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Bridgeway Behavioral Health Services (BBHS) is applying for grant funding to expand Assertive Community Treatment (ACT) in Essex County, NJ. The project, titled BBHS Transition Age Youth Assertive Community Treatment (TAY ACT), will provide behavioral health ACT services for underserved and at-risk TAY, age 16-26, experiencing serious mental illness (SMI), severe emotional disturbance (SED), and who may experience co-occurring substance use disorders. TAY ACT intends to serve 62 unduplicated TAY in the first year and at least 103 unduplicated individuals over the five-year grant project with a census of 85 persons receiving services. Essex County is diverse in terms of race, ethnicity, and family income. The largest locale in the county, Newark, has over 35% poverty rate compared to 15.8% of all Essex County. 30% of Newark area households experience at least one severe housing problem (overcrowding, cost, lack of kitchen, lack of plumbing). Bridgeway has selected to serve the Newark urban area, defined as Newark, Irvington, and East Orange, where there are significant disparities along many dimensions between young African Americans and their counterparts from other racial groups. The Essex County Point in Time Count identified 1695 (90.6%) of the total county homeless in Newark alone. 524 were age 24 and under, representing the second largest cohort after chronically homeless. The most prevalent disabling conditions for homeless youth were mental illness and substance abuse. Essex County, NJ is a medically underserved area with limited access to medical and mental health (MH) care. There is one primary care physician for every 1,180 people, one dentist for every 1,050 people, one mental health care provider for every 450 people, and one primary care provider (nurse practitioners, physician assistants, and clinical nurse specialists) for every 1,270 people. With ACT grant funding, BBHS will build on our 50+ years serving these communities by: • Increasing access to ACT Services for TAY to include multidisciplinary team outreach/in-home and in-community BH treatment service provision available 24/7. The ACT psychiatrist will provide psychiatric evaluation and prescription and the RNs will manage the medication delivery system to ensure medication availability when, where, and how the TAY, and family, prefer. The team provides the TAY, and family, support and education for housing security, employment and education, co-occurring substance use disorders, case management, activities of daily living teaching, peer support, crisis intervention, illness management and recovery, wellness recovery action planning, medical health management in coordination with primary health providers, and supportive counseling and therapy. • Improving housing stability for TAY who are homeless or housing insecure. • Expanding educational and vocational opportunities for service recipients through use of readiness assessment and supported employment/supported education EBP interventions. • Improving quality of care for TAY by incorporating evidence-based practices and tools to monitor and treat depressive disorders and co-occurring substance use disorders reducing severity of depression and substance use and improving behavioral health outcomes by reducing rates of Emergency Dept (ED) and hospitalization, substance use, homelessness, and criminal justice system involvement. • Maintaining a well-trained ACT team. The team will be trained to provide high-fidelity ACT services, as measured by the TMACT, beginning with the 5-day ACT training provided by the BBHS ACT Training and Technical Assistance Center. The team will be trained to provide evidence-based practices and trauma informed care. • Improving quality of life and perception of care as determined by TAY, and family, using survey tools and outcome measures.

MCCC is applying for funding under the FY23 Assertive Community Treatment (ACT) program to expand the organization’s current ACT programming for transition-aged youth and adults with serious mental illness (SMI) or serious emotional disturbance (SED). The need for this project and the expansion and maintenance of programming stems from the increase in mental illness that has been seen due to direct impacts of the COVID-19 pandemic, compounded by the rural community and the staffing challenges in finding licensed behavioral health providers that can provide the care residents need at an affordable cost within the community. Objective 1: By the end of the 5-year grant period, at least 70% of consumers will reduce their use of inpatient services (e.g., residential, hospitalization) as a result of SMI or COD. Objective 2: By the end of the 5-year grant period, at least 60% of consumers will reduce their substance use. Objective 3: By the end of the 5-year grant period, at least 65% of consumers will reduce their rate of hospitalization through integrated primary health care offered by MCCC. Objective 4: By the end of the 5-year grant period, at least 40% of consumers who smoke will engage in tobacco cessation services to reduce their past 30-day use. Objective 5: By the end of the 5-year grant period, at least 70% of consumers will reduce the number of days of homelessness. Objective 6: By the end of the 5-year grant period, at least 65% of consumers will increase their use of recovery/peer support services. Objective 7: By the end of the 5-year grant period, at least 60% of consumers will improve their employment status and/or access to disability benefits. Objective 8: By the end of the 5-year grant period, at least 80% of consumers will increase their access to eligible public benefits/health insurance. Objective 9: Expand the organization’s current ACT program, identifying best practices and lessons learned from the organization’s current programming, expanding access to ACT services by at least 330 consumers over the five-year program. Objective 10: Review the organization’s standardized policies and procedures for program admission, service provision, and transitions to a less intensive level of care, as appropriate, reviewing these policies by end of the first year of funding and continuously reviewing over the course of funding and beyond. Objective 11: Expand core ACT services, including comprehensive assessment, crisis, illness management/recovery, individual supportive therapy, SUD treatment, peer/family support, employment programming, assistance with daily living, enhancing support networks, case coordination and psychotropic medication services, increasing the number of active attendees in programming by at least 50 in the first year. Objective 12: Enhance a sustainability plan that will equip providers with the knowledge, skills and resources to address SMI and SED and connect with vulnerable populations to reduce mortality and hospitalizations. Objective 13: MCCC will conduct basic ACT training, utilizing the SAMHSA Using Multimedia to Introduce your EBP tool, across community organizations, providing at least 10 trainings each year of programming. Objective 14: MCCC will conduct more intensive training for MCCC staff including the SAMHSA Training Frontline Staff and Evaluating Your Program sessions, ensuring 100% of applicable staff have access to intensive ACT training to carry out their daily job functions. Objective 15: MCCC will enhance the organization’s sustainability plan that will focus on ensuring all services are billed monthly under Medicaid billing rates, monitor changes across billable services and work to identify state and federal funding to continue the expansion of this program. Number of Unduplicated Individuals to be Served with Award Funds Year 1: 50, Year 2: 70, Year 3: 70, Year 4: 70, Year 5: 70

The Prairie Ridge Integrated Behavioral Healthcare Assertive Community Treatment (ACT) grant will focus on expanding the reach of our existing ACT Team. Prairie Ridge Integrated Behavioral Healthcare (Prairie Ridge) is a nonprofit community-based provider of integrated behavioral healthcare in North Central Iowa. Our catchment area consists of eight, largely rural counties (Cerro Gordo, Floyd, Mitchell, Worth, Winnebago, Kossuth, Hancock, and Franklin) that are significantly underserved. All eight counties are designated by HRSA as Medicaid Mental Health professional shortage areas (HPSAs). In 2020, Prairie Ridge initiated our Medicaid-only Assertive Community Treatment (ACT) program to provide intensive support and treatment services to individuals with Serious Mental Illness (SMI) living within a 25-mile radius of Mason City. However, that 250-mile radius only covers a small portion of our geographically expansive service area. A significant portion of residents living in the eight counties we serve have no access to an ACT team. When individuals with SMI cannot access ACT, they are often more easily lost to behavioral health care and have more frequent hospitalizations. Based on these significant gaps, we are proposing to expand our ACT program's radius to the entirety of the eight counties in our catchment area. Our population of focus is adults and transition-aged consumers 18 and over with SMI or serious emotional disturbance (SED) who live within the entirety of our eight-county service area. In alignment with those needs, Prairie Ridge's goals and measurable objectives include: 1) Expand our current ACT program to serve individuals in a larger geographic area; 2) Support ACT consumers to build recovery capital and address their whole person needs to help them live safely and with stability in their communities of choice; and 3) Improve health and functioning of ACT consumers to decrease their mortality rates. Number to be Served: Through this expansion of our ACT team, we will increase access to 24/7, evidence-based, multidisciplinary team-based services for adults and transition-aged consumers 18 and over with SMI and SED including the following numbers of clients served each year: 40 unduplicated individuals by the end of Year1; 15 additional unduplicated individuals by the end of Year 2 (for a total of 55 individuals being served); 7 additional unduplicated individuals in Year 3 (for a total of 62 individuals served); and 6 additional unduplicated individuals in Years 4 and 5 (for a total of 74 individuals served).

Centerstone’s ACTion in Florida will expand and maintain a recovery-oriented Assertive Community Treatment (ACT) program according to fidelity to improve behavioral health outcomes and support community living for adults (18+) with serious mental illness (SMI). ACTion’s multi-disciplinary team will provide all ACT Core Services for 55 unduplicated focus population adults in Manatee and Sarasota counties, Florida (Y1: 30; Y2-4: 7/yr.; Y5: 4). ACTion’s focus population comprises an anticipated 35,919 (5.2%) catchment area adults with SMI whose demographics and socioeconomics are expected to mirror those of Centerstone’s clients with SMI, with 68% male, 32% female, 83% White, 14% African American, and 8% Hispanic/Latino individuals. An estimated 70% live below poverty, 74% are unemployed, and 49% have less than a high school diploma/GED. ACTion will serve subpopulations from among the area’s estimated 70,372 Veterans; individuals from minority communities, including 113,973 racial/ethnic minority and/or 31,774 LGBT adults; and/or 7,864 criminal justice-involved adults. ACTion will be implemented according to SAMHSA’s ACT Evidence-Based Practices (EBP) Knowledge Informing Transformation (KIT), integrating strategies to ensure culturally competent, trauma informed, and recovery oriented care according to SAMHSA’s TIP 59: Improving Cultural Competence; TIP 57: Trauma-Informed Care in Behavioral Health Services; and the Recovery-Oriented Systems of Care (ROSC) Resource Guide. Additional EBPs will be integrated to complement implementation of core ACT services (e.g., evidence-based supportive therapies will include Cognitive Behavioral Therapy (CBT) and CBT for Psychosis; SUD treatment, Integrated Treatment for Co-Occurring Disorders; support services, Whole Health Action Management; etc.). Key ACTion strategies/interventions include community collaborations, program standards, key plans (i.e., Training, Evaluation, Continuity of Operations/Sustainability), an Advisory Group, outreach/engagement, crisis assessment/intervention, comprehensive assessment, Individual Treatment Plans, SMI treatment/interventions, illness management and recovery, supportive therapy, substance use treatment, recovery/support services (e.g., employment and benefit assistance, activities of daily living, peer support), and case management. ACTion’s 4 goals with measurable objectives include: Goal 1: Expand/maintain an ACT project comprising core services and characteristics, and assemble/train 6.5 FTEs and provide ACT core services, assessment, crisis intervention/treatment, and recovery/support services to 55 adults. Goal 2: Develop capacity to expand/maintain a comprehensive service continuum, and establish an Advisory Group comprising 20% clients/family and other stakeholders; review/refine 5 policies/procedures; expand/maintain Letters of Commitment from 20 stakeholders; conduct outreach to 250; provide basic/intensive ACT training to 8 project staff and ACT model training for 950 agency staff/community providers; develop 2 strategies to address staff turnover/cross training; and identify 2 funding mechanisms for sustainability. Goal 3: Improve client health status/outcomes, and reduce mental health symptomatology among 70% and suicide crisis among 80%; link 100% in need with employment/education; and achieve 50% with low/no problems related to substance use, 80% with no past 30 day homelessness, 80% with no past 30 day hospitalization, 60% with no past 30 day criminal justice involvement, 80% reporting functioning well in daily life, 80% with positive perception of care, at least weekly interaction among 80%, 80% knowing who to call from the ACT team, and social connectedness among 70%. Goal 4: Develop/refine a replicable service model, and report annually on a comprehensive evaluation and biannually on subpopulation disparities; collect/analyze demographic data; and produce 5 materials for dissemination/replication.

Centerstone’s ACTion in Illinois will establish and maintain a recovery-oriented Assertive Community Treatment (ACT) program according to fidelity to improve behavioral health outcomes and support community living for adults with serious mental illness (SMI). ACTion’s multidisciplinary team will provide all ACT Core Services for 60 unduplicated focus population adults in Jersey, Madison, and St. Clair counties, Illinois (Y1: 30; Y2-3: 10/year.; Y4-5: 5/year). ACTion’s focus population comprises an anticipated 18,029 (4.3%) catchment area adults with SMI whose demographics and socioeconomics are expected to mirror those of Centerstone’s clients with SMI, with 39% male, 62% female, 67% White, 14% Black, and 15% Hispanic/Latino individuals. An estimated 97.5% live below poverty and 15% have less than a high school diploma/ GED. ACTion will serve subpopulations from among the area’s adults who are homeless (286); are racial, ethnic, sexual, and gender minorities (e.g., 3,441 LGB and/or 4,120 racial/ethnic minorities); are criminal justice system-involved (1,457); and/or have a co-occurring mental and substance use disorder (10,555). ACTion will be implemented according to SAMHSA’s ACT Evidence-Based Practices (EBP) Knowledge Informing Transformation (KIT), integrating strategies to ensure culturally competent, trauma-informed, and recovery-oriented care according to SAMHSA’s TIP 59: Improving Cultural Competence; TIP 57: Trauma-Informed Care in Behavioral Health Services; and the Recovery-Oriented Systems of Care Resource Guide. Additional EBPs will be integrated to complement implementation of core ACT services (e.g., evidence-based supportive therapies will include Cognitive Behavioral Therapy [CBT] and CBT for Psychosis; SUD treatment, Seeking Safety; support services, Whole Health Action Management; etc.). Key ACTion strategies/interventions include community collaborations, program standards, key plans (i.e., Training, Evaluation, Continuity of Operations/Sustainability), an Advisory Group, outreach/engagement, crisis assessment/intervention, comprehensive assessment, Individual Treatment Plans, SMI treatment/interventions, illness management and recovery, supportive therapy, substance use treatment, recovery/support services (e.g., employment and benefit assistance, activities of daily living, peer support), and case management. ACTion’s 4 goals with measurable objectives include: Goal 1: Establish/maintain an ACT project comprising core services and characteristics, and assemble/train 8 FTEs and provide ACT core services, assessment, crisis intervention/treatment, and recovery/support services to 60 adults. Goal 2: Develop capacity to expand/maintain a comprehensive service continuum, and establish an Advisory Group comprising 20% clients/family and other stakeholders; review/refine 5 policies/procedures; expand/maintain Letters of Commitment from 20 stakeholders; conduct outreach to 500; provide basic/intensive ACT training to 9 project staff and ACT model training for 600 agency staff/community providers; develop 2 strategies to address staff turnover/cross training; and identify 2 funding mechanisms for sustainability. Goal 3: Improve client health status/outcomes, and reduce mental health symptomatology among 70% and suicide crisis among 80%; link 100% in need with employment/education; and achieve 50% with low/no problems related to substance use, 80% with no past 30-day homelessness, 80% with no past 30-day hospitalization, 60% with no past 30 day criminal justice involvement, 80% reporting functioning well in daily life, 80% with positive perception of care, at least weekly interaction among 80%, 80% knowing who to call from the ACT team, and social connectedness among 70%. Goal 4: Develop/refine a replicable service model, and report annually on a comprehensive evaluation and biannually on subpopulation disparities; collect/analyze demographic data; and produce 5 materials for dissemination/replication.

Kanza Mental Health & Guidance Center, Inc. a non-profit community mental health center serving Brown, Doniphan, Jackson, and Nemaha Counties in rural northeast Kansas is establishing an Assertive Community Treatment (ACT) program for adults and transitional-aged youth ages 18 years and older who experience serious mental illness or severe emotional disturbance and who are experiencing or at-risk of hospitalization, homelessness, or incarceration due to complex mental health challenges. ACT is an evidence-based program designed to provide comprehensive community-based services to persons with serious mental illness through a dedicated multidisciplinary treatment team who provides frequent contacts and supports. The project aims to serve 50 persons in its first year, and 100 persons annually thereafter, for a total of 450 people served through the project from September 2023-2028. The project goals include 1) establishing an operational, high-fidelity ACT program to better meet the needs of the population of focus who are at risk of hospitalization, homelessness, or incarceration; 2) improve the quality of life and functioning of individuals served by providing them with recovery-oriented, person-centered care and support they need to live independently in their communities of choice. The objectives include 1) Years 1-5, enroll no less than the number of individuals to be served annually; 2) complete comprehensive assessment and an individualized care plan with each client within 30 days of enrollment to reduce symptom severity by at least 25% within 6 months of enrollment; 3) provide weekly home and community-based contacts within 30 days of enrollment each year to reduce hospitalization, homelessness, and incarceration rates by 50%; 4) reach 80% or higher fidelity in the ACT program by end of Year 2 and maintain through Years 3-5; 5) increase reduction in homelessness, hospitalizations, incarceration, mortality, and substance overdoses compared to the year before program implementation starting in Years 1-2 and reaching at least 50% reduction in Years 3-5; 6) Years 2-5, within 6 months of enrollment, the ACT team will collaborate with at least 5 community partners of each client; 7) Years 2-5, the ACT team will provide recovery- and trauma-informed training to at least 100 community members with the goal of increasing education and awareness of mental health and stigma; 8) Years 2-5, within 12 months of enrollment, support at least 80% of clients in achieving at least one personal goal related to recovery, housing, employment, education, or criminal justice involvement.

The Prestera Assertive Community Treatment Initiative (PACT) establishes a high-fidelity ACT program for transition-aged youth & adults with SMI/SED with the goal of improving behavioral health outcomes in Kanawha & Putnam counties in West Virginia whose population suffers from high opioid overdose death rates, high rates of foster care use & poor social determinants of health. The project will serve 300 clients (50 (Y1), 55 (Y2), 60 (Y3), 65 (Y4), 70 (Y5)). Project goals (interventions/strategies) include: (1) Establish a recovery-oriented ACT program for transition-aged youth and adults with SMI or SED by (A) Developing standardized policies and procedures for program admission, service provision & care transition; (B) Expanding workforce capacity to provide ACT to transitional youth by hiring: Project Director, Therapist, Case Managers, Provider, Nurse, Team Leader & Peer Recovery Support Specialist; (C) Developing an ACT implementation training plan; (D) Implementing the ACT implementation training plan; (E) Implement the Core Services of an ACT Program & (F) Assessing the needs of criminal justice involved transitional youth in the community and the need for associated adaptations to the ACT model. (2) Implement the ACT program to fidelity to ensure high quality services for transition-aged youth and adults with SMI or SED by (A) Hiring an ACT Evaluator to evaluate the program; (B) Developing an evaluation plan that includes adherence to the high fidelity TMACT tool; (C) Implementing the evaluation plan to ensure adherence to the high fidelity TMACT tool; (D) Ensuring that all ACT services are provided in line with organizational policies and procedures via the TMACT high-fidelity tool & (E) Completing a TMACT fidelity assessment review & ACT evaluation annually. (3) Improve behavioral health outcomes for transition-aged youth and adults with SMI or SED by (A) Serving 300 consumers; (B) Empowering consumers to exhibit a statistically significant decrease in substance misuse at 6-month follow-up; (C) Empowering consumers to have statistically significant improvement in NOMs mental health outcomes at 6-month follow-up; (D) Empowering consumers to have statistically significant reduction in psychiatric hospitalization usage at 6-month follow-up; (E) Empowering consumers to have statistically significant improvement in community involvement at 6-month follow-up; (F) Empowering consumers to remain in treatment for at least 6-months throughout the life of the grant; (G) Monitoring disparity group outcomes to ensure equal access/service/outcomes/retention & (H) Establishing culturally competent referral pathways for African American & LGBTQI+ youth. (4) Maintain the ACT program for transition-aged youth and adults with SMI or SED by (A) Forming an ACT Stakeholder Group of key community stakeholders; (B) Developing a continuity of operations and sustainability plan & (C) Working with Medicaid to identify outcomes required to sustain the program.