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Burke’s FY 2023 Certified Community Behavioral Health Clinic – Improvement and Advancement (CCBHC-IA) Grant Program endeavors to improve, enhance, and expand capacity for our Chronic Care Management (CCM) Model within the East Texas region. This project shall target adults with serious mental illness (SMI), children and youth with serious emotional disturbance (SED), and individuals with co-occurring psychiatric diagnoses, substance use disorders (SUD), and/or physical health disorders in our twelve counties: Angelina, Houston, Jasper, Nacogdoches, Newton, Polk, Sabine, San Augustine, San Jacinto, Shelby, Trinity, and Tyler. The CCBHC-IA Program shall serve 600 individuals each year, with a cumulative 2250 unduplicated individuals served over the project period. Through use of these funds, Burke shall expand current service delivery capacity for integrated behavioral health and primary care, physical screening, care management, and population health monitoring by adding 0.5 FTE Medical Doctor, 3.0 FTE Nurses, 5.0 FTE Care Managers, 1.0 FTE Applications Programmer, and 0.5 FTE Population Health Coordinator. These staff shall reach the historically under-served target population, reduce Social Determinants of Health (SDOHs) related to economic instability and access to care, and build upon current care coordination projects. Project staff will focus on measurable objectives, implement provisions to improve population health indicators, such as high blood pressure, BMI, and unhealthy alcohol use, reduce access to physical care by 10% and trauma symptomology by 10% in the Hispanic subpopulation of focus, implement NetsmartTM CareManager software for risk stratification, and develop a needs assessment and sustainability plan. Burke shall formally partner with Brown Family Health Center, Inc. as its Designated Collaborating Organization (DCO) for this project, to provide primary care and infectious disease vaccination. The Medical Doctor and Nurses shall work to conduct physical health and infectious disease screenings, chronic disease prevention, and referrals. The Care Managers shall coordinate consumers enrolled on the Medical Doctor’s caseload to improve retention, maintenance, and daily functioning post-project. The Applications Programmer and Population Health Coordinator shall work on CareManager implementation and execution, Health Information Technology (HIT) interoperability, and endeavor to monitor health outcomes and inequity across the project timeline to address appropriate interventions when needed.

The Mental Health Center of Greater Manchester’s (MHCGM) Certified Community Behavioral Health Clinic (CCBHC) will continue its process of transforming the community behavioral health system for the Greater Manchester area. With a population of focus (POF) of individuals across the lifespan with or at risk for mental illness and/or substance use disorder, including SMI (Individuals with Serious Mental Illness), SUD (Individuals with Substance Use Disorders), SED (Children and adolescents with Serious Emotional Disorders), and CoD (individuals with co-occurring mental and substance use disorders) residing in the city of Manchester and the towns of Candia, Auburn, Londonderry, Bedford, Goffstown, Hooksett, and New Boston New Hampshire (a population of about 207k) through this funding. The individuals in this population have complex and overlapping needs that require an integrated approach to address effectively. The proposed CCBHC IA program will provide focus on 2 of the 9 Core services of CCBHCs; improved primary care screening and monitoring of key health indicators, health risks, and peer supports. There will be an added focus on the 15-census tract area identified in the Greater Manchester 2022 Community Needs Assessment, where life expectancy is lower, opportunity atlas scores are dire, crime is higher, and poverty is widespread. We will also have added focus on Black, Hispanic Asian, and the LGBTQI+ community in our POF. Implementing this proposal, MHCGM's CCBHC will address the needs and gaps of the POF by increasing patient engagement and care access, thus improving POF outcomes. Additionally, this proposal is expected to create a more efficient and effective delivery system for integrated behavioral health services by streamlining processes and reducing duplication of services while ensuring that patients receive comprehensive, integrated care. To do this, the MHCGM CCBHC IA grant focuses on infrastructure development, improved communication of needs and integration with the population of focus, and ensuring improved access to CCBHC services for the POF.

Texas Panhandle Centers (TPC) will use this grant to improve trauma-informed and evidence-based services for our population of focus (POF) of adults, children, youth, and families with serious mental illness (SMI), serious emotional disturbance (SED), substance use disorders (SUD), or co-occurring disorders (COD) in our 21-county service area. We (TPC) will dedicate project resources primarily to accessibility of services for children, youth, and their families. We have been certified as a CCBHC by Texas since 2022 and continue to operate in compliance with CCBHC certification criteria as described in Attachment 11. We directly provide all nine core required services. The CCBHC-IA grant will allow us to build on our CCBHC-E accomplishments and continue improving the quality of CCBHC services and expanding access to additional populations in our service area. Our particular focus will be on improving compliance with the updated CCBHC criteria; improving access to crisis and ongoing services to children, youth, and families; expanding access to integrated care; improving our capacity to capture quality measures for performance improvement; improving accessibility and acceptability of services to our LBGTQIA+ population; and addressing our critical need for additional licensed clinicians to provide EBPs. TPC will serve approximately 6,000 children, youth, and adults during each project year and a total of 7,000 unduplicated people across the four-year project. The grant will achieve the following goals: 1) Maintain compliance with all CCBHC requirements: improve consumer and family engagement in CCBHC planning, implementation, services, and evaluation activities and advance data capabilities for CCBHC quality measure reporting; 2) expand integration of behavioral and physical health care to meet the needs of individuals and families who receive treatment for SED, SMI, SUD, or COD and who lack primary care and/or screen positive for diabetes, cardiovascular disease, or other health risks; 3) establish a crisis diversion program for youth and families who are experiencing emotional or behavioral health crises in the service area; 4) improve CCBHC services and supports for the LGBTQIA + population by training staff to provide population-specific services; 5) recruit and retain more licensed professionals of the healing arts (LPHA) at TPC by increasing the number of credentialed supervisors (LPC-S and LCSW-S) and building our capacity to provide licensing opportunities to aspiring LPHAs.

As a qualified local government behavioral health authority and SAMHSA provider with 55 years of proven expertise serving the populations of focus in North Mississippi, the North Mississippi Commission on Mental Illness/Mental Retardation dba Communicare and Designated Collaborative Organizations (DCOs) will transform and advance it CCBHC, by expanding access to integrated coordinated behavioral and primary healthcare. NAME: CCBHC-IA. POPULATIONS SERVED: All individuals across the lifespan who are in need of behavioral health services, including those with SMI; individuals with SUD, including opioid use disorder; children and youth with SED; individuals with COD; and individuals experiencing a mental health or substance us related crisis; and members of the armed forces/veterans/families. Health care access will be prioritized for racial, ethnic, and LBGTQIA+ underserved minorities: 50% male; 49% female; 1% transgender; 50% African American; 2% Hispanic/Latinx; 1% multiracial; 2% veterans/armed forces; 2% HIV+/Hepatitis+ and 45% COD. STRATEGIES: 1) Improve access to care providing a comprehensive range of outreach, screening, assessment, treatment, care coordination, and recovery supports based on a needs assessment with fidelity to the CCBHC Certification Criteria; 2) Support recovery from mental illness and/or substance use disorders by providing access to high-quality mental health and substance use services regardless of an individual's ability to pay or residence; 3) Enhance crisis response with use of standardized screening and quality measures; 4) Use a trauma-informed approach, standardized instruments and symptom rating scales to advance treatment and integrated care; 5) Advance person-centered treatment planning with peer recovery supports, and care coordination; 6) Implement measurement-based care to drive clinical decision-making and inform quality improvement strategies; 7) Create a sustainability plan to ensure financial autonomy; and 8) Ensure CCBHC Accountability Board governance. EBPs: Motivational Interviewing (MI); Screening, Brief Intervention, and Referral to Treatment (SBIRT); Measurement-based care (MBC); Medications for Opioid Use Disorders (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); ACT; Long-Acting Injectables Medical Evaluation/Management; Peer Recovery-Oriented Support Services; and Wellness Recovery Action Planning (WRAP). GOALS: 1) Advance Health Equity and 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 examinations; 6b) 100% will receive evidence-based behavioral health services; 6c) 80% will improve mental health functioning; 6d) 80% will reduce substance use; 6e) 80% will improve employment status; 6f) 55% will improve housing stability; 6g) 75% will reduce use of emergency room services; and 6h) 55% will reduce inpatient psychiatric admissions. NUMBERS SERVED: 150 in Years 1-4 = 600 total.

Community Mental Health (CMH) of Ottawa County Certified Community Behavioral Health Clinic (CCBHC) serves individuals who are living with or at risk of developing severe mental illness (SMI), serious emotional disturbance (SED), substance use disorders (SUD), and/or co-occurring disorders (COD). Grant funds will be used to enhance services and expand outreach to SMI, SED, and SUD populations across the lifespan living below the poverty level with a particular focus on the Hispanic population. Grant funds will be used to reduce the rates of obesity, diabetes and prevalence of tobacco use for these populations. Preliminary FY23 data suggests the suicide rates in Ottawa County have remained stagnant for several years, as the population dramatically increases yearly. The CCBHC will also improve outreach to the Hispanic communities, implement a comprehensive crisis continuum and address high rates of SUD by training staff in evidenced based practices. CMH expects to serve a total of 890 individuals (380 in year 1, 160 in year 2, 170, in year 3, and 180 in year 4). CMH serves approximately 3,875 individuals across the lifespan. The CCBHC service population is 78% Caucasian, 11% Black or African American, 1.6% Asian and 5% Hispanic (10% in the county). Ethnicity of the group is 74% not of Hispanic or Latino origin. 43% of the service group is female, 57% is male, and 0.05% identified as unknown. 84.3% of the target population is obese or overweight (66% for the County), 10% are diabetic (12.3% for the County) and 61% smoke tobacco on a daily or weekly basis (14.3% for the County). The CCBHC will complete a Body Mass Index (BMI) screening on 60% of the population (increasing by 10% each subsequent year) and demonstrate a BMI reduction by 10% in adults served by 9/30/24 (increasing by 2% each subsequent year). The CCBHC will offer 100 classes to educate on nutrition, health, and exercise in year one, increasing by 10% each year. 10 classes a year will be conducted in Spanish. At least 30% of individuals identified as a tobacco user will receive an intervention each year. 90% of individuals will receive a diabetes screening annually and 50% of those identified as diabetic will be referred to a Community Health Worker (increasing by 10% each subsequent year). The CCBHC will increase the number of Hispanic individuals served by 20% by 9/1/2024 and increase by 2% each subsequent year. The CCBHC will increase outreach contacts to the Hispanic population by 20% in year one and increase by 2% each subsequent year. 80% of clinicians will be trained in Zero Suicide by 9/30/2024. By 9/30/2026, 100% of individuals who are at risk of suicide will have a care management plan in place. 100% of all clinicians will be trained in Screening, Brief Intervention, and Referral to Treatment (SBIRT) by 6/1/2025 and 75% of individuals seeking treatment for SUD will receive an intervention in year one and that will increase by 5% each subsequent year.

Project Name: Healio Health Improvement Project. Project Description: Helio Health a New York State Certified Community Behavioral Health Clinic (CCBHC) seeks grant funding to improve CCBHC services at its Meadows Clinic in Syracuse New York by increasing staff and operational capacity for 24/7 mobile crisis response and BH services for children and families. The population of focus includes persons of all ages, regardless of ability to pay, with SMI, SED, SUD, and COD. CCBHC IA services will focus on reducing disparities among 1) children and adolescents (ages 0-18) with complex (BH) needs; and 2) youth and adults experiencing a BH crisis. The geographic catchment area includes 5 CNY counties: Onondaga, Cayuga, Cortland, Madison, and Oswego (pop: 773,329) with the largest share of services provided to residents in Onondaga County, which has high prevalence of behavioral health conditions including SMI, SED, SUD, and COD. Significant health disparities and low socioeconomic conditions are exacerbated by difficulty in accessing services particularly among children and adolescents and more rural parts of the region. Helio Health, a not-for-profit healthcare leader offering a full continuum of behavioral health, social services, and housing programs throughout Central New York will leverage existing CCBHC services including MH, SUD and primary care screening and monitoring of key health indicators and health risks throughout the project period. Over the grant period, we expect to serve 28,000 clients. Grant funding will be used to improve existing CCBHC services with a focus on increasing 24/7 mobile crisis response capacity and treatment services for children, youth, and families. We aim to achieve four goals: Goal 1. Increase access to high-quality, 24/7 mobile crisis services for individuals experiencing a BH crisis as measured by: (1) increasing the number of mobile crisis services provided from baseline in Year 1 by 50%; (2) ensuring all persons receiving mobile crisis services will have discussed a crisis plan as demonstrated by clinical documentation in the individual’s record by January 2024; Goal 2. Increase access to and availability of high-quality and culturally responsive services for children, adolescents, and their families as measured by: (1) completing Strengthening Families Program Training (25-person cohort) and developing internal referral process for this new resource by January 2024; (2) implementing the Strengthening Families Program by March 2024; (3) increasing the number of parents, guardians and families involved in children’s services by 30% over the grant period. Goal 3. Train staff to implement EBPs that address the needs of our populations of focus as measured by: (1) increasing counselors trained in TF-CBT by 50% to improve MH treatment for children, adolescents, and their families by July 2024; (2) providing Solution Focused Therapy certification for 20 staff members by August 2024. Goal 4. Improve EBP fidelity through continuous quality improvement and measurement-based care as measured by: (1) embedding a Quality Improvement Specialist at the clinic site to monitor and maintain adherence to EBPs and achievement of CCBHC improvements by November 2023; (2) increasing the percentage of patients referred to and engaged with one or more additional CCBHC care team services (Peer, Targeted Case Manager, or PRS) by 20% during the grant period.

Abstract The Central Montana Certified Community Behavioral Health Clinic Improvement and Advancement (CCBHC-I-A) Grant will allow Many Rivers Whole Health (MRWH) to focus on improving and advancing service and program development, including expanding care coordination services which were developed under our CCBHC-E grant award, closing 2/14/2023. Our populations of focus for this grant will include all clients in our catchment area with any mental health or substance use disorder diagnosis in Cascade and Lewis and Clark counties in North Central Montana. We will also work to expand our CCBHC service reach to our surrounding rural counties with expansion of care coordination, access to care point personnel and crisis services. MRWH has more than 4 ½ decades of experience providing behavioral health services, serving the 15 counties in our region. Nine of the thirteen counties served are classified as “Frontier” with fewer than 7 people per square mile. Since the beginning of the CCBHC-E grant project 2/15/2021, MRWH has provided 135,813 services, of which 2,787 unduplicated clients were served. Our goals and measurable objectives for this project are: Goal 1: Expand access and improve the range of CCBHC services within our service region through increased screening, referrals, and tracking to ensure whole person care. Objective 1.1: By the end of Year 1, increase to 90% the number of clients screened, referred, and tracked for primary healthcare issues. Objective 1.2: By the end of Year 1, provide screening, referral and tracking to 90% of the individuals with co-occurring opioid, alcohol, or tobacco use disorders receiving Medication Assisted Treatment and/or behavior modification counseling. Objective 1.3: By the end of Year 1, increase to 90% the number of clients receiving screening, referrals and tracking for peer support, housing, and/or vocational services. Objective 1.4: By end of Year 2, work with local school district and community partners to advance and improve utilization of screening, referral, and tracking for whole person care services for at least 90% of youth who are enrolled in MRWH behavioral health school programming. Goal 2: Expand MRWH’s ability to link clients to the full continuum of community-based care and recovery/social support services. Objective 2.1: By end of Year 1, expand our capacity for care coordination to include the hiring and training of an additional 3 Care Coordinators. Objective 2.2: By the end of Year 1, establish point of contact personnel for all rural counties regarding crisis referrals, behavioral health resources, access to care points and behavioral health consultative services. Objective 2.3: By the end of Year 4, establish Memoranda of Understanding and have referral systems in place for crisis stabilization and/or receiving facility beds/services in all served counties. Goal 3: Increase cultural competency of our employee team through evidence-based training and with the input of our clients, family members and community partners. Improve clinical outcomes by development of a culturally competent approach to whole person care. Objective 3.1: By end of Year 1, identify, develop, and implement specific evidence based cultural competency, diversity, and inclusion curriculum(s), both on the macro agency level and on the micro personnel level for specific training needs by position. Curriculum is based upon target population of American Indians; however, will also include: LGBQT+, elderly, minority races and youth. Objective 3.2: By end of Year 1, complete CCBHC Community Needs Assessments in Cascade and Lewis and Clark Counties. By the end of Year 2, complete CCBHC Community Needs Assessment in all other counties. Objective 3.3: By end of Year 2, complete of evidence-based training curriculum for all employees to include refresher training as part of annual training schedule.

Allegan County Community Mental Health Services dba OnPoint via the CCBHC-IA program (O-CCBHC) proposes continued improvement of access and increased capacity to community-based mental health and substance use disorder treatment and support. These services would be offered to the population of focus for individuals across the lifespan: (1) mild to moderate or serious mental illness, (2) substance use disorders inclusive of co-occurring conditions, and (3) serious emotional disorders; with focus on the uninsured, underinsured, veterans, homeless, or otherwise without access to care. These services, inclusive of 24/7 crisis, will be delivered to anyone in the service area who needs it; regardless of ability to pay or place of residence. This project will address the identified needs of access to mental health and substance use treatment, poor health outcomes, and limited behavioral health providers. Access to mental health and primary care services for individuals living in Allegan County is generally difficult, however, the target population faces even greater adversity with the specific services suited to their conditions. The O-CCBHC project will extend the reach and impact of services for local accessibility. Over the life of the grant, O-CCBHC is committed to serving 1050 individuals (200 in year 1, 250 in year 2, 300 in year 3, 300 in year 4). The first goal of the project is to increase the capacity of O-CCBHC to provide access to evidence-based behavioral health care for uninsured and underinsured adults, children, and families in Allegan County. Measurable objectives include: A) By 9/30/24, O-CCBHC will increase access capacity for un- and under-insured adults, children, and families by no less than 30%. B) By 9/30/24, no less than 30% of access will be same day access. C) By 9/30/24 O-CCBHC will demonstrate 85% compliance with CCBHC 24/7 crisis response standards. D) By 3/31/24, O-CCBHC will onboard 2.0 FTE peer outreach specialists to identify and engage the target population. E) By 12/31/23, clinicians embedded in the O-CCBHC housing department will provide community-based behavioral health access, screening, and assessment for homeless and precariously housed individuals. The second goal of the project is to increase evidence-based behavioral health services for un- and under-insured adults, in Allegan County through O-CCBHC. Measurable objectives include: A) By 9/30/24, O-CCBHC will increase provision of evidence-based behavioral health services to un- and under-insured adults, children, and families in Allegan County by no less than 35%. B) By 9/30/25, all O-CCBHC clinicians will be trained to fidelity in no less than an average of 3 identified EBPs. The third goal of the project is to strengthen the continuum of substance use prevention and treatment services to decrease the impact of substance use in the lives of individuals and families in Allegan County. Measurable objectives include: A) By 9/30/24, O-CCBHC will serve no less than 50 individuals through recovery management services. B) By 9/30/24, O-CCBHC will increase community-based delivery of SUD treatment services by no less than 35%. C) By 9/30/24, O-CCBHC will engage no less than 50 adults in evidence-based SUD prevention services. D) By 9/30/24, O-CCBHC will increase medication assisted treatment capacity by 25%. The O-CCBHC project will also augment OnPoint's evidence-based practice capacity to support the ongoing service needs for those who are uninsured and underinsured. Performance measures will be managed through the quality infrastructure to support the service array. Consumers will be meaningfully involved in the governance of O-CCBHC and their own care. This project will assist in the development and continuation of state demonstration.

The Milwaukee Center for Independence (MCFI)proposed Whole Health CCBHC-IA project will improve and advance its to serve all CCBHC populations of focus (PoFs), i.e., all individuals across the lifespan in need of behavioral health (BH) services in Milwaukee County (MC) with SMI, SUD, COD, and children/youth with SED. MCFI will focus on expanding its capacity to address BH disparities (BHDs) in school-age children and adolescents with SED, and LGBTQI+, particularly those with SMI. Almost half (49.0%) of current CCBHC clients are African American (AA). This is disproportionate compared to AA’s 27.6% representation in the general MC population, but consistent with the prevalence of BHDs (as they intersect with social drivers of health, SDOH) among them, so MCFI will continue to prioritize services to them. Almost all those served by MCFI are low-income. Of major service gaps to be addressed by MCFI include that, per its most recent community needs assessment, that though culturally competent treatment is available for LGBTQI+, what is lacking is LGBTQI+ -specific treatment for those with SMI. MCFI has for decades been the region’s primary provider of services for SMI. MCFI will develop capacity to serve LGBTQI+ with SMI by training its staff (by partner LGBT Community Center of Milwaukee) on working with LGBTQI+. The project will also address the community’s significant need to MCFI will address the need for treatment services for children and adolescents with SED. Children’s Wisconsin (CW), the largest healthcare system in the state serving children, has an average waiting list of 9 months. CW has agreed to refer children and families from its waiting list to MCFI’s new Children’s Behavioral Health Clinic. MCFI’s child/adolescent therapists will be trained in the EBP Trauma-Focused CBT to serve this population. Serving as DCOs will be Milwaukee County Behavioral Health Services, which will provide crisis mental health services; the Milwaukee VA Medical Center, which will accept referrals of veterans for treatment; and 3) NAMI, which will offer programming to families of participants by NAMI-trained family member peers. Project goals are: 1) Expand and enhance access to behavioral health (BH) services for all CCBHC PoFs; 2) Improve/enhance MCFI’s ability to address clinical treatment needs of all CCBHC PoFs across the lifespan; 3) Design & implement a consistent comprehensive screening, assessment, and treatment planning protocol; 4Enhance care coordination/ integration across the spectrum of health services (BH, physical health, & SDOH); and 5) Participants will experience improvement in their mental health and well-being.

Advantage Athens-Clarke CCBHC Improvement project will provide a comprehensive and evidence-based system of care focused on targeted intervention for youth and families, individuals at high risk of suicide or overdose, those in need of integrated health services, and those facing disparities in access to care based on minority or socioeconomic status. We plan to serve 1550 individuals over the course of the project: 200 yr1, 400 yr2, 450 yr3, and 500 yr4. Advantage's Athens-Clarke County Clinic population of focus includes adults and youth with isolated or co-occurring behavioral health disorders and substance use disorders, who are uninsured or underinsured or who lack meaningful access to needed behavioral health care. Athens-Clarke County is an urban community of over 128,000 individuals of whom 58% are white, 25% are Black or African American, 3.8% are Asian, with less than 1% American Indian/Alaska Native and Native Hawaiian/Other Pacific Islander and 6.7% identifying as 2 or more races. 11.1% of Athens-Clarke County residents identify as Hispanic. Athens-Clarke County is a community facing significant healthcare access challenges alongside increasing rates of youth behavioral health crises and drug overdose deaths. Suicide remains a leading cause of death, and many residents continue to face chronic health conditions associated with poverty. Advantage's Athens-Clarke County CCBHC Improvement project goals align closely with the needs identified in this community: Goal 1: Enhance programming for youth and families by providing increased staff training on youth-specific interventions and by establishing a Family Treatment Tea (FTT) model for families with youth experiencing significant behavioral health challenges. Goal 2: Enhance our integrated health program through increased coordinated primary care activities, expanded health education programming focused on chronic illness prevention, and expansion of our coordinated care model through improved referral relationships and care coordination activities. Goal 3: Improve substance use disorders programming for high-risk substance users by providing staff training on prevention and intervention with high-risk SUD populations and targeted intervention to address identified risk factors and provide support during times of transition. Goal 4: Elevate standards of care for individuals presenting with recent or current suicidal ideation by providing staff training on suicide specific care and targeted intervention to prevent suicide deaths.

Hillcrest Family Services (HFS), the leading provider of behavioral health services in Eastern Iowa, with over 35 current programs, including 5 community mental health centers (CMHCs) and serving people at every stage of life: children, youth, adults, and seniors, proposes to establish a Certified Community Behavioral Health Clinic (CCBHC). We provide a full range of person-centered, evidence based behavioral health services and are the largest school mental health provider in the region. Committed to the vulnerable, we are the only provider in Dubuque and Jackson County certified by the region for behavioral health care to those unable to pay. We are pursuing this opportunity to expand and continue out current CCBHC services. Our expansion efforts seek to address the unmet behavioral health needs of Dubuque and Jackson counties, particularly in rural areas and specifically the need for 1) Improve community behavioral health through reducing barriers to access and proving quality care, 2) Reduce excessive drinking by offering an array of services delivered by peers and newly trained staff focused on engaging and retaining people and 3) Increase early engagement of children with their families to improve outcomes for children and adolescents with SED. Our CCBHC will deliver quality screening, assessment, and treatment, 24/7 crisis services, person centered care coordination, physical health screenings and coordination, psychiatric rehabilitation and peer support, targeted case management and integrated care of veterans fir children and adults. We are partnering with our local FQHC, working closely with our VA partners, providing services in the jails and hospitals, and delivering services in schools. To support this work, we will hire additional staff with lived experience, therapists, case managers, and care navigators. We propose to improve behavioral health through increased access by expanding hours, providing additional free/low-cost transportation options, connecting more closely to people transition from institutions and training all clinicians in Cognitive Behavioral Therapy (CBT). We will reduce excessive drinking by increasing the number of people with lived experience we have available to support those who need services, placing staff in a hospital ED to deliver Screening, Brief Intervention, and Referral to Treatment (SBIRT) and training all CCBHC staff in Harm Reduction. Lastly, we will increase the early engagement of children and families by expanding our family outreach efforts, ensuring the availability of care coordination, and expediting follow up plans for those children who screen positive for depression. Our efforts will be conducted using evidence-based and emerging practices to support care for behavioral health conditions. In addition to SBIRT mentioned above, HFS will use Seeking Safety, a trauma-informed intervention effective in reducing symptoms in people who have experienced trauma or SUD Motivational Interviewing, a recognized engagement practice for structured communication to assess readiness and/or promote behavior change; Collaborative Problem Solving (CPS) and Parent Management Training (PMT), both practices recognized to support parents coping with a child's behavioral challenges; Dialectical Behavioral Therapy (DBT), effective for youth and adults with suicidal ideation and risk; Multidimensional Family Therapy (MDFT), a recognized intervention for youth substance use and antisocial behaviors; and Acceptance and Commitment Therapy (ACT), an evidence-based practice for behavioral health disorders in adults. We will provide extensive training, use data to assess our progress and engage the people we serve in improving our program. Throughout all CCBHC services, we will ensure that consumers receive client-centered care that is free from stigma and that is culturally and linguistically appropriate to meet the consumer's individual context and care needs.

CCA will continue to improve and advance to be certified as a fully operational CCBHC, providing the complete scope of CCBHC services to individuals regardless of ability to pay. CCA will implement infrastructure enhancements to improve overall quality and coordination of care. CCA will advance four program areas: Peer Specialist Services, Complex Care Management Services, MedTeam Programming, and Emergency Services Prescriber access. These projects will address the needs of a wide range of clients across the lifespan, including individuals with: 1) a mental or substance use disorder who seeks care, including those with a serious mental illness (SMI), substance use disorders (SUD), including opioid use disorder; 2) children and adolescents with a serious emotional disturbance (SED); 3) individuals with a cooccurring disorder (COD); and 4) individuals experiencing a mental health or substance use related crisis. A priority will be placed on serving underserved populations (homeless, veterans, BIPOC, etc.). The program will serve people who reside in a five-town area in the northern and eastern Providence County (RI) that covers an area of 131 sq. mi. and a population of 130,845.

Through a FY24-27 CCBHC IA Grant, Wilder will improve access, affordability, and quality of mental health and substance use services to residents in Ramsey County, MN who are underserved and experiencing substantial disparities related to mental health and substance use disorder service access and outcomes – especially culturally and linguistically specific care. Wilder’s project will prioritize residents who are below 200% of the federal poverty line, speak a primary language other than English, and/or are from cultural and ethnic minority communities, with specific efforts to deepen engagement with Black/African American, East African, Afghan, and Southeast Asian communities. The project will reach 2,000 clients annually and 3,500 clients total. This project addresses financial, cultural, and language barriers and overall accessibility to be responsive to clients’ needs, including high-acuity co-occurring mental health and substance use needs, comorbid physical health conditions, and coinciding social determinants of health (e.g. housing, transportation, immigration benefits, civil legal services, government benefits, and food access concerns). Our project proposes the following services to improve our CCBHCs impact in our community: - Expand accessibility and affordability of core CCBHC services by growing our provider base, diversifying provider types, and offering uncompensated care coverage for clients - Refine population health strategies and care management pathways by improving our patient health registry, analyzing trends, and supporting clinicians in data-driven clinical decision-making - Redesign care coordination processes and implementation by engaging community to inform meaningful, whole-family, multilingual/multicultural care coordination needs and shaping our assessments, communications, referrals, and follow-ups on this basis. - Deepen integration and development of our workforce, to reflect these newly-improved strategies for care and to increase our ability to train and team collaboratively/interprofessionally Through these activities, we will accomplish the following goals and measurable objectives: 1. Increase capacity and affordability of culturally-responsive behavioral health services for clients in Ramsey County to reduce current disparities in access among our focus population. a. By end of Y2, Wilder will increase clinical staff capacity from 120 to 134 FTEs and at least 50% of new staff will be representative of our focus population. b. By end of Y2, Wilder will have eight FTE certified peer specialists/cultural brokers (we currently have four FTE) and 75% will represent our focus population. c. By end of Y4, Wilder will increase capacity from 48,824 to 54,683 CCBHC encounters annually (12% increase) with 75% serving our focus population. d. By end of Y4, Wilder will support uncompensated care costs of >3,500 CCBHC encounters for ~500 individuals with 75% from our focus population. 2. Increase and improve care management and care coordination practices to reduce outcome disparities among high-complexity/acuity behavioral health clients in our focus population. a. By end of Y1, 90% of clients will have current CMS Social Determinant of Health screens and follow-up plans in place for client-prioritized social needs. b. By end of Y2, 65% of direct service staff will use data from a refined population health management and care management strategy to inform their client care, documented in EHR and measured by management case audits. c. By end of Y3, 75% of direct service staff will use new care coordination pathways in client care, documented in EHR and measured by management case audits. d. By end of Y3, 75% of clients will self-report that their whole-family care is being successfully coordinated. e. By end of Y4, 75% of clients will maintain or improve functioning as compared to their previous measurement.

Tessie Cleveland Community Services Corporation (TCCSC) is a 501(c)3 non-profit behavioral health agency and has been providing services to children, adolescents, adults, and families since 2005. TCCSC’s CCBHC was established in 2020 and the population of focus is majority African-American (31%) and Latino (41%) children, adolescents, and adults with lower socioeconomic status (95% are Medi-Cal/Medicare eligible), that are SED, SMI, are experiencing mental health and SUD crisis, have co-occurring mental and substance use (COD) and/or, long term and serious SUDs. Through this grant, TCCSC will provide services to 100 clients annually and 400 throughout the lifetime of the project. TCCSC provides services that are individualized based on the unique dynamics of each client and family and tailored to address their strengths, needs, and desired outcomes. In addition to our clinic services, TCCSC utilizes in-home services including psychotherapy; counseling; crisis response; case management; linkage; and parenting education to increase child safety in the home and prevent child abuse, maltreatment, and neglect. TCCSC provides clients and families with exposure therapy to increase their comfort level in seeking resources outside the community. TCCSC’s service delivery plan includes programs and events that incorporate strengthening a family’s protective framework. In addition to these services, TCCSC uses a myriad of Evidence-Based Practices (EBP’s) enabling our clinicians to become self-directed, problem-based, treatment providers who can integrate the results with their clinical expertise. TCCSC selected EBP’s proven to be effective with our focal population such as Dialectical Behavioral Therapy (DBT) and Motivational Interviewing (MI). TCCSC’s CCBHC serves the South Los Angeles area and this grant will help us address the behavioral health disparities for African-American and Latino children, adolescents, and adults who live < 100% FPL. The grant will impact: 1) lack of access to care by a) retaining current staff levels and decreasing the turnover rate; b) increasing the number of uninsured clients receiving services; and c) providing in-home/community services when transportation is an issue; 2) lack of culturally competent services by a) retaining bilingual staff who reflect the focal population; b) hosting community education and training events to address social determinants of health that contribute to health disparities, such as poverty, racism, and discrimination of LGBTQIA?+; and 3) expand access to victims of community-based trauma by establishing partnerships with local law enforcement agencies.

Berks Counseling Center (BCC) will expand access to and engagement in in evidence-based assessment, screening, and treatment to reduce health disparities and advance care. The population of focus (POF) to be served is Berks County heterosexual, bisexual, asexual or homosexual individuals, 5+ years, living with mental health conditions, substance use disorder (SUD) and co-occurring disorders with behavioral health needs but cannot or choose not to access treatment due to health disparities and inequities. These may include but are not limited to stigma, race/ethnicity, socioeconomic status, sexual orientation and gender identity as well as the social determinants of health (SDOH). Berks County consists of urban, suburban and rural communities with a population of 430,449. Approximately 22% of its population resides in the city of Reading; 32% of its residents live at or below the poverty line. Although BCC serves all of Berks County most clients are city residents with higher concentrations of specific sub-groups of people facing economic, cultural, or linguistic barriers to health care. In Reading, most residents are Hispanic (67.7%) and African American (13.3%). Spanish is the first language in 53.3% of homes in Reading. If funded, this grant will embed certified peer specialist and certified recovery specialist in every clinical care treatment team with a focus of hiring diverse staff with lived experience to reflect all aspects of diversity within the community served. BCC will expand efforts to address the SDOH and the impact they have on MH and SUD treatment, recovery and overall physical health outcomes by hiring additional case managers to a assure aa case manager is embedded on every clinical care team. BCC will provide bus passes, taxicab fare or transportation in company vehicles for clients identifying transportation as a need. If food insecurity or lack of medication is identified, case manager will work to resolve underlying issues and as a result, 80% of client will show resolution of at least one barrier at follow up SDOH screening. BCC will continue to evaluate and address local health disparities including but not limited to stigma, race, ethnicity, socioeconomic status, sexual orientation and gender identity, to improve access to patient centered, whole person care for all members of the community. BCC staff will attend DEI Cultural Competency Training and will take a lead in promoting non-judgmental, welcoming and affirming safe space for care of LBGTQ, BIPOC and any other marginalized ethnic population. AS a result, BCC will reduce the level of perceived stigma, as evidenced by an increase n the number of clients identifying as LGBTQ, BIPOC or other ethnic population clients both seeking and remained engaged in treatment by 15% per year. A diverse representative group of BCC staff and patient volunteers will review all policies, procedures, and marketing material and evaluate for biases on an annual basis. BCC will convert a restroom located on the main floor of building into an "all gender" restroom in the first year of the grant. BCC will improve client experience of care and outcomes by involving clients and family members in care and affording them an opportunity to play a broader role in the governance of the CCBHC including increasing client and family feedback as part of CQI efforts and utilizing that feedback to address barrier sand enhance services and supports by inviting up to two, active or graduated clients, to join the Advisory Work Group each year of the grant. BCC will facilitate two annual focus groups consisting of a mix of clients, graduated clients, and family members to evaluate the services and programs oat BCC and ways to improve them. BCC will serve 140 clients in year one, 185 in year two, 230 in year three, 275 in year 4 for a total of 830 unduplicated individuals during the timespan of the grant.

Comprehensive Healthcare (CHC), a Community Mental Health Center with 50 years of experience, strives to improve and advance the CHC Certified Community Behavioral Health Clinic (CCBHC) Project within Yakima County, Washington. Comprehensive Healthcare seeks to improve access to community-based mental health and substance use disorder treatment and support, including 24/7 crisis services, to anyone in the Yakima County service area who needs support, regardless of their ability to pay or place of residence. As a CCBHC, CHC continues to focus on serving any individual with a mental health or substance use disorder who seeks care, including those with serious mental illness (SMI), substance use disorder (SUD) including opioid use; children and adolescents with serious emotional disturbance (SED); individuals with co-occurring mental health and substance disorders (COD); and individuals experiencing a mental health or substance use-related crisis. CHC strives to address health disparities and provides services to individuals regardless of race, ethnicity, sex, sexual orientation, gender identity, age, and/or socioeconomic status. Over the course of this four-year grant CHC will serve a total of 5200 unduplicated individuals: 1000 in Year One, 1200 in Year Two, 1400 in Year Three, and 1600 in Year Four. Strategies and interventions will include system and service transformation to enhance responsiveness and support for a wide array of clinical needs, implementing chronic disease management, increased substance use disorder services, enhancement of the CHC Walk-in Clinic, improving the identification of and response to suicide risk, increased services and supports for homeless individuals, increasing access to peer support specialists, and training to increase practitioner skills and competencies. Goals and objectives will be achieved by improving service delivery structures through enhanced outreach and engagement by hiring additional staff to increase service delivery capacity, adding a Medical Assistant position at the Walk-in Clinic, implementing use of the Columbia Suicide Severity Rating Scale (C-SSRS), implementing the Just in Time prescribing model, and hiring of bilingual staff and/or representatives of marginalized populations to support services to underserved populations. CHC will further enhance services through ongoing targeted training of staff and consultants including but not limited to Motivational Interviewing, cultural competency, trauma informed services, developmentally appropriate care, and treatment of older adults.

Through SAMHSA’s Certified Community Behavioral Health Clinic (CCBHC) Improvement and Advancement Grant, Community Mental Health Affiliates, Inc. (CMHA) will increase access to and improve the quality of community-based behavioral health and substance use treatment in order to effectively address the needs of adults, adolescents, and children with Serious Mental Illness (SMI), Co-Occurring Disorder (COD), Substance Use Disorder (SUD), and Serious Emotional Disturbance (SED) in central Connecticut. CCBHC service population includes individuals and families in CMHA’s greater New Britain service area, which includes the localities of: Berlin, Bristol, Burlington, Kensington, New Britain, Plainville, Plymouth, Southington, and Terryville. US 2022 Census data shows a target population of 253,286 which includes: 148,467 ages 18-64; 36,721 over age 65; 55,121 ages 6-17; and 12,977 under age 5. CMHA is the only agency which currently provides CCBHC services to a primarily and historically underserved population of adults, children and families in the central Connecticut region. Last year, CMHA served 3,170 consumers in this target area – 2,706 adults 18 and over (including 476 age 60+); and 464 children and adolescents age 1-17. Nearly half (44%) are Caucasian, 39% are Hispanic (a majority are Puerto Rican), 13% are African-American, and 4% are other/unknown. Most (93%) fall at/below 200% of the Federal Poverty Level, with 67% on Medicaid and 26% on Medicare, and nearly all (90%) have been exposed to trauma. Approximately 13% speak Spanish as their primary language. More than half (52%) identify as female, and 47% identify as male, with 1% transgender/nonbinary. The majority (81%) are heterosexual, with 12% indicating LGBTQ+. Agency and community data indicates a need for more Open Access hours; continued services and supports for Veterans/Military; Targeted Case Management (TCM) and intensive care coordination for adults age 60+ and Arabic speaking populations; and increased access to treatment for children and youth. CCBHC goals include: 1) Support recovery from mental illness and/or SUD among target population adults, children and families through expanded 24/7 Mobile Crisis, Open Access Clinic, and Respite Services; 2) Reduce behavioral health issues, disparities, trauma symptoms, suicide, and substance use among target population children, adolescents, and adults through enhanced clinic and community-based treatment services; 3) Reduce the likelihood of chronic disease and premature death among target population adults and children through CCBHC-embedded integrated primary care; 4) Promote wellness and recovery among CCBHC consumers by enhancing psychiatric rehabilitation, peer, and family recovery supports; 5) Equip CCBHC staff with the skills to care for specialized populations and reduce behavioral health disparities; 6) Meet CCBHC goals/objectives by creating project management and governance structures; and 7) Implement infrastructure activities and assessments to improve and sustain CCBHC services. CMHA’s CCBHC will serve a total of 700 individuals over four years.

SERV Centers of New Jersey (SERV), a not-for-profit behavioral health organization serving individuals across New Jersey proposes to improve its Certified Community Behavioral Health Clinic (CCBHC) program, Partners in Wellness, at its Clifton Community Behavioral Health Center under funding opportunity SM-23-016. SERV provides CCBHC services to individuals of all ages at its Passaic County, NJ, location, and will enlarge its geographic catchment area from Passaic County to include bordering towns in Bergen, Essex, Hudson, and Morris Counties. SERV's proposal has three goals: 1. Improve access to behavioral health services to underserved communities in the catchment area, 2. Ensure the availability of evidence-based crisis services in the proposed catchment area, 3. Improve individuals' behavioral health care outcomes and efficiency of services. SERVs CCBHC program will collaborate with local psychiatric emergency response, methadone treatment providers for opioid use disorder, inpatient/residential service providers for substance use disorder, medical and supportive services for individuals at risk of infectious diseases, and community stakeholder organizations in the catchment area. SERV has existing care coordination contracts with Straight & Narrow (Catholic Charities), Turning Point, EDGE NJ, St. Joseph's Healthcare System, and NJCRI and will finalize partnerships with other service and referral partners. To support this work, SERV will hire a full-time licensed clinician, two on-call crisis clinicians, one Certified Peer Recovery Specialist (CPRS), two on-call crisis CPRS, one APN, one Crisis Coordinator, one Intake Specialist, and a driver. SERV proposes to expand the accessibility of services by addressing barriers to care like transportation, language access, low-cost care access, and availability of services. SERV will develop a transportation program to ensure individuals without personal transportation can receive services. CPRS will conduct outreach in rural, Hispanic/Spanish-speaking, and other underserved communities within the catchment area. These goals will be conducted using evidence-based practices, including Seeking Safety, a trauma-informed intervention effective in reducing substance use among women who have experience trauma and have a substance use disorder; Screening, Brief Intervention, and Referral to Treatment (SBIRT), protocol; Trauma-Focused/Cognitive Behavioral Therapy, a counseling modality with longstanding success among individuals with S/MI and/or SUD conditions; Motivational Interviewing, a recognized engagement practice for structured communication to promote behavior change; Wellness Recovery Action Planning, an evidence-based practice to address mental health needs, which affect 80% of the individuals SERV serves. Throughout all CCBHC-IA services, SERV will ensure that individuals receive care that is recovery-focused and is culturally and linguistically appropriate to meet their unique context and care needs. All new staff will be trained on national standards for Culturally and Linguistically Appropriate Services (CLAS) and their implementation in a behavioral health setting. Throughout the project period, SERV will remain in compliance with the CCBHC Criteria, and beginning July 1, 2024, SERV will comply with the updated criteria.

As a CCBHC-IA awardee, ICL (Institute for Community Living, Inc.) will improve and advance outreach, engagement, and integrated behavioral health treatment for 1,000 at-risk residents of Brooklyn, NY across the lifespan. i.e., children, youth, adults and their families through a Whole Family Health Model (WFHM), with a focus on Spanish-speaking populations, recent immigrants and asylum seekers, and veteran families. The Health Hub CCBHC serves the geographic catchment area of Bedford-Stuyvesant, East New York/Starrett City/Cypress Hills, and Brownsville/Ocean Hill in Brooklyn, New York. These neighborhoods are among the most at-risk, high-need areas in NYC, with disproportionately poor health outcomes. They are home to primarily communities of color, including a large number of immigrants. ICL’s Health Hub, located in East New York, Brooklyn, delivers integrated, holistic care in a single site in partnership with our co-located FQHC partner, Community Healthcare Network, Inc. (CHN); services include primary care, family support, MH/SUD outpatient programs, recovery programs, and care coordination to address behavioral and physical health concerns of the highly diverse, underserved local population. CCBHC funding will enable us to continue to address significant health disparities experienced by Latino families with children, who lack health insurance, and experience other barriers to quality care. We will extend our outreach efforts to new immigrants and asylum seekers, who have come to NYC in great numbers over the past few months. The project’s goals are to: (1) Increase access to comprehensive BH services for individuals and families, with limited resources, language, and other barriers to care; (2) Improve BH and other outcomes for individuals and families, with limited resources, language, and other barriers to care; and (3) Enhance CCBHC Infrastructure to promote care coordination, monitoring, and advancement. To encourage outreach and engagement, we will utilize a comprehensive Spanish outreach initiative, engage community partners, such as shelters, and conduct bi-weekly presentations to local providers and agencies to streamline referrals into the CCBHC. We will enhance our capacity to serve our Spanish-speaking clients by adding bilingual case management staff. In addition, we will continue to intensify services for veteran families. We will collaborate with CHN to provide primary care screening, monitoring, and services to our clients. As a part of our WFHM, we will continue to develop a Family Care Plan in our EHR and improve care coordination with other providers via electronic data sharing. To ensure services are responsive to community needs, we will convene a bilingual Advisory Work Group and conduct comprehensive needs assessments that will inform our staffing, training, and service activities. The project will serve 250 unduplicated individuals in each year of the project and 1,000 individuals over the course of the 4-year grant.

Hopewell Health Centers (HHC) is a Federally Qualified Health Center and Community Mental Health Center serving Southeastern Ohio. It has been a SAMHSA certified CCBHC since 2021. The target population are the 18,000 residents in the seven county service region who are diagnosed with a severe mental illness and can benefit from CCBHC services. Through this project, HHC will enhance services at existing CCBHC sites and expand to an additional county (Washington) and two clinics (Belpre and Marietta) resulting in an additional 550 new clients receiving CCBHC services in the region.

The Frontier Health CCBHC Expansion project will be implemented int he geographic catchment area of Northeast Tennessee (NE TN) & Southwest Virginia (SW VA) also known as Appalachian Highlands (AH). The population of focus will be any AH's a race/gender/sexual orientation underserved low-income adults with serious mental illness (SMI), serious substance use disorder (SUD) or co-occurring disorder (COD) with barriers to traditional services: those with co-morbid conditions and any race/gender/sexual orientation children with serious emotional disturbance (SED). The project will impact & address behavioral health disparities in low-income male, female, transgender; white, black Hispanic; older adults; veterans; and higher acuity clients while ultimately benefiting our entire 37,700-person client base through improved services & expanded technical/clinical capabilities including interpretative services in English, Spanish, & American Sign Language.

Project Summary: South Central Family Health Center (SCFHC) has been delivering high quality health services to diverse, low-income residents of Los Angeles, California for four decades. SCFHC is a nonprofit community health center with Federally Qualified Health Center designation obtained in 2002, operating ten sites and a pharmacy. With funding, we will improve our CCBHC, established in 2020, by expanding the CCBHC from one site to all ten of our sites. Geographic Catchment Area: Our service area encompasses eight zip codes in South Los Angeles County, and five zip codes in Southeast Los Angeles County. Project Name: CCBHC-IA to Serve Diverse Populations in South/East Los Angeles County, California Populations to be served: Our CCBHC will serve low-income adults and children in South and Southeast Los Angeles who have behavioral health diagnoses, including severe mental illness, severe emotional disturbance, substance use disorders, and co-occurring disorders. SCFHC anticipates serving primarily low-income Hispanic and African American individuals in a service area that is 98% non-white. Number to be served: Year 1: 175; Year 2: 200; Year 3: 250 Year 4: 250; Life of project: 875 Project strategies/interventions: SCFHC will use the following evidence-based interventions in combination: Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), Medication Assisted Treatment (MAT), Patient-Centered Medical Home (PCMH), and Trauma-Informed Care (TIC). These interventions and screenings are delivered in English and Spanish. Project goals and measurable objectives: Our goals include: Increase awareness of available mental health care, including services for severe emotional disturbance, serious mental illness, and/or substance use disorders; Decrease the symptoms of psychological distress among CCBHC patients; Improve cultural competency to better serve diverse patients; and Reduce the incidence of suicide attempts and death by suicide. Measurable objectives are as follows: (1) Each year, maintain a social media presence to raise awareness of CCBHC services, to reach 500 individuals per year; (2) By the end of year 1, develop a CCBHC brochure to distribute in the service area; distribute 1,000 copies each year; (3) Each year, screen 90% of those projected to be served by the CCBHC for depression and anxiety; 75% of at risk patients will accept a referral to mental health services; (4) Each year, 65% of CCBHC patient will have reduced risk for anxiety as indicated by assessment scores; (5) Each year 65% of CCBHC patient will have reduced risk for depression as indicated by assessment scores; (6) Provide cultural competency training to 100% of CCBHC direct service providers; (7) Each year, screen 90% of those projected to be served by the CCBHC for suicide risk; 75% of those at-risk will accept referral to targeted case management; and 85% of those at-risk will develop a crisis plan.

Project Summary: Catholic Charities, Diocese of Trenton (CCT), with over a century of service, focuses on promoting recovery and strengthening families in New Jersey. Through CCBHC-IA, CCT will expand its CCBHC behavioral health and mental health services to underserved communities in Mercer and Burlington Counties. Through this project, CCT will grow services for individuals of all ages with behavioral health diagnoses in its catchment area. Geographic Catchment Area: Mercer and Burlington Counties, New Jersey Project Name: CCT CCBHC Improvement and Advancement to Serve Individuals with BH Diagnoses in Mercer and Burlington Counties, New Jersey Populations to be served: Our CCBHC will serve low-income, uninsured adults and children, primarily Black/Latino, with a behavioral health diagnosis, including Severe Mental Illness (SMI), Serious Emotional Disturbance (SED), Substance Use Disorders (SUD), and co-occurring disorders (COD). Number to be served: Year 1: 210; Year 2: 315; Year 3: 315 Year 4: 315; Life of project:1,155 Project strategies/interventions: CCT will use a combination of several evidence-based- interventions, including Illness and Management Recovery (IMR), Motivational Interviewing (MI), Medication Assisted Treatment (MAT), and Trauma-Informed Care. Project goals and measurable objectives: CCT’s goals for this project include: Increase the number of individuals who are aware of mental health resources; Decrease symptoms of psychological distress through increased access to mental health services, Reduce suicide risk, and prevent death by suicide; Reduce the prevalence of alcohol misuse and related risks; and Reduce the incidence of substance use, including opioids. CCT’s corresponding CCBHC-IA measurable objectives include: Each year, we will reach 5,000 individuals through a media and in-person campaign to raise awareness of CCBHC services; Each year, we will conduct outreach and education at appropriate, targeted venues at six (6) community events, to reach a total of 600 individuals per year; Each year, screen 90% of those projected to be served by the CCBHC for mental health conditions, (PHQ-9, GAD-7); 85% of those at-risk will accept a referral to mental health services; Each year, 65% of CCBHC patients will have reduced risk for depression and anxiety, as indicated by improvements in PHQ-9 and GAD-7 scores between assessments; Each year, screen 90% of those projected to be served by the CCBHC for suicide risk using C-SSRS; 85% of CCBHC patients screened at-risk for suicide will develop a crisis plan, and 85% of those at-risk will accept a referral to targeted case management services; Each year, screen 90% of those projected to be served by the CCBHC for substance use, using DAST10/20 and AUDIT-C; 75% of those at-risk will accept a referral to SUD services and; Each grant year, 65% of CCBHC patients will have reduced substance use, as indicated by improvements in screening scores between DAST10/20 and AUDIT-C assessments.

The NorthKey Certified Community Behavioral Health Clinic Improvement and Advancement (CCBHC-IA) Project will support the expansion of integrated behavioral healthcare to children, adolescents, and adults in the eight county Northern Kentucky region. Emphasis will be placed on outreach and service to individuals who face barriers related to inadequate access to healthcare or who belong to historically marginalized groups. This initiative will include transportation, public education, care coordination with law enforcement, crisis response, and physical health promotion. As a CCBHC certified by the Commonwealth of Kentucky and a Joint Commission accredited and licensed Regional Community Mental Health Center, NorthKey will implement strategies to close the treatment gaps that exist in Northern Kentucky to ensure a comprehensive, integrated, coordinated, and person-centered system of behavioral healthcare is sustained. The region served by NorthKey represents over 470,000 individuals in a community devastated by the opioid epidemic. The racial demographic is primarily white, with a broad range of economic diversity across the urban, suburban, and rural counties. The number of Kentuckians reporting frequent mental distress has increased, and co-occurring physical health conditions exacerbate the well-being of Northern Kentuckians. The average ratio of mental health providers in the region is only 1,320:1, as compared to 390:1 for Kentucky. Similarly, the average ratio of physical health providers is 2,518:1, as compared to 1,540:1 for Kentucky. There is an urgent need to ensure immediate access to integrated behavioral healthcare to everyone in the region regardless of their ability to pay or place of residence. NorthKey's Health Equity and Diversity committee will take the lead in specifically addressing disparities that exist for Black, Indigenous, People of Color (BIPOC); LGBTQ individuals; and persons of lower socioeconomic status. This project will: (1) increase the penetration rate of adults and youth with serious mental illness, serious emotional disturbance and substance use disorders served by the CCBHC, (2) expand suicide prevention outreach, treatment and care coordination efforts for adults and youth identified at risk for suicide and (3) increase the availability of integrated physical health and primary care support to ameliorate chronic co-morbidities that drive poor health outcomes. Objectives for the NorthKey CCBHC-IA project include: reduce missed visits by providing transportation; expand financial and insurance enrollment assistance; increase public education to promote access to services and reduce stigma; increase care coordination with community partners to support effective care transitions; expand the consumer advisory council; partner with law enforcement to coordinate crisis care; improve care transitions with regional hospitals and emergency departments; expand workforce to specialize in school crisis response; increase collection and monitoring of physical health measurements; utilize Community Health Workers to provide health education and healthcare navigation; and expand primary care services to improve health outcomes. Key activities include: continued partnership in the Kentucky CCBHC Demonstration project; specialized services and care coordination for members and family of the armed forces and veterans; meaningful involvement of consumers and family members in design and evaluation of services; updated community needs assessment; and the development of a sustainability plan. This project will serve 1,190 unduplicated individuals: 275 in year one, 290 in year two, 305 in year three, and 320 in year four.

Kennebec Behavioral Health (KBH)is seeking to improve and advance its existing CCBHC program in Somerset County, Maine. KBH, along with its DCO, Crisis and Counseling, currently provides the nine SAMHSA required activities to its CCBHC clients in Kennebec and Somerset Counties in Maine. Through the CCBHC Expansion Grant, KBH has expanded access, developed care coordination capacity, and established new competencies in each area. With NOFO SM-23-016, Certified Community Behavioral Health Clinic Improvement and Expansion Grant, KBH will implement improvements and enhancements for populations with the greatest unmet behavioral health needs. The CCBHC-IA services will be focused on Somerset County, where there is significant and multiple health disparities. The goals and objectives for KBH's CCBHC IA grant are the following: GOAL 1: Improve mental health outcomes of clients in Somerset County, including children aged 0-18 with SED and persons of all ages who are at risk of SMI, SUD, and COD, with expanded focus on chronic conditions. Objectives include developing and utilizing a population health dashboard to enhance monitoring and reporting capacity on health data, quality measures, gaps in care, and quality improvement initiatives. GOAL 2: Enhance access to care to improve health outcomes for children aged 0-18 and young adults aged 18-25 experiencing trauma and/or living in poverty in Somerset County. Objectives include identifying and implementing standardized screenings for trauma and social determinants of health for children aged 0-18 and young adults by 9/30/24. GOAL 3: Enhance access to care to improve health outcomes for veterans and military-connected people in Somerset County. Objectives include increasing access to care for veterans and military-connected people by hiring a full time Military/Veterans Liaison who will support engagement, and provide coordinated care and consultation. GOAL 4: Enhance access to care to improve health outcomes for persons with SUD and COD in Somerset County, with a focus on individuals with justice system involvement. Objectives include providing specialized case management services focusing on recovery and harm reduction to adults with SUD and COD in the Somerset County Community Corrections re-entry program. During the four-year grant period, KBH will serve a total of 1150 unduplicated individuals.