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Cascadia’s CCBHC Improvement effort will focus on people with co-occurring substance use and mental health disorders (COD), including people with any mental illness, severe mental illness, people who inject drugs (PWID), and those with acute and/or chronic physical health sequelae of COD. For Oregon residents with COD, access to care is particularly difficult. Oregon ranks second highest in addiction rates in the nation and is 50th in access to treatment. Oregon ranks third highest in unmet need for mental health treatment, with only 45 percent of adults with mental illness in Oregon receiving any form of treatment. Oregon experienced a 45 percent increase in unintentional overuse deaths in 2020-2021—a faster pace of increase than the national average. The cost of hospitalizations due to IDU-related SBIs are increasing, recently costing the state more than $200 million during a 1-year period. Although Cascadia currently provides healthcare to individuals in this population of focus, challenges in diagnosing substance use disorder (SUD) in people with co-occurring mental illness limit our ability to provide needed healthcare. Cascadia has identified two goals to guide our organization towards a more comprehensive and sustainable model of integrated healthcare for individuals with complex, co-occurring mental health and substance use issues: • Goal 1: is to improve access to and quality of integrated health services among people with co-occurring mental health and substance use disorders • Goal 2: is to increase organizational capability to implement harm reduction as a care and treatment model across all behavioral health programs. Cascadia intends to apply the goals to all nine core CCBHC services with objectives focused on bolstering screening and assessment for COD, rapid engagement in services and deployment Integrated Treatment Specialists on care teams. In addition to the evidence-based practices currently implemented, Cascadia will use SAMHSA’s Integrated Treatment for Co-Occurring Disorders Evidence Based Practices KIT to inform the improvement of operations. Data collection, analysis, reporting, and quality improvement will occur on an ongoing basis over the four-year grant period, with focused study on 375 participants with COD.

Since 1971, Cornerstone Montgomery (CM) has delivered comprehensive, community- and evidence-based mental health and co-occurring mental health and substance use disorder treatments and supports, specifically targeting individuals who are living in poverty and require severe behavior health interventions. CM is one of five organizations in Maryland to become a Certified Community Behavioral Health Center (CCBHC) and we were one of the original two when we received the 2018 SAMSHA CCBHC expansion grant. The goals of the proposal project, Cornerstone Montgomery Integrated Care Expansion, are to 1) increase CM's service capacity so more people with mental health and substance use disorders in Montgomery County, Maryland can access integrated treatment and 2) improve physical and behavioral health outcomes by implementing care coordination and treatment with medical support staff. This will enable CM to improve access to community-based mental health and substance use disorder treatment and support, to anyone in CM's service area who needs it, regardless of their ability to pay or place of residence. The Cornerstone Montgomery Integrated Care Expansion will promote health equity by reducing health disparities for any individual with a severe and persistent mental health or substance use disorder who seeks care. CM serves up to 3,000 people each year ages 12 and up. Over the 4 years of this grant, we expect to serve an additional 520 individuals. We also expect to improve the health of the people we serve by ensuring that clients are linked with a Primary Care Provider (PCP), receive diabetic screening, and have access to smoking cessation treatment. CM will achieve this by 1) expanding our services to children and adolescents down to age 5, 2) expanding American Society of Addiction Medication (ASAM) Level 1 services including implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT) screening across the agency, 3) improving the coordination of all services to better serve the whole individual by adding primary care services, and 4) improving somatic and psychiatric care by adding nursing staff to our crisis team. CM client demographics are as follows: Race/Ethnicity: 10% Latino/Hispanic, 29% African American, 5% Asian/Pacific Islander, 1% American Indian/Alaskan, 44% White, and 11% Other Sex: 51% Male, 41% Female, 8% Other Age: 1% Aged 17 & under, 33% Aged 18-39, 36% Aged 40-59, 30% Aged 60+ Socioeconomic Status: Over 85% of people served receive benefits/entitlements and/or other public assistance and are very low to low income. Insurance: 4% uninsured, 47% Medicaid, 8% Medicare, 26% MA/MC. 5% Private, 10% Private/MA or MC. CM will apply a diversity, equity, and inclusion lens throughout our policies, procedures, and practices ensuring that underserved populations and communities have a fair and just opportunity to be as healthy as possible. We will continue our trauma informed approach with the goal of being an inclusive, welcoming, and therapeutic home for the people we serve.

Community Health Project, Inc dba Callen-Lorde Community Health Center (Callen-Lorde) is a Federally Qualified Health Center serving over 17,800 patients making 108,801 visits annually at our sites in Brooklyn, the Bronx and Manhattan, New York City. Callen-Lorde is applying for funding in response to SAMHSA’s Funding Opportunity Announcement: Certified Community Behavioral Health Clinics Improvement and Advancement Grants (CCBHC-IA). Callen-Lorde’s population of focus is comprised of low-income lesbian, gay, bisexual, and transgender, and queer (LGBTQ) persons ages 13+ residing and seeking services within the geographic catchment of the borough of Brooklyn in New York City, including homeless youth and adults. The target population is inclusive of LGBTQ persons of all racial and ethnic backgrounds, with an emphasis on reaching Black, Indigenous and Persons of Color, who are overrepresented among low-income communities. With CCBHC-IA funding, Callen-Lorde will provide services for 950 patients over the four year grant period.

As an essential safety-net provider of services, successfully coordinating and delivering mental health (MH) and substance use disorder (SUD) services since 1988, Citizen Advocates (CA) seeks to leverage our success as an existing CCBHC to solidify sustainability and expand services to the population of St. Lawrence County, NY. The largest county geographically in NYS, the population of 107,740 finds greater than 1 in 5 living in poverty, 2x the national average, levels which escalate in children to nearly 1 in 3. While the population is primarily Caucasian at 92%, there is a large reservation community regionally with approximately 3,500 residents CA seeks to ensure are supported. Approximately 1% of NYS veterans are residents of SLC, or 7,739 individuals. Residents experience high rates of adult obesity, tobacco use, diabetes well above the state average, coupled with a high rate of self-inflicted hospitalizations at 5.6 per 10k, and 17.6 per 1,000 among teens. The opioid epidemic has severely impacted this community as well, with ED visits and hospital discharges related to non-fatal opioid use per 1,000 significantly higher in SLC than rest of state, at 393.3 compared to 303.6, respectively. Admissions to SUD treatment for ages 12 and up were 764.4 in SLC compared to NYS. CA is poised to support this population in need, as demonstrated by our provision of evidence-based, trauma-informed services to 1563 people over the course of the CCBHC to date. This grant is critical to solidify sustainability and enable us to serve a total of 2000+ consumers, adding an average of 170 unduplicated new consumers year over year during the 4-year grant cycle. To accomplish this, our goals and strategies include increasing the access and awareness of Medication Assisted Treatment (MAT), with associated benchmark goals such as increasing the number of unique individuals served by MAT by at least 50 year over year, providing at minimum 2 education sessions to PCPs on MAT a year, and 4 community forum trainings on Narcan, capturing at least 50 people. Age-adjusted MAT prescribing rates had increased by 200% during the first grant cycle and expect continued increase by at least 50% each year. Another goal is to increase the use and access to preventative BH and wellness treatments, where during this grant cycle CA will work to additionally partner with local Tribal Leaders to ensure access to crisis services are met, and increase Native American consumers by 10% in year one. Trauma Informed Care staff training program will be implemented, with key principles employed throughout CA's service approach, and at minimum 2 staff trainings will be hosted. These trained staff will inform outreach to marginalized populations, with the goal to mitigate rates of suicidality, especially among teens, and launch a veterans-focused group. Within this framework, an additional 2 staff persons at minimum will be trained on EMDR, an EBP proven to mitigate the response to trauma. Other key program strategies include increasing the provision of Crisis Services by 20% in year one, launching Signs of Suicide, EBP prevention program for school-aged children, and providing special training to the crisis team on suicide prevention.

GLMHC is proposing to open an additional three (3) Urgent Recovery Centers (URC) and three Community Based Structured Crisis Centers (CBSCC) in Washington, Kay, and Delaware County for a total of six crisis units in the GLMHC catchment. The grant funds would be utilized to staff the additional URCs and CBSCCs. The additional crisis units in the above counties would allow for increased crisis coverage in Washington, Delaware, Nowata, and Kay Counties This would decrease transport time for clients coming for crisis services, allow services to be provided in a community familiar to the client, and allow for increased family and social support involvement in services and discharge planning.

PROJECT ABSTRACT SUMMARY PROJECT NAME: FAMILY SERVICE LEAGUE (FSL) CCBHC-IA Family Service League (FSL) proposes to help transform community behavioral health through the provision of comprehensive, trauma-informed, integrated, coordinated, and whole person-centered behavioral health care by expanding the Riverhead CCBHC. With CCBHC-IA funding, FSL endeavors to increase access to community-based MH and SUD treatment, as well as improved and advanced mobile crisis response services (24/7/365) for Suffolk County residents, irrespective of their ability to pay. Population of focus: Adults, families, and veterans with diagnoses of serious mental illness (SMI), substance use disorders (SUD), opioid use disorders (OUD), co-occurring mental health and substance use disorders (COD), and integrated physical and behavioral health disorders, as well as children (5+) and adolescents with serious emotional disturbance (SED). Geographic Catchment Area: Suffolk County, NY which covers 912 square miles. According to the US Census QuickFacts, July 1, 2021 (v2021), the socio-demographic data is as follows: Population estimate: 1,526,344; Language other than English spoken at home by ages 5+: 22.5%; Foreign-born: 15.3%; Veterans: 5%/59K. Age/Gender: 5.4% under 5 years; 21% under 18 years; 18% over 65 years; 51% female; and 49% male. Gender Identity (Adults): Male 48.3%; Female 48.8%; Transgender 0.2%; Other 1%; Missing 1.7%. Sexual Orientation/Adults: Heterosexual 85.4%; Gay/Lesbian 3.6%; Bisexual 5.3%; Other 2.2%; Refused 3.6%. Race/Ethnicity: White, alone (not Hispanic/Latino) - 67%; Black - 9%; Native American - 0.6%; Asian - 4%; and Hispanic/Latino - 20% (2 or more races counted twice). Education: High school graduate+, age 25+ years - 90.4%; Bachelor's degree+, age 25+ years - 35.6%. Health: Under 65 + disability - 6.2%; under 65 & no insurance - 5.4%. Income: Per capita income $42,204; Poverty: 7.3%. Catchment Area/Service Delivery Site: The Riverhead CCBHC is located within a HRSA designated Primary Care and Mental Health (MH) Health Professionals Shortage Area (HPSA, 2019) and a Medically Underserved Area/Population (MUA/P) for Mental Health (MH) in the North & South Forks (HRSA, 2020). Although Riverhead is the projects hub and the locus of Article 31, 32 licensed clinics (mental health and addictive disorder, respectively), all of FSL's health facilities will be utilized, including DASH (Diagnostic, Assessment and Stabilization Hub). Disparities: Riverhead is an urban to rural, impoverished, Agri-area with lower educational attainment, higher rates of chronic medical conditions e.g., diabetes, obesity, and high prevalence rates of SMI. This has translated to increased rates of mental health and substance use emergency department visits (LIHC, CHNA 2019-21). For example, in August 2021, overdose calls to 911 went non-stop for three days until six residents succumbed to fentanyl laced cocaine. (New York Times, August 31, 2021). Goal: Sustain previous CCBHC Expansion Grant gains and reduce reliance on unnecessary high cost, acute-care or criminal justice involvement by providing a continuum of crisis responsive behavioral health care that is coordinated, evidence-based, whole person-centered, trauma-informed, addresses the social determinants of health (SDoH) and needs of the community through the provision of wrap around, culturally, and linguistically appropriate services (CLAS). Goal: Expand Mobile Crisis Services to include a Crisis Intervention Team (CIT) focused on supporting the recovery of high utilizers of crisis response service referrals from law enforcement. These referrals represent individuals who OD on opioids, have a behavioral health disorder, and a historical, as well as disproportionate interface with law enforcement. Over the course of the grant, 700 adults will be served, and 200 children, total 900. Annually 225, 175 adults and 50 children.

Transitions Requiring Active Coordination (TRAC) has two components: case management and primary health services. Case management will assist consumers transition to aftercare services from inpatient psychiatric admissions in order to address their mental health needs and decrease other barriers. Additionally, TRAC will provide access to primary health care located directly in the TRMC behavioral health building to increase access to healthcare. TRMC's target population face significant barriers so the TRAC team will strive to make their lives easier.

Neighborhood Service Organization will utilize CCBHC expansion funding to continue to expand the number of persons whom CCBHC services are provided during the four-year period of the grant. Building on the success and growth experienced to during the first grant period. NSO experts to serve an unduplicated total of 1,970 individuals during the four-year period. As one of the largest providers of behavioral health and homeless services in the geographical catchment area of Wayne County, Michigan, which includes the state's largest and most populous city, Detroit. We will focus CCBHC funding on addressing the needs of high-risk , underserved families, adults, and children , including individuals experiencing homelessness with severe mental illnesses, substance abuse disorder, co-occurring disorder, and severe emotional disturbance. With 1.75 million residents, Wayne County ranks as Michigan's largest and least healthy county ( County Health Rankings, 2018). These high-risk communities face significant barriers related to social determinants of health such as lack of housing, and transportation, experience a high degree of unmet behavioral health need, and inadequate access to quality health care. Wayne County includes 17 mental health provider shortage areas (HPSAs) with an average score of 17, 23 primary care HPSAs with an average score of 20, which is the worst in the state ( health resource service administration). The opioid overdose epidemic is significant and growing in Wayne County which Detroit obesity rate 41 % and diabetes rate at 14.2%. Other indicators include smoking 31%, and lack of personal health provider 20%, all well above state and national rates ( MI BRFSS 2015-2017). Overall, there remains a pressing need for CCBHC services in our community to expand critical mental health, substance abuse, and primary care services to the uninsured, underinsured, and underserved. Goals for the four- year grant period continues and build on the process that Neighborhood Service Organization has achieved in implementing the CCBHC structure. The goals are: 1. Provide comprehensive evidence based trauma informed mental health and substance abuse to adults , families, and provide services to children. 2. Provide multidisciplinary, integrated behavioral health and primary care consistent with the behavioral health home model. 3. Provide timely and convenient access to care through system redesign, telehealth, and same day access. 4. Improve data driven population health management to improve quality care and health outcomes. 5. Expand access to SED services for children. Activities to achieve these goals include a community needs assessment, a plan to expand access to SED waiver services for children, and veterans, identification of additional training opportunities in a variety of evidence-based practices; enhanced data sharing to improve care coordination; expansion of psychiatric telemedicine services; a plan to reduce no-show rate and increase same day intake appointments, and development of a risk stratification model to improve data driven population health management.

As a qualified local government behavioral health authority and SAMHSA provider with 50 years of proven expertise serving the populations of focus in Southeast Mississippi, Singing River Services and DCOs will improve and advance the CCBHC in Region XIV, further expanding access to integrated primary and behavioral healthcare services with comprehensive person and family-centered evidence-based treatment that is trauma-informed and culturally relevant. Name: CCBHC-IA. Populations served: 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; 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 for: 50% Male; 49% Female; 1% Transgender; 20% African American; 2% Hispanic/Latinx; 1% Multiracial; 2% veterans/armed forces; 2% HIV+/Hepatitis+ and 45% COD. Strategies: 1) Improve access to care with expanded services, social marketing and targeted outreach; 2) Enhance crisis response planning with use of standardized screening and quality measures; 3) Use a trauma-informed approach, standardized instruments and symptom rating scales to advance screening, assessment, diagnosis and integrated care; 4) Advance person-centered treatment planning with peer recovery supports, and care coordination; 5) Implement measurement-based care to drive clinical decision-making, inform continuous quality improvement strategies and effective person-centered treatment planning; 6) Create a sustainability plan to ensure financial autonomy; and 7) Ensure CCBHC Accountability Board governance, oversight and planning involves 51% consumer and/or family member involvement during the 4-year project. EBPs: MI, S-BIRT, CBT, TF-CBT, Rx for Change: Clinician-Assisted Tobacco Cessation; EMDR; ACT; Disease Management, Long Acting Injectables and other MAT/MOUD; Peer Support Services; WRAP and Measurement-Based Care. Goals: 1) Plan, develop, implement and sustain CCBHC-IA services increasing access and availability to high-quality integrated care responsive to emerging needs in Region XIV; 2) Support recovery from SMI/SED/SUD/COD challenges delivering comprehensive community-based MH/SUD crisis stabilization, treatment, care coordination and peer recovery-oriented support services 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 consumer needs; 4) Utilize a CQI approach, work to measure and improve the quality of services to inform improvements, evaluation and sustainability; 5) Meaningfully involve consumers and family members in their own care and the broader governance of the CCBHC; 6) Improve integrated care treatment outcomes while addressing 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/physical examination; 6b) 65% will improve mental health functioning; 6c) 65% will reduce substance use; 6d); 6) 65% will improve employment status; 6e) 65% will improve housing stability. Numbers Served: 100 (Year 1) 25 children/adolescents; 75 adults; (Years 2-4); 175 - 150 adults; 25 children/adolescents = 625 total.

Hope, Health, and Balance NOFO: Certified Community Behavioral Health Clinic: Improvement and Advancement Grant Funding Opportunity: SM-22-012 Applicant: Porter-Starke Services Inc. Amount Requested Year 1: $997,783 Porter-Starke Services (PSS) has had a CCBHC in Porter and Starke Counties in Indiana since 2020, with State certification of Starke County in 2016. Porter-Starke Services has maintained full compliance with the CCBHC Compliance Criteria with target populations of seriously mentally ill adults (SMI), seriously emotionally disturbed children and adolescents (SED), substance use disorder (SUD), Opiate Use Disorder (OUD), and those with Co-Occurring mental and substance use disorders (COD) during the current CCBHC grant period. PSS will serve a total additional number of individuals of 1,050 for the project period. PSS directly provides all nine core CCBHC services. PSS will increase services to the LGBTQ+ community who are at higher risk for intimate partner violence and mental health/addictions and are less apt to receive culturally appropriate assessment and treatment. Both Porter and Starke Counties are designated Mental Health Professional Shortage Areas (HRSA 2021). Both counties have high rates of adult smoking (Starke 23%, Porter 21%), adult obesity (both 33%), excessive drinking (Starke 17%, Porter 21%), alcohol impaired deaths (Starke 29%, Porter 18%), and have opioid death rates above the state rate (Starke 42.4, Porter 20.3). Suicides have averaged 28.6 for Porter and 3 for Starke over the past five years. Approximately 188 (42% of the capacity of 449) of jail inmates in Porter County have a mental health and/or substance use diagnosis. Numbers in Starke County are 42 of a jail capacity of 108. Needs assessments indicate the following issues in both counties: access to mental health services, substance use and abuse, and suicide. To improve the CCBHC program, PSS project goals include: 1) decrease inappropriate admissions to jail (N=100) and emergency rooms (N=250), 2) for the target populations, increase rates of screening for mental health, addictions, and social determinants to 75%, 3) increase rates of appropriate medical/laboratory screenings for the target populations to 50%, 4) Improve behavioral health functioning as measured by standardized assessments (CANS and ANSA) in at least one domain for 40% of the target populations, 5) Increase participation in addictions treatment or relapse prevention for those with a diagnosis of SUD, OUD, or COD by 50%, 6) Develop community strategies and recommendations to reduce overdose deaths through active participation and attendance at a minimum of 80% of the meetings of County-based Fatality Review Committees, 7) Increase follow-through with primary medical care and coordination of care between behavioral health and medical care by 50% for the target populations, 8) Decrease avoidable chronic illness by improving scores on medical screenings for 35% of at-risk enrolled individuals, 9) Increase HIV and viral Hepatitis screenings by 50% of those at risk for Hepatitis and/or HIV, 10) Improve identification of LGBTQ+ individuals and provide culturally responsive and appropriate mental health and substance use services to at least 50 LGBTQ+ individuals, and 11) Establish AOT in Porter and Starke Counties, with 6 AOT Court Orders annually.

The Integrity Certified Community Behavioral Health Clinic (CCBHC) will deliver consumer-centered, trauma-informed, and evidence-based behavioral health services to adults with substance use and mental health disorders (SUD) in Essex County, NJ. This includes individuals with mental or substance use disorders, including those with serious mental illness (SMI), opioid use disorder, 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. Given recent increases in drug-related deaths and well-documented health disparities among the Black population, Integrity House will focus its efforts on engaging and providing services to individuals who identify as Black/African American. Integrity will provide the following services directly and through designated collaborating organizations: crisis mental health services; screening, assessment and diagnosis; patient-centered treatment planning; outpatient mental health and substance use services; outpatient primary care services, including screening and monitoring of key health indicators; targeted case management; psychiatric rehabilitation services; peer support and family supports; and intensive, community-based mental health care for members of the armed forces and veterans. Key project objectives include the following: 100% of participants who remain enrolled in treatment at Integrity will receive a comprehensive biopsychosocial assessment within 30 days; 100% of consumers who remain enrolled for 30 days will complete a person-centered treatment plan within 30 days; 100% of consumers who remain enrolled for 30 days will be assessed for common mental health disorders within 30 days; 100% of consumers who remained enrolled for 10 days will be screened for suicide risk within 10 days; 100% of consumers will have access to crisis management and support services; 60% of consumers who remain enrolled for six (6) months will be brought below the high-risk threshold within six (6) months; 50% of consumers in need of withdrawal management services will complete treatment at the Bergen New Bridge Medical Center; 75% of consumers who complete withdrawal management services at the Bergen New Bridge Medical Center will subsequently enroll in treatment at Integrity House; 70% of consumers who enroll in treatment at Integrity House and note this as a goal, will be employed or enrolled in a vocational or educational program within 12 months of enrollment; 100% of consumers who enroll in treatment at Integrity House will have access to medication-assisted treatment (MAT); every 300 consumers who do not report having a primary care provider will have access to one (1) FTE primary care provider; 100% of consumers who remain enrolled for 30 days will be offered HIV screening within 30 days; 100% of consumers who remain enrolled for 30 days will be offered viral hepatitis screening within 30 days; 60% of consumers who remain enrolled for 180 days with a systolic blood pressure of 130 or above will demonstrate a reduction in systolic blood pressure within 180 days; 50% of consumers who remain enrolled for 180 days who report a 3 or 4 on the NOMS tobacco question will demonstrate a reduction in score within 180 days. Integrity will serve 500 individuals each year for four (4) years for a total of 2,000 individuals to be served by 2026.

Bridges Healthcare's Project Engage will extend the reach of CCBHC services to Bridges new service locations in West Haven and Stratford, Connecticut, and implement two new strategies – a Wellness-on-Wheels mobile vehicle program and a dedicated Community Outreach Specialist – in order to make both primary care screenings and mental health/substance use services more accessible to low-access and underserved populations in those areas. Populations served/clinical characteristics. The program's focus is on the residents of West Haven and Stratford (population 107,000), and in particular on health disparities exhibited by their Hispanic, Black, and low income populations (over 28,000, 22,000, and 10,000, respectively). Each of these populations exhibit low access to care for one reason or another, and consequently are at high risk for poor health outcomes. In the case of the Hispanic population, at least four barriers to care result in inadequate medical care and create adverse health outcomes – a high uninsured rate, financial insecurity, a language barrier, and, in many cases, concerns associated with non-citizenship status. Resulting health discrepancies include high rates of HIV for all the target populations, as well as high rates of hypertension, obesity, diabetes, and depression. In the last three years, the drug mortality rate among non-Hispanic Black residents more than doubled and now is highest among any demographic group. Among Hispanic residents, the rate increased by 40%. Financial insecurity is a factor for all. Cost is the reason for not getting needed mental health care cited by nearly half of those with serious mental illness. Proposed strategies and interventions. The purpose of the WOW mobile vehicle program is to provide access to care to clients at locations convenient to them. Target neighborhoods might include groups who are without insurance, homeless, non-English-speaking, or, for other reasons, not comfortable in a traditional office setting. Services will be provided regardless of an individual's citizenship or ability to pay. In Year 1, the vehicle will conduct a variety of health screenings, monitor key health indicators, and identify chronic diseases and comorbid conditions; offer client education, counseling, and support as needed; and provide a warm hand-off to either case management or treatment as needed. Starting in Year 2, we will provide substance use/mental health screening and harm reduction services (e.g., syringe exchange). The Community Engagement Specialist (CES) will proactively identify and engage underserved or difficult-to-engage clients, by establishing informal and formal collaborations and partnerships in the communities we serve, outreach in informal settings like churches, community centers, or in other community settings, and helping clients find resources and services to support and enhance their recovery process. Goals/Objectives. Goal I: To enhance and improve access to behavioral and physical health services through the Wellness-on-Wheels (WOW) program and active Community Engagement efforts. Objectives 1-3: The WOW program serves 100 clients per year, 50% receiving referrals to primary or specialty care, 23% Hispanic and 19% Black. Objective 4: Starting in Year 2, add mental health/addiction screenings for 90% of those served. Objective 5 and 6: The Community Engagement Specialist participates in 40 events and meets with 50 clients per year. Goal II: To increase the number of clients served at our West Haven and Stratford locations. Objectives 1-2: Stratford and West Haven locations serve 100 clients in year one and 125 in subsequent years, 23% Hispanic and 19% Black. Unduplicated Clients Served. We project that the project will serve 250 unduplicated individuals in the first year and 275 for subsequent years. The total number of unduplicated clients during the project period is 1075.

Flushing Hospital Medical Center (FHMC), located in Queens, New York (NY), proposes to continue operation of the Flushing CCBHC in collaboration with 7 partners. The proposed project, Flushing CCBHC-IA, will provide behavioral health services (psychiatric and substance use disorders [SUD]) to any individual who seeks care. A sub-population of focus includes individuals across the lifespan who belong to non-White minority groups. FHMC, with Arms Acres, NYC Health+Hospitals/Elmhurst, Jamaica Hospital Medical Center, NADAP, the NY State Office of Mental Health NY City Field Office for ACT, the United State Department of Veterans Affairs VA NY Harbor Healthcare System, and Transitional Services for NY, proposes the following: Goal 1: Together with partners, continue to provide access to culturally and linguistically competent, community-based mental health and SUD treatment and support, including 24/7 crisis services as a CCBHC. Obj. 1.1: By Month 4, update MOUs, as applicable, with Designated Collaborating Organizations (DCO) to provide services that are not provided by FHMC. Obj. 1.2: Maintain CCBHC certification. Obj. 1.3: At least 500 patients with SMI, CODs, or SUD will receive CCBHC services by the end of the project period. Obj. 1.4: Increase representation of consumers on the Flushing CCBHC Advisory Council by adding three Peer Advocates with lived experience to further improve operations. • Goal 2: Improve treatment compliance and follow-up for patients with SUD treated at the Flushing CCBHC, particularly for those in minority groups. Obj. 1.1: Reduce the percentage of patients that leave the FHMC inpatient Chemical Dependency Unit Against Medical Advice (AMA) from 35% to 25%. Obj. 1.2: At least 70% of SUD patients referred for psychiatric rehabilitation services after detox will receive direct contact from CCBHC staff to confirm initiation of and improve retention in treatment. Obj. 1.3: Maintain Ancillary Withdrawal Management program according to NYS OASAS protocols. Obj. 1.4: Improve validity and reliability of patient demographic data collected in Epic to 100% through a cross-reference of patient surveys and Epic data by the end of the project period. • Goal 3: Improve health outcomes for minority patients with SMI and SUD, and for patients who are at increased risk for diabetes, metabolic syndrome, cardiovascular and respiratory diseases, HIV, and Viral Hepatitis. Obj. 3.1: 100% of patients with SMI who are using antipsychotic medications will be screened for diabetes. Obj. 3.2: 100% of patients will be screened for tobacco use and receive a cessation intervention. Obj. 3.3: Monthly, generate one Epic report each for patients with diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and other COD to provide opportunities for enhanced care to specialized groups of patients. Obj. 3.4: Monthly, generate one Epic report based on race/ethnicity, to provide opportunities for enhanced care to minority patients. • Goal 4: Continue to expand prevention services for patients at risk for OUD; improve access to OUD treatment services and improve treatment outcomes for patients with OUD. Obj. 4.1: 100% of CCBHC health care providers will obtain and maintain a buprenorphine waiver. Obj. 4.2: At least 50% of clinic patients with OUD will receive MAT. This program will serve 200 individuals in Year 1, and 100 individuals annually in Years 2-4, totaling 500 unduplicated individuals over the 4-year budget period.

New funding from the U.S. Substance Abuse and Mental Health Services Administration will help the nonprofit behavioral healthcare provider Community Health Resources (CHR) expand recovery-oriented services for people of all ages in NE CT. Titled CT Hope, this proposal aims to expand a range of services for individuals with serious mental illness (SMI), substance use disorders (SUD), opioid use disorders (OUD), co-occurring disorders (COD) and serious emotional disorders (SED) in the catchment area. The population to be served is individuals with SMI, SUD, OUD, COD, and SED from a 21-town catchment area in Northeastern CT: Marlborough, Windham, Scotland, Canterbury, Plainfield, Sterling, Columbia, Coventry, Mansfield, Chaplin, Hampton, Brooklyn, Killingly, Pomfret, Eastford, Ashford, Willington, Union, Woodstock, Thompson and Putnam. Services will be delivered in existing CHR locations in Putnam, Danielson and Willimantic. Population and demographics of the POF vary in the catchment area, with the smallest town (Union) having less than 1,000 residents, and the largest, Mansfield, having 26,543, with a total population of 175,223 (Census, 2020). Consisting of towns in Tolland and Windham counties, which average 90.3% White, 9.2% Hispanic, 3.6% Black and 3.25% Asian, an outlier is Willimantic, which has 47.8% Hispanic/Latinx. The catchment is 50.2% female, and 16.8% of the population is over age 65. 11.4% of families speak a primary language other than English, with 43.6% of Willimantic's population speaking a primary language other than English. Clinical characteristics of the population showcase a need for increased care for individuals of all ages with SMI, SUD, OUD, COD, and SED. Strategies and interventions include increasing the availability of services to all within the POF. Project goals and measurable objectives include: 1) Provide crisis stabilization services to reduce high-risk behavior that may contribute to suicide, violence, hospitalization, accidental overdose, or grave disability for youth and adults with SMI, SED, SUD, and COD with the following objectives: 1a) Grant funds will establish same-day access to Child Crisis services. Develop collaboration protocols with local police, hospitals, Mobile Crisis, DOC and EDs so 75% of adults are seen within 24 hours of crisis events, 1b) Develop care coordination services to engage 75% of youth and families in outpatient care after hospitalization or crisis assessment, 1c) Create same-/next-day access to MAT for all three FDA-approved medications for OUD for clients, 1d) Add child therapy services to create first-time access to clinic-based BH treatment for children and families who are under-insured, and 1e) Divert people with SMI/SUD from the legal system during crisis episodes. Goal 2: Establish integrated primary and behavioral health care for youth and adults in NE CT with the following objectives: 2a) Use data from standardized evaluations to identify youth at risk for chronic medical and behavioral health conditions and provide EBP Care Coordination, 2b) Provide four annual family health wellness celebration events using CATCH.org curriculum, 2c) Establish inter-agency team-based care and implement EB Measurement-based Care, 2d) Use evidence-based treatment with children and adolescents experiencing depression and anxiety, 2e) Provide intensive, community-based integrated healthcare to members of the Armed Forces/Veterans/their families, 2f) Establish collaboration with the Willimantic Veterans Community Center and 2g) Educate staff on military culture. Goal 3 is to expand access to peer and recovery support resources for consumers with the most serious and complex mental illness and SUD. We will expand use of peer recovery supports to consumers in NE CT and use grant funds to hire a Community Support Specialist. In all, we expect to serve 555 people through the duration of the project, 80 in year one, 150 in years two and three, and 175 in year four.

The One Stop Wellness of the Finger Lakes through of the Finger Lakes Area Counseling and Recovery Agency (FLACRA) is an established and attested CCBHC seeking to engage in the improvement and advancement activities to enhance and expand services at the current sites Yates and Ontario counties. The population(s) of focus for this project is adults, youth and children with a SMI, SED, SUD or COD, primarily low-income/Medicaid recipients. The project will continue, enhance and expand comprehensive CCBHC services directly and through Designated Collaborating Organizations and partnering providers. The key contexts for the goals and objectives are the characteristics of the population(s) of focus, the socio-economic and environmental factors that surround these populations, disparities and inequity brought to light during the pandemic and the resulting trauma and stressors impacting on mental wellness and use of substances, highlighting the need for an integrated, trauma-informed, recovery-oriented and equity focused approach. These services will be enhanced through the establishment and expansion of school-based sites and development evidence-based approaches and practices, such as Applied Behavioral Analysis (ABA) to serve the cohort of children and youth with serious behavioral concerns. The ability to provide off-site services will allow for services to be provided at home or at alternative sites, meeting the needs of students on out-of-school suspension due to their behaviors. The addition of school-based outpatient services is expected to support schools with earlier treatment interventions and linkage to recovery support services being made available before concerns escalate to a level prompting suspension. Partnerships will be fostered for the establishment of pro-social opportunities for youth through Recovery Centers or alternate sites. Further development of staff knowledge and capacity to extract data from the EHR and other systems to make data-driven decisions, identify and improve practice patterns, drive quality and promote an interdisciplinary team approach through information sharing within the EHR will occur. Adherence to SPARS and NOMS requirements and accuracy and identification of disparities will be an area of focus. Additional staff/consultant support will be needed to monitor fidelity to EBP practices. A total of 1,266 unduplicated and 2,961 duplicated (across grant years) individuals will be served by the Project over the 4-year period, Year 1: 593, Year 2: 682, Year 3: 784; Year 4: 902. FLACRA is a NY State Office of Mental Health (OMH) and Office of Addictions Services and Supports (OASAS) licensed provider of a range of services at multiple sites in the Finger Lakes region of NY, including outpatient clinics, crisis overdose response, stabilization, detoxification, residential, recovery support, care management and home and community-based services (HCBS). FLACRA is innovative and the agency lead for Finger Lakes and Southern Tier Behavioral Health Care Collaborative (FLST BHCC/IPA) and an active, founding member of the Finger Lakes IPA (FLIPA). Services will be grounded in person-centered planning approaches, attention to the cultural norms and beliefs, and trauma-informed practices. Evidence-based practices and approaches will be used as appropriate to each individual, including Motivational Interviewing, Cognitive Behavioral Therapy, Rational Emotive Behavior Therapy, Solution Focused Therapy, Matrix Model, Seeking Safety, Living in Balance, ABA and CRAFT. Certified Recovery Peer Advocates (CRPA) and Peer Specialists (NYCPS) will be embedded in outpatient and all in-community and co-located locations providing additional support to individuals and families.

Oaks Integrated Care (Oaks) is seeking to improve and advance its existing CCBHC program in Mercer County, New Jersey to continue serving individuals that present with complex health needs, including individuals with serious mental illness (SMI), substance use disorders (SUD), co-occurring mental and substance disorders (COD), youth and adolescents with serious emotional disturbances (SED), Veterans, pregnant women, indigenous people, and the general population receiving Behavioral Health (BH) treatment in need of coordinated wraparound care. Advancement funding for the Mercer County CCBHC is an opportunity to continue addressing the primary obstacles to treatment access, address gaps in care, and provide centralized and coordinated care. Despite the significant number of agencies that serve the target populations in Mercer County, the lack of adequate coordination results in fractured care that does not treat the holistic needs of individuals and produces poor outcomes of care. The CCBHC is crucial in addressing the primary obstacles to treatment access, gaps in care, and providing centralized and coordinated care. The CCBHC provides behavioral health services treatments to meet the challenges of both serious mental illness and substance abuse disorder. The Mercer County CCBHC expects to serve a total of 2,800 individuals and families over the 4-year project period. The primary areas of advancement that this proposed grant focuses on are: enhancing our psychiatric rehabilitation service offerings through the introduction of Housing and Educational/Vocational Specialists; enhancing capacity to support mobile outreach and partner coordination for individuals utilizing the upcoming 988 initiative; licensing our YPC facility to provide traditional OP MH services with new staff; introducing an EPB Specialist to provide oversight of fidelity monitoring; and working with and training local clergy to assist individuals in need of services. With the funds provided by the US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), the Mercer County CCBHC will continue to provide a single point of contact for those with Behavioral Health issues to obtain behavioral and related physical health services, evaluations, and screenings.

Pesach Tikvah CCBHC will provide a broad range of accessible, affordable, culturally appropriate, bilingual integrated outpatient MH, physical health monitoring, SUD services and care coordination.to serve an unduplicated 800 individuals with CCBHC IA grant funding (200 annually). Services will be delivered in the Williamsburg and Borough Park neighborhoods in Brooklyn, New York to adults with serious mental illness (SMI), substance use disorders (SUD), opioid use disorders (OUD) and co-occurring disorders (COD), as well as children and teens with serious emotional disorders (SED) and their family members. PT will focus on people of Orthodox Jewish/Hasidic (Orthodox) ethnic group to reduce disparities in healthcare access and outcomes. Orthodox typically have large family sizes and struggle with significant disparities in income, healthcare access and outcomes. They experience heightened barriers to accessing care due to high rates of stigma, low socioeconomic status, cultural and language barriers. Grant goals include 1) Expand access to well-coordinated, integrated services by increasing availability and capacity of behavioral health services, integrating substance abuse services, and integrating primary care screening/monitoring; 2) Support recovery by improving the quality of care and clinical outcomes for high-risk individuals by implementing evidence-based integrated mental and SUD treatment and programming, targeted care management (TCM), community-based care and enhanced use of data; and 3) Reduce total cost of care for highest risk clients (reducing usage of inpatient admissions, days in hospital, ED visits) by increasing access to integrated care and using real-time data to drive decision-making and prevent relapse and worsening of symptoms. Strategies/Interventions for Improvement/Advancement include: 1) Improving Mobile Crisis by hiring 2 EMTs affiliated with a local volunteer first responder organization that is a trusted resource in the population of focus. 2) Fully implement, improve and integrate standalone SUD services using EBP for 70 individuals in Year 1, 3) Engage in additional patient motivation and outreach to increase patient participation in primary care screening and 4) Continue to expand TCM program to 100 patients using NYS HH model (Year 4) so it can reach break-even and become sustainable, 6) Continue to expand community based services and peer supports by hiring at least 8 additional psychosocial rehab and/or peer providers, 7) Implement additional supervision and coaching to 75 staff to ensure fidelity to EBPs, 8) Train 75 staff and make goal of supervision to increase use of screening instruments to enable measurement based care (MBP), 9) Leverage PSYCKES and Healthix (NYS/NYC electronic health information exchanges) to improve care transitions, 10) Maintain Outreach Coordinator to update and maintain Care Coordination agreements with at least 20 partners/required care settings, per criteria, 11) Maintain Data Analyst to utilize business intelligence and add Data Dashboards to enable rapid access to data and meaningful use of data, 12) Update and implement a data-driven CQI plan by year 2 of the grant, 13) Increase use of measurement-based care by 25% from baseline through use of screening instruments (i.e. PHQ9, GAD7, AUDITC), 14) Plan and complete a Needs Assessment that will inform further development of programs and supports to fill service gaps in 2024.

BHcare is seeking a CCBHC-IA Grant to reinforce efforts from the CCBHC-Expansion Grant to improve access to care for adults with SMI, SUD, and co-occurring disorders and to implement new Evidence-Based Practices for children and families as well as LGBTQ+ identifying clients based upon assessment of local needs and disparities. BHcare also intends to build our agency capacity for measurement-based care approaches and model program sustainability. BHcare, an existing CCBHC-Expansion grant recipient, is seeking a CCBHC-IA Grant to support and enhance culturally competent and trauma informed recovery services. BHcare has successfully met CCBHC criteria and project goals through evaluation and monitoring and intends to implement additional efforts to support wellness and recovery services for priority populations that have disproportionately struggled with access. BHcare will augment evidence-based practices and integration efforts begun with initial CCBHC implementation efforts. Through the assessment and evaluation of our CCBHC Expansion implementation, as well as national, regional, and community needs assessments, BHcare has identified continuing need for enhanced access to services for all adults with SMI, SUD, and co-occurring disorders, continuing service and access needs for children and families, and the need for culturally responsive and affirming services for the LGBTQ+ community. Specific strategies include: -Admissions Navigators will connect at least 80% of adults and children seeking services to same day access to initial evaluation and 85% to next-day psychiatric evaluation with medication services -Mitigation of COVID access barriers to onsite care through an Infection Preventionist who will track staff COVID cases and ensure compliance with CDC recommendations for 100% of staff who exhibit COVID symptoms and/or test positive for COVID-19 -Training 10 clinicians within 24 months in two children's evidence-based practices (Circle of Security and Triple P), serving at least 20 families and their children in years 2 and 3 -Training 90% of staff within 24 months on the terminology, general identity development, and disparities among LGBTQ+ populations across the lifespan, and best practices for behavioral health service providers -Evaluating changes in attitudes, knowledge, and behaviors in working with LGBTQ+ clients via staff self-assessment (90% target), and perceptions of a welcoming environment (85% target) and staff competency (80% target) via consumer satisfaction surveys for LGBTQ+ identifying individuals -Enhancing measurement-based care, as evidenced by 65% of chart reviews of person-centered recovery plans will reveal that screening and assessment tool scores informed measurable and actionable goals, objectives, and recovery criteria within 24 months BHcare proposes to serve 250 unduplicated individuals in year 1 and 300 individuals each year after for a total of 1150 individuals served in the Lower Naugatuck Valley and Shoreline regions of Connecticut. BHcare's Local Mental Health Authority direct service area comprises 6.6% of Connecticut's total population with the eleven-town region having a total population of 237,026

Samaritan Daytop Village’s (SDV) proposed Enhanced Staten Island (E-SI) Certified Community Behavioral Health Center (CCBHC) to be located in Staten Island, NY will expand and enhance the quality of integrated outpatient mental health, substance use, and primary care services through the provision of culturally competent, person-family centered, evidenced-based treatment services. The SDV proposed Enhanced Staten Island CCHBC will be an extension of the currently operating Staten Island CCBHC. The population of focus (POF) will be primarily low income, minority children, adolescents, adults, and veterans having a SMI, SED, SUD, or COD as they experience elevated rates of trauma, morbidity, visits to the Emergency Department (ED), preventable hospitalizations and mortality. In Year 1, the Enhanced Staten Island CCBHC will provide comprehensive services to 180 people having SMI, SUD, SED, and COD in order to expand the provision of comprehensive CCBHC services to 400 unique POF members over the 4-year period (94 in Yr. 1, 96 in Yr. 2, 120 in Yr. 3, and 90 in Yr. 4). The Enhanced Staten Island CCBHC will expand access to critically needed trauma-informed, person-family centered assessment, treatment planning, comprehensive outpatient mental health and substance use treatment services, outpatient screening and monitoring of primary health indicators, medication administration and monitoring of medication for adverse effects, targeted case management, psychiatric rehabilitation services, social support opportunities, comprehensive recovery and family supports delivered by peer advocates, intensive treatment services for members of the armed services and veterans and the delivery of 24/7 crisis management and intervention services. The Enhanced Staten Island CCBHC will expand the use of evidence-based treatment services by using: Motivational Interviewing, Integrated Dual Diagnosis Treatment, Individual Placement, and Support, Cognitive Behavioral Therapy for anxiety and depression, Screening, Brief Intervention and Referral to Treatment, Cognitive Processing Therapy, and Multidimensional Family Therapy. The Enhanced Staten Island CCBHC has 4 overarching goals/objectives: (1) Decrease mental health symptoms and substance use among the POF by conducting screening, assessments, and treatment planning and providing evidence-based, person/family centered, integrated, outpatient mental health and substance use treatment services; (2) Improve health and decrease health disparities among the POF by providing integrated primary care screening and health monitoring services, increasing health insurance coverage and connection to a primary care physician; (3) Increase social connectedness and employment among the POF by providing psychiatric rehabilitation services (PRS) and social support opportunities; and (4) Decrease preventable Emergency Department visits and hospitalizations by providing access to 24/7 crisis services.

Community Healthlink's (CHL's) ""Improving Access for All to Behavioral Health Treatment that Works: Implementing Evidence-Based Practices with and for Our Diverse Communities"" will provide at least five (5) evidence-based practices to individuals and families with serious mental illness (SMI) or substance use disorders (SUD), including opioid use disorders (OUD); children and adolescents with serious emotional disturbance (SED); and individuals with co-occurring mental health and substance disorders (COD) in Central Massachusetts. The overarching goals of our projects are to increase equitable access to and outcomes from the full range of community behavioral health services using evidence-based practices that are implemented with fidelity and a fit for our diverse communities and to improve the behavioral health and quality of life of the population of focus in Central Massachusetts through this project. More specifically, we have the following 6 goals: 1) Community Healthlink will improve access for all the communities of central Massachusetts access to behavioral health treatment that works; 2) over the four years of the project, implement with fidelity to the model and in a sustainable way, using the best available implementation models, no less than five (5) evidence-based practices, as a member of SAMHSA's Implementation Science Pilot, including Solution-Focused Therapy, Dialectical Behavior Therapy, Motivational Interviewing, Cognitive Behavioral Therapy for Psychosis, and Collaborative Assessment and Management of Suicidality; 3) Using approaches supported by or emerging from Implementation Science, and in partnership with UMass Chan iSPARC and SAMHSA's Implementation Science Pilot, create a culture and environment for access to evidence-based practices; 4) make and document any adaptations to the implemented evidence-based practices for subpopulations participating in the evidence-based practices in collaboration, when able, with model developers and/or trainers, our implementation science partner iSPARC, and the SAMHSA implementation pilot team; 5) individuals participating in evidence-based practices will demonstrate improvement from baseline on health measures by the end of treatment as measured by standardized measures used or recommended for each model, by identified measures used if none are recommended for the model, and/or by health indicators from NOMS; and 6) over four years, improve access by subpopulations by 20% to closer align our service population with our community population as evidenced by the demographic characteristics of participants in the project. Over the course of the entire project period, with SAMHSA funding, we propose to serve 1,450 unduplicated individuals: 250 in year 1, 300 in year 2, 400 in year 3, and 500 in year 4.

WACGC will improve and enhance its current slate of CCBHC services to 505 new clients in the target population - children (0+) with SED and persons of all ages who are at risk of: 1) SMI 2) SUD, 3) COD and 4) individuals with mental health issues also at risk for chronic health conditions in their 6-county catchment area in Western Arkansas. Specific attention will be given to individuals who identify as veteran or minority (race, ethnicity, gender, and economic). WACGC CCBHC serves 6 counties in the western most portion of Arkansas: Crawford, Franklin, Logan, Polk, Scott, and Sebastian. Most of the diverse geographic area is extremely rural with the urbanization concentrated in Fort Smith, the 3rd largest city in Arkansas (Population 88,404; U.S. Census, 2022). All 6 counties are HRSA-designated Medically Underserved Areas and Health Professional Shortage Areas in the primary health and behavioral health domain. The 6-county catchment area is 79% Non-Hispanic White, 11% Hispanic, 4% Non-Hispanic Black / African American, 2% Asian, 2% Native American, and 3% Multiracial. Over 18,000 (7%) veterans are in the catchment area. Across the 6 counties, about 16% of people are in poverty, 14% are experiencing severe housing problems, 24% of children are in poverty and 72% are eligible for free or reduced lunch (County Rankings, 2022). Further, 15% drink alcohol excessively, 19% are food insecure, 26% are in poor to fair health, 17% experience frequent physical duress, 20% experience frequent mental duress, and 13% are uninsured (2022 County Rankings).To meet the continued needs of the clients of the WACGC CCBHC we have identified 4 main goals. Goal 1: Improve and enhance the current slate of services for the target population in the catchment area through targeted behavioral health equity activities including the retention of PCC staff (Y1-4) and the mobile behavioral health unit (Y1-4). We will increase the provision and scope of services offered by WACGC to the target population through PCC, ACT, and mobile crisis teams (Y1-4). Provide additional and on-going EBP training, including trauma informed care, recovery care, targeted case management, SUD treatment to all clinical staff involved in the care of the target population (Y1-4). Goal 2: Expand PCP services at the Fort Smith campus by 10%, to children ages 5+ (Y2-4), to include general wellness exams for clients (Y2-4) and to include assessing for, and treatment of, chronic health conditions for clients 5+ (Y2-4). Goal 3: Increase accessibility for historically underrepresented and under resourced communities through mobile behavioral care coordination and services by using the mobile health unit 3 days per week (Y1-4) in targeted catchment areas to create a continuum of care. Goal 4: Identify and improve underlying social determinants of health (SDOH) for target population through the implementation of assessment of SDOH (Y1-4), risk stratification (Y2-4) and Care Pathways (CPW) (Y2-4). We will implement risk stratification procedures to address identified gaps in SDOH and CPWs to individually address SDOH and create care plans for clients at greatest risk. Finally, we will raise awareness about the social challenges that our clients are facing and action that can be taken to create more supportive environments for health across our catchment area and the State. Finally, to sustain our CCBHC we are implementing more EBPs for the reduction of costly resources, hospitalizations, and jail time for clients using the most behavioral health services. Risk stratification reduces use of resources through optimizing care for individuals based on their risk levels. CPWs optimize resource allocation and are cost-effective as they provide more streamlined approaches to target individual's healthcare needs while eliminating unnecessary procedures.

Upstate Cerebral Palsy (UCP) is one of the largest human service providers in Central New York. UCP’s Community Health and Behavioral Services (CHBS) is a NYS Article 31 Outpatient Mental Health (MH) Clinic and Office of Addiction Support and Services (OASAS) Article 32 Outpatient Substance Use Disorder (SUD) treatment program that serves over 5,200 individuals annually, many of whom have a myriad of medical, behavioral, and social challenges. With this grant, UCP-CHBS will expand and increase access to services in our area for 500 individuals with serious mental illnesses (SMI), serious emotional disturbances (SED), SUD, and co-occurring disorders (COD) over the project period. UCP has identified four goals to guide the CCBHC-IA project over the course of the award period: (1) Increase organizational and regional capacity to Provide Integrated MH/SUD Services, (2) Support individuals who receive MH/SUD services in recovery via comprehensive community-based treatment and supports, (3) Provide improved access to quality care for individuals served by CCBHC, and (4) Meaningfully involve individuals served and family members in their own care and the broader governance of the CCBHC.

The Tropical Texas Behavioral Health (TTBH) CCBHC Improvement and Advancement Program proposes to expand and enhance through process improvement, health outcome improvement and expanded policies and procedures of its behavioral health services to treat adult with Substance Use Disorder (SUD), Primary Care and Co-Occurring Disorders (COD) through the enhancement of the Care Coordination model via the CCBHC Enhancement grant. The target population are individuals identified with Severe and Persistent Mental Illness (SPMI) with major depressive disorder, bipolar disorder, schizophrenia, and other related disorders. TTBH has 55 years in operation as the Local Mental Health Authority (LMHA) for the region in South Texas known as the Rio Grande Valley (RGV) composed of 1.3 million residents with about 90% Hispanic population. TTBH serves residents of Hidalgo, Cameron, and Willacy Counties with poverty levels of 23.9%, 24.4% and 24.7%, respectively, almost double of the state at 13.4% and the U.S. at 11.4%, based on 2020 US Census. HRSA identifies our counties as Medically Underserved Areas and Health Professional Shortage Area for Primary Care, Psychiatrist, Psychologists, Licensed Professional Counselors and Licensed Chemical Dependency Counselors. Additionally, our 2021internal data indicates 24.50% of all clients assessed by TTBH outpatient services were considered low income and/or uninsured. From the TTBH adult population served, 6% identify as LGBT and of individuals experiencing homeless or displacement, 11% reported SUD/COD. Also, TTBH veterans account for 5% of all clients served. TTBH's Care Coordination team will provide services to address behavioral health issues as well as referral to internal clinical services to primary care, substance use disorders, veteran services, assisted outpatient treatment (AOT) and crisis services. TTBH consistently employs evidence-based practices to assess client's needs to determine the most appropriate type of care. TTBH provides clients with support services such as a drop-in center and employment and housing assistance. TTBH clients have the advantage of receiving enhanced integrated services by Care Coordinators in each of our four clinics throughout the RGV. The TTBH CCHBC-IA program will focus on adults with serious mental illness, SUD, COD and chronic medical conditions. Based on research, these conditions are often inter-linked. Based on publication by Harter et.al, 2003, specific mental or substance-use diagnoses place individuals at higher risk for certain general medical conditions. For example, person with anxiety disorders have higher rates of hypertension, cardia and gastrointestinal problems, genitourinary disorders, and migraines. Given this evidence, the intervention services identified for this program include: 1) Improved coordination and access to SUD and COD treatment services for adults; 2) Improved access to routine whole-person integrated care with Primary Care services, and 3) Enhancement of Care Coordination services to improve continuity of care. The program goals and objectives include: 1) Expand access to care coordination activity with integrated behavioral health, primary care, and substance use disorder services; 2) Improve preventative care and screening outcomes related key health indicators; 3) Improve screening outcomes related to client depression; 4) Improve screening outcomes for substance use clients. At least 400 unduplicated clients will be assessed for services and enrolled annually and at least 1600 unduplicated clients will be screened and enrolled over the four-year life of the grant.

St. Joseph's Rehabilitation Center, Inc. (SJRC) CBHC-IA will bring care coordination directly to individuals in rural Northern NY (including remote areas of the Adirondacks) in order to expand access to integrated services, address comprehensive health needs and complex medical issues, and preserve critical services in rural regions with limited resources. SJRC CCBHC-IA anticipates serving 2,925 unduplicated individuals throughout the project period. SJRC CCBHC-IA intends to target populations of focus identified through the prior CCBHC Community Needs Assessment (CNA) including children, families, justice-involved individuals, and LGBTQI+ communities in Essex and Franklin County where access to health care is a crosscutting priority. Based on NYS CHIRS data, in 2018 in Franklin County, there were 59 primary care physicians (PCPs) and 274 mental health (MH) providers per 100,000 population compared to 82 and 289 respectively for NYS as a whole. In Essex County the shortages were even more pronounced, in 2018 there were 42 PCPs and 155 MH providers per 100,000 population. The CCBHC-IA program will allow SJRC to address needs identified through the CCBHC-E FY20 CNA while enriching service delivery. SJRC intends to target populations of focus identified through the CNA including children, families, justice-involved individuals, and LGBTQI+ communities. The CNA also identified the need for integrated comprehensive care that addresses SDOH - Many CCBHC-E consumers indicated SDOH needs (housing instability, food insecurity, unemployment) and feelings of limited social connectedness. The CCBHC-IA funding will support additional partnerships and in-community/embedded care with CBOs serving the identified populations of focus. SJRC intends to expand relationships with county DSS, jails and local hospitals to provide critical behavioral health services to justice-involved individuals with the goal of reducing relapse and recidivism. Relationships with school districts, the Tri-Lakes Prevention Coalition (spearheaded by SJRC), and County DSS will support SJRC’s goals to expand services to children and families, targeting those at-risk of separation. Additionally, SJRC will enhance the intentional outreach to persons who identify as LGBTQI+ through a specialized advisory committee (supported by the CCBHC-IA Project Director).

Project Abstract for New Vista’s Certified Community Behavioral Health Clinic Improvement and Advancement Grant (CCBHC-IA) New Vista is a Community Mental Health Center (CMHC) and CCBHC serving 17 counties in central Kentucky and offering person-centered, trauma-informed, integrated behavioral health, substance use and primary care services. The CCBHC-IA grant provides additional support and allows New Vista to increase service access and address the social determinants of health that negatively impact the clients we serve. New Vista offers a comprehensive array of services, serving urban and rural communities. This project will improve healthcare outcomes for clients across the region. The populations of focus for the proposed programs include individuals who have been most negatively impacted by the pandemic: those with a Serious Mental Illness (SMI), Substance Use Disorder (SUD), Co-Occurring Disorder (COD), and/or Severe Emotional Disturbance (SED) in a 17 county catchment area that our CMHC currently serves in Kentucky. These counties include Anderson, Bourbon, Boyle, Clark, Estill, Fayette, Franklin, Garrard, Harrison, Jessamine, Lincoln, Madison, Mercer, Nicholas, Powell, Scott, and Woodford. Demographically, Kentucky is about 87% white and 10% African American and the poverty rate is 14.9%, with higher rates in rural areas. These demographics align with the population residing in New Vista’s service region. New Vista plans to serve 300 clients in the first year of this grant and increase clients served by 10% each grant year for a total of 1393 clients served. This grant allows New Vista to expand transportation services to the entire 17 county area served, as well as support alternative transportation like rideshare and public transportation. The new staff hired as part of this grant will allow New Vista to increase the number of children served in schools and expand MOUD services in counties where it is not currently available. Adding a peer to the mobile crisis team will allow New Vista to enhance best practices while building sustainability. Improving data collection and referral tracking will strengthen New Vista’s ability to identify and address care gaps in order to eliminate barriers so that all those in need of services can access them. This grant will allow New Vista to provide resources when no other resources exist allowing clients to access needed medication, food, medical aids, or housing necessities to stay connected to care and improve health outcomes. In this way, New Vista will address needs that otherwise would not be addressed.