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Summary: EHN seeks to address the unmet needs of El Paso residents by expanding its services to youth and young adults and fill in services gaps in the services currently received by individuals between the ages of 16 to 25. The goal is to ensure these individuals receive the same intensive care throughout their transition and assist them in the process. Project Name: Healthy Transition Program Population to Be Served: El Paso County males, females, and LGBTQ+ members, between the 16 to 25 years old, experiencing some serious emotional disturbance (SED), and/or serious mental illness (SMI), prominently Hispanics (83%). Project Goals and Objectives: EHN has established three goals to guide project delivery and systemic implementation. First, to enhance and expand access for transition-aged youth and young adults including the continuity of care and support. Second by establish a mechanism for referral to appropriate treatment and recovery support and. Lastly, the implementation of public awareness and cross-system provider training. EHN aims to accomplish these by establishing a clubhouse model for these individuals, by providing behavioral health interventions, and utilizing a referral and screening process to identify the correct services. EHN will also establish referral procedures, conduct a needs assessment, and a strategic plan. EHN will also establish referral procedures and conduct a needs assessment and a strategic plan. Finally, EHN will develop, implement, and provide a training plan for mental health professionals and providers on the developmental needs of the transition-age group. Number to Be Served: The Healthy transition grant will enable EHN to provide transition services to these individuals and intends to serve the following people for the length of the program: EHN will serve a total of 250 unduplicated young adults, 50 each year for 5 years. Another 375 referrals to treatment and support services, 75 referrals each year for 5 years. Lastly EHN will train 500 health professionals in the development needs of transitional-age youth and young adults, 100 each year, for 5 years.

Harbor Homes, Inc. d/b/a Harbor Care will implement a state-wide evidence-based methamphetamine and stimulant use disorder treatment and recovery support services program (MERIT) for priority populations that misuse methamphetamines/ stimulants: (1) adults who are homeless or at risk of homelessness, and (2) adults who have high imminent risk of harm in accordance American Addiction Society of Medicine (ASAM), to include those who have recently overdosed, are intravenous drug users, pregnant/ parenting, and/or who have co-occurring disorders or tri-morbid medical/ behavioral health/ substance use disorders (Target Population). These individuals are the most likely to be polysubstance users and often require residential treatment with significant integrated medical care. The geographic service area includes all cities and towns within New Hampshire, with a focus on Hillsborough County (Target Region). Working with a wide range of statewide community partners including residential and outpatient substance use treatment and recovery housing providers, Federally Qualified Health Centers, and the statewide network of 19 Recovery Community Centers, Harbor Care’s proposed program, known as MERIT (Motivating and Empowering Recovery through Integrated Treatment), will provide integrated primary care, substance misuse treatment (residential and outpatient), mental health care/psychiatry, and oral health care, in conjunction with recovery housing, long-term and enhanced recovery support services, and specialty care services to 165 adults living with methamphetamine and/or other stimulant use (MSUDs) in NH over a 3-year period, including polysubstance users. Harbor Care will implement in-person and telehealth-based universal screening within 25+ service access points throughout NH used by the Target Population, to ensure those with the greatest need are recruited for the program. The project goal is to reduce NH’s most vulnerable community members’ MSUDs while facilitating self-sufficiency, through implementation of evidence-based programming and integrated primary/ behavioral health care throughout the public and private sector that addresses the Target Population’s whole health and wellness, social determinants of health and substance use/ co-occurring disorders. This goal will be met through four objectives over the three-year grant period: 1) Expand a comprehensive recovery-oriented system of care that is team-based and coordinated through all stages of recovery (pre-contemplation, acute treatment, relapse prevention) by integrating behavioral health (SUD treatment and mental health care), primary and oral health care, recovery support services and housing; transforming services across systems in accordance with the SAMHSA/HRSA-defined Level VI Integrated Care platform (Full Collaboration in a Transformed/ Merged Integrated Practice) between substance use disorder, mental health care, primary care, and oral health care providers. 2) Provide outreach to 425 homeless/at-risk individuals - including pregnant and parenting women, veterans, and individuals with co-occurring disorders - with MSUD (125 in Y1, 175 in Y2, 125 in Y3). 3) Provide integrated primary/ behavioral/ oral health care and SUD treatment, intensive case management, and individualized long-term recovery-oriented supports to 165 individuals (50 in Y1, 65 in Y2, 50 in Y3) who enroll in MERIT; 4) Train and/or educate 200 (50 in year one; 50 in year two; 100 in year three) of NH’s first responders, health and human service providers, and medical, behavioral, and peer recovery workforce to increase their capacity to apply best practices that can reduce the rise of MSUDs. Evaluation results will be shared with stakeholders through a conference in year 3 of the grant period. Grant-funded staff will utilize evidence-based practices through a trauma-informed, harm-reduction model to meet the needs of the population of focus.

The Lawrence County (IL) Health Department (LCHD) will deliver high quality substance use treatment, recovery and other needed services to at-risk pregnant and postpartum woman and their children within a three county service area (Lawrence, Crawford and Richland Counties) in rural southwestern Illinois. The project mission is to provide comprehensive services for pregnant and postpartum women with substance use disorders (SUDs), along with services for their minor children, in a residential setting that supports and sustains recovery. In order to fulfill this mission, LCHD will provide a continuum of care and services to a target population consisting of pregnant and postpartum women with SUDs who are living below the federal poverty level, uninsured, unemployed, and/or underemployed. There is significant need for this project because there is a tremendous lack of appropriate treatment and recovery resources available to this population in the region, especially safe and stable recovery housing. This will be a family-centered project that will provide these women and their families with care and services such as: 1) SUD screening, assessment, and treatment (including medication assisted treatment, if needed); 2) recovery support services; 3) behavioral health care; 4) primary health care; 5) case management and care coordination; 6) harm reduction services; 7) family and child development resources and supports; and, 6) additional human and social services and supports, as required. LCHD is seeking to reduce infant and maternal mortality among populations with high needs and health disparities, decrease disruption of the family families through improved access to treatment in a safe and stable living environment, and increase access to clinically appropriate care and services for these families. All care and services provided will be based on research-validated evidence-based practices (EBPs). The main project outcome will be significantly improved maternal and child health that in turn reduces the negative impact of substance use on project participants, their children and family members. Additional key outcomes achieved through the project include: abstinence from substance use among project participants; access to safe, decent and affordable housing; improved access to vocational development and employment opportunities; significant reductions in participant criminal justice system involvement; significantly increase access to, and retention in, treatment and recovery services; improved social connectedness; and, improved treatment and recovery outcomes among populations demonstrating health disparities. LCHD will carry out the project in close coordination with a wide array of community-based partner and collaborating organizations. LCHD is the largest public health provider in the service area, and also is the service area State designated Community Mental Health Center (CMHC). It has the organizational experience, expertise and capacity to carry out this project effectively. It has significant experience in the administration and oversight of federal grant funding, and is currently a SAMHSA grantee under the Certified Community Behavioral Health Clinic (CCBHC) grant program. LCHD is requesting $525,000 in funding annually over a five year project period.

Magnolia Women’s Recovery Program (MWRP) serves pregnant and parenting women 18 years and older who want to overcome their cooccurring substance use disorders (SUD) and mental health issues. Their minor children, partners, and family members also benefit from our services. The women struggle to overcome unaddressed adverse childhood experiences that have led them into cycles of addiction. MWRP will serve 16 women per year for a total of 80 women over five years in our residential, gender-specific, family-focused, healing-centered, trauma-informed environment. Our residential treatment program for pregnant, postpartum, and parenting women with co-occurring substance use and mental health disorders will close gaps and offer access to care not otherwise available to them. Strategies and interventions offered to women like “Allison” include: 1. Assessments and screenings: a. Women and family member screening and assessment for co-occurring disorders, b. Fetal Alcohol Syndrome Disorder screening for women and adult family members, c. Tobacco screening and NRT for women and adult family members, 2. Case management and connection to socioeconomic resources to build a sense of belonging, self advocacy, and holistic sustainability, 3. Trauma Informed Cognitive Behavioral Therapy + Dialectic Behavioral Therapy: a. Groups and individual sessions for women and children, b. short-term family counseling, c. Therapeutic supportive partners’ group, d. children’s group; this variety of counseling is appropriate because they have proven effective strategies to address the social determinants of health and co-occurring dependencies often linked to traumatic events and implement new coping methods, 4. Mental health and wellness education and treatment for minor children is an additional method to address the whole family because these activities ensure proactive ways to decrease the impacts from ACEs and other social determinants of health, 5. Family support: a. Parenting education for partners and family members during and after MWRP, b. The Celebrating Families! curriculum is an evidence-based program deeply aligned with the MWRP mission, leading to an increase in sustainable success of mothers due to caring support from families, 6. Art therapy for women and children is a somatic practice that aids women and children in processing the impacts of trauma. Goal 1 Substance Use: Decrease substance among 16 pregnant and post-partum women in the community by implementing EBPs at MWRP that address behaviors that lead to use disorders. By August 30, 2024, assess 16 participants for SUD, mental health, and other support services through tracking the numbers of women enrolled and SUD assessments conducted. Goal 2 Mental Health: Decrease number and frequency of mental health episodes among pregnant and post-partum women in the community by implementing evidence-based programs at MWRP that teach coping and self-actualized care skills. By August 30, 2024, conduct 52 group therapy sessions (once per week) and 832 individual sessions (once per week per person) with the 16 women enrolled in program and will be measured using data indicating the number of group and individual therapy sessions held and attended. Goal 3 Healthy Families: Increase healthy behaviors among pregnant and postpartum women their children, partners, and families by implementing EBPs at MWRP that tackle behaviors that lead to unhealthy outcomes and substance use. By August 30, 2024, hold nutrition (52 hours), smoking cessation (52 hours), child development and parenting (104 hours) classes for 16 women enrolled in the program. This will be measured by the number of nutrition, smoking cessation sessions and nicotine replacement therapies (NRT) distributed and used, child development and parenting classes held.

Through the Concord Children's Interconnected Systems Project, the Concord School District (CSD), in direct collaboration with Riverbend Community Mental Health Center, will serve as a hub for school-based mental health services, family behavioral health education, and timely facilitated referrals for external clinical care. As New Hampshire's capital city, Concord is home to over 4,000 pre-K through grade 12 public school students, more than a third of whom qualify for free or reduced lunch. All five elementaries, the single middle school, and the sole high school are perennially Title I schools, and at any given time, 80-150 of our students experience homelessness. As the state's most common refugee resettlement community, Concord has welcomed thousands of New American students to its schools over the past decade. Pre-pandemic, 35% of CSD high schoolers reported symptoms of clinical depression; that figure has risen to 39%, as has the number who have seriously considered suicide (23%). The overarching goals of the project are to: 1) Build the capacity of stakeholders with a shared interest in and responsibility for children's mental health through intentional collaboration, workforce development, community-wide training, and codified policy change; 2) Implement tier 1, preventative approaches in classrooms, preschool - grade 12, to create an equitable school climate that supports students' behavioral health needs in a post-COVID world; 3) Respond to the increasing need for targeted interventions through expanded social work and alternative education capacity at the middle school, the facilitation of skills groups in the elementary schools, and the implementation of restorative practices at the secondary level; and 4) Mitigate barriers to clinical care needed by school-aged youth and young adults with SED/SMI by establishing responsive pathways to school- and community-based individual therapy, Wraparound, and crisis intervention. To respond to the increased behavioral health needs of students, care coordination infrastructure is a chief priority; two CMHC/School Liaisons and a Home-to-School Liaison will be the conduit between the school district, community mental health center, and families to effectively facilitate co-located services, participate in a multi-tiered system of supports for behavioral health and wellness (MTSS-B), and support school- and community-based prevention programming. The District and Riverbend will partner with the State Departments of Health & Human Services and Education, youth- and family-serving entities (e.g. Concord Family YMCA, Parent Information Center), and local health and social service providers (e.g. Waypoint, Community Bridges) for training and technical assistance. Tier 1 prevention programming, including evidence-based, developmentally appropriate mental health training and social-emotional instruction with a trauma-responsive lens, will benefit all students in the district, with a targeted focus on primary grades and middle school. This project will also clinically serve 10% of our student population through tier 2/3 services per year for a total of 1,600 unduplicated youth enrolled in school- and/or clinic-based mental health services throughout the project. We will work with no fewer than 800 families, through training and family therapies, project-wide.