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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.

Centerstone will plan, develop, and implement a new CCBHC in Fort Myers, Florida (C-CCBHC), to provide comprehensive, integrated, coordinated, person-centered behavioral health care; improve access to community-based mental health and substance use disorder treatment; and support 24/7 crisis services, regardless of an individual’s ability to pay or place of residence. C-CCBHC will serve 900 unduplicated individuals (Y1: 80; Y2: 220; Y3-4: 300/yr.). C-CCBHC will serve any individual with a mental or substance use disorder who seeks care at Centerstone’s Ft. Myers CCBHC, including those with serious mental illness (SMI); substance use disorder (SUD), including opioid use disorder; children and adolescents with serious emotional disturbance (SED); individuals with co-occurring mental and substance disorders (COD); and individuals experiencing a mental health or substance use-related crisis. C-CCBHC’s focus population demographics are expected to mirror area individuals and current clinic clients: 66% White; 8% Black; 23% Hispanic/Latino, with 49% male and 51% female. Of the area’s nearly 1,130,100 adults, 23% are expected to have AMI; 5.5%, SMI; 17%, SUD; 2%, OUD; and 8%, COD. Among the roughly 231,410 youth, 20% are expected to have major depressive episode; 5%, SUD; 1%, OUD. Key C-CCBHC strategies include increasing access/availability of services responsive to community needs (e.g., crisis services; screening/assessment/diagnosis, including risk assessment; treatment/crisis planning; outpatient mental health/substance use services; primary care screening and health monitoring; targeted case management; psychiatric rehabilitation; peer and family supports; and community-based mental health care for Armed Forces/Veteran populations); meaningfully involving service recipients/families in their care; and applying a continuous quality improvement (CQI) approach. C-CCBHC will integrate SAMHSA’s TIP 59: Improving Cultural Competence and 57: Trauma-Informed Care in Behavioral Health to implement evidence-based interventions addressing the full array service recipients’ behavioral health needs (e.g., Cognitive Behavioral Therapy, Motivational Interviewing, Dialectical Behavior Therapy, Assertive Community Treatment, Multi-Systemic Therapy, Parent Management Training, Seeking Safety, Integrated Dual Disorders Treatment, MAT, Illness Management and Recovery, and DIMENSIONS). C-CCBHC will accomplish the following goals: 1) Establish comprehensive, integrated, coordinated, and person-centered community-based services via the CCBHC; 2) Enhance infrastructure/capacity for a full continuum of quality/inclusive coordinated care; 3) Increase access to/availability of timely/high quality services; 4) Implement a measurement-based care process to ensure a comprehensive scope of evidence-based services/supports; 5) Improve health status/outcomes for treatment service recipients across the lifespan; and 6) Apply a CQI approach to drive systems, improve the quality of services, and ensure ongoing service delivery. As a result of these goals/improvements, the project will achieve the following measurable service recipient-related objectives: Decrease symptomatology among 45% with mental health disorders; decrease substance use among 45% of those with SUD/OUD/COD; provide ITPs for 100% of service recipients; improve housing stability among 80% who are homeless/marginally housed; provide 100% with employment case management services per ITPs; improve health indicators among 75% of participating service recipients; reduce past 30-day tobacco use by 30% among tobacco cessation activity participants; achieve no past 30-day criminal justice system involvement among 60% with criminal justice histories; achieve no past 30-day ER/hospitalizations among 60% of service recipients with hospitalization histories; achieve/maintain an 80% follow-up rate; and achieve satisfaction of experience/care among 80% of service recipients/families.

Project Summary: Southland Integrated Services (Southland) is a non-profit, community-based health center, with Federal Qualified Health Center (FQHC) designation since 2015. Southland was established in 1979, to support the resettlement of refugees. We have expanded operations over the years in response to the rapidly evolving needs of the area Vietnamese-American population. Already operating as a “satellite” DCO for another grantee, we are now prepared to establish our clinic independently as a CCBHC. Geographic Catchment Area: Orange County, of southern California Project Name: CCBHC for Orange County Adults and Children with MH/SUD conditions Populations to be served: Orange County residents of all ages (children, adults, seniors) with a behavioral health diagnosis, with emphasis on those with SMI, SED, SUD, and COD, including low-income residents, and/or Vietnamese individuals in need. Number to be served: Year 1: 125; Year 2: 200; Year 3: 225 Year 4: 250. Life of project: 800 Project strategies/interventions: Southland will use a combination of several evidence-based- interventions, including Cognitive Behavioral Therapy, Family Psychoeducation, Assertive Community Treatment, and Strengths-based Case Management. These interventions and screenings will be provided in English, Vietnamese, and Spanish. Project goals and measurable objectives: Our goals include: reduce suicide risk; prevent death by suicide; decrease symptoms of psychological distress; reduce cultural stigma; increase access to MH and SUD care by increasing awareness of services; and reduce use of substances. Our Measurable objectives include: (1) Each year, screen 80% of those projected to be served by the CCBHC for suicide risk; 70% of those at-risk will accept referral to targeted case management. (2) Each grant year, 80% of CCBHC patients screened at-risk for suicide will develop a crisis plan. (3) Each year, screen 80% those projected to be served by the CCBHC for depression; 70% of those at-risk will accept referral to mental health services. (4) Each grant year, 60% of CCBHC patients will have reduced risk for depression as indicated by improvements in PHQ-9 scores between assessments. (5) Each grant year, screen 80% of those projected to be served by the CCBHC for trauma; 50% of those at-risk will accept referral to services. (6) Each grant year, reach 1,000 people through a social media campaign, focusing on CCBHC content and education. (7) Each grant year, distribute 5,000 CCBHC brochures developed in multiple Asian languages, electronically, and in strategic locations across the service area. (8) Each grant year, provide three (3) community educational workshops. (9) Each grant year, screen 80% of those projected to be served by the CCBHC for substance use; 70% of those at-risk will accept referral to SUD services. (9) Each grant year, 60% of CCBHC patients will have reduced substance use, as indicated by improvements in screening scores between assessments.

North Central Behavioral Health Systems (NCBHS) will provide comprehensive, coordinated behavioral health care to children and youth with serious emotional disturbance (SED), adults with serious mental illness (SMI), and people with substance use disorders (SUD) and/or co-occurring disorders (COD) in the service area of LaSalle County, Illinois. Individuals experiencing a mental health or substance use-related crisis, service members, veterans, and military families will also receive care. As a Certified Community Behavioral Health Clinic (CCBHC), NCBHS will provide a comprehensive range of services to the population of focus, including expanding primary care screening; monitoring of behavioral health and physical health conditions for individuals of all ages; expansion and enhancement of the crisis system of care; screening, assessment, and outpatient and community-based EBPs for clients of all ages; and Medication-Assisted Treatment/Recovery services for people with opioid use and alcohol use disorders. NCBHS expects to reach 2,520 children, youth, and adults over the course of the 4-year grant. NCBHS CCBHC has five goals: (1) establishing the CCBHC infrastructure; (2) establishing universal screening, assessment, and monitoring of mental health, substance use, and physical health conditions; (3) ensuring access to integrated primary care and behavioral health care and continuity of care for individuals with complex needs; (4) expanding access to Medication-Assisted Treatment/Recovery services for individuals with identified needs; and (5) establishing a behavioral health urgent care clinic model to decrease the use of hospitals and emergency rooms. NCBHS will implement, expand and enhance nine required services as part of its CCBHC and will have the organizational capacity to provide comprehensive, coordinated, integrated, culturally competent, trauma-informed, recovery-oriented, and person- and family-centered behavioral health services that meet all CCBHC requirements. NCBHS offers and will enhance a comprehensive array of evidence-based practices (EBPs) that meet the cultural and linguistic needs of the children, youth, and adults it serves. The array of EBPs will help individuals with SMI, SED, SUD, or COD achieve their recovery goals. NCBHS will expand its capacity over the 4-year period to measure, assess, and report on client outcomes, clinical quality measures, and its performance as a CCBHC.

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.

Agape Health & Wellness Center Project Primary and Behavioral Health Integration ABSTRACT Agape Health & Wellness Center, Inc (Agape) a non-profit organization in Jacksonville, FL, provides treatment and services to individuals of all demographics and cultural backgrounds with a core focus in primary health, behavioral health, substance use, housing, and HIV/ AIDS testing, counseling and education to both adults and children. Agape proposes to implement Project Primary & Behavioral Health Integration (PBHI) by seeking funding to transform its community clinic and service compendium into a health center delivering high-quality behavioral health services that are person- and family-centered, integrated, comprehensive, and coordinated. To accomplish this, Agape proposes to implement Project PBHI to establish a Certified Community Behavioral Health Clinic (CCBHC) offering services including, mental health, substance abuse, primary care, and mobile 24-hour crisis intervention unit. Project PBHI will target individuals with a mental or substance use disorder who seek 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 and substance disorders (COD); and individuals experiencing mental health or substance use-related crisis. Number of Unduplicated Individuals to be Served with Grant Funds Year 1 Year 2 Year 3 Year 4 Total 100 150 150 100 500 Project PBHI will utilize a multidimensional crisis intervention approach that links clients into an array of services and compendium of evidence-based practices designed to specifically improve the lives of the population of focus. Project PBHI will achieve the goals and objectives by recruiting, hiring/assigning, and training a competent and multidisciplinary team that is comprised a Project Director, Psychiatric Medical Director, Family Nurse Practitioner, Licensed Professional Counselors, Licensed Vocational Nurse, Substance Abuse Counselors, Recovery Support Specialist, Patient Navigators, and Evaluator.

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.

Ravenwood Health, a Geauga County, OH behavioral health care provider with 57 years’ experience serving children, adolescents, and adults with mental health and substance use disorders, will achieve systems-wide and individual-level outcomes with the CCBHC model. The project will serve 650 children and adults over four years, expanding access to care, and linkage to EBP services informed by university-based fidelity models from nationally-recognized researchers. Ravenwood Health’s proposed project serves 1) adults with severe mental illness; 2) children and adolescents with serious emotional disorders (SED), and 3) individuals with co-occurring mental and substance abuse disorders. This population of focus resides in Geauga County, a predominately rural catchment area that is home to an historically African-American enclave in the northwest corner of the County that is affected by the social determinants of health. The project serves 70 individuals in year 1, 130 in year 2, 200 in year 3, and 250 in year 4. The project goals and objectives are informed by a county-wide needs assessment, the 2023-2025 Geauga County Community Health Improvement Plan, which identifies Behavioral Health and Health Care Access and Quality as two of its top 3 health gap priorities. The project goals are two-fold, producing systems-wide and individual-level outcomes. First, Ravenwood Health will improve access to care on a systems-wide level within the catchment area through the full implementation of the CCBHC model by 9/29/2027. Objective A. Establish a comprehensive health care model which includes care coordination services at Ravenwood Health CCBHC. Objective B. Expand the diversity, equity, and inclusion of Ravenwood Health CCBHC for individuals in need of mental health services. Objective C. Increase and enhance evidence-based practices (EBP) in place at the Ravenwood Health CCBHC by implementing and monitoring practice-specific fidelity measures. EBPs that will be added without modification during the CCBHC implementation include Trauma-Focused Cognitive Behavioral Therapy, Mobile Response Stabilization Services and Screening, Brief Intervention and Referral to Treatment. EBPs in use today that will be used or improved include Eye Movement Desensitization and Reprocessing, Intensive Home-Based Therapy, Motivational Interviewing, and Peer Support. Second, Ravenwood Health will improve mental health and substance abuse treatment outcomes for individuals by utilizing the CCBHC model Objective A. Increase referrals and assessments of unduplicated individuals to Ravenwood Health CCBHC for mental health and substance use disorder services. Objective B. By 9/29/2024, increase the number of unduplicated individuals linked with 1 or more EBP-informed services at Ravenwood Health CCBHC by 20%. Objective C. Improve client outcomes for mental health, quality of life and social functioning for unduplicated Ravenwood Health CCBHC clients. Project evaluators from Case Western Reserve University’s Begun Center for Violence Prevention will conduct outcome data collection and performance measurement. System- and individual-level change as set forth in project goals will be evaluated by measuring increases in fidelity and service access to a powerful array of carefully matched services.

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.

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.

Fairbanks Native Association (FNA), a Tribal organization, proposes the Athabascan Behavioral Health Clinic (Clinic) in response to the CCBH-PDI Notice of Funding Opportunity for FY 2022. The purpose of this project is planning, development, and implementation of a Certified Community Behavioral Health Clinic (CCBHC) serving individuals in the traditional Athabascan Indian territory of the Fairbanks North Star Borough of Alaska (FNSB). The FNSB population is 95,593. FNSB weather, which can reach 50 degrees below zero in winter, is a significant barrier to service provision and access to care, as many of our service population do not own personal vehicles. The disproportionate rates of American Indian and Alaska Native (AI/AN)* behavioral health and other negative indicators of wellbeing spans decades but was not well documented until two seminal reports were published in the 1980’s: the Pulitzer Prize winning article “A People in Peril: A Culture in Crisis” (Anchorage Daily News, 1988) and the Alaska Federation of Natives' 1989 report “A Call for Action.” The situation was so dire Congress empaneled the Alaska Natives Commission to assess the health, behavioral health, social, and financial status of Alaska Natives. In all categories of the commission report, Alaska Natives were negatively and disproportionately represented. Since these reports there have been some decreases in substance abuse (NSDUH, 2019), but in mental health, suicide, and trauma, the situation remains dire. AI/AN people in Alaska experience psychological stress 1.7 times higher than White people. FNA provides the most extensive behavioral health continuum of care in Alaska, serving all ages from infancy through adulthood. However, mental health services continue to be the most significant service gap in the FNSB. The Clinic will address this service gap by significantly increasing mental health services. Proposed new mental health service units include: (1) Crisis Mental Health with a 24-hour mobile crisis intervention team, (2) Mental Health Outpatient, (3) Mental Health Outpatient for members of the armed forces, (4) Psychiatric rehabilitation, and (5) a Primary Care Clinic. All existing and new services will be provided and integrated into the service umbrella of the Clinic, primarily co-located in the same building to create a one-stop shop for the entire continuum of care. The Clinic will transform the community behavioral health system and provide comprehensive, coordinated behavioral health care. The following goals guide the Clinic: (1) increase access to and availability of high quality services that are responsive to the needs of the community, (2) support recovery from mental health and substance abuse disorder challenges via comprehensive community-based mental health and substance abuse disorder treatment and supports, (3) use evidence-based practices that address the needs of the individuals the CCBHC serves, (4) continually work to measure and improve quality of services, and (5) meaningly involve consumers and family members in their own care. The Clinic will serve 1,208 individuals over the four year life of the project. All FNA Behavioral Health services are developed, delivered, and evaluated in collaboration with the local Behavioral Health Community Coalition (BHCC). BHCC members represent the following service domains: Substance Abuse, Mental Health, Primary Care, Social Services, Education/Employment, Child Welfare and Foster Care, Early Childhood Development & Child Care, Justice, Housing, Veterans, and Cultural/Spiritual. The BHCC also includes five FNA Behavioral Health consumers. *FNA services both American Indian and Alaska Natives by mutual agreement.

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.

As a CCBHC-PDI grant awardee, Hospital Menonita CIMA (CIMA) will provide CCBHC services to the municipalities of Juncos, Las Piedras, Yabucoa, Humacao, Naguabo, Ceiba, and Culebra in southeastern Puerto Rico. CIMA will serve all individuals across the lifespan in need of behavioral health (BH) care, with a particular focus on addressing BH disparities for individuals over 65 years old with BH disorders and youth with substance use disorders (SUD). CIMA's project goals are to: 1. Increase capacity to provide mental health treatment to older individuals (age 65 and above); 2. Improve and expand mental health and trauma-related evidence-based screenings and practices; 3. Increase access to evidence-based SUD services; and 4. Increase access to wrap-around services to address clients' physical health and social needs. We will address these goals by: (1) incorporating clinical pathways for elderly population-related diagnoses and for depression, PTSD, and anxiety, implemented with at least 80% fidelity on the fidelity scale; (2) screening at least 75% of CCBHC clients for suicide using the Columbia Suicide Severity Rating Scale (C-SSRS) annually; (3) screening at least 75% of CCBHC clients BH disorders annually using standardized and validated instruments (e.g., PHQ-9, GAD-7, CRAFFT, AUDIT, C-SSRS, FTND, CAST, TSQ, S2BI, CAGE); (4) increasing referrals to our First Episode Psychosis (FEP) program by 15% over baseline; (5) reducing Assertive Community Treatment (ACT) participants' emergency department (ED) use by 50%; (6) increasing the number of clients who initiated medication-assisted treatment (MAT) and the SUD youth program by 25% from baseline over the grant period; (7) increasing the number of clients who receive vocational counseling by 15% from baseline; and (8) increasing the number of clients receiving primary care screening by 20% from baseline. We will collaborate with the Mental Health and Anti-Addiction Services Administration (MHAASA), the government entity responsible for mental health and SUD in Puerto Rico, to provide 988 crisis hotline and mobile crisis services. We will also establish a referral agreement with NeoMed, a local FQHC providing primary and HIV care, and Estancia Serena, a residential detoxification center that provides MAT for individuals with SUD. We will partner with the University of Puerto Rico - Medical Sciences Campus (RCM) to adapt our evidence-based practices to ensure they are culturally and linguistically appropriate for our population and provide training in measurement-based care to our staff. Finally, we will partner with Plan de Salud Menonita (PSM), an operating division of Mennonite General Hospital, Inc. (MGHPR) and a health insurance plan that provides coverage for 200,000+ commercial and Medicaid beneficiaries in Puerto Rico, to identify individuals with serious mental illness (SMI), serious emotional disturbance (SED), SUD, and co-occurring disorders (COD) to refer them to our CCBHC and gather beneficiary data to identify high-utilizing patients for TCM engagement. The project will serve 400 unduplicated individuals in the first two years of the project and 600 individuals in the last two years of the project, for a total 2,000 individuals over the course of the project.

Red Rock Behavioral Health Services (RRBHS) will replicate our successful CCBHC model in Norman, OK, to serve a catchment area (CA) of Cleveland and McClain counties, HRSA designated shortage areas with significant health and BH disparities. We will develop and implement population health management (PHM) systems, incorporate social determinants of health into assessment, strengthen health screening and monitoring, and expand clinical services. The proposed project, EqualOps: Tackling the Social Divide, will serve 500 unduplicated individuals in the CA, (100 in year 1, 125 each in years 2 and 3, 150 in year 4). Service expansion is vital, as the OK Department of Mental Health and Substance Abuse Services estimates that 89.2- 94.8% of CA adults who need BH services do not receive them. RRBHS delivered trauma-informed, community based and culturally appropriate BH care and services to 15,806 individuals across Central OK in 2022, many of whom had serious mental illness (SMI), serious emotional disturbance (SED), substance use disorders(SUD), co-occurring disorder (COD) and other BH needs. The CA has 344,893 residents, with 51% assigned female at birth and 19.1-25.3% under 18(Census); 3.8% are LGBTQ (Williams Institute). Across Norman (the county seat of Cleveland County and the third largest city in OK), Cleveland and McClain counties, between 69.5-72.9% are white, 1.3-5.7% are Black, .8-5.6% are Asian or Pacific Islander, 4.1-7.5% are Native American, 8.7-9.9% are Latinx and 6.5-11.2% speak a language other than English at home(Census). Poverty rates are 9.2-16.7%, with nearly 50% of RRBHS clients in poverty. McClain County is HRSA-designated rural. The CA is in tornado alley and experiences significant community level trauma from frequent natural disasters. Also located in the CA is the University of OK (OU), with approximately 30,000 students; college aged young adults (18-24) have unique BH challenges and high BH need. The CA has higher than national rates of being uninsured (10.9-16.4%), not having a primary care provider, alcohol and substance use, suicide, diabetes, heart disease and hypertension. There are two goals: Goal 1 is to reduce BH access gaps, and expand access to and availability of high quality, trauma informed BH services and supports. Objectives and activities include: 1.1 reduce wait times and increase capacity via staff hiring (clinicians for virtual outpatient care, popular in our rural CA, Peers) and expanded weekend/evening hours; 1.2 increase service availability for children and youth via hiring, outreach and infrastructure expansion to increase enrollment; 1.3 increase availability and accessibility of services for college age young adults (18-24) via staff hiring, training, and outreach to and relationship building with the OU. 1.4 add an additional crisis response team via clinician hiring. Goal 2 is to develop and implement population health management (PHM) systems to better track and address health outcomes and social determinants of health (SDOH), fuel data-driven disparity reduction, improve health and BH outcomes and further tailor services to the CA's needs. Objectives and activities include: 2.1 institute standardized tracking of SDOH with a SDOH screening tool used at entry to care and treatment review; the tool will be integrated into our EHR, with dashboards created; 2.2 Revise our risk stratification tool to include SDOH; 2.3 Staff training in SDOH, PHM; 2.4 Develop, implement PHM systems, adding management level Director of PHM, Senior Data Engineer, EHR improvements to better identify and address data driven health priorities (disparities, health conditions and behaviors, outcomes); 2.5 Build capacity for tracking and facilitating client access to primary care by establishing relationships with healthcare provides/agencies and improving referrals, asking about asking about primary care ; 2.6 Improve internal rates of health screenings via hiring, training and infrastructure building.

The Andrews Center, located in Public Health Region 4 of Texas, a region of the state that has shown increased rates of suicide attempts, suicide completion, and substance misuse in recent years, adopted the CCBHC model in 2020 to improve the quality of trauma-informed and evidence-based services to meet the increased demands of the community. Adherence to the CCBHC criteria has led to an increased awareness of the importance and value of data collection and analysis (from community needs assessments as well as internal quality measures) and the utility of sharing the data to inform decision-making that improves the overall quality of services provided to the community. The purpose of Andrews Center's Certified Community Behavioral Health Clinic Improvement and Advancement (CCBHC-IA) grant program is to enhance treatment services to address growing concerns of substance misuse and deaths by suicide by increasing staffing in key areas (such as the mobile crisis outreach team, psychiatry, care coordination, and substance use disorder treatment) to address gaps in mental health care and substance misuse treatment as identified by recent community needs assessments for the service area; improve and advance quality data collection, analysis, monitoring, and use for best-practices decision making; and using these efforts to improve timely access to crisis services, substance use disorder treatment, and outpatient mental and behavioral health care services. The population of focus is children, adolescents, and adults who are experiencing serious mental illness (SMI), substance use disorder (SUD), co-occurring mental and substance disorders (COD), and/or serious emotional disturbance (SED). With increased availability and accessibility of needed crisis services in conjunction with a strategic staffing plan driven by an updated community needs assessment, Andrews Center's CCBHC-IA program will target the following goals: 1. Increase timely access to crisis services for children, adolescents, and adults who are experiencing SMI, SUD, COD, and/or SED to reduce consequences of non-treatment. 2. Increase timely access to evidence-based outpatient behavioral health care for chidden, adolescents, and adults who are experiencing SMI, SUD, COD, and/or SED to reduce consequences of non-treatment. 3. Escalate care coordination activities to reduce risk factors contributing to poor health outcomes. Andrews Center will serve 400 unduplicated individuals each year of the grant project, totaling 1600 unduplicated individuals during the life of the project with an anticipated ongoing increase beyond the four-year funding opportunity. The coordinated impact of the project will have a positive impact on local emergency departments, county jails, and law enforcement as the citizens will be better able to access appropriate and timely mental health care.

Volunteers of America Chesapeake and Carolinas (VOACC) proposes the advancement and improvement of the VOA-Hope Center, its Certified Community Behavioral Health Center (CCBHC) serving Prince George’s County, Maryland. Over this 4 year grant, the CCBHC will serve 750 adults with severe mental illness, individuals with substance use disorders, children/adolescents with serious emotional disturbance, and individuals with co-occurring disorders. The population(s) of focus will be veterans and those experiencing behavioral health disparities, such as low-income individuals and homeless persons. Strategies and Interventions. The VOA-Hope Center-Maryland provides all 9 services in compliance with CCBHC criteria: 1) Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis intervention services, and crisis stabilization. 2) Screening, assessment, and diagnosis, including risk assessment. 3) Patient-centered treatment planning. 4) Comprehensive outpatient mental health and substance use services. 5) Outpatient Primary Care Services. 6) Targeted case management. 7) Psychiatric Rehabilitation Services. 8) Peer Support, Counselor services, and Family Supports. 9) Intensive, community-based mental health care for members of the armed forces and veterans. VOACC will provide 6 allowable activities for advancement: 1. Develop partnerships with service providers/stakeholders 2. Training/workforce development for staff/community providers. 3. Tobacco cessation workshops. 4. Activities to address behavioral health disparities and SDH. 5. Efforts to expand diversity, equity, inclusion, and accessibility. 6. Develop/implement outreach/ referral pathways to engage/target demographic groups representative of the community. Goals and Measurable Objectives Goal 1: Improve and advance existing CCBHC operations to better serve those experiencing behavioral health disparities in the catchment area. Objective 1: Implement Business Intelligence to create data dashboards in real time to assess data. Objective 2: Decrease ERrelated healthcare utilization by referring 95% consumers to community-based/internal resources. Objective 3: Link 100% of eligible uninsured individuals to Medicaid and other means-tested programs within 30 days of intake. Objective 4: Link 80% of individuals identified as having employment support needs to job/educational training opportunities within 60 days. Objective 5: Implement 6 Allowable Activities within 90 days. Goal 2: Identify, address, and reduce barriers that affect accessibility to and outcomes of behavioral health treatment. Objective 1: Review/update the 2022 Needs Assessment of the catchment area and identify subpopulations that experience behavioral health disparities within 6 months of award; partner with PGC Health Dept. for full assessment in 2025. Objective 2: Reduce barriers to treatment through outreach to those identified as highest need within 30 days of award (and ongoing). Objective 3: Improve holistic health outcomes by formalizing partnerships with community-based organizations in areas of highest need. Goal 3: Increase awareness and address the disproportionate impact mental health/substance use has on targeted subpopulations of Prince George’s County. Objective 1: Implement anti-stigma campaign with G.O.A.T. to address those most likely to experience attitudinal barriers to treatment within 6 months of award. Objective 2: Serve 750 unduplicated consumers over the course of project period, retain 80% of consumers in or compliant to treatment regimen during aftercare at 6 months. Objective 3: Administer 750 surveys over the course of the project period to assess program effectiveness and develop a framework for continuous quality improvement. Number of Individuals to be Served: ? Year 1 - 150 ? Year 2 – 175 ? Year 3 - 200 ? Year 4 - 225 ? Total - 750

Barry County Community Mental Health Authority (BCCMHA) proposes to improve overall health and wellbeing of residents of Barry County, Michigan -- a rural county of 63,544 residents. The Barry County catchment area has a dearth of both primary care physicians (PCPs) and behavioral health (BH) providers per population ratio. The CCBHC-IA project will allow BCCMHA to fill identified service gaps through expansion, increased outreach capacity, and intensification of care coordination with community partners to foster integrated care. Populations of focus for the project are all individuals across the lifespan in need of BH services within the catchment area. Subpopulations include individuals with comorbid medical conditions with special focus on those diagnosed with diabetes, those with a BMI of 30 or greater, and those with co-occurring mental health and substance use disorders (SUD). BCCMHA recognizes veterans and LGBTQI+ persons as populations underserved in the catchment area and has identified these groups as additional subpopulations of focus. Over the four-year period BCCMHA aims to serve at minimum 495 unique individuals, averaging 120 new individuals per year. The goals of the CCBHC-IA project are to increase access and utilization of behavioral health (BH) services, identify and address substance misuse, and improve healthcare access and quality for all community residents. The project will achieve these goals by implementing the following strategies: 1) increase access to BH services for County residents through coordination with psychiatric inpatient facilities to ensure that a minimum of 60% of individuals receiving treatment have a follow-up visit with a BH provider within 7 days of discharge; coordination with the local emergency department (ED) to ensure that at minimum 40% of adults seen at the ED for with a principle BH diagnosis have a follow-up visit with a BH provider within 7 days; 2) increase outreach and penetration regarding available BH services through utilization of an outreach liaison to increase community contacts by 10% annually; utilization of a veterans navigator to increase the number of veterans, members of the armed forces, and military families by 5% each year; 3) demonstrate improved outcomes through adoption of measurement-based care strategies; 4) increase initiation and engagement of SUD treatment through coordination with local ED to ensure individuals seen with a principle SUD diagnosis have a follow-up with a BH provider within 7 days; improved screening and brief interventions and follow-up for positive screens; and 5) deliver integrated care for BH and physical health risks and needs through referrals and follow-up to community PCPs and through monitoring and management of diabetes leading to 60% of adults diagnosed with diabetes having an A1c below 9.0% in grant year 1. BCCMHA will collect, analyze, and disseminate data from the CCBHC project to inform sustainability efforts and continue programming after the lifetime of the award.

Severe mental illness (SMI) and substance use disorder (SUD) "is the most urgent health need impacting [Western Massachusetts]," according to Baystate Health's 2022 Community Health Needs Assessment (CHNA). Substance use disorders, including opioid use, were of "particular concern." The intersection of physical and mental health care has become a place of great need following the COVID-19 pandemic. In Hampden County, "one in seven adults (15%) reported their mental health was not good for 14 days or more within the prior 30 days... this exceeded the statewide rate of 13%." The CHNA also reports "between 2016-2020, deaths of despair [in Hampden County] were ... 29% higher than the state rate." The four cities our CCBHCs serve lie in the Pioneer Valley catchment area - primarily West Springfield, with Springfield, Chicopee, and Holyoke as satellite locations. The Merrick and Memorial neighborhood census tracts, encompassing the Park Street CCBHC in West Springfield, have an average poverty level of 13.5%, nearly 1.5x the rate of West Springfield at large. This neighborhood has a significant population of refugee families with unique cultural and linguistic needs, with 26% being foreign-born - approximately three times the rate in Hampden County. The satellite Springfield and Holyoke clinics are located in neighborhoods with poverty rates of 27.7% and 30.9%, respectively. The population served is especially vulnerable because they are often under- or un-insured and experiencing housing insecurity or homelessness. The Western MA Network to End Homelessness reports that individual homelessness has worsened since the COVID-19 pandemic began, with just over 2,800 people in Hampden County without homes in 2022. Approximately 3% of the population is uninsured in the four census tracts where these CCBHCs are located. Due to high poverty and low employment numbers, we can assume that even those insured likely have fraught access to affordable, adequate health care in these areas federally designated as medically underserved. All four clinics are in Health Professional Shortage Areas (HSPA). The present project will utilize resources to support expanding the number of referrals to and availability of primary care at these CCBHCs alongside continuing the nine core CCBHC services. We will provide enhanced primary care screening and monitoring of key health indicators and health risks to people with SMI and SUD/OUD in neighborhoods where vulnerable populations live - especially under and uninsured people and individuals experiencing housing insecurity or homelessness. These are areas of need identified in CHD's needs assessment. This integration of care will improve care delivery, client experience, and outcomes. The project will serve a total of 600 individuals over the course of the 4-year project.

Catholic Charities, Inc. – Archdiocese of Hartford (CCAOH) currently provides effective, high quality, trauma-informed, recovery-oriented, person- and family-centered behavioral health care to children, youth, adults and veterans through its CCBHC. The target population is primarily Hispanic persons in the City of Hartford and surrounding communities (i.e., East Hartford, New Britain, and West Hartford). Among the target population, 28% have Limited English Proficiency, 29% live under the federal poverty level, 22% do not have a medical home, and 11% are uninsured. The CCBHC is located in the City of Hartford at CCAOH’s Instituto de la Familia Hispana (IHF), a Hispanic-led community center offering culturally and linguistically competent behavioral health and community services to Greater Hartford’s Hispanic community for over 45 years. Seventy-seven percent (77%) of adults and 91% of children/youth served through the IHF CCBHC are Hispanic. More than 800 people participate in CCBHC coordinated services annually. Our data analysis determined statistical significant differences in the care that the CCBHC provides. CCBHC consumers have improved in functioning level and symptom reduction. A deeper dive into the data shows that more adult consumers improved when they participated in both therapy and support services vs. therapy alone – 80% vs. 65% on depression (PHQ-9) and 69% vs. 61% on anxiety (GAD-7). Also, our staff’s cultural/linguistic competence has produced a high rate of success among Hispanic adults for symptom reduction (81% receiving therapy and support services improved on PHQ-9 and 74% on GAD-7). Trauma disorders are common diagnoses at the IHF CCBHC among children, youth, adults and veterans. The smoking rate is 29% for all consumers and 34% for men. Within the target population and regards to prevalence, CCAOH estimates that thousands of adults, children, youth and veterans are currently experiencing behavioral health issues and not receiving treatment. Service gaps include lack of availability of bi-lingual therapy (Spanish speaking); need for more culturally-competent clinicians; need for more mental health services for Hispanic children; and an overall need for outpatient mental health services for children/youth. With this grant, persons receiving care and their family members will provide input into project design, evaluation, and changes. The Project Management Team will continually review CCHBC results and address health disparities in program access, service use and client outcomes. Based on two years of experience and emerging community needs, the IHF CCBHC will: 1) Expand and enhance the outpatient treatment capacity for Hispanic children with the evidence-based treatments of Brief Strategic Family Therapy (BSFT) and Eye Movement Desensitization and Reprocessing (EMDR) Therapy; 2) Enhance outpatient services for Hispanic adults experiencing trauma by providing EMDR Therapy; 3) Enhance outpatient and community support services for Veterans; and 4) Improve child/adult clinical outcomes and staff/client retention by implementing Measurement-Based Care (MBC). To improve our assessment of consumers’ cultural factors, we will implement Cultural Formulation Interviews. To address tobacco use among our population, we will offer an evidence-based tobacco cessation treatment approach. The IHF CCBHC will continue to operate in compliance with the revised CCBHC Certification Criteria and provide/broker all nine (9) required services. CCAOH has developed DCOs/MOUs for mobile crisis services, inpatient services, veteran referrals, and EBP training. Community needs assessments will be conducted by February 2024 and by February 2027. CCAOH will continue to contract with the University of CT (UConn) Health Center for external evaluation services.

The proposed Reimagining Mental Health Care project will focus on individuals across the lifespan with mental health and substance use needs in Park Center’s primary catchment area in northeastern Indiana, specifically in Allen County (hub clinic) with additional services provided in Adams and Wells counties. Because Allen County has the second largest city (Fort Wayne) in Indiana and is home to the most diverse population in the region, specific outreach will be targeted toward LGBTQ+ and minority populations facing disparities in care. The project will serve 500 unduplicated individuals in Year 1, 550 in Year 2, 600 in Year 3, and 650 in Year 4, for a total of 2,300 individuals served over the grant period. Project goals and measurable objectives: The overall goal of the proposed Reimagining Mental Health Care project is to further improve care delivery and expand capacity—with specific outreach focused on those facing disparities in care. The specific project goals are as follows: • GOAL 1: Increase capacity of Park Center to provide mental health and substance use services. Objective 1a: Increase the number of providers who are willing to prescribe MAT and are routinely doing so by 10% each year of the project. Objective 1b: Increase the number of individuals served in substance use services, including peer support, by 10% each year. • GOAL 2: Increase capacity of crisis mental health services and improve pathways within the CCBHC and with other community partners’ outpatient services. Objective 2a: Recruit and train mobile intervention team staff to increase the capacity of crisis behavioral health services by 10% each year of the grant. Objective 2b: Through collaboration with community organizations, increase utilization of the 24/7 helpline number by 10% each year of the award period. Objective 2c: Increase the number of patients connected to ongoing outpatient services after hospitalization by 20% each grant year. • GOAL 3: Increase collaboration between physical and mental health services. Objective 3a: Refine referral and communication pathways between PPG, Alliance Health (FQHC), and Park Center no later than the end of year two of the award period. Objective 3b: Ensure that 90% of individuals seen in behavioral health services have a primary care provider and 80% have seen or will see them within 365 days of their first appointment. • GOAL 4: Increase the diversity of the behavioral health workforce and the population(s) served, specifically among LGBTQ+ and minority communities. Objective 4a: Strengthen partnerships with local institutions of higher education to develop strategies for recruitment of diverse students into social work and counseling programs. Objective 4b: 95% of Park Center behavioral health personnel will complete both Parkview’s online diversity course, annual in-person trainings, and a cultural competency self-assessment each year to identify ongoing training needs. Objective 4c: Develop/increase the number of support groups, IOP services, and outreach programs to engage/target LBGTQ+ and minority populations (primarily in Allen County, which has the largest minority population in the geographic area) within the first year of the award period.

Gulf Coast Center Connect & Care will advance opportunities for early intervention by improving timely access to behavioral health services. C&C will enhance crisis stabilization and follow-up services for high-risk individuals to improve protective factors related to suicidality. C &C will expand care coordination, promoting the whole health of individuals served across treatment transitions. Implement Just-in-Time Scheduling to reduce No-show Rates, utilize C-SSRS Screening to determine high-risk individuals- placing them on the Pathway to Care for more intense interventions and focused connection and follow-up. Advance opportunities for early intervention by improving timely access to behavioral health services. Enhance crisis stabilization and follow up services for high-risk individuals to improve protective factors related to suicidality. As well as, expand care coordination promoting the whole health of individuals served across treatment transitions.

Bridge Counseling Associates, Inc., (Bridge) a Nevada Certified CCBHC proposes to ameliorate identified fragmentation in coordination of integrative healthcare and access to a behavioral health continuum as ongoing challenges in a high need and under-resourced area of the City of Las Vegas region at its location at 4221 McLeod Drive in Las Vegas. Bridge's CCBHC project proposes to serve all ages, genders, orientations, disabilities, cultures, religious affiliations and race/ethnicities, including those with serious mental illness; substance use disorder; children and adolescents with serious emotional disturbance; adults/adolescents with co-occurring mental health and substance use disorders; and adults, children, and adolescents experiencing a trauma-induced, mental health and/or substance use-related crisis, including members of the military, veterans and their families. The geographical catchment area within the Las Vegas metropolitan area is considered a minority-majority city, with Hispanic/Latinx (32.3%), and Black/African American (11.6%) as the primary population. In 2022, 20.9% of area residents reported no health care coverage, higher than the national rate of 9.8%. Residents identifying as Hispanic/Latinx report higher rates of uninsured status at 22.4%, with Black/ African Americans at 11%. Strategies and interventions include all CCBHC required activities including: 1) operate in compliance with CCBHC criteria; 2) collaboration with the state to maintain state CCBHC certification; 3) provide all nine core CCBHC services - crisis mental health services; screening, assessment, and diagnosis, including risk assessment; patient-centered treatment planning or similar processes, including risk assessment and crisis planning; outpatient mental health and substance use services; outpatient clinic primary care screening and monitoring of key health indicators and health risk; targeted case management; psychiatric rehabilitation services; peer support and counselor services and family supports; intensive, community-based mental health care for members of the armed forces and veterans; 4) conduct two community needs assessments; 5) submit attestations of compliance to SAMHSA; 6) infrastructure development activities; 7) meaningfully involve consumers and family members through an Advisory Team; 8) develop sustainability plan; 9) participate in SAMHSA CCBHC Technical Assistance Center activities. Goals and objectives include: Goal 1: Plan, develop and implement the CCBHC person-and family-centered integrated services and use targeted outreach to increase access and availability of high-quality services that are responsive to the emerging needs while addressing health inequities and behavioral health disparities. Objective 1.1: Between 09/30/2023 and 09/29/2027 ensure 100% of the 600 participants will enroll in services using targeted outreach strategies and social marketing efforts. Objective 1.2: Between 09/30/2023 and 09/29/2027, 100% of participants will receive accurate diagnosis and access to person-centered treatment planning. Goal 2: Improve behavioral health treatment outcomes while addressing health-related disparities and inequities each year of the 4-year project period. Objective 2.1: Between 09/30/2023 and 09/29/2027, 75% of consumers will improve mental health functioning outcomes as documented by NOMS between intake and discharge. Objective 2.2: Between 09/30/2023 and 09/29/2027, 75% of consumers with SUD will reduce substance use, as documented by NOMS between intake and discharge. Objective 2.3: Between 09/30/2023 and 09/29/2027, 80% of consumers will improve employment/education status as documented by NOMS between intake and discharge. Bridge will serve 150 people in year 1, 150 in year 2, 150 in year 3, 150 in year for a total of 600 people over the 4-year grant.

Project LCSC CCBHC-IA will offer the full array of CCBHC services to 800 unduplicated individuals (200 annually), primarily from Lakewood, NJ (population 138,070), who are facing serious mental illness, substance use disorders, opioid use disorders and co-occurring disorders, and youth with serious emotional disturbance. This population is primarily Orthodox Jewish with 15.4% experiencing 14+ days of mental distress, the 3rd highest rate in NJ. This group experiences health disparities due to stigma, low socioeconomic status (25.1% of Lakewood residents live at or below poverty (54.91% below 200% poverty), significantly higher than the regional proportion of 11.4% (23.8% below 200% poverty)) and cultural and language barriers. Strategies designed to reduce disparities in healthcare access and heightened challenges to accessing care are as follows: 1) Improve mobile crisis services thereby reducing avoidable hospitalization and ED use; 2) Maintain open access scheduling, as well as extended evening and weekend hours; 3) Fully implement, improve and integrate standalone SUD services using EBP's; 4) Hire a Grant funded Medical Director and Nurse Care Manager to oversee primary care screening and monitoring; 5) Provide robust, quality targeted care management (TCM) services; 6) Maintain highly successful community-based services and peer supports; 7) Implement CCBHC specific training, supervision and/or coaching to staff; 8) Increase use of evidence-based screening instruments to enable measurement-based care; 9) Improve care transitions and care coordination, by securely sharing health information with our provider network; 10) Maintain an Outreach Coordinator to develop, update and/or maintain Care Coordination agreements; 11) Maintain 7-member CCBHC Community/Consumer Advisory Board; 12) Implement a data-driven Continuous Quality Improvement (CQI) plan; 13) Maintain sliding fee scale so all services are available regardless of ability to pay, and 14) Refine HIT to collect, track and report data and quality measures. Our (4) CCBHC Project specific goals are as follows; 1) expand access to culturally competent, well-coordinated, integrated services by increasing availability and capacity of LCSC's CCBHC; 2) Implement evidence-based screening, assessments, and treatment, TCM, community-based care and better use of data; 3) Increase access to integrated care and use real-time data to drive decision-making; and 4) Ensure financial sustainability and operational efficiency of our CCBHC. examples of our measurable objectives tied to these project goals include implementation of open access same day scheduling, expanding collaborations to 20 Community Based Organizations, universal standardized screening/assessment for all CCBHC patients, expansion of peer services, delivery of community-based supports including PSR, supported employment, and peer supports to 50 of the highest needs individuals annually; identification of 100% of clients at-risk of relapse and intervene early; develop EHR-based alerts for screening and follow up across 100% of CCBHC enrollees; and diversification of revenue streams by seeking grants, implementing fee-for-services options, and engaging in partnerships with new payers.

The Southern Highlands CCBHC-IA Initiative will provide comprehensive, coordinated behavioral health care for all people in need of behavioral health services at Southern Highlands’ Mercer County Clinic which serves Mercer, McDowell & Wyoming Counties in WV. The target population suffers from SUD, poor mental health, low mental health workforce capacity, poor SDOH & poor disparity group outcomes. The Initiative will serve 4,000 clients (1,000/year). Project goals (interventions/strategies) include: (1) Provide a comprehensive suite of CCBHC services for the target population with fidelity to the CCBHC Certification Criteria and based on regular needs assessments by (A) initiating a Project Director & Coordinator to manage the CCBHC Initiative; (B) ensuring agency compliance with the CCBHC Certification Criteria; (C) collaborating with the state to obtain CCBHC certification; (D) conducting the required needs assessment; (E) completing the CCBHC Attestation post needs assessment; (F) implementing the needs assessment driven training plan; (G) supporting processes & procedures for collecting, reporting & tracking encounter, outcome, and quality data; and (H) ensuring agency participation in the CCBHC Technical Assistance Center activities. (2) Enhance SHCMHC’s Mercer County CCBHC service provision for the target population by (A) enhancing crisis services by hiring 3 Mobile Crisis Case Managers, 2 Case Managers, 3 Mobile Crisis Peers, a Mobile Crisis Coordinator & Assistant Crisis Evaluator to provide 24 hour mobile crisis and follow-up services; (B) enhancing screening/assessment services by adding the Columbia Suicide Screener and a crisis assessment; (C) enhancing SUD service via enhancement of an ACT-like intensive program for treatment resistant SUD clients; (D) expanding telehealth services via hiring a Telehealth Coordinator; (E) enhancing peer services via addition of 3 mobile crisis peers and one SUD peer; (F) creating & initiating a tobacco cessation program; (G) working to obtain MOUs with veteran serving organizations; (H) enhancing treatment/crisis planning & targeted case management; (I) continuing to partner with Tug River for primary care service provision; and (J) continuing to provide psychiatric rehabilitation services. (3) Enhance CCBHC infrastructure development at SHCMHC’s Mercer County CCBHC Clinic by (A) maintaining Health Information Technology (HIT) systems to facilitate care coordination; (B) building partnerships to support electronic health information exchange & care coordination; and (C) updating and implementing a CCBHC-wide data-driven continuous quality improvement (CQI) plan. (4) Support recovery from mental illness and or substance use disorders by providing access to high-quality mental health and substance use services to the target population by (A) coordinating outreach efforts; (B) serving a total of 1,000 clients annually; (C) clients having a statistically significant decrease in illicit substance use at 6-month NOMs follow-up; (D) clients having statistically significant improvement in mental health outcomes at 6-month follow-up; (E) clients having statistically significant improvement in social connectedness at 6-month follow-up; (F) clients having statistically significant decrease in tobacco use at 6-month NOMs follow-up; (G) having 80% of clients remain in treatment for at least 6-months throughout the life of the grant; (H) monitoring disparity group data to ensure equal access/use/outcomes/retention; (I) supporting annual Crisis Intervention Training (CIT) Training for law enforcement partners; and (J) developing outreach/referral pathways that engage/target all disparity groups. (5) Sustain CCBHC services beyond grant funding to serve the focus population by (A) having the Project Director lead the peer-driven CCBHC Advisory Board; and (B) creating a sustainability plan for each budget line item to ensure service sustainability.

Samaritan Daytop Village’s (SDV) proposed Certified Community Behavioral Health Center (CCBHC) will improve and advance the quality of integrated outpatient mental health, substance use, and primary care services available in Suffolk County, NY. Through the grant, the Suffolk CCHBC will serve at least 600 low income, children, adolescents, adults, and veterans, many from communities of color, who are experiencing SMI, SED, SUD or COD, and work to reduce pervasive health disparities. Suffolk County, on the eastern part of Long Island, is mostly suburban and the fourth most populated county in NY, with a population of 1.52 million, including over 58,000 Veterans. The poverty rate for residents of Suffolk County is 6.4%, and 5% of residents are uninsured. Suffolk residents are 66% non-Hispanic White, 21% Hispanic/Latino, and 9% Black. Nearly 16% are foreign-born. Suffolk is considered to be among the most racially segregated metropolitan areas in the U.S. Based on available data, some 20,000 Suffolk residents on Medicaid would benefit from mental health treatment, and possibly as many as 70,000 residents may need intervention for their substance use risks but do not currently receive it. The population of focus experiences elevated rates of trauma, morbidity, visits to the ER, and preventable hospitalizations and mortality. In each Year of the 4-year grant, the Suffolk CCBHC will provide comprehensive services to 150 people with SMI, SUD, SED, and COD as well as their families. The Suffolk CCBHC will build on the success of its existing CCBHC services; the clinic’s CCBHC attestation was approved in 2021. We will continue to provide trauma-informed, person/family-centered comprehensive assessments, diagnoses, and treatment planning, comprehensive outpatient mental health and substance use treatment, screening and monitoring of primary health indicators, medication administration and monitoring of medication for adverse effects, targeted case management, psychiatric rehabilitation services, comprehensive peer recovery and family supports, intensive treatment services for members of the armed services and veterans, and 24/7 crisis management and intervention services. Through this grant, we will further expand access to bi-lingual services and groups held in Spanish as well as culturally and linguistically competent community partners; offer comprehensive services to clients who on Methadone treatment; enhance medical management for greater integration and monitoring of quality indicators and services; further expand psychiatric rehabilitation services; and enhance services to Veterans through dedicated team members. The Suffolk CCBHC will expand the use of evidence-based treatment services by using: Motivational Interviewing, Integrated Dual Diagnosis Treatment, Individual Placement, and Support, Cognitive Behavioral Therapy for anxiety and depression, Screening, Brief Intervention, and Referral to Treatment, Cognitive Processing Therapy, and Multidimensional Family Therapy. As a result, we intend to accomplish the following goals/objectives: (1) Decrease mental health symptoms and substance use among the POF by conducting screening, assessments, and treatment planning and providing evidence-based, person/family centered, integrated, outpatient mental health and substance use treatment services; (2) Improve health and decrease health disparities among the POF by providing integrated primary care screening and health monitoring services, increasing health insurance coverage and connection to a primary care physician; (3) Increase social connectedness and employment among the POF by providing psychiatric rehabilitation services (PRS) and social support opportunities; and (4) Decrease preventable Emergency Department visits and hospitalizations by providing access to 24/7 crisis services.