFA) training will be provided to individuals in the community who interact with adults and youth impacted by the disasters. The Disaster Response Grant data collection and performance measurement approach will have two primary components: collecting and reporting required Government Performance and Results Act (GPRA) measures and conducting project performance assessments.

The Kentucky Disaster Behavioral Health Response Grant will provide crisis services, mental health and substance use disorder treatment, recovery services, and other related supports to adults and school-aged children in 21 counties in the Appalachian region of Kentucky impacted by natural disasters during 2019. Rates of psychological distress among survivors double after a disaster with nearly one-third of survivors reporting a post-disaster mental health disorder. The confluence of the natural disasters with the opioid crisis, suicide crisis, and the COVID-19 pandemic place individuals in these communities at particularly high risk for serious psychological distress, especially those with pre-existing behavioral health conditions. In partnership with the KY Department for Behavioral Health, Developmental and Intellectual Disabilities, access to disaster behavioral health service and supports will be expanded in the catchment areas served by Cumberland River Behavioral Health, Kentucky River Community Care, and Mountain Comprehensive Care during the 12-month project. In addition to increasing access to crisis services and school- and community-based care, grant funds will support workforce development in evidence-based disaster behavioral health treatment approaches, provide community education and awareness events about the behavioral health consequences of natural disasters, and create Accessing Telehealth through Local Area Stations (ATLAS) to expand access to evidence-based screening, assessment, treatment, and recovery support services.

In an effort to address substance misuse and anxiety, depression, and other mental health issues that may stem from natural disasters, the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) aims to provide mental and substance use disorder treatment, crisis counseling, and other related recovery supports to Tennesseans ages 18 and over impacted by the 2019 floods. The Tennessee Disaster Relief Initiative aims to develop and implement a comprehensive plan of evidence-based mental and/or substance use disorder treatment services, screen and assess clients for the presence of behavioral health conditions, provide treatment and recovery supports and make available crisis mental health services. It is estimated 3,000 Tennesseans will be served by this project.

Florida's Hurricane Michael Disaster Response Project will focus on continued recovery efforts for both children and adults who are experiencing substance misuse, stress, anxiety, depression, or other behavioral health symptoms, and in need of mental or substance use disorder treatment, crisis intervention, care coordination and other supports. Primary focus will be on school age children through partnerships with local school districts. Schools in the affected areas have reported that as a result of the trauma form directly experiencing the storm, and the complicated physical, psychological, and financial ongoing recovery, there has been a dramatic increase in mental health referrals. This is expected to be compounded by the mental health impact of the COVID-19 pandemic. For adults, one focus area will be parents with child welfare involvement who present with behavioral health conditions. Data from the area's network management agency for child welfare show that 438 children have been placed in foster care services since the date of the storm. Reunification efforts are hampered by limited access to needed services for the parents of these children. Consistent with pre-hurricane trends, many of the parents are presenting with substance use disorders or co-occurring mental and substance use disorders. Funds will also be allocated to community service providers for a comprehensive array of treatment and recovery support services for adults with mental and substance use disorders who were impacted by the hurricane. Franklin, Liberty, Bay, Gulf, Jackson, Calhoun and Washington counties in the Florida panhandle will comprise the target area served with grant funds.

The North Dakota Disaster Response State Grant program will provide mental and substance use disorder treatment, crisis counseling, and other related supports for adults impacted by the 2019 flooding disasters. North Dakota plans to focus efforts on adults impacted by the disaster, which occurred in 29 of the 52 counties in the state. Approximately 17% of adults age 18 and older in ND met the criteria for any mental illness in the past year and 9% had a substance use disorder in the past year. The addition of stress related to the 2019 natural disasters is likely to exasperate or worsen existing behavioral health needs. North Dakota intends to provide additional treatment/recovery service to approximately 100 adults. The goals of North Dakota's Disaster Response Grant program are to increase the availability of treatment and recovery support services for adults impacted the disaster, increase community capacity to address behavioral health needs increased by disasters, increase outreach, engagement and training available to increase the ability of individuals to recognize signs and symptoms of behavioral health conditions.

Hawaii Disaster Response State Grant Program (HI-DRS) - A Statewide Response for School-Aged Youth (K-12) and Adults Impacted by Natural Disasters with Behavioral Health Signs & Symptoms. The Hawaii Coordinated Access Resource Entry System (CARES) Line is a hub-and-spoke statewide initiative that is being expanded to function as a "one stop shop" for a continuum of care (COC) with services for substance use, mental health and crisis line services in Hawaii. Hawaii CARES is responsible for the following: (1) Collect real-time data on utilization of substance use disorder treatment and recovery services for all ASAM-aligned levels of care to maintain and facilitate client flow through the COC; (2) Monitor the effectiveness of the screening and referral process; (3) Authorize client services utilization; (4) Review all referrals for services; (5) Review requests for extension of services; and (6) Conduct continuous quality improvement of services delivered by its health provider network. Hawaii CARES also has at its hub (1) a gateway call center that assures universal intake of clients in order to create a client record in an electronic health record; (2) and authorizing agent for screening, intake, care coordination, and referral to in-network and out-of-network behavioral health, crisis mobile outreach and primary care providers; and (3) a system quality assurance agent that monitors operational effectiveness. Hawaii DRS Project activities seek to expand and promote Hawaii CARES as a natural disaster response source to serve up to 400 clients impacted by substance use, and over 400 adult and young consumer who require evidence-based developmentally appropriate mental health and/or crisis mobile outreach services. The Project aims to improve statewide coverage to youth who require mental health services by expanding crisis mobile outreach workforce in coordination with family guidance centers statewide. To expedite service delivery to affected population, existing direct service behavioral health provider contracts will be utilized. The Project will also implement targeted media campaigns and convene a speaker bureau to design training content and up to 40 online workshops to raise awareness and train providers, community coalitions, interested HI Department of Education staff and school communities on behavioral health impacts of disasters.

Our Kansas Behavioral Health Integration into Schools (BHIS) program will focus on improving mental health of children and adolescents affected by tornados and flooring in 2019. These weather events created damaged in 70 of the 105 counties, most of which exist in rural or frontier areas. Our project aims to increase access to school-based behavioral health services through this catchment area, evaluating existing programming through implementation of the Multi-tiered Systems of Support framework (MTSS). To accomplish this, we will import elements from a successful Pennsylvania school-based screening program which combines staff training in evidence-based practices and interventions, access to standardized screening and referral technology, and ongoing technical assistance and implementation support. To implement this program, we will collaborate with Drexel University's Center for Family Intervention Science (CFIS) and software company Medical Decision Logic, Inc (mdlogix). Together, these two teams have built statewide suicide prevention infrastructure across the state of Pennsylvania (70% of counties), with a particular focus on schools. This proposed program is supported by BH-Works, a cloud data and workflow platform that provides tools for screening students, coordinating care, conducting virtual visits, tracking individual outcomes, and analyzing and reporting population data. All elements of this proposed project, including use of BH-Works, will be made available to 20 community mental health centers (CMHCs) from counties affected by these 2019 disasters, as well as schools they serve. We plan to engage with 20 CMHCs, recruiting at least 9 of them to use BH-Works to provide screening and intervention to students on school sites. Since many of the school districts in the catchment area have small student populations, we aim to screen at least 250 students by the end of this 1-year project period. Most of these screenings will be indicated, with the student being referred for assessment by school staff. We will train 25 providers in Attachment Based Family Therapy (ABFT), certify 75 Question-Persuade-Refer (QPR) trainers, and provide QPR training to staff in at least 75 school districts. We will also provide Mental Health First Aid training to staff in at least 20 school districts. As part of our community engagement component, we will conduct town hall meetings in at least 5 of the affected counties and expand the state's Youth Leaders in Kansas (YLINK) program to 12 additional groups in these catchment areas. We will build on this infrastructure through future state and federal funding opportunities.

The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) will implement the Embrace initiative to provide services to children in the 2019 disaster declared areas affected by the severe storms and floods. The months long onslaught of storms inundated the ground, flooded rivers and streams, and taxed levees across northern Oklahoma. With damage estimates at $22 million, the Federal Emergency Management Agency (FEMA) approved disaster assistance for 27 Oklahoma counties. Children in these counties are at heightened risk of developing anxiety, depression, and post-traumatic stress, impacting their mental and physical health, quality of life, and school success. Embrace OK goals are to: 1. Develop and implement a school wide referral process for students identified as needing mental health or substance use treatment as a Tier 3 intervention. 2. Rapidly provide direct treatment services in schools to school age youth to maximize student’s social, emotional and behavioral self-management skills utilizing evidence-based practices and best practice models. 3. Develop community and family mental health awareness and outreach campaigns to increase knowledge of issues and awareness of school and community based resources. 4. Increase school’s capacity to respond and prevent mental health problems associated with disaster by equipping school districts with comprehensive, multi-tiered plans. Partnering with 20 Local Education Agencies (LEAs) and 6 Community Mental Health Centers (CMHCs), Embrace will offer mental health and substance use disorder treatment, crisis services, and other related support services for school-aged youth from the 27 disaster-affected counties. Embrace will rapidly deploy evidence-based treatment and crisis services and equip school districts with a multi-tiered plan and a sustainable infrastructure for a continuum of treatment, intervention, and preventive services to mitigate the development of future behavioral health problems associated with the disaster. LEAs will select best-fit, developmentally appropriate, and evidence-informed prevention and treatment interventions based on the varying student needs, grade levels, and other issues (i.e. readiness, capacity, sustainability) at each school. Interventions will include practices and services to identify acute clinical needs and provide early interventions for those at high risk and/or developing signs of distress. ODMHSAS will facilitate impactful and effective working partnerships between LEAs and CMHCs to identify early indicators and mental health and substance use problems, rapidly complete clinical assessments, and seamlessly establish clinical treatment plans and services. Embrace OK will partner with Oklahoma State University (OSU) to assist the LEAs in developing comprehensive, sustainable Multi-Tiered System of Support (MTSS) plans, conduct local needs assessments, and connect LEAs to state and local training and programming. Embrace LEAs will develop a Multi-Disciplinary Team (MDT) to guide referral and treatment planning and practices with the CMHC and address individual student mental health needs and a planning committee to develop a comprehensive, multi-tiered plan for implementation. Embrace will partner with the University of Oklahoma E-TEAM to evaluate outcomes of individual students and families, community outreach, and teacher professional development to assess the impact of the model and ensure sustainability for Embrace LEAs, teachers, students, families, and communities.

The Behavioral Health Division, Minnesota Department of Human Services, will focus the 2020 Disaster Response Grant Program from SAMHSA on school-aged children and youth (K-12) and their families, who have been impacted by severe flooding on four American Indian reservations and in 51 counties, including in Ramsey County, the seat of Minnesota’s capital, St. Paul. On 06/12/2019, FEMA declared the severe weather incident a natural disaster, FEMA-4442-DR. School-aged children and youth (K-12) and their families (“population of focus”) who have been impacted by this declared natural disaster, FEMA-4442-DR, present with trauma- and stressor-related clinical symptoms, indicating prolonged and severe stress, anxiety, depression, Post-traumatic Stress Disorder (PTSD), and Substance Use Disorder (SUD) which call for specific interventions, including counseling services. In addition, traumatized children and youth show a marked decrease in social functioning and academic performance, further exacerbating their clinical symptoms. The demographic makeup of the population of focus is: 51.5% male and 48.5% female; 36.9% American Indian and Students of Color; 38% are students with a reduced/free school lunch; 16.6% are students in special education; 10% are English language learners; and less than 1% are homeless. The main intervention strategy involves the provision of evidence-based, culturally and linguistically competent, and developmentally appropriate school-based and community-based mental health services across all 51 counties and on four American Indian reservations impacted by the declared natural disaster, FEMA-4442-DR. Mental health services include, but are not limited to, the initial screening and assessment of the client, the referral to a provider, followed by service delivery and counseling. All services provided to the client adhere to the National CLAS Standards. The infrastructure for the implementation of this strategy already exists in form of the school-linked mental health resources and multi-tiered systems of support (MTSS) in Minnesota’s schools, and services related to this declared natural disaster will build on this infrastructure to ensure high efficiency. The respective program goals are: a) train 120 mental health and SUD providers; and b) serve 5000 school-aged children and youth (K-12) and their families in one year.

South Dakota (SD) Disaster Response: 605 STRONG will mobilize trained crisis counselors to conduct community outreach to a projected 2,500 individuals impacted by 2019-weather related disasters, which caused significant damage to public and private infrastructure and continues to impact the farm/rural economy due to lingering financial impacts from those events. Through screening and referral processes, we anticipate providing behavioral health treatment assistance and recovery support services to 1,500 adults and 950 school-aged youth in the 20-county catchment area. Skill development in post-disaster evidence-based practices (EBPs) is central to the state's approach. Clinicians serving adults and families will have access to training in selected EBPs. Recovery support services will also be issued to clients based on need. Specific to the K-12 population, comprehensive school safety planning will be facilitated, in partnership with experienced trainers in the PREPaRE model and in-state subject matter experts at the University of South Dakota, impacting at least 20 school districts and an estimated 300 school-based professionals in the catchment area. Following additional training in mental health crisis interventions post-disaster events, an estimated 40 school-based and partnering community-based mental health professionals will be better equipped to recognize risk factors that predict psychological trauma and provide mental health crisis interventions in school settings to impacted youth. A cohort of up to 20 of these trained professionals will be recruited to become in-state trainers in the model, building a sustainable platform to expand the model statewide. School-based mental health professionals will be supported by a new Behavioral Health Support in Schools program hosted by the University of South Dakota's ECHO Hub. Schools will also have access to mini-grants to support installation of telehealth equipment, which can be leveraged to provide in-school mental health supports via virtual networks. Lastly, the state will develop regionalized plans that pair community-based resources with available state-level services to support rapid mobilization of behavioral health response in disaster situations.

To serve South Carolinians experiencing mental health and substance use crises due to the impact of Hurricane Florence, the South Carolina Department of Mental Health (SCDMH) will implement the Highway to Hope Mobile Response Program (H2H) for adults and children. This mobile care program will integrate mental health and primary care and take services directly to affected rural patients who may not have funds or transportation needed to obtain care. The H2H concept is based on a successful, sustainable mental health mobile program implemented by the SCDMH Charleston-Dorchester Mental Health Center for rurally-located patients. The H2H will offer direct crisis services, assessment, evidenced-based therapies, primary care, nursing care, psychiatric care, and suicide prevention strategies. The H2H will also provide a one stop shop for referrals to additional community-based services, such as employment assistance, care coordination/case management, peer support, homeless/housing assistance, deaf services, and services for non-native English speakers. Both in-person and virtual services will be offered. The H2H will utilize a fleet of nine RVs that will be operated by staff to be hired by three SCDMH outpatient mental health centers. Six RVs will be staffed full-time by an RN, an adult serving mental health professional (MHP), and a child serving MHP and will be designated for patients in the areas most rural communities. Three RVs will be staffed full-time by an RN, a school mental health (SMH) clinician, and an adult clinician and will be designated for patients at local schools not currently offering SCDMH SMH services and their parents. While SCDMH has one of the most robust SMH programs in the nation (currently deploying school mental health clinicians to over 848 schools out of more than 1,200 public schools in the state), the mental and physical well-being of children living in this area are still of concern, as at least 87 have not been in contact with either the local school districts in these catchment areas or the South Carolina Department of Social Services (DSS) since the arrival of COVID-19 in the state in March 2020. Also, there are 88 schools in the affected area that do not currently offer SCDMH SMH services. To monitor progress in reaching and serving citizens affected by the overwhelming devastation of Hurricane Florence, SCDMH will track figures related to patients seen, services rendered, caseloads, diagnoses, improvements to daily living skills, and reductions in the level of care needed. SCDMH projects that during the initial year of implementation, the H2H program will have a mental health caseload of at least 1,440 adults and 360 children across the service area at any given time; new patients/SCDMH readmissions across the service area will total 3,000; daily living skills will increase for 80% of patients, and levels of care will be reduced for 75% of patients. Through the H2H, SCDMH will produce demonstrable and productive outreach and care to some of the states most rural and disenfranchised citizens. SCDMH is confident the H2H will become a model program for other rural areas by providing mental health and primary care in the right place, at the right time.