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The proposed FRUITION System of Care will serve 7 rural underserved Northeastern Mississippi counties (Benton, Chickasaw, Itawamba, Lee, Monroe, Pontotoc and Union) to support the implementation, expansion, and integration of the SOC approach by creating sustainable infrastructure and services. The SOC will improve mental health outcomes for children and youth, birth through age 21, children and youth with serious emotional disturbance and those with early signs and symptoms of serious mental illness, including first episode psychosis and their families by focusing on mental health and related recovery support services, sustainable financing, cross-agency collaboration, EBPs: TF-CBT; Wraparound; Youth-Guided/Family Driven-Peer/Family Supports; FEP; Person Centered Planning; Active Parenting; First Episode of Psychosis: Mental Health First Aid; Youth Mental Health First Aid; QPR; ASIST; Safe Zone-LGBTQ; and enhanced policy and infrastructure with youth-guided and family driven leadership. Project Name: FRUITION System of Care. Populations served: Birth to 21 age; 45% African American; 1% Hispanic; 2% Multi-racial; 1% Native American; 1% Asian and 1% LGBTQ; 85% at, or below poverty level; 10% between (0-5); 90% 6-21 age; 50% child welfare involved. Strategies: FRUITION System of Care seeks to expand trauma-informed, cultural and linguistically appropriate EBPs, supports and policies with a cross-agency approach of coordinated service delivery and integration of mental health services, ensuring effective cross-agency expansion and the provision of mental health and related recovery support services to participants with SED and those with early signs of SMI, including FEP to include an array of non-mental health supports, i.e. vocational counseling, afterschool programming, health-related services, substance abuse prevention, stable housing, independent living skills and advocacy. Each participant will work with a care team that facilitates the identification and implementation of an individualized service plan in partnership with the child/youth, family, natural supports and professional supports to achieve their personal goals. FRUITION System of Care will develop a cross-agency infrastructure through an integrated system of care and ensure national and local evaluation and performance assessments are conducted. Goals: 1) Expand Region 3 Mental Health cross-agency collaboration to serve SED individuals and those with early signs and symptoms of SMI, including FEP; 2) Provide a broad array of accessible and coordinated services/supports; 3) Ensure individualized, managed care; Plan, deliver, and evaluate these services with the full participation of families and youth in a culturally and linguistically sensitive manner; and 4) Facilitate broad-based, sustainable systemic support for the population of focus. Objectives: Annually and over 4-years: 1) 80% of participants will improve diagnosis; 2) 80% of participants improved mental illness symptomatology; 3) 80% of participants will improve employment/education; 4) 80% of participants will reduce criminal justice involvement; 5) 80% of participants will improve stability in housing; 6) 80% of participants will reduce readmission to psychiatric hospitals; 7) 80% of participants will improve social support/social connectedness; and 8) 85% of participants will report a high client perception of care. # served: 100 in Year(s) 1-4, totaling 400 in 4 years.

The MHAASA of Puerto Rico (PR) will implement a System of Care Expansion and Sustainability Grant (SOC-ESG) Project to provide comprehensive mental health (MH) services dor children and youth. from birth through age 21, with SED and their families, and promote infrastructure development to ensure sustainable policies, legislation, financing and the integration of quality evidence-based practices in public and private service systems. The targeted areas will be local jurisdictions of Yauco in the Southern Region and Manati in the Northern MH services for children/youth. Emotional trauma in children increased recently due to severe damages from severe and continuing earthquakes impacting primarily Southern PR. The SOC-ESG will implement Required Activities to achieve the goals and objectives, including outpatient and intensive day treatment, offered in clinic in Yauco, supplemented by home visits, including to foster homes and group homes of children in protective care. Over a 4-year grant period, 350 children/youth with SED or symptoms of SMI and their families will be served. Individual, group and family counseling, with professional consultation and review and management of medications will be offered by a multi-disciplinary staff trained on the SOC and Wraparound EBP's. Arrangements will permit 24-hour/7-day a week emergency services through MHAASA's children's residential MH programs and collaborating partners, as well as intensive home-based services when the child is at imminent risk of out of home placement. The MHAASA has commitments of collaboration from the Special Education Program; Juvenile Justice System and Family Department Protective services, Foster Care and Independent Living Programs for referrals and for assisting youth in transition to MH services as adult. Collaboration through the PUEDO Project will permit other support (vocational education and employment skill development and placement) for youth with early onset of SED/SMI. The intensive wraparound strategies of the SOC-ESG will ensure services and supports sustain family participation, including peer support activities. A Governance Structure Board will be created for decision-making at the policy level, with authority and accountability for the SOC-ESG Project in both local jurisdictions, and multiple partnering agency, and family representation. To ensure that the project is sustainable, adoption by the Health Insurance Administration ("ASES" in Spanish) for treat Medicaid/CHIP eligible children, youth and families will be promoted. Using lessons learned form the pervious projects, the PR SOC-ESG will expand evidence based MH services in the Northern and Southern Regions of PR, and improve MH infrastructures through a Project Governance Body (composed by the project key staff, youth and family members) and two Interagency/Community Committees (ICC), comprised of child serving agencies in the local jurisdictions. One million per year is requested.

Region 6 Behavioral Healthcare proposes to expand and enhance services in the rural Nebraska counties of Cass and Washington, with special focus on school-based mental health services in eight school districts that serve 7,578 birth-21 children/youth. Region 6 System of Care proposes a hybrid approach of infrastructure development and delivery of services to ultimately connect 450 children/youth (birth-21) with severe emotional disturbances (SED) and their families to mental health services (75 in Y1 and 125/year thereafter). The proposal features a school-based single point of access for mental health services for the children/youth with SED and their families. Two districts within this rural geographic catchment have over 40% of students eligible for Free and Reduced Lunch. The area is experiencing a shortage of mental health professionals, fragmented services, and challenging 50-mile drives to services in urban Omaha. Once infrastructure has been established to increase capacity for population access and service use, activities will focus on connecting the population to services/interventions through early identification, so access and use can occur in the least restrictive, most normative environments that are clinically appropriate. Licensed personnel will screen 90% of the geographic catchment's school-age children and refer 100% of those identified through screening to appropriate Multi-Tiered System of Support tiers or community-based services. Continuous accountability and assessment activities will not only ensure sustainability of service integration, but also strengthen the cross-system infrastructure. Capacity for improved mental health outcomes is further boosted via a cadre of 8 Parent Mentors matched with 145 families with children facing SED challenges. In addition, 400 teachers, school personnel/administration, families and other stakeholders will participate in training on evidence-based practices and/or awareness regarding children's behavioral health. Workforce capacity for mental health services will be increased by integrating at least 6 post-doctoral fellows into the rural schools.

The Standing Rock Sioux Tribe (SRST) through their Tribal Substance Abuse Treatment Program, the Wellness Program and the Child Protective Services (CPS) proposes the Systems of Care (SOC) project to improve the mental health outcomes for children and youth, birth through 21 years, with Serious Emotional Disturbances (SED), and their families/primary caregivers, residing on the Standing Rock Indian Reservation, North Dakota by bolstering the current infrastructure to assure tribal-wide access to evidence based assessment, treatment modalities and recovery services. The goals of the SOC project include strengthening program services capacity by hiring the lead family coordinator, parent aides, case managers, licensed supervisory social workers, business manager, and project evaluator; strengthening the capacity of SRST treatment program and tribal systems to increase utilization of culturally relevant evidence-based programs for providing clinical services and supports to address SED; increasing collaborations among Tribal and non-Tribal agencies to increase early access to behavioral health care; preventing the initiation and progression of youth substance abuse (including tobacco use) in the community by implementing promotion and prevention strategies with school age youth in educational settings; and promoting family and community support for individuals with behavioral health issues and their families. To achieve these goals the project team will increase staff capacity through new hires; develop a systematic network of communication channels for improved coordination of care for clients by creating a well written and agreed upon plan between partner agencies and family members; develop guidelines for integration of information technology functions in the behavioral health workflow; develop a High Fidelity Wraparound team; utilize online assessments to increase client reach; compile/revise existing policies and procedures for behavioral health; improve patient tracking systems among providers both on and outside the reservation by improving integrated data capturing capabilities; partner with the North and South Dakota DHS; partner with Sitting Bull College School of Social work to recruit local interns; plan and organize culturally relevant and cross-cultural training of primary care, behavioral health providers, and all departments of Indian Health Service (IHS) serving Standing Rock Tribal members; implement substance use prevention education within the tribal school systems; and promote healthy lifestyle choices, positive communication, personal success and cultural involvement to support strong family relationships. The project is slated to serve fifty unduplicated youth and their families in the first year, and an additional one hundred in each subsequent year for a total of 350 over the life of the project. Additionally, we hope to reach the reservation population of 8,612 through community education and media messages.

The Breakthrough project, located in Orlando, Florida will serve children ages 0-8 exhibiting symptoms of a mental health disorder and located in high-risk zip codes for poverty, crime, child maltreatment, negative health outcomes and domestic violence. The County in conjunction with the Youth Mental Health Commission (YMHC), an eighteen member board, project offers strong positive mental health assessment and interventions utilizing evidence-based practices while strengthening infrastructure for the identified early childhood systems. Project goals are focused on improving the early childhood infrastructure, increasing the capacity of the community to provide early screening and intervention, improving the competency level of early childhood providers and pediatric offices to respond effectively to the behavioral, social and emotional needs of young children, increasing the use of evidence-based practices in mental health treatment centers for young children and their families and increasing the capacity of the Healthy Start Coalition of Orange County (HSCOC) to provide clinical support to parents. Assessment is the foundation of an effective system and the project will utilize screen approximately 200 children per year using the Ages and Stages Questionnaire, Social Emotional, version 2 (ASQ:SE-2) and the Child and Adolescent Needs and Strengths Assessment (CANS) to determine the strengths and needs of the family. Children needing intensive service will be provided with Parent Child Interaction Therapy (PCIT) or Child Parent Psychotherapy (CPP). The project will serve 50 children the first year, 75 children the second year and 100 children the third and fourth year for a combined service to 325 children in this modality. Expectant mothers and young toddlers identified as high-risk for negative outcomes will receive supports via the evidence-based Nurse Family Partnership Home Visiting Program under the Healthy Start Coalition. The infrastructure for early childhood will be expanded with the provision of Early Childhood Mental Health Consultation - Georgetown model to increase the competency of early childhood providers. A web-based referral, assessment, and navigation model will be expanded to families and the community. Additionally trainings to increase expertise on early childhood mental health will be provided throughout the community and will initially focus on clinicians providing mobile crisis services and those within the school system. Orange County seeks to sustain the systemic gains from prior System of Care awards and expand effective assessment, interventions and supports to children and their families.

Advancing a Texas System of Care is a statewide initiative led by the Texas Health and Human Services Commission (HHSC) to strengthen coordination of behavioral health services and supports among child- and youth-serving agencies at both the state and local levels and improve outcomes for children, youth, and families at home, at school, in the community, and throughout life. HHSC will collaborate with the Texas Institute for Excellence in Mental Health at the University of Texas at Austin and other behavioral health stakeholders for implementation of initiative goals at the state and local levels. HHSC will partner with Local Mental Health Authorities Integral Care in Travis County, Emergence Health Network in El Paso County, and Pecan Valley, which serves a six-county region in North Central Texas to develop and implement local systems of care for children and youth 3 to 21 years old with a serious emotional disturbance and their families. This will include developing local governance boards. The proposed services and infrastructure approach will address identified gaps and increase system capacity to support an array of effective and coordinated services and supports focused on school-based mental health. Through this collaborative partnership, each community will enhance existing services with a team to include: Local Project Director, School-Based Interventionist, School-Based Therapist, Youth Peer Support Specialist, and Certified Family Partner. Team members will be embedded within one or more school districts to provide consistent school-based services and supports, as well as coordination with community-based care to meet the goals identified by youth and their families. The team will create a local community-based outreach and engagement plan with strategies and action steps to raise public awareness, reduce stigma, educate community partners on the program and screening procedures, and provide outreach and engagement to children, youth, and families. It is expected that 75 children and youth will be enrolled in services in Year 1, followed by 100 in Year 2, 100 in Year 3, and 100 in Year 4. A total of 375 youth and families will be served through the four-year cooperative agreement. Goals and objectives in the Advancing Texas System of Care initiative will facilitate access to behavioral health services and supports to all eligible children and youth, strengthen state and local system of care leadership, implement policies to improve behavioral health systems, implement strategies to support sustainable infrastructure, and promote youth and family members as leaders in system planning efforts to expand and sustain the system of care approach. The proposed initiative will utilize a quality improvement process to plan and implement activities, evaluate the progress of implementation, and adjust as necessary. As the Children and Youth Behavioral Health Subcommittee (CYBHS) is the oversight body for the Texas System of Care (TxSOC), the TxSOC strategic plan will be reviewed during quarterly CYBHS meetings and input toward project implementation will be provided.

To improve mental health outcomes of children and youth with serious emotional disturbance and their families, Florida proposes to continue implementation of System of Care to two distinct local jurisdictions, St. Lucie and Martin Counties. Both sites have behavioral health disparities. Access to care needs will be addressed through outreach and engagement with traditional and non-traditional services and supports, training and coaching of evidence-based practices (EBPs). A Coordinated Specialty Care program will "catch" youth with early onset of SED or first episode of psychosis between youth and adult mental health systems as well as provide best evidence-based practices for this group. Additionally, one project goal is to increase the use of suicide care EBPs by increasing workforce trainings and providing quantifiable efforts in Zero Suicide care pathway.

Cherokee, Union and Spartanburg counties in South Carolina have a disproportionately high number of children with Severe Emotional Disturbance (SED). This is reflected in higher numbers of hospitalizations to state psychiatric facilities and high rates of abuse and neglect. In many ways, the three identified counties are a microcosm of the entire state. Some areas are very rural with declining populations and other areas growing with increasing economic disparity and the fastest growing Latinx community in the state, and these counties need support with expanding the infrastructure and capacity to provide intensive, community-based services to maintain children, youth and young adults in the least restrictive setting possible. While there have been multiple efforts to meet the social, emotional and behavioral health needs of the community, only recently have there been attempts to look holistically and develop a comprehensive approach to the overwhelming needs which are prevalent in our schools, emergency rooms/hospitals and the mental health clinics. With the leadership of the local United Way, the Mary Black Foundation, and many other community partners, the South Carolina Department of Mental Health and the South Carolina Department of Children's Advocacy are proposing a comprehensive array of services and supports to meet the varied needs of this very diverse community. This proposal envisions a matrix of services and supports, across ages, and across presenting problems, utilizing evidenced- based and promising practices, in a full scale effort to reduce psychiatric hospitalizations, behavioral health emergency room visits, out of home placements and improve the mental health of children and families throughout all three counties. The System of Care will work with the already-existing resources, identify service gaps and implement services and supports to fill those gaps. Specific areas of focus includes South Carolina's youngest, 0-6 year olds, those interfacing or involved with the Child Welfare System, and the Juvenile Justice System, frequent users of the only psychiatric hospital in the area, children in danger of removal from the home schools and community as well as those returning, and the older teens and young adults who need assistance to transition to adulthood. This proposal provides the community with an excellent opportunity to FOCUS (Family Options for Cherokee, Union and Spartanburg) on families with a project that reflects the voice and choice of the children, youth and families while improving the overall health of the communities where they reside.

The Pennsylvania Department of Human Services (DHS), Office of Mental Health and Substance Abuse Services (OMHSAS), seeks to continue to build, expand, and integrate its System of Care (SOC) approach by creating sustainable infrastructure and services to improve the mental health outcomes for children and youth under the age of 21 with or at risk of serious emotional disturbances (SED) and multi-system involvement. Pennsylvania (PA) is a large and diverse state in which human services are the county agencies' responsibility. The state sets policy and provides funding while the county manages behavioral health, child welfare, and juvenile justice services at the local level. The Pennsylvania Care Partnership (the Partnership), which oversees the day-today-System of Care activities statewide, will continue to build on the progress made through previous Substance Abuse and Mental Health Services Administration (SAMHSA) SOC grants at the state and county level. Currently, 44 of PA's 67 counties have developed or are developing and implementing the SOC approach. The Partnership will use the System of Care Expansion and Sustainability grant to add four new counties and continue moving its SOC approach towards wide-scale adoption. The four counties were selected through a competitive process that included youth and family input. Criteria for the selection included geographic location, need, and interest. The new partner counties are Blair, Delaware, Greene, and Lackawanna. These counties have extensive experience working with youth with complex mental health issues, and families. The selected counties have experience developing and implementing other system change efforts and are willing to collaborate across systems, and pilot new service delivery models. Each county has proposed 1-3 possible evidence-based/enhancements to their current county service array and will work with the Partnership to develop and implement these new delivery models. The potential models include the expansion of High Fidelity Wraparound, peer-driven case management, enhanced services for transition-age youth, and enhanced supportive living programming. Combined, these four counties will enroll and serve 65 children and youth in year one, 85 in year two, 85 in year three, and 65 in year four for a total of 300 children and youth. At the state level, the leadership updated their SOC strategic plan and identified several infrastructure challenges, including the ongoing need to align the child-serving systems; family and youth engagement during the pandemic; ongoing challenges to provide culturally and linguistic competent services and supports; and strengthening the roles and responsibilities of the state and county SOC leadership teams. The overall vision for the four years of this grant and beyond is that every youth and family in the Commonwealth will be able to access and navigate a unified network of effective services and supports, which are family and youth-driven, community-based, culturally and linguistically competent, and meets their individual needs.

The TCC System of Care for the Yukon Koyuk Subregion will enhance TCC's culturally appropriate SOC model which directly addresses trauma on individual, family, and community levels and expand the TCC SOC model to other communities by formalizing the TCC processes, systems, and policies. By enhancing and expanding the TCC SOC model, we will prevent and reduce negative impacts of trauma and historical trauma; thereby improving overall community mental health throughout the Yukon Koyukuk sub-region. Our project has four primary goals. First, this project will solidify the TCC SOC model for replication throughout the YK subregion by integrating SOC principles (interagency collaboration, individualized strengths-based, culturally competent, involving family and youth, community-based, and accountable) throughout the TCC SOC policies and practices. We will review policies and systems related to: TCC BH Services, local crisis response team, local advisory council, parent/family activities, youth activities, Whole Family Approach, advisory board, and developing MOAs with partners. Second, we will expand and strengthen community capacity to support youth at risk and their families. We believe that cultural healing will strengthen our region’s capacity to support youth at risk and their families. Cultural healing is examining the effects of historical trauma on the community, families, and our way of life; asking the community what were the traumatic events that occurred here? How did the community respond? What were the resiliency strategies that allowed the community to survive? What is healthy living from an Indigenous Alaska Native approach. Our objectives focus on facilitating cultural healing. Cultural healing is connecting people to their cultural identify through understanding traditions, customs, and practices. Third, we will improve services focused on engaging family and community in high-quality, effective, culturally competent services and supports focuses on providing mechanisms to increase parental/family collaboration to enhance youth outcomes. This goal will address an important gap we identified: most families do not engage in services when their child is receiving mental health services. We believe that when families engage in services with their children the child and family’s outcomes improve. Our objectives describe the impact we believe will occur for youth when we provide Whole Family services and training to parents, family members, and community in terms of youth entering and completing therapy and participating in non-traditional mental health services and supports. Finally, we will enhance, expand, and sustain training to support TCC SOC model in the TCC region to address the overall lack of access to a spectrum of effective community-based services and supports for children and youth at risk or with SED and their families in our SOC communities. Our objectives are focused on training SOC staff to build community capacity, ensure community-based services, and to implement evidence-based practices with consistent fidelity. TCC Behavioral Health Services (BHS) will provide evidence-based and culturally competent mental health services to children with SED that reflect principles of trauma informed care. Our key partners include Tribal Workforce Development Services, Yukon-Koyukuk School District, TCC Infant Learning Program and Head Start, TCC Wellness and Prevention Program, local Elders and youth, State of Alaska Office of Children's Services, and our city and Tribal Councils.

Massachusetts (MA) proposes to use SOC Expansion and Sustainability Funding to enhance access to mental health and co-occurring substance use disorder (SUD) services for young adults ages 16-21 (YA) with a specific focus on developing and expanding culturally responsive systems of care. MA will expand its eight-city network of Young Adult Access Centers to two additional cities. These Centers offer peer support and are low-threshold hubs for engaging YAs in behavioral health services, while offering a welcoming, fun and supportive community. The MA Department of Mental Health (DMH) recognizes that older teens and young adults with Serious Emotional Disturbances (SED) have unique developmental and clinical needs and are often challenging to engage, especially those who face additional challenges of housing insecurity, low educational attainment and unemployment. DMH has worked closely with YA to design, implement and evaluate the effectiveness of Young Adult Access Centers that offer supports that are tailored to YA preferences and needs and responsive to the diverse cultures in the community. In non-COVID times, Access Centers provide a physical location where it is comfortable for YA to drop in. They are staffed by trained peers, who assertively reach out to YA disconnected from services, engage them in wraparound planning, and assist them to access needed MH, SUD, and health treatment, housing, education, and employment. Additionally, DMH recognizes that for many of these YA, rebuilding connections with families and other natural supports can be beneficial to their recovery and wellness. Access Centers strive to engage families with the consent of the YAs. With COVID, Access Centers are using Zoom and phone contact to keep in touch with YAs, who are experiencing a higher degree of distress and suicide and overdose risk. Clinical consultants will support the teams to navigate these challenges. The Commonwealth has chosen two cities, Chelsea and New Bedford to be sites for new Access Centers. Both are cities with high Latinx populations, many of them recent immigrants. Both experience high rates of poverty and high unemployment which have been exacerbated by the COVID pandemic. Chelsea has had the highest rate of COVID infections, and New Bedford has one of the highest rates of opiate related deaths in the state. Youth and young adults who may have already been struggling with unemployment, housing insecurity and food insecurity are also now increasingly isolated. The goal of YA Access Centers is to increase the numbers of YA with MH and co-occurring SUD at high risk who engage in wraparound planning and access child and adult services on their own terms and in service of their own goals. After start-up, the Centers expect to serve 100-150 annually or 400-600 in total. In addition, the Centers will work closely with their respective DMH Area Offices to strengthen the ability of local service systems to better meet the needs of YA. Finally, DMH will work across state agencies to streamline access for young adults seeking MH and SUD treatment, insurance coverage, benefits, housing and employment opportunities.

Through the Expanding and Sustaining Franklin County’s Trauma-Informed System of Care Project, Franklin County will expand trauma-informed home and community-based modalities, including (1) comprehensive, school-based services and supports; (2) intensive in-home clinical services; and (3) crisis support services. The project will serve Franklin County youth throughout the full rural county, where the majority of the population is 82.7% white, 7.1% Native American, and 5.7% black; 26.9% of children live below the poverty level, and the county rate of indicated child abuse and neglect reports is the highest in New York State. Youth served will be aged 2-21 with SED, with a focus on youth in foster care and/or at risk of out-of-home placement. The total number of unduplicated youth to be served is 404 over the four-year period (137 in Year 1; 89 in Year 2; 89 in Year 3; and 89 in Year 4). Additionally, 4-8 project staff will be trained in Functional Family Therapy; 3 care coordinators will be trained in high-fidelity Wraparound; 25 parents will receive the Nurturing Parenting curriculum; and 20 SOC agency members and community partners will receive the non-violent Therapeutic Crisis Intervention train-the-trainer model, and will proceed to train an additional 500 SOC agency members and community partners, school staff, and parents. The goals of the project are to increase evidence-based, trauma-informed school and community-based services to improve youth behavioral functioning, reduce out-of-home care, accelerate permanency. Related to these goals, objectives are for 70% of youth to show improvement in behavioral health functioning; for 90% of youth to remain in their homes without requiring out-of-home placement; and for 75% of youth in foster care to achieve permanency.