SAMHSA Grants Dashboard

The Integrated Healthcare +Housing (IH+H) program has been specifically designed to improve the health and healthcare of people with experiences of serious mental illness and homelessness. This project will greatly expand an innovative on-site partnership between a licensed mental health provider, Pathways to Housing PA (PTHPA), and a Federally Qualified Health Center (FQHC) run by Project HOME to provide integrated healthcare within an evidence-based Housing First model. The following interventions will expand the scope and reach of the current pilot integrated care model: 1) Establishment of a IH+H coordination team and a IH+H care team to enhance integrated care coordination, 2) expansion of on-site medical services to 5 days/week, 3) addition of a Guided Care nurse to PTHPA team services to coordinate care integration and care transitions, 4) addition of evidence based practices in tobacco cessation, weight loss, and screening for co-occurring substance use disorders, 5) formalizing and enhancing our partnerships with two other local FQHC's providing specialized primary care services to our population. Selected goals and objectives include: Goal 1: Improve the health of the population. Goal 2: Improve the participant's experience of care. Goal 3: Decrease unnecessary costs. We expect to serve a total of 350 unique individuals: 100 people in year 1, 200 in year 2, 300 in year 3, and 350 in year 4.

LVHN-Muhlenberg Mental Health Clinic (MHC) will embed a primary care practice within its existing clinic as part of a 4-year SAMHSA grant. This integrated clinic to be known as the Whole Health Connection (WHC), will focus on improving health indicators related to chronic medical comorbidities in the Seriously Mentally Ill (SMI): providing mental and primary healthcare in one location. A team of mental health and primary care clinicians, care managers and social supports, will provide advanced mental health services, and primary care using a scheduled, collaborative, and communicative approach. All services provided by the WHC are considered standard of care using the principles and core activities of a Patient Centered Medical Home. The clinic serves 1,600 individuals with 64% reporting at least one major medical comorbid condition and 34% with at least two additional conditions. The service area (Lehigh, Northampton and Carbon counties) has a combined population of more than 800,000 making PA's third most populated region. Minorities comprise more than 54% of Allentown area residents, almost 43% are Hispanic or Latino. Approximately 30% of Allentown area residents live at or below 100% federal poverty level. Approximately 700 clients will be enrolled in the clinic in the first year, growing steadily over 4 years to 1700 patients.

Through this grant proposal, NHS Delaware County and four primary care practices plan to develop a model of person-centered, highly integrated primary and behavioral health care for individuals with serious mental illnesses who receive targeted case management services through the NHS community mental health center located in Delaware County, Pennsylvania. The project is intended to address the complex healthcare needs of adults with serious and persistent mental illnesses (e.g., schizophrenia, bipolar disorder, major depressive disorder, etc.) who also have co-occurring chronic at-risk physical health conditions (e.g. diabetes, cardiovascular disease, etc.). In a pre-project review of charts, over 70% of individuals with serious mental illnesses from the center had a co-morbid chronic physical health condition-diabetes, COPD, cardiovascular disease, asthma, etc.

The Integrated Healthcare +Housing (IH+H) program has been specifically designed to improve the health and healthcare of people with experiences of serious mental illness and homelessness. This project will greatly expand an innovative on-site partnership between a licensed mental health provider, Pathways to Housing PA (PTHPA), and a Federally Qualified Health Center (FQHC) run by Project HOME to provide integrated healthcare within an evidence-based Housing First model. The following interventions will expand the scope and reach of the current pilot integrated care model: 1) Establishment of a IH+H coordination team and a IH+H care team to enhance integrated care coordination, 2) expansion of on-site medical services to 5 days/week, 3) addition of a Guided Care nurse to PTHPA team services to coordinate care integration and care transitions, 4) addition of evidence based practices in tobacco cessation, weight loss, and screening for co-occurring substance use disorders, 5) formalizing and enhancing our partnerships with two other local FQHC's providing specialized primary care services to our population. Selected goals and objectives include: Goal 1: Improve the health of the population. Goal 2: Improve the participant's experience of care. Goal 3: Decrease unnecessary costs. We expect to serve a total of 350 unique individuals: 100 people in year 1, 200 in year 2, 300 in year 3, and 350 in year 4.

LVHN-Muhlenberg Mental Health Clinic (MHC) will embed a primary care practice within its existing clinic as part of a 4-year SAMHSA grant. This integrated clinic to be known as the Whole Health Connection (WHC), will focus on improving health indicators related to chronic medical comorbidities in the Seriously Mentally Ill (SMI): providing mental and primary healthcare in one location. A team of mental health and primary care clinicians, care managers and social supports, will provide advanced mental health services, and primary care using a scheduled, collaborative, and communicative approach. All services provided by the WHC are considered standard of care using the principles and core activities of a Patient Centered Medical Home. The clinic serves 1,600 individuals with 64% reporting at least one major medical comorbid condition and 34% with at least two additional conditions. The service area (Lehigh, Northampton and Carbon counties) has a combined population of more than 800,000 making PA's third most populated region. Minorities comprise more than 54% of Allentown area residents, almost 43% are Hispanic or Latino. Approximately 30% of Allentown area residents live at or below 100% federal poverty level. Approximately 700 clients will be enrolled in the clinic in the first year, growing steadily over 4 years to 1700 patients.

LVHN-Muhlenberg Mental Health Clinic (MHC) will embed a primary care practice within its existing clinic as part of a 4-year SAMHSA grant. This integrated clinic to be known as the Whole Health Connection (WHC), will focus on improving health indicators related to chronic medical comorbidities in the Seriously Mentally Ill (SMI): providing mental and primary healthcare in one location. A team of mental health and primary care clinicians, care managers and social supports, will provide advanced mental health services, and primary care using a scheduled, collaborative, and communicative approach. All services provided by the WHC are considered standard of care using the principles and core activities of a Patient Centered Medical Home. The clinic serves 1,600 individuals with 64% reporting at least one major medical comorbid condition and 34% with at least two additional conditions. The service area (Lehigh, Northampton and Carbon counties) has a combined population of more than 800,000 making PA's third most populated region. Minorities comprise more than 54% of Allentown area residents, almost 43% are Hispanic or Latino. Approximately 30% of Allentown area residents live at or below 100% federal poverty level. Approximately 700 clients will be enrolled in the clinic in the first year, growing steadily over 4 years to 1700 patients.

LVHN-Muhlenberg Mental Health Clinic (MHC) will embed a primary care practice within its existing clinic as part of a 4-year SAMHSA grant. This integrated clinic to be known as the Whole Health Connection (WHC), will focus on improving health indicators related to chronic medical comorbidities in the Seriously Mentally Ill (SMI): providing mental and primary healthcare in one location. A team of mental health and primary care clinicians, care managers and social supports, will provide advanced mental health services, and primary care using a scheduled, collaborative, and communicative approach. All services provided by the WHC are considered standard of care using the principles and core activities of a Patient Centered Medical Home. The clinic serves 1,600 individuals with 64% reporting at least one major medical comorbid condition and 34% with at least two additional conditions. The service area (Lehigh, Northampton and Carbon counties) has a combined population of more than 800,000 making PA's third most populated region. Minorities comprise more than 54% of Allentown area residents, almost 43% are Hispanic or Latino. Approximately 30% of Allentown area residents live at or below 100% federal poverty level. Approximately 700 clients will be enrolled in the clinic in the first year, growing steadily over 4 years to 1700 patients.

The Integrated Healthcare +Housing (IH+H) program has been specifically designed to improve the health and healthcare of people with experiences of serious mental illness and homelessness. This project will greatly expand an innovative on-site partnership between a licensed mental health provider, Pathways to Housing PA (PTHPA), and a Federally Qualified Health Center (FQHC) run by Project HOME to provide integrated healthcare within an evidence-based Housing First model. The following interventions will expand the scope and reach of the current pilot integrated care model: 1) Establishment of a IH+H coordination team and a IH+H care team to enhance integrated care coordination, 2) expansion of on-site medical services to 5 days/week, 3) addition of a Guided Care nurse to PTHPA team services to coordinate care integration and care transitions, 4) addition of evidence based practices in tobacco cessation, weight loss, and screening for co-occurring substance use disorders, 5) formalizing and enhancing our partnerships with two other local FQHC's providing specialized primary care services to our population. Selected goals and objectives include: Goal 1: Improve the health of the population. Goal 2: Improve the participant's experience of care. Goal 3: Decrease unnecessary costs. We expect to serve a total of 350 unique individuals: 100 people in year 1, 200 in year 2, 300 in year 3, and 350 in year 4.

The Integrated Healthcare +Housing (IH+H) program has been specifically designed to improve the health and healthcare of people with experiences of serious mental illness and homelessness. This project will greatly expand an innovative on-site partnership between a licensed mental health provider, Pathways to Housing PA (PTHPA), and a Federally Qualified Health Center (FQHC) run by Project HOME to provide integrated healthcare within an evidence-based Housing First model. The following interventions will expand the scope and reach of the current pilot integrated care model: 1) Establishment of a IH+H coordination team and a IH+H care team to enhance integrated care coordination, 2) expansion of on-site medical services to 5 days/week, 3) addition of a Guided Care nurse to PTHPA team services to coordinate care integration and care transitions, 4) addition of evidence based practices in tobacco cessation, weight loss, and screening for co-occurring substance use disorders, 5) formalizing and enhancing our partnerships with two other local FQHC's providing specialized primary care services to our population. Selected goals and objectives include: Goal 1: Improve the health of the population. Goal 2: Improve the participant's experience of care. Goal 3: Decrease unnecessary costs. We expect to serve a total of 350 unique individuals: 100 people in year 1, 200 in year 2, 300 in year 3, and 350 in year 4.

Through this grant proposal, NHS Delaware County and four primary care practices plan to develop a model of person-centered, highly integrated primary and behavioral health care for individuals with serious mental illnesses who receive targeted case management services through the NHS community mental health center located in Delaware County, Pennsylvania. The project is intended to address the complex healthcare needs of adults with serious and persistent mental illnesses (e.g., schizophrenia, bipolar disorder, major depressive disorder, etc.) who also have co-occurring chronic at-risk physical health conditions (e.g. diabetes, cardiovascular disease, etc.). In a pre-project review of charts, over 70% of individuals with serious mental illnesses from the center had a co-morbid chronic physical health condition-diabetes, COPD, cardiovascular disease, asthma, etc.

Through this grant proposal, NHS Delaware County and four primary care practices plan to develop a model of person-centered, highly integrated primary and behavioral health care for individuals with serious mental illnesses who receive targeted case management services through the NHS community mental health center located in Delaware County, Pennsylvania. The project is intended to address the complex healthcare needs of adults with serious and persistent mental illnesses (e.g., schizophrenia, bipolar disorder, major depressive disorder, etc.) who also have co-occurring chronic at-risk physical health conditions (e.g. diabetes, cardiovascular disease, etc.). In a pre-project review of charts, over 70% of individuals with serious mental illnesses from the center had a co-morbid chronic physical health condition-diabetes, COPD, cardiovascular disease, asthma, etc.

Through this grant proposal, NHS Delaware County and four primary care practices plan to develop a model of person-centered, highly integrated primary and behavioral health care for individuals with serious mental illnesses who receive targeted case management services through the NHS community mental health center located in Delaware County, Pennsylvania. The project is intended to address the complex healthcare needs of adults with serious and persistent mental illnesses (e.g., schizophrenia, bipolar disorder, major depressive disorder, etc.) who also have co-occurring chronic at-risk physical health conditions (e.g. diabetes, cardiovascular disease, etc.). In a pre-project review of charts, over 70% of individuals with serious mental illnesses from the center had a co-morbid chronic physical health condition-diabetes, COPD, cardiovascular disease, asthma, etc.

Primary and Behavioral Health Care Integration at Creative Health Services, Inc., Community Health and Dental Care, Inc., Total Woman Health and Wellness OB/GYN and the Pottstown Memorial Medical Center Emergency Department will serve adults with serious mental illness (SMI) and individuals with co-occurring substance use disorders who have or are at risk for co-morbid primary care conditions and chronic diseases. This collaboration will result in a health home for persons with SMI, those who are least likely to access and benefit from traditional primary care. An integrated primary and behavioral health professional treatment team will provide on-site primary care services and/or medically necessary referrals and linkages to primary care services for approximately 300 annually and 1240 through the lifetime of the project. Evidence based treatments, including screening, brief intervention and referral for treatment (SBIRT), motivational interviewing, peer support, and, for both mental and physical health treatments/supports, action-based efforts to improve overall health, wellness, and community integration will be delivered with heavy reliance on reliable and valid measurement tools, with the consumer as an active member of the care team. Evidence-based wellness and prevention activities including (but not limited to) smoking cessation, nutrition counseling, and physical activity programs will be extensively employed. Overall specific outcomes anticipated by the project include improved specific condition and general health status, increased quality of life, decreased hospitalizations and/or ER utilization for medical and/or psychiatric conditions, improved dentition, increased consumer self-management skills, increased WRAP development, and decreased substance abuse. This project will allow us to partner with individuals diagnosed with severe mental illness toward greater overall health, wellness and recovery.