Grants Dashboard

Project Name: Kanza Certified Community Behavioral Health Clinic Planning, Development, and Implementation Grant (CCBHC-DPI) Project Summary: Kanza Mental Health & Guidance Center, Inc. is a Community Mental Health Center (CMHC) in northeastern Kansas that proposes to establish a Certified Community Behavioral Health Clinic (CCBHC). This will enable the agency to expand and enhance access to comprehensive, coordinated behavioral health services for individuals with serious mental illness (SMI), serious emotional disturbance (SED), substance use disorder (SUD), and co-occurring disorders (COD) in Brown, Doniphan, Jackson, and Nemaha Counties. Kanza seeks to address health disparities faced by individuals who are uninsured and under-insured and by three populations of focus: American Indians, veterans, and individuals experiencing homelessness. As a licensed CMHC and the only crisis resource in the four-county area available 24/7, Kanza provides many of the required CCBHC services, though there is a need to expand these to more individuals and provide whole-person integrated and coordinated care. Kanza proposes to enhance existing services and add additional services to meet CCBHC criteria by focusing on organization capacity, including hiring additional staff, providing staff training in cultural competency and evidence-based practices (EBPs) relevant to the target populations, and implementing a new electronic health record (EHR) system, plus expanding its mobile crisis services and SUD services. Population to Be Served: Kanza serves individuals with SMI, SED, SUD, and COD through four office locations in Brown, Doniphan, Jackson, and Nemaha Counties in Kansas. All four federally-recognized American Indian tribes in Kansas are located in the region. Brown and Jackson Counties, in particular, have large American Indian populations (9.5% and 8.9%, respectively). Approximately 2,766 veterans live in the region, representing 1.7% of the state’s total veteran population. Additionally, the rates of residents under the age of 65 without health insurance in three of the four counties exceed the national average. Through this project, Kanza will emphasize reaching and serving individuals who experience significant barriers to accessing the services they need; this includes those who are uninsured or under-insured, an increasing number of the agency’s clients that are from low-income households and experiencing homelessness, as well as American Indians and veterans. Strategies/Interventions: Grant funds will support the expansion of services offered and the use of EBPs, such as Assertive Community Treatment (ACT), Medication-Assisted Treatment (MAT), and Individual Placement and Support (IPS). Most significantly, Kanza will enhance its existing mobile crisis services, increasing access to individuals regardless of their location, and SUD services, providing assessment and treatment to fit individual needs. Kanza will build organizational capacity through additional full-time and contracted part-time personnel, targeted staff training, and a new EHR that will improve data collection and patient outcome tracking. Goals and Objectives: The goals of this project are to increase organizational capacity to deliver and track high-quality CCBHC services; to increase CCBHC service penetration into and provide high-quality services for the targeted populations; and to improve access to care through enhanced mobile crisis services and SUD services to individuals in the region. Kanza proposes to serve a total of 1,575 unduplicated individuals throughout the four-year period of performance.

FPHSA operates five clinics across southeast Louisiana, serving our catchment area of Livingston, St. Helena, St. Tammany, Tangipahoa, and Washington parishes. This grant will allow us to improve services for our population of focus: adults, youth, and children with SMI, SED, SUD, or COD, as well as to address disparities experienced by individuals who identify as Hispanic or Latino or LGBTQ+ and rural residents of our service area. Communities in our service area are still reeling from the COVID-19 pandemic, which exacerbated existing needs and demand for behavioral health services across a largely rural region. Three recent community health needs assessments identified mental health, substance use and addiction, and trauma as priority issues within the service area. The reports noted that significant barriers—including a severe lack of substance use services (particularly for youth), long wait times, lack of care coordination, racism, and stigma—make accessing the limited services available even more difficult. This project will allow us to address significant behavioral health disparities and gaps in access to services, care coordination, and substance use treatment services in the communities we serve. All five of our clinics, located centrally in the service area, will support these expanded services, bringing high-quality, needed services to historically underserved areas of our region. The goals of our project include (1) conducting a behavioral health-focused needs assessment to identify priorities and opportunities for improvement; (2) develop our health information technology to support care coordination and continuous quality improvement through improved data capture, reporting, and analyses; (3) improve behavioral and physical health outcomes for persons served through improved case management and care coordination to address individuals’ medical needs and their social determinants of health; (4) improve access to care by expanding clinic hours; (5) increasing access to services for children, youth, and their families by hiring additional providers and expanding substance use services for youth; (6) increase access to and engagement in medication-assisted treatment (MAT) by training additional prescribers and reducing stigma among community healthcare providers; and (7) reduce disparities in behavioral health service access, utilization, perceptions of care, and outcomes through outreach to priority populations and offering culturally competent care. We will serve 5,000 individuals in Year 1, 5,250 in Year 2, 5,500 in Year 3, and 5,750 in Year 4. Assuming that some individuals will engage in services over multiple grant years, we anticipate serving 9,000 unduplicated individuals over the full grant period.

The Start Certified Community Behavioral Health Clinic (CCBHC) will provide comprehensive, coordinated, person- and family-centered behavioral health care to children, youth, and families in need of support recovery for serious mental illness (SMI); substance use disorder (SUD) including opioid use; serious emotional disturbance (SED); cooccurring mental and substance disorders (COD); and to individuals experiencing a mental health or substance use-related crisis regardless of an individual’s place of residence, ability to pay, or age. The CCBHC will address the behavioral health disparities of specific populations including Veterans and people experiencing homelessness. The CCBHC will serve Assumption, Lafourche, St. Charles, St. James, St. John the Baptist, St. Mary, and Terrebonne parishes in the Bayou Region of Louisiana. The total population of the seven-parish service area is 469,438 and 2.2% identify as American Indian/Native Alaskan; 0.9% Asian; 23.7% Black or African American; 6.3% Hispanic or Latino; 55.2% White; and 4.9% two or more races. There are 63,394 individuals living below the poverty line in the service area and 22,998 are uninsured. The service area is home to 17,623 Veterans. There are 4,731 homeless individuals in the service area. Start will enhance and expand outreach, screening, assessment, early intervention, comprehensive treatment, care coordination, and recovery support services for all individuals in the service area. The following table identifies the program goals and measurable objectives. Goal 1: Increase access to and availability of behavioral health and substance use services for individuals across the lifespan for the population of focus. Objective 1.1: By month 3, hire project staff to enhance behavioral health and substance use crisis services; screening & assessment; treatment; outpatient primary care screening; outpatient mental health and substance use services; case management; rehabilitation & recovery supports; and peer support. Objective 1.2: By month 5, complete staff training on using EBPs that address the needs of the individuals the CCBHC serves; follow the staff training plan for annual refresher training throughout the funding period. Goal 2: Support recovery from mental health and substance use disorder challenges via comprehensive community-based mental and substance use disorder treatment and supports. Objective 2.1: Provide evidence-based treatment & comprehensive supportive services for 250 individuals in Year 1; 400 in Years 2; 700 in Year 3; and 1,000 in Year 4 for a total of at least 2,350 individuals. Objective 2.2: By month 6, ensure that a mental health screening is embedded into the FQHC primary care visit. Goal 3: Continually work to measure and improve the quality of services. Objective 3.1:By month 2, develop a CCBHC-wide data-driven Continuous Quality Improvement (QCI) plan for clinical services and clinical management; implemented beginning month 4. Objective 3.2: Develop a Data Collection Plan & partnership logic model by month 3. Begin collecting and tracking encounter, outcome, and quality data by month 4. Goal 4; Meaningfully involve people with lived experience of mental and substance use conditions, individuals who have received/are receiving services from the clinic, and family members in their own care and the broader governance of the CCBHC. Objective 4.1: Complete a community needs assessment by month 6 and a follow-up by month 42 that will integrate input from consumers and family members into the assessment using feedback from client surveys and the CCBHC Board. Objective 4.2: Conduct recruitment of CCBHC Board members following CCBHC Certification Criteria 6.B: Governance Option 1 beginning month 1. Commence quarterly CCBHC Board meetings month 6. Objective 4.3: Develop a comprehensive, person-centered Individualized Treatment Plan (ITP) that includes needs, strengths, abilities, preferences, and goals, expressed.

LUK Crisis Center, Inc. (LUK) proposes to develop a Certified Community Behavioral Health Clinic (CCBHC), serving residents of the 27 communities that comprise the North Central Massachusetts region. LUK’s CCBHC will serve individuals throughout the lifespan in home-, clinic-, community-, and school-based settings. Services will be provided to children and youth who have a serious emotional disturbance (SED), adults with a serious mental illness (SMI), individuals with a substance use disorder (SUD), individuals with co-occurring mental health and substance use disorders (CODs), and people experiencing a mental health or substance use crisis, regardless of ability to pay. LUK’s CCBHC will provide rapid assessment and triage into behavioral health services and targeted case management as needed. LUK’s CCBHC will utilize evidence-based models such as High Fidelity Wraparound and Motivational Interviewing. With our Designated Collaborating Organization (DCO), Community Health Connections, we will achieve the goals of the project, which include development of the infrastructure to support the CCBHC, completing required activities to achieve CCBHC status, and supporting consumers’ recovery from mental illness and/or substance use disorders. The number of unduplicated individuals to be served each year is as follows: Year 1 – 250, Year 2 – 350, Year 3 – 400, Year 4 – 500, for a total of 1,500 CCBHC consumers over the four years of funding.

Maine Behavioral Healthcare (MBH) is proposing to plan, develop, and implement (PDI) a Certified Community Behavioral Health Clinic (CCBHC) in Midcoast Maine (ME) encompassing Waldo and Knox Counties, which include the island communities of Islesboro, Matinicus, Monhegan, North Haven, and Vinalhaven (the Islands). MBH has established clinics in the Midcoast area: one in Rockland (Knox County) and one in Belfast (Waldo County). Each works closely with Coastal Healthcare Alliance (Waldo County General Hospital and Pen Bay Medical Center) the local hospital system and members of MaineHealth. These two clinics, collectively led by a leadership team comprised of a Regional Medical Director, Practice Manager, and Clinical Director, will form the Midcoast CCBHC. The population of focus (POF) for the Midcoast CCBHC will include those that are rural, low income or living in poverty, seniors, youth, pregnant or parenting, living with disabilities, and housing insecure. The disparities the CCBHC project will impact are access; health inequities based on race, poverty especially in the coastal fishing community, ethnicity, or culture; stigma; and the lack of availability of a continuum (screening through ongoing recovery) of integrated mental health, substance use disorder, and primary care services and supports. The Midcoast CCBHC will serve 625 over the lifetime of the project (Y1=75, Y2=150, Y3=200, Y4-200). MBH has a history of implementing recovery-oriented, trauma-informed, and equity-based programs, practices, and policies that are the primary means for improving behavioral health. MBH currently provides, directly or through its DCO partner (Sweetser), many of the core CCBHC services. MBH under the guidance of the Project Director (PD) and the Clinical Leadership of the Regional Medical Director and Clinical Director, will implement infrastructure activities to address the operational changes needed to meet the certification criteria and improve the quality and effectiveness of services including strategies to address behavioral health workforce shortages and improve access to care by implementing a two-year advanced clinical training program. Goals for the funding period: 1) Increase access and availability to behavioral health services, 2) Improve integration of SUD, MH, and COD programming, and 3) Continually work to measure and improve the quality of services. Objectives include recruitment, hiring, training, and retaining staff positions; implementing team-based care; expanding the existing Hub and Spoke model for SUD to include all behavioral health populations, improving protocols and processes; and developing and implementing systems to track clinical and programmatic data including referral, services, workflow, and outcomes.

Improving Access to Care in Southern Maine Sweetser seeks to provide increased access to all CCBHC core services for individuals in central and western York County, Maine through its Sanford, Maine clinic site. Sweetser aims to decrease the prevalence of hopelessness and consideration of suicide, particularly among youth, as well as increase the screening and access to evidence-based treatment for substance misuse in all ages. Sweetser offers a statewide network of comprehensive mental and behavioral health, development, and education services to children, adults, families, and military. Through this project, Sweetser intends to increase access to quality services in York County, Maine. Sweetser intends to serve a total of 750 individuals throughout four years; serving 150 individuals in Year One, and 200 individuals in each of the subsequent three years. Through this project, Sweetser aims to decrease the prevalence of youth hopelessness and consideration of suicide by increasing risk screening and access to evidence-based treatments. Sweetser also aims to increase screening and access to evidence-based treatment for substance misuse in youth and adults. Sweetser aims to expand access, availability, and quality of services through increased provider resources, enhanced trainings of evidence based and evidence informed practices, and ongoing evaluations.

Honor Community Health (HCH) is a Federally Qualified Health Center (FQHC) that provides comprehensive medical, mental health, oral health, enabling services, specialty care, reproductive health (Title X), and HIV/AIDS services (Ryan White); it is also a designated Health Care for the Homeless FQHC that provides comprehensive care to homeless populations while combating their unique barriers to care. The proposed project will serve the geographic catchment area of Oakland County, Michigan, situated in the southeast region of the state, with a focus on the city of Pontiac, an area in the county with disproportionate rates of poverty that contribute to access barriers to behavioral health care. Key services that HCH will implement include: expanding capacity to provide comprehensive, coordinated team-based mental health and SUD treatment; expanding targeted case management, with a focus on the homeless population; expanding the array of psychiatric rehabilitation services available to patients to help them remain in community settings; expand peer services; and establish high-quality mental health care for the veteran population. After four years, Honor Community Health will serve 6,000 unique patients. CCBHC funding will allow Honor Community Health to achieve three goals: • Goal I: To Increase engagement in behavioral and physical health services in the community by improving access to care to reduce health disparities within our target population. • Goal II: To increase opportunity of care coordination with partners by increasing screening activities to ensure access to maintain mental and physical health. • Goal III: Increase access to rehabilitation services and supports that improve ability to achieve and maintain MH and SUD recovery, including psychiatric rehabilitation and peer supports. Honor Community Health is well-positioned to establish a fully compliant CCBHC program within one year of award and already provides a significant array of mental health and substance use treatment services, support services, and integrated primary care services.

ABSTRACT Project Name: Integrated Hope and Healing Certified Community Behavioral Health Clinic (CCBHC) Project Summary: The Integrated Hope and Healing CCBHC is a neighborhood-centric mobile and physical clinic in 2 westside neighborhoods and 3 eastside neighborhoods, using harm reduction, evidence-based practices, innovative recovery supports, and warm transfers to Designated Collaborating Organizations, to measurably reduce health disparities, while increasing positive social determinants of health. Population To Be Served (Demographics And Clinical Characteristics): BFDI targeted western zip codes are 48228 and 48235, and the eastern zip codes are 48205, 48224, and 48234. The targeted zip codes have 12-20% of Detroiter’s who have not accessed health insurance and/or access to services; 90% of the target population is Black, and 8% Latino; 30% of residents are below the federal poverty level, with 47% of residents being 50% below poverty standards; and 17% of work-age residents are unemployed. Furthermore, 7% of the population identify as LGBTQIA2+. Selected zip codes are negatively impacted by lack of transportation to access care. Strategies And Interventions: Evidence-Based Screening and Assessment Tools. Project will use assessment tools deemed effective with the target population: UNCOPE, Drug and Alcohol Problem (DAP) Quick Screen, Patient Health Questionnaire (PHQ), Generalized Anxiety Disorder-7 (GAD-7), Child and Adolescent Functioning Assessment Scale (CAFAS), Mental Illness and Addiction Screening (MIDAS), and LOCUS (Level of Care Utilization System), the Columbia-Suicide Severity Rating Scale, the Drug Abuse Screening Tool, and the Michigan Alcohol Screening Test. Evidence-Based Interventions. Evidence-based clinical interventions include, but are not limited to: Cognitive Behavioral Therapy (CBT), Trauma – Focused CBT, Parent Management Training – Oregon, Parenting Through Change, Wraparound, contingency management, Restorative Practices, and motivational interviewing, Measurement-based Care screens and assessments. Project Goals and Measurable Objectives: Goal 1: Decrease behavioral health disparities through accessible, high quality, community-connected continuums of care to mobility-limited residents in 5 Detroit neighborhoods. Objectives: (1) 1500 behavioral health and physical health screenings and recovery plans as evidenced by completed screenings and plans in the BFDI Electronic Health Record. (2) 80% of uninsured individuals will acquire health insurance, as evidenced by results of their health screens, completed consents for ongoing services, and post-service access questionnaire. (3) 75% of individuals not receiving treatment services and screen positive for behavioral health will consent to services. Goal 2: Improve health outcomes within 5 resource-limited neighborhoods. Objectives: (1) Establish medical and behavioral health homes for underserved residents. (2) 70% of individuals in active treatment will measurably increase their level of functioning. Number Of People Served Annually And During Project Duration: 375 annually; 1500 total.

Van Buren Community Mental Health Certified Community Behavioral Health Clinic will provide CCBHC services to adults with Serious Mental Illness, children with Serious Emotional Disturbance, individuals with Substance Use Disorders, and adults and children with mild-to-moderate mental health conditions who may be at risk for more serious behavioral health conditions. Grant funds will be used to: Provide all CCBHC services; enhance infrastructure and capacity for improved care coordination for those at risk for poor health outcomes; Increase provision of evidence-based practices due to high rates of PTSD, Depression, Anxiety, and suicide; and Increase screening and follow-up for specific health risk behaviors including alcohol and tobacco. Under this grant, VBCMH proposes to serve 585 individuals with grant funds over the next 4 years, with additional broad community and population impacts (Year 1=180, Year 2=125, Year 3=135, Year 4=145). Van Buren County is a rural county in southwest Michigan with a population of 75,692. Per the 2020 US Census population estimates, over 13% of people in the county live in poverty. The racial and ethnic composition of the county is 81.2% white, non-Hispanic, 3.8 % Black or African American, 1.2% American Indian or Alaskan Native and less than 1% Asian, Native Hawaiian or Other Pacific Islander. 2.8% of the population identifies as two or more races. 12.3% of the county population is Hispanic. Of the 2,500 individuals served by VBCMH in FY22, 49% were female, 48% were male. 2% identified with one of the following: agender, androgynous, bigender, questioning, fluid, non-binary, or transgender. 8.2% of VBCMH service recipients identify as gay, lesbian, bisexual or another sexual orientation other than heterosexual. 23.1% of county residents are under the age of 18 and 18.7% are over the age of 65. In FY22, 26.9% of individuals served by VBCMH were under the age of 18 and 9.4% were aged 65 and older. 80% of the individuals served by VBCMH are at or below the poverty line. Based on internal data, while VBCMH has seen an increase in the number of veterans served each year, (up 61% from FY20 to FY22), This represents only a small percentage of the Van Buren County's veteran population (6% of the civilian population 18+). Specific program objectives include: 1) Increase provision of TF-CBT by 20% in year 1 and an additional 10% each subsequent year 2) Increase number of staff trained in Seeking Safety and Motivational Interviewing 3) Increase screening and follow up for specific health risk behaviors including alcohol (50% in year one, increasing by 5% each subsequent year) and tobacco use (60% in year 1, increasing by 10% each subsequent year), 4) Implementation of an EMR module to track external referrals to providers (50% year 1, increasing by 5% each subsequent year, 5) Increase percentage of individuals connected to a primary care provider (40% in year 1, increasing by 5% each subsequent year, and 6) Increase screening for social drivers of health (SDoH), 40% post implementation followed by an additional 10% each subsequent grant year. VBCMH CCBHC seeks to increase access to and availability of high-quality services that are responsive to the needs of the community, using evidence-based practices including Trauma-Focused CBT, Motivational Interviewing, Seeking Safety, Screening, Brief Intervention, Referral and Treatment (SBIRT) and Question, Persuade, Refer (QPR) to address targeted community needs and risk factors. VBCMH will continue to build on the foundations of person-centered/family-centered supports and services that are recovery-oriented, trauma-informed, and equity-based, involving those with lived experience in all aspects of the CCBHC. During the grant period, VBCMH will partner with the community to complete a comprehensive Community Needs Assessment to inform future program design and enhancements, staffing, and clinical practices.

The purpose of Lincoln Behavioral Services proposed CCBHC planning, development and implementation project is to increase access to integrated, holistic, evidence based practices and quality care, program expansions and pathway improvements. Services are designed for individuals who are in crisis, experiencing a substance use or opioid use disorder, chronic health conditions, and are at risk for suicide and/or violent behaviors. Wayne County serves over 75,000 individuals with some of the highest poverty rates, suicide and school violence rates, poor mental health and decreased follow-through on chronic physical health conditions than other counties in Michigan. These combined factors represent a higher demand for integrated services. LBS will invest in infrastructure to facilitate care coordination, population health analytics and monitoring, increased access and engagement into services through targeted interventions to address health disparities and social determinants of health. Evidence based treatment, staff training and expanded staffing will increase integrated health services (mental health, prevention and engagement, SUD/OUD and/or physical health) to 1500 individuals over four years (Y1 250, Y2 350, Y3 425, Y4 475). LBS populations of focus are youth, veterans, LGBTQI+, and African Americans individuals lacking fully integrated, coordinated care, residing in the city of Detroit and all remaining communities in Wayne County, Michigan. LBS will use the CCBHC-PDI funding to advance three primary goals: (1) reduce barriers to access for veterans, LGBTQI+ and African American communities, including medication assisted treatment for SUD and OUD, and suicide prevention; (2) reduce school violence and school avoidance by decreasing/eliminating bullying/cyberbullying, homicide and threats of violence among students K-12, including LGBTQI+ and African American youth; and (3)reduce health inequities and improve access to primary care among veterans, LGBTQI+, youth, and African-American communities with mental illness. Anticipated outcomes include improved treatment retention and recovery, increased professional competency (including culturally competent interventions), decreased school avoidance, threats of violence and suicide rates; improved management of chronic health conditions, and improved access for the identified populations of focus. Care coordination and staffing will focus on screening, prevention, connection to resources, follow-up and intervention on health concerns, SUD/OUD support services and crisis stabilization. Screening and ongoing primary care needs will be provided on site by LBS. The provision of crisis services will be accomplished through LBS, Designated Collaborating Organizations and community stakeholders. LBS will develop an Advisory Council with membership represented by clients, family members, community stakeholders, and other advocates to obtain input and feedback on the identified goals and outcomes. LBS will enhance data collection and reporting to demonstrate improved access, engagement of target populations and increase care coordination through LBS's EHR and the Health Information Exchange.

Summary of Project: Pine Belt Mental Healthcare Resources, a CARF accredited qualified public behavioral health authority with 50 years of proven expertise serving the populations of focus in Southern Mississippi and Designated Collaborative Organizations (DCOs) will implement a CCBHC to transform community behavioral health systems in Region 12 and expand access to quality care in 13 rural, medically underserved counties by strengthening infrastructure and advancing trauma-informed integrated care delivering comprehensive person-centered coordinated behavioral health services. Name: CCBHC-PDI. Populations of focus: All individuals across the lifespan who are in need of behavioral health services, including those with SMI; individuals with SUD, including opioid use disorders; children and youth with SED; individuals with COD; and individuals experiencing a mental health or substance use related crisis; and members of the armed forces/veterans/families. Health care access will be prioritized for racial, ethnic and LGBTQI+ underserved groups addressing health disparities: 80% at or below poverty; 52% Female; 47% Male; 1% Transgender; 60% African American; 5% Multiracial; 3% Hispanic/Latinx; 5% armed forces/veterans/families; 2% diagnosed with HIV and/or Viral Hepatitis; 40% trauma-involved; 45% COD. Strategies/Interventions: 1) Planning, development, and implementation of a CCBHC meeting CCBHC Certification Criteria in partnership with DCOs; 2) Providing a comprehensive range of culturally, linguistically responsive outreach, screening, assessment, trauma-informed SMI/SED/SUD/COD outpatient treatment, care coordination, and peer recovery supports based on a needs assessment that aligns with the CCBHC Certification Criteria; 3) Supporting recovery from mental illness and/or SUD by expanding access to 24/7 crisis services, high-quality evidence based mental health and SUD services, including, recovery-oriented peer supports regardless of an individual’s ability to pay. EBPs: Motivational Interviewing (MI); Screening, Brief Intervention, and Referral to Treatment (SBIRT); Measurement-based Care (MBC); Medications for Opioid Use Disorder (MOUD); Rx for Change: Clinician-Assisted Tobacco Cessation; Seeking Safety; Cognitive Behavioral Therapy (CBT); Trauma-Focused Cognitive Behavioral Therapy (TF-CBT); Eye Movement Desensitization and Reprocessing (EMDR); Peer Recovery-Oriented Support Services; and Wellness Recovery Action Planning (WRAP). Goals: 1) Advance Health Equity with Expanded Access to Care Across the Lifespan; 2) Expand Peer Recovery Oriented Care; 3) Provide Person-Centered Care; 4) Measure Quality Care; 5) Ensure Collaborative Consumer Leadership; 6) Provide Whole-Person Care. Objectives: 1) 100% timely submission of Disparities Impact Statement, Needs Assessment and CCBHC Attestation; 2) Increase DCOs by 5% annually; 3) 100% accurate diagnosis and access to person-centered treatment; 4) 80% report high perception of care; 5) 51% consumer involvement in board governance; 6a)100% will receive physical health measurements and physical examination; 6b) 100% will receive evidence based behavioral health services; 6c) 55% will improve mental health functioning; 6d) 55% will reduce substance use; 6e) 55% will improve employment status; 6f) 55% will improve housing stability; 6g) 55% will reduce use of emergency room services; and 6h) 55% will reduce inpatient psychiatric admissions. #Served: Years 1-4 150, = 600 total.

Region IV Mental Health Services, a qualified public behavioral health authority with 50 years of proven expertise serving the populations of focus in North Mississippi and Designated Collaborative Organizations (DCOs) will implement a CCBHC to transform community behavioral health systems in Region IV and expand access to quality care in 5 rural, medically underserved counties by strengthening infrastructure and advancing trauma-informed integrated care delivering comprehensive person-centered coordinated behavioral health services. Populations of focus: All individuals across the lifespan who are in need of behavioral health services, including those with SMI; individuals with SUD, including opioid use disorders; children and youth with SED; individuals with COD; and individuals experiencing a mental health or substance use related crisis; and members of the armed forces/veterans/families. Health care access will be prioritized for racial, ethnic and LGBTQI+ underserved groups addressing health disparities. Goals: 1) Advance Health Equity with Expanded Access to Care Across the Lifespan; 2) Expand Peer Recovery Oriented Care; 3) Provide Person-Centered Care; 4) Measure Quality Care; 5) Ensure Collaborative Consumer Leadership; 6) Provide Whole-Person Care. Objectives: 1) 100% timely submission of Disparities Impact Statement, Needs Assessment and CCBHC Attestation; 2) Increase DCOs by 5% annually; 3) 100% accurate diagnosis and access to person-centered treatment; 4) 80% report high perception of care; 5) 51% consumer involvement in board governance; 6a)100% will receive physical health measurements and physical examination; 6b) 100% will receive evidence based behavioral health services; 6c) 55% will improve mental health functioning; 6d) 55% will reduce substance use; 6e) 55% will improve employment status; 6f) 55% will improve housing stability; 6g) 55% will reduce use of emergency room services; and 6h) 55% will reduce inpatient psychiatric admissions. #Served: Years 1-4 150, = 600 total.

AWARE's Certified Community Behavioral Health Clinic (CCBHC) Planning, Development and Implementation Project will provide the full continuum of CCBHC services to individuals of all ages in Lewis & Clark County. Lewis & Clark County has been experiencing ongoing gaps in service and unmet behavioral health needs. Closure of Helena's crisis stabilization facility in 2020 and ongoing development of crisis services present critical issues for the community. AWARE's CCBHC project is poised to meet the pressing, unmet health needs and gaps in Lewis & Clark County by facilitating services for a community identified as high risk for suicide, opioid overdose, and other deaths of despair. AWARE plans to serve 500 individuals through the implementation of CCBHC services and collaborations. Revitalizing community-based services, under the comprehensive CCBHC model will springboard services into a community with proven need. As one of Montana's largest providers of human services, AWARE is ready and able to become the sole provider of comprehensive CCBHC services and to fill essential needs in the county and its surrounding rural regions. AWARE will coordinate healthcare services for our community's most vulnerable individuals by investing in a network designed to provide a seamless, integrated process to address each person's unique health needs. This integrated approach will leverage community collaborations to support physical and behavioral health care while offering broader connection to supports not traditionally provided by primary care by connecting clients with housing, employment, and other social services. AWARE's CCBHC will provide care to all with special attention to increasing care for historically disenfranchised people living with a disability, identifying as LGBTQIA+, members of a tribal nation, and underserved veterans. By increasing access and decreasing stigma, it is hoped health outcomes for Lewis and Clark County will improve.

CPNJ’s CCBHC clinic will be located in Essex County, NJ and will serve all individuals across the lifespan with serious mental illness, serious emotional disturbance, substance use disorders, and co-occurring disorders; this population of focus will include historically underserved communities including those who self-identify as Black, Hispanic, and LGBTQ+. The catchment area (CA) is Essex County, NJ, a highly urban county with disparities in access due to a lack of behavioral and mental health services. The CA’s population is 852,720. Of the total population 323,837 self-identify as white; 329,047 as Black; 47,362 as Asian. 201,744 of the population self-identifies as Hispanic or Latino. CPNJ’s CCBHC will create a transformative behavioral health system that provides comprehensive outreach, screening, assessment, treatment, care coordination, and recovery supports. CPNJ’s CCBHC will serve 250 unduplicated individuals annually, totaling 1,000 individuals over the total project period. Goal/Objectives: Streamline, integrate and provide rapid access to expanded evidence based behavioral and mental health care through CPNJ’s Essex County CCBHC. Objective 1: By month 6 of year 1, Project Director (PD) and Project Evaluator (PE) will facilitate an inclusive community needs assessment, which will be updated in months 6-12 of year 3 to guide CCBHC services and infrastructure development. Objective 2: By the end of month 6 of year 1, establish a walk-in rapid access behavioral health center staffed by 1.0 Psychiatric Advanced Practice Nurse (PAPN), 2.0 Crisis Access masters-level licensed Therapists (CAT), 1.0 Targeted Case Manager (TCM), and 1.0 Peer Support Specialist (PSS) who will provide rapid access to screening, assessment and treatment services to 250 individuals annually. Objective 3: By month 6 of year 1, Hire an Outreach and Training Specialist who will provide 100 outreach and training encounters in historically underserved Essex County neighborhood locations to increase knowledge. Objective 4: By month 12 of year 1, the CATs and the PAPN will screen 250 individuals utilizing validated instruments; facilitate clinical assessment for 75% of those screened; assist 100% of those assessed in developing an individual recovery plan that outlines services, benchmarks and responsible staff for all domains with Targeted Case Manager and Peer Support Specialist accompanying each through service delivery, especially attending to transitions with 80% retained in treatment after 6 months. Objective 5: By month 12 of year 1, provide comprehensive SUD services to a minimum of 65 individuals via our DCO Integrity House the largest provider of SUD services in the CA; by the end of year 1, Care Plus will also secure its own license to provide SUD services in this County through the state of NJ. Objective 6: By Month 12 of year 4, APN will increase availability from 2 days per week to 5 days per week to provide a minimum of 1,000 intakes to expedite comprehensive screening assessment and diagnosis. Objective 7: By Month 12 of year 2, DCO will provide intensive psychiatric rehabilitation services to an additional 100 consumers, and an additional 200 school aged youth will receive more timely linkage to care such as psycho-educational social skills and skill building. Objective 8: By month 12 of year 1, a minimum of 250 individuals will be connected to Peer Support Services. Objective 9: By month 12, year 1 TCM will assist 100% of veterans served in establishing eligibility for VA benefits and connect them to CCBHC benefits as necessary. Objective 10: To ensure the project is meeting goals and addressing disparities, by month 4 of year 1 enlist a culturally/linguistically diverse Advisory Committee comprised of more than 55% individuals with lived experience representative of the POF; add at least one veteran receiving CCBHC services. Objective 11: Achieve full compliance with CCBHC certification and submit attestation by the end of year 1.

Santa Fe Recovery Center, Inc. (SFRC) proposes to establish a Certified Community Behavioral Health Clinic (CCBHC) in McKinley County, New Mexico (NM), managed by SFRC’s Four Corners Detox Recovery Center (FCDRC) in Gallup. The population of focus are the individuals of all ages living in and around the county with serious mental illness (SMI), substance use disorder (SUD) including opioid use; children with serious emotional disturbance (SED); individuals with co-occurring mental and substance use disorders (COD); and individuals experiencing a mental health or substance use-related crisis. The catchment area is McKinley County, NM, in the heart of Indian country. Description of Specific Populations: With a total population of 69,830, 79.9% of McKinley County residents are Native Americans, primarily of the federally recognized Navajo Nation and Zuni Pueblo. Hispanic residents are 14.6% of the county’s population, and 7.8% are White. McKinley County is the state’s “unhealthiest county"" and has NM’s highest rate of clients receiving “no treatment” for their behavioral health needs at 36.5%. According to a 2022 Community Health Needs Assessment, survey respondents indicated Substance Abuse (85.7%) and Mental Health problems (71.4%) as the county’s top two health problems – ahead of obesity, diabetes, and heart disease. In Year 1, SFRC will provide 700 unduplicated McKinley County residents a comprehensive range of outreach, screening, assessment, treatment, care coordination, and recovery supports by providing access to high-quality mental health and SUD services, regardless of an individual’s ability to pay. The project will focus on groups currently facing health disparities, as identified in a community needs assessment to be completed within six months of the project start date. SFRC's goals and Implementation Plan address the nine core CCBHC services and all Required Activities. Goal 1. SFRC successfully implements Certified Community Behavioral Health Clinic (CCBHC) services to address individuals’ mental health and substance use disorders in McKinley County. Goal 2. SFRC provides a comprehensive range of services, treatment and recovery supports to improve consumers’ physical and behavioral health outcomes. Goal 3. SFRC increases access to high-quality mental health and SUD services, regardless of an individual’s ability to pay.

All Faiths Children’s Advocacy Center (AFCAC) has been serving families in the New Mexico community since 1956, offering a variety of quality behavioral health services. There is a need to increase services to address substance use, suicidality, and mental health in New Mexico. New Mexico continues to have unmet needs and behavioral health disparities for serious mental illness, substance use disorder (SUD), individuals with co-occurring disorders (COD) and children and youth with serious emotional disturbances. Service gaps include lower accessibility to services, lack of substance use disorder and mental health providers, and lack of transportation. CCBHC PDI funds will be used to increase outreach and access to behavioral health treatments and build our capacity to provide comprehensive, higher acuity care for adults, adolescents, and children and increase the number of patients we serve. In CY2022 we served 2,931 patients. We anticipate 775 individuals to be eligible for CCBHC services in Year One, 825 in Year Two, 925 in Year Three, and 1,125 in Year Four. By the end of the four year grant period, we expect to serve 1,325 unduplicated patients. Our goals are to decrease health disparities for SUD and COD, enhance access to behavioral health services for families, and commence substance use disorder services. We will do this by establishing a school district partner in Valencia County, increasing services for veterans, closing racial/ethnic disparities affecting access to behavioral health services, hiring nine culturally reflective staff to reduce our current waitlist, enhancing our data collection of sexual orientation and gender identity (SOGI) information, expanding our delivery of telehealth services, applying for and obtaining our SUD license, launching SUD services and beginning referrals for SUD services.

Westchester Jewish Community Services (WJCS) will establish a CCBHC in Hartsdale, New York, Westchester County, to increase community access to high-quality, community based integrated behavioral health services, including mental health, substance use treatment services and primary care screenings, as well as provide seamless connection to additional services to address Health Related Social Needs for underserved populations. Our population of focus is low-income populations across the lifespan, especially Blacks and Hispanics who are disproportionately impacted by income and BH disparities in Westchester. As part of the project, WJCS will leverage its existing services as a certified MH and SUD provider in Hartsdale, 2 miles from White Plains, New York’s tenth largest city. Primary care screening and monitoring of key health indicators and health risks will be provided through the project and delivered in an integrated manner to allow for more comprehensive assessment and treatment of physical, mental health, and substance use disorders in a manner that is less likely to be stigmatizing, more consistent with the target community’s help-seeking behaviors, and relatively seamless in care. Over the grant period, we expect to serve 3,500 unduplicated clients. Four overarching goals guide this work. Goal 1: Improve access for individuals with or at-risk for MH or SUD through enhanced integration of culturally and linguistically responsive BH, physical, and social services; Obj. 1: During the grant period, LPNs will complete the health review form in our EHR for 90% of all consumers and capture demographic data to identify and address BH disparities. Obj. 2: During the grant period, CCBHC staff will complete and conduct an HRSN screening administered in our EHR for 80% of people receiving services. Obj. 3: During the grant period, 60% of individuals from our focus population receiving services to address needs from HRSN screening will have improvements in employment, food insecurity, or housing. Obj: 4 During the grant period, increase outreach efforts in community-and employment settings to increase treatment access for hard-to-reach, low-income, and underserved populations. Obj. 5: Maintain a No-Show Rate at or below 10% across the 4 years of the grant. Goal 2: Improve BH outcomes by addressing socioeconomic disparities experienced by low-income priority populations through peer supports and comprehensive IBH treatment; Obj. 1: During the grant period, our new Peer/Family Support Specialist will meet with all consumers who score low on the HSRN screening tool. Obj. 2: Increase the number of community partnerships with providers that address HRSN. Obj. 3: Achieve and surpass an engagement rate of more than 50% after 4 treatment sessions. Obj. 4: Implement and integrate NY State OASAS license to increase number of consumers in our focus population receiving culturally responsive evidence-based integrated SUD services by 60% in year 4. Goal 3: Implement culturally and linguistically responsive Evidence-Based Practices (EBP) for our focus population’s needs. Obj. 1: Increase staff trained in culturally responsive SUD EBPs (Encompass and CRAFT) by 60% by year 2. Obj. 2 Increase staff trained in culturally responsive Cognitive Processing Therapy (CPT) by 50% by year 2. Obj. 3 Train Employment Specialist on culturally responsive Individualized Placement and Support by year 1. Obj: 4 Implement /increase diversity, equity and inclusion training for all new employees.

Champlain Valley Family Center (CVFC) CCBHC will target individuals in need of BH care in rural northeastern New York's high poverty counties of Clinton, Esses, and Franklin with a focus on adults experiencing serious mental illness (SMI), children experiencing serious emotional disturbance (SED), those who have substance use disorders (SUD), and/or co-occurring mental health/substance use disorders (COD), especially those discharged from the regional hospital following a psychiatric admission, justice-involved individuals, and individuals and families representing the military/Veteran population. Our area includes four mental health HPSA designations, its average per capita income is $26,348 annually, 22.7% of the region's population is on Medicaid, and 5.1% do not have health insurance. The average suicide rate is 13.6 per 100,000. In 2021 our area's opioid overdose rate had increased by 637% since 2015 and our local hospital has 200 adolescents and 40 adults boarded in the ER for more than a day at any given time; 50% were diagnosed with SUD yet only 42.2% received an outpatient follow up appointment within 7 days of release and only 11.1% of youth up to age 17 diagnosed with SUD received a follow up care appointment within 7 days. As well, 70% of this population requires MAT that they do not receive. Our region's six adult correctional facilities, release apx. 138 individuals annually who have an SUD and 1,250 individuals are on probation or parole, yet we are seeing only a few of these high risk clients. Veterans comprise 8.4% of the population within our region, in contrast to a NYS average of 3.9%, however the two clinics meant to serve them are not presently able to provide timely access to clinical assessment and Veterans and their families require information and support related to SUD and suicide prevention. The CCBHC model offers a vital framework and critical expansion funding for CVFC's integrated mental health and substance use treatment services for children and adults. Our goals include expanding access and timely initiation of community-based BH services, reducing overdose and suicide, providing transportation support to treatment from the hospital and upon release from jail integrating primary care to address co-occurring chronic conditions, and establishing a process to monitor Continuous Quality Improvement. To accomplish these goals, we will expand our peer and clinician capacity, hire a Nurse Practitioner capable of prescribing MAT, implement Dialectical Behavioral Therapy in our clinic and school-based services, co-locate services in our local hospital and jail, partner with Homeward Bound a Veteran Peer organization to serve Veterans, and establish DCO collaborations with primary care clinics and our regional mobile crisis provider. As a result, we will expand access to care for 50 new, unduplicated children and adolescents each year via school-based DBT training and 75 new unduplicated children and adolescents with SED and 200 adults with SMI/SUD/COD will engage in DBT to avoid overdose/suicide, 160 individuals with an Opioid Use Disorder will receive MAT, 300 clients will be provided with transportation to care and services, and we will provide pre-discharge assessments and warm handoffs from the hospital for 45 new adult and adolescent patients annually, conduct 75 BH screenings for justice involved individuals each year, and increase our BH care for veterans by 5% in Y1 and 5% each year thereafter. As well, 70 % of clients served at the CCBHC will be connected to a PCP in year 1. Additionally, we will integrate care to track and monitor client health, medication adherence, and areas for needed improvement in Year 2 and each year thereafter. CCBHC funding will allow CVFC to serve an additional 980 individuals over the grant period, including 180 in Y1, 225 in Y2, 265 in Y3, and 310 in Y4.

Finger Lakes Area Counseling & Recovery Agency (FLACRA) proposes to expand its current integrated care service delivery model through the Certified Community Behavioral Health Clinic (CCBHC) Planning, Development, and Implementation (PDI) Grant. Currently, FLACRA's East Ave Clinic provides services for individuals with serious mental illness (SMI) and substance use disorders (SUD) and is in the approval process for the expansion of services for children and adolescents with serious emotional disturbances (SED) and is currently designated to provide services for individuals with co-occurring disorders (COD) and is seeking support to expand its service. A total of 2,761 unduplicated individuals (across grant years) will be served over the 4-year period through this CCBHC: Year 1- 596, Year 2- 665, Year 3- 720 and Year 4- 780. The East Ave Clinic is approved for the NYS OMH Integrated Outpatient Services (IOS) designation and is providing fully integrated substance use disorder treatment and mental health services and is pending approval to serve children ages 5 and older for mental health treatment and psychiatric support. As a result of obtaining the current IOS designation, services already offered include several of the required CCBHC Core Services including care coordination and primary care services. We will expand our CCBHC services through Designated Collaborating Organizations (DCO) partnerships to extend crisis care, psychiatric emergency and inpatient care and primary care services. Since the pandemic, the socio-economic and environmental factors in the City of Rochester service area populations have widened health disparities and inequitable access to care, as well as compounded trauma and stressors exacerbating behavioral health (BH) and substance use disorders (SUD). The residents of the most significantly impacted zip codes in the City of Rochester will benefit from the addition of a CCBHC that is integrated, trauma-informed, recovery-oriented and operates from an evidence-based and equity focused approach. FLACRA has extensive experience providing treatment and recovery support for mild to serious mental illness and serious emotional disturbances, SUDD and co-occurring disorders. The CCBHC PDI Grant will be used to build on existing comprehensive services and expand support for adults and children with the clinic and through school-based services and collaborations. Services will be grounded in evidence-based care, person-centered planning approaches, attention to cultural norms and beliefs and trauma-informed practices. The goals and objectives of the PDI Grant include: (1) implementing and enhancing services aligned with a CCBHC model; (2) increasing the number of providers with diverse specialty areas and cultural skillsets, trained in evidence-based interventions such as Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy for Adults (DBT) and Adolescents (DBT-A), Trauma Focused CBT (TF-CBT), CBT for Psychosis (CBTp), Family Psychoeducation, Social Skills Training (SST), Functional Family Therapy (FFT), Matrix Model for Teens and Young Adults, Peer Advocacy/Support, Seeking Safety, Living in Balance, Community Reinforcement and Family Training (CRAFT), Motivational Interviewing (MI) as well as Medication Assisted Therapy (MAT); (3) expanding off-site services to meet the BH needs of children and families in high need school settings; (4) increasing peer and recovery support services; (5) augmenting technology to support EMR data extraction to make data-driven decisions that identify and improve practice patterns, drive quality and promote and interdisciplinary Team-Based Care approach; and (6) adhering to SPARS and NOMS requirements and accuracy through tracking performance and clinical quality metrics that help improve quality of life perceptions, improve outcomes and reduce disparities in both access and outcomes.

The Jewish Board of Family and Children's Services (the JB) is one of the largest BH service providers in New York City (NYC), with expertise in trauma informed, culturally appropriate care. The population of focus is people of all ages with SMI/SED/SUD/COD and other BH challenges. The JB will implement a CCBHC to serve Taskforce on Racial Inclusion and Equity (TRIE)-defined high BH inequity areas in Manhattan. The service area (SA) is: Morningside & Hamilton Heights (TRIE 2), Central (TRIE 3) and East (TRIE 4) Harlem, and Washington Heights/Inwood (TRIE 5). The SA has 588,776 residents, 34-59% of whom speak a language other than English at home, generally Spanish; 27 - 68% are Latinx, 7 - 44% are Black and 11 - 36% are white, and 3-10% are Asian, with 21% under 18. 7.9% of adult NY state residents and 12% of Latinx and 9% of non-Latinx NYC high schoolers are LGBTQ+. The SA has higher than NYC average rates of poverty, substance use, drug related deaths, psychiatric hospitalizations, premature mortality, avoidable hospitalizations, new HIV diagnoses, uninsurance, going without needed care and other indicators of chronic lack of access to consistent, linguistically and culturally appropriate, affirming BH, primary, reproductive and other health care. NYC was an epicenter of Covid-19, with mortality doubled for Black and Latinx New Yorkers, increasing BH need while reducing the BH workforce. Black, Latinx and LGBTQ+ New Yorkers have higher rates of unmet BH need, with significant health and BH inequity and access gaps in the SA. The JB has expertise in BH equity, LGBTQ+ affirming care, serving diverse, underserved populations and linguistically and culturally appropriate care, with representative, bilingual staff who can provide all services in Spanish, reducing access barriers. The proposed CCBHC will integrate services currently provided at two main SA sites into a single service hub. We will serve a total of 1035 unduplicated individuals (225 YR1, 248 YR2, 270 YR3 & 293 YR4). Goal 1 is to increase access to/availability of a continuum of integrated BH services in order to reduce BH crisis, psychiatric hospitalization, suicide attempts and overdose deaths. Objectives and activities: 1.1 Improve timely access to BH care via staff hiring; expanding the Facilitated Intake Team (FIT, completes intake activities, initial care planning); Bridges to Care Team (B2C, provides crisis response, follow up and bridge clinical services while arranging for outpatient care), with OP wait times reduced to 10 business days by month 12. 1.2 Reduce inpatient admissions & crisis incidence; by month 12, 75% of crisis clients who are admitted inpatient will have an OP appointment scheduled, and 90% of all clients will have a crisis prevention plan documented. 1.3 Increase outpatient service offerings and availability to adults via staff hiring. 1.4 Training in SUD/COD/harm reduction, MAT, IDDT for 100% of relevant staff by month 12, with the SUD team to be expanded in year 2. 1.5 Increase timely identification of SUD/COD and facilitate access to services via enhanced SUD screening & diagnosis; By month 12, 100% of clients age 12+ will be screened, with 80% of positive screens to receive diagnosis & 75% to receive follow up. 1.6 Improve suicide screening, with 95% of clients screened by month 9, and 90% of positive screens receiving risk assessment & care navigation. By month 12, 95% of clients will be re-screened at treatment review, and 100% of relevant staff will be trained in evidence-based suicide prevention (CAMS). Goal 2 is to reduce historic BH and health disparities in the SA via increased health screening, monitoring, follow up and care coordination. Objectives and activities are: 2.1 Improve capacity for health screening by hiring a nurse & a Patient Navigator by month 6. 2.2 Improve health screening rates; by month 9, 70% of clients will be screened, 95% screened by M12 and 85% of positive screens have f/u included in treatment plans.

The Jewish Board(JB) is applying for a 4-year, $1 million annual CCBHC PDI grant to increase access to and fill gaps in care at its New York State (NYS)-licensed Grand Concourse Mental Health Outpatient Treatment Program(GC MH Clinic) located at 2488 Grand Concourse, Bronx, NY 10458 (and co-and near located mental health (MH) services) which currently serves 1,443 diverse, primarily low-income New Yorkers ages 0 and older annually. JB's Service area is the contiguous economically disadvantaged Fordham-Bronx where the JB GC MH programs are located (zip codes 10458, 10467, 10468); Crotona-Tremont (zip codes 10453, 10457, 10460); and Highbridge-Morrisania (zip codes 10451, 10452, 10456). The population primarily Hispanic (53%) and Black (34%). Most (90%) are low income on Medicaid and/or Medicare. Children ages 0-17 years are a third (34%) of the population; and those with serious mental illness are 77%. People with co-occurring substance use disorders (SUD) ) are 8% and will increase significantly when JB secures certification for an outpatient SUD Clinic. Many Bronx residents have economic and social challenges: 10% are uninsured; 34% are foreign-born; 59% speak a language other than English. Over 4 years, JB will serve 7,215 individuals (Yr. 1-1,587, Yr. 2-1,732, Yr. 3-1,876, Yr. 4-2,020) Strategies/Interventions: JB currently provides 8 of the 9 CCBHC core services. CCBHC grant funds will be primarily used to improve timely access to care and achieve CCBHC certification by expanding (1) clinical intake (screening/assessment) to reduce wait times; (2) crisis services to increase capacity to provide crisis stabilization care; (3) primary care screening/monitoring to offer services to more at-risk clients; and (4) peer services to better support recovery. These improvements will be implemented within 6 months of award. Funds will be used to open a new outpatient SU Treatment Program within a year of award co-located with JB MH Clinic that will add SU treatment capacity at the proposed CCBHC. Also, intensive, community-based MH for members of armed forces/veterans will be implemented within a year Project Goals/Measurable Outcomes: (1) Improve timely access to evidence-based outpatient MH care: Within 12 months of award, JB will reduce the wait time for initial routine intake appointments to 5 business days and urgent intake appointments to 1 day; and reduce the wait time for consumers waiting for an initial treatment visit by a clinician to 20 business days for routine needs and one day for urgent needs. (2) Improve Primary Care Screening & Follow-Up: 6 years: JB will increase annual age and risk appropriate primary care screening of CCBHC consumers to 45% in year 2 and 60% in Years 3-4 from 5% currently; and increase follow-up and interventions for clients who have medical condition identified by CCBHC staff (3) Improve Tobacco Use Cessation Intervention 14 years+: JB will progressively increase evidence-based tobacco use cessation interventions among consumers screened positive for tobacco use from 10% in 2022 to 60% by Year 4. (4) Improve timely access to evidence-based SUD services for adults: JB will commence offering SUD services in Year 2 to 50 adults and increase capacity in Years 3-4 to 70 adults annually. Today, MH Clinic/PROS clients needing SUD care are referred to other Bronx providers that may not have capacity to assist them and/or individuals may not follow-up with the referral. Additionally, JB will increase the number of clients newly diagnosed with a SUD who initiate SUD treatment within 14 days of diagnosis to 60%, compared with no initiation currently.

The Seneca County Integrated Wellness Center of the Seneca County Mental Health Department (SCMHD) will establish a Certified Community Behavioral Health Center at the Seneca County Community Counseling Center (Seneca County Mental Health Department) in Waterloo, NY. Seneca County is a small rural county in the Finger Lakes Region of Upstate New York. The county experiences high rates of poverty and ranks among the lowest counties in New York State for health outcomes and health factors which considers health behaviors, clinical care, social and economic factors, and physical environments. Seneca County is designated by HRSA as a Health Provider Shortage Area for Mental Health-Medicaid Eligible Populations and Primary Care. The rural nature of this area, along with few behavioral health providers, high poverty rates and a limited public transportation system presents challenges for access to care. This requires a comprehensive approach to address the needs of those with behavioral health challenges, along with trauma related to poverty and/or the effects of adverse circumstances. The Population(s) of focus for this project is adults, youth and children in need of behavioral health services, including individuals with SMI, SUD, COD and people experiencing a mental health or substance use disorder related crisis. The populations to be serviced will be primarily individuals with limited/no income, uninsured/underinsured or Medicaid recipients. The project will provide comprehensive CCBHC services directly and through Designated Collaborating Organizations. A total of 2,300 individuals will be served by the Project over the 4-year period - 350 individuals in year 1 and 650 individuals annually in years 2-4. The project goals are to: - Establish and operate a CCBHC in the rural community of Seneca County, New York that fully meets the CCBHC Criteria. - Increase the availability of, and access to, comprehensive CCBHC services for persons with SMI, SED, SUD, COD in the rural community of Seneca County, New York. - Support recovery from mental health and substance use disorder challenges through comprehensive community based CCBHC services for persons with SMI, SED, SUD, COD in the rural community of Seneca County, New York. - Provide evidence-based mental health and substance use interventions across CCBHC services that address the needs of populations of focus to improve participant retention and outcomes. - Conduct comprehensive continuous quality improvement processes to measure and improve the quality of services. - Ensure meaningful involvement of people with lived experience of mental health and substance use conditions, individuals who have received/are receiving services from the clinic, and family members in their own care and the broader governance of the CCBHC. As a small, rural community, there is a strong emphasis on partnership and collaboration to meet the behavioral health needs of the population, with integrated approaches across behavioral health, primary care, recovery support providers and crisis response systems (including law enforcement). The CCBHC will use integrated approaches across its outreach, engagement, and service delivery to fully address the needs of the populations of focus. As the CCBHC is further developed, enhancements will focus on strategies to address underserved populations, with CQI processes in place for continued modifications as disparities are identified and as new populations and/or needs emerge through needs assessment.

Project Name: Enhancing Mental Health and Substance Use Services for the Diverse Population of Youth, Families and Residents of the South Bronx. Summary: This project aims to address the pressing and unmet mental health and substance use needs faced by the diverse population residing in the South Bronx. The target population includes residents of Mott Haven, Morrisania, Hunts Point, Highbridge, East Tremont, and Melrose. These neighborhoods exhibit socioeconomic disparities, with a high percentage of Hispanic residents and limited access to quality healthcare. The project's goals include improving access to comprehensive mental health and substance use disorder services, reducing behavioral crises, and enhancing overall health outcomes. Throughout the project's four-year duration, it is anticipated to serve 1,484 individuals, with an equal distribution between children (ages 5-18) and adults (ages 19 and older). The projected number of unduplicated individuals to be served annually is as follows: Year 1: 275, Year 2: 342, Year 3: 415, Year 4: 452. Strategies and Interventions: The project will implement a range of core services, such as crisis mental health services, early intervention/prevention, crisis response services, stabilization services, screening, assessment, diagnosis, patient-centered treatment planning, outpatient mental health services, targeted case management, service referral and linkage, psychiatric rehabilitation services, intensive community-based mental health care for armed forces and veterans, and substance use services. The service delivery will be tailored to meet the specific needs of the population, taking into account cultural and linguistic considerations and access to care. Project Goals and Measurable Objectives: Become fully compliant with CCBHC requirements by the end of Year 1. Objectives: (1) Implement at least 5 of 9 core services by March 2024 and complete all core services by September 2024. (2) Establish a robust data infrastructure integrated with Electronic Medical Records (EMR) for efficient data collection, analysis, and utilization. (3) Maintain adherence to certification criteria for enhanced Medicaid reimbursement. Increase equitable access to comprehensive mental health and substance use disorder services for youth, families, and adults in the Bronx. Objectives: (1) Provide Social Determinants of Health (SDOH) assessments to 100% of CCBHC patients. (2) Offer targeted case management services to 100% of CCBHC patients. (3) Facilitate warm hand-offs and care coordination with local health, social, and human service agencies. (4) Engage 100% of CCBHC patients in peer support services. (5) Enhance cultural responsiveness through staff trainings. (6) Collaborate with local Department of Veterans Affairs facilities to better serve veterans and their families. (7) Enroll eligible patients with lapsed Health Home eligibility in the VNS Health Behavioral Health CCBHC. Decrease the risk and occurrence of behavioral crisis events among the population served. Objectives: (1) Conduct substance use disorder screening for 100% of CCBHC patients. (2) Ensure enrollment of CCBHC patients with substance use disorder in treatment. (3) Provide suicide risk assessments to 100% of CCBHC patients. (4) Reduce the risk of suicide by 75% using the Zero Suicide model. (5) Deliver Medication Assisted Treatment to 100% of CCBHC patients in need. (6) Establish robust care coordination with external agencies for seamless transition and integration of care. Improve overall health outcomes for youth, families, and adults in the Bronx. Objectives (1) Conduct primary care screenings and health monitoring for 100% of CCBHC patients. (2) Screen patients for tobacco/electronic cigarette use and enroll 80% of CCBHC patients in cessation intervention.

WellLife Network (WLN) proposes to provide comprehensive, high-quality coordinated behavioral health care in Nassau County, NY by planning for, developing, and implementing a new Certified Community Behavioral Health Clinic (CCBHC) that meets SAMHSA’s updated CCBHC Certification Criteria. WLN will provide a comprehensive range of person- and family-centered outreach, screening, assessment, treatment, care coordination, crisis services, and recovery supports based on a community needs assessment. WLN’s CCBHC will serve Nassau County’s more than 1.38 million residents, including children, adults, families, and veterans diagnosed with serious emotional disturbance (SED), serious mental illness (SMI), and co-occurring (COD) mental health (MH) and substance use disorders (SUD) experiencing isolation and loneliness post-COVID-19 pandemic. Residents’ median age is 42 years and 50.8% of the population identifies as female. Its racial distribution is 72.2% White, 17.6% Latino, 11.9% Asian, and 13.1% Black. More than 22% are foreign-born and 28.8% speak a language other than English at home. More than 38,000 are veterans. While county-level data is not available, more than one million adults in NY identify as LGBTQ+. Nassau’s primary care provider-to-population ratio is 143:100,000 and the mental health (MH) provider-to-population ratio is 314:100,000. One-quarter of Long Island families are unable to find a mental health provider who takes their insurance and 3.6% of Nassau County residents are uninsured. Recent studies show the COVID-19 pandemic has exacerbated SUD and MH issues among youth, children, and adults, with approximately 25% of residents indicating that drug and alcohol abuse and mental health depression/suicide are two of Nassau County’s biggest ongoing health concerns. Despite its affluence, Nassau County lacks sufficient services to address the myriad needs of child and adult residents with SMI, MHD, SUD, and COD, including community-based services that support peer connection, medication-assisted treatment (MAT), and 24/7 mobile crisis services. To offer a comprehensive array of services to Nassau County residents, WLN will: 1) Develop a staffing and training plan reflective of community needs; 2) Increase availability and accessibility of service to the population of focus by developing and implementing a service delivery plan based on the community needs assessment and hiring and training the appropriate staff to deliver those services; 3) Improve care coordination for clients to ensure seamless transitions across myriad health services by implementing electronic health record (EHR) improvements for data collection and analysis, executing Memorandums of Agreement with Designated Collaborating Organizations (DCOs), and updating care coordination protocols; and 4) Increase compliance with CCBHC Certification Criteria by providing mobile crisis services, incorporating screening tools in the EHR, providing primary care screening and monitoring, developing and implementing a targeted outreach plan to veterans, and establishing a clubhouse model of psychosocial rehabilitation for children/youth in WLN’s pediatric community residences and in its supported housing for adults with SMI. Evidence-based practices include Assertive Community Treatment, the Clubhouse Model, Cognitive Behavioral Treatment (CBT), Family Psychoeducation, Integrated Dual Diagnosis Treatment, MAT, Motivational Interviewing, Seeking Safety, and Trauma-Focused CBT. Five of nine CCBHC Certification Criteria will be in place within 6 months of the grant award and all criteria will be met within 12 months of award. WellLife Network’s CCBHC will provide a continuum of evidence-based approaches to 415 unduplicated individuals: 75 in Year 1, 100 in Year 2, 115 in Year 3, and 125 in Year 4.

Ohel Children's Home and Family Services' proposed CCBHC will expand and enhance access to comprehensive, trauma-informed, and integrated care to all individuals living experiencing behavioral health (BH) conditions and comorbid conditions in Rockaway, Queens (CD14). We will prioritize children and pregnant and postpartum women (PPW) from diverse backgrounds; we aim to address significant disparities among children with a disproportionate number of ACEs, and among PPW with peripartum depression. We anticipate that many of our CCBHC clients will be white and from the Orthodox Jewish community, as Ohel has a particular cultural competence in serving faith-based communities. Through our geotargeted outreach based on data from the city's Taskforce on Racial Inclusion and Equity, we will actively engage individuals from diverse backgrounds, including Veterans. According to US Census data, CD14 is 36% White, 30% Black, 29% Hispanic, 2% Asian, and 3% Other. Ohel currently provides most of the CCBHC required services and will complete its community needs assessment by month 6, and its staffing and sustainability plans by month 12. Through the PDI grant, Ohel will extend our mobile outreach to 24/7, hire 4 additional on-call clinicians, and train all crisis workers to respond to pediatric BH crises. We will begin using new evidence-based screening tools for children (PEARLS) and adults (RODS, MAST). We will hire 1 CASAC; 1 RN to provide onsite primary care; 1 RN with SUD experience to expand our SUD services, including MAT; and 1 peer specialist with lived SUD/MH experience. We also plan to expand our CFTSS program to include PSR, and our TCM program to serve more individuals in the community, including uninsured and those with commercial insurance. In addition to enhancing our EHR to capture more assessment data, we will train our staff to better capture client demographic data in our EHR. With this grant, we will increase our total unduplicated individuals served annually from 647 to 1147 by the end of year 4. Our goals and measurable objectives include: (1) Expand access to BH services for PPW via the following objectives: 1.a: Increase number of PPW treated for SMI, SUD, or COD by 20% by year 4; 1.b: Increase number of individuals, including PPW, with SUD who are receiving individual or group therapy by 20 each year of the program; and 1.c: Increase number of providers prescribing MAT by 2 by year 4. (2) Increase BH crisis services via the following objectives: 2.a: Expand mobile crisis hours to 24/7 by the end of year 1; 2.b: Implement Safety Planning Interventions for Children (C-SPI) to expand crisis services to include children 6-12 years old by the end of year 1; and 2.c: Increase number of crisis interventions by 20% by year 4. (3) Increase community-based services for high acuity children and youth and PPW via the following objectives: 3.a: Increase number of children 0-17 and transitional youth 18-21 treated for SCP, SED, or SUD by 20% by year 4; 3.b: Increase enrollment in CFTSS for 20% by year 2; and 3.c: Increase number of PPW we are treating with an EBP by 20% by year 4. (4) Develop partnerships and create referral pathways for children from diverse backgrounds across the entire SA via the following objectives: 4.a: Outreach to new community partners and provide children's BH educational sessions in 2 new community settings in our SA each year of the grant (8 total); and 4.b: Outreach to Black, Hispanic/Latino, and Asian families (populations historically underrepresented in our client base) through culturally specific social media pages by the end of year 1. (5) Improve pediatric BH outcomes and reduce health disparities via the following objectives: 5.a: Improve documentation of client self-reported race, ethnicity, sexual orientation, and gender identity by 50% by the end of year 1; and 5.b: For children ages 4-17 with a high PSC-17, 25% will have a decrease of 4 points within a year across all races and ethnicities.