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The North Central Iowa Mental Health Center, Inc. dba Berryhill Center in Fort Dodge, Iowa is a not-for-profit entity associated with UnityPoint Health and is in rural Webster County. With federal CCBHC Improvement and Advancement grant funding, it is our goal to increase treatment accessibility, improve pathways to mental health services and increase access to needed services in our community. The Berryhill CCBHC Improvement and Advancement Project will be available to all persons with mental health and substance use needs in Webster County (population 37,114) and is in rural North Central Iowa. Berryhill served 8.7% (3,228) of Webster County Residents in 2022, and is the primary safety-net mental health services provider in the region. It is estimated that in year one of our project 2,817 individuals will be served and in each subsequent year we will serve an additional 299 patients, for a total of 13,062 persons served over the project's lifetime. To reach our goal of increased access to Mental Health and Substance Use Disorder Services (SUD) in the region, we have identified three key areas and related goals with measurable objectives to achieve the most impactful outcomes. Goal#1: To decrease new patient wait times for psychiatric, therapy and SUD evaluation to be seen within 14 days of referral. This goal will be achieved by creating a team-based model of care that addresses patients' needs during the initial service inquiry. Success will be measured in the length of time for a scheduled evaluation after referral. Additionally, we will also track and fill center no-shows, striving for same-day access. Progress will be monitored by and Electronic Health Record (EHR) dashboard and daily huddles with the team of care. Goal #2: Implement comprehensive screening activities to increase access and availability to high-quality services that are responsive to the needs of the community. This goal will be achieved by hiring two Care Navigators and utilizing Behavioral Health Consultants in the Emergency Department (ED). Care Navigators and Behavioral Health Consultants will assist patients in navigating the processes of establishing care with outpatient services. This data will indicate improvements made in care delivery over time by the number of patients served at Berryhill. Goal#3: Increase quality in outpatients services by utilizing Evidence-Based Practices (EBP's) aimed at stabilization and health maintenance. This goal will be achieved by utilizing a team-based approach and programming, such as, Integrated Health Homes, Community Support Program, Assertive Community Treatment and Care Navigation to engage individuals in Evidence-Based programming, community resources and natural supports. Depression screening tools will be utilized to track outcomes associated with enrollment in EBP's.

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 1640 Alta 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 is considered a minority-majority city, with Hispanic/Latinx (38.3%), and Black/African American (20.4%) as the primary population. In 2022,13.8% of area residents reported no health care coverage, higher than the national rate of 9.8%.vii Residents identifying as Hispanic/Latinx report higher rates of uninsured status at 21.4%, with Black/ African Americans at 10%. 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.

Burrell Behavioral Health (Burrell) requests $4,000,000 over four years for Project CCBHC-IA to transform Burrell's community behavioral health system by enhancing and improving the established CCBHO. Project CCBHC-IA will serve Burrell's 18-county geographic catchment area (GCA) in Missouri to improve access to community-based mental health services and substance us disorder treatment and support, including 24/7 crisis services, to anyone in the GCA regardless of their ability to pay or place of residence. CCBHC-IA's population of focus (POF) is any individual with a mental or substance abuse disorder who seeks care, including those with a serious mental illness (SMI), substance use disorder (SUD), including opioid use disorder, children and adolescents with a serious emotional disturbance (SED), individuals with a co-occurring disorder (COD), and individuals experiencing a mental health or substance use related crisis. Studies show nearly 53% of adults in Missouri with a mental illness have unmet needs for specialized treatment and 57% of children with a Major Depressive Episode (MDE) never receive treatment; screening, assessment, and treatment needs are high (MHA, 2022). A 2021 Kaiser Family Foundation study found that overdose death rates have increased in Missouri from 16.4 per 100,000 to 36.5 per 100,000 - more than a 125% increase. Since 2010 Missouri's suicide rates have been consistently higher than the United States and in 2020 suicide was the third leading cause of death for youth 10-17 and adults 25-34 (CDC, WISQARS 2020). Burrell recognizes significant gaps in the GCA and will address them through this grant by modernizing aspects of the current mental health system, enhancing service delivery models, and improving the total health - physical, mental and social - of clients. Project CCBHC-IA will serve at least 400 clients annually (1,600 total). Burrell's Project CCBHC-IA will use the following strategies to implement the required activities: 1) Utilize current process, procedure and historical knowledge to improve upon the existing CCBHC model in place; 2) Continuously evaluate and assess effectiveness of programming to refine strategies and ensure delivery of high-quality care services and; 3) Maintain adherence to CCBHC Certification Criteria throughout the project period with oversight provided by Burrell's Accreditation Department. The Project Objectives include: 1) Use the CCBHC model to improve access to comprehensive community-based mental health, SMI, SUD, SED and COD care and services; 2) Deliver customized health, human and social services and supports using a wrap-around service model; 3) Provide top quality care and services utilizing evidence-based practices with fidelity on a consistent basis; and 4) Deliver care and services resulting in high levels of client satisfaction (e.g. - customer satisfaction).

Ohel Children's Home and Family Services' Brooklyn CCBHC will expand and enhance access to comprehensive, trauma-informed and integrated care to all individuals living experiencing behavioral health (BH) conditions and comorbid conditions in the service area (SA). We will prioritize children and pregnant and postpartum women (PPW) from diverse backgrounds; we aim to address significant disparities in the SA among children with a disproportionate number of adverse childhood events (ACEs), and among PPW with peripartum depression. We anticipate that many of our CCBHC clients will be white and from the Orthodox Jewish community, as Ohel has a particular cultural competence in serving faith-based communities. Through our geotargeted outreach we will actively engage individuals from diverse backgrounds, including Veterans. According to US Census Data, Brooklyn residents are 49.9% White, 33.3% Black, 12.9% Asian, 3.9% Other, and 18.8% identify as Hispanic/Latino. Through our CCBHC expansion, Ohel will train all crisis workers to respond to pediatric BH crises. We will begin using new evidence-based screening tools for children (PEARLS) and adults (RODS, MAST). We will begin providing ancillary withdrawal management and will expand our tobacco cessation program. We also plan to expand our targeted case management (TCM), Children and Family Treatment and Support Services (CFTSS), and Community Oriented Recovery and Empowerment (CORE) programs to serve more individuals in the community, including the uninsured and those with commercial insurance. We will hire one additional peer specialist and expand our training program for existing staff. In addition to enhancing our EHR to capture more assessment data for measurement-based care, we will also train our staff to better capture client demographic data in our EHR to identify and eliminate disparities in services and outcomes. We served 1320 patients in 2022, and we will increase our total unduplicated individuals served by 600 by the end of year 4. Our goals and measurable objectives include: (1) Expand access to BH services for PPW via the following objectives: 1.a: Increase number of PPW treated for SMI, SUD, or co-occurring disorders by 20% by the end of year 4; 1.b: Increase the number of individuals, including PPW, with SUD who are receiving individual or group therapy by 20 each year of the program; and 1.c: Increase the number of providers prescribing MAT by 1 by year 4. (2) Increase BH crisis services via the following objectives: 2.a: Implement Safety Planning Interventions for Children (C-SPI) to expand crisis services to include children 6-12 years old by the end of year 1; and 2.b: Increase number of crisis interventions to 20% by year 4. (3) Increase community-based services for high acuity children and youth and PPW via the following objectives: 3.a: Increase number of children 0-17 and transitional youth 18-21 treated for Suicide Care Pathway, SED, or SUD by 20% by year 4; 3.b: Increase enrollment in CFTSS by 20% by the end of year 2; and 3.c: Increase the number of PPW we are treating with an EBP by 20% by the end of year 4. (4) Develop partnerships and create referral pathways for children from diverse backgrounds across the entire SA via the following objectives: 4.1: Outreach to new community partners and provide children's BH educational sessions in 2 new community settings in our SA each year of the grant; and 4.b: Outreach to communities in the SA through social media that have high health and socioeconomic disparities by the end of year 1. (5) Improve pediatric BH outcomes and reduce health disparities via the following objectives: 5.a: Improve documentation of client self-reported race, ethnicity, sexual orientation, and gender identity by 50% by the end of year 1; and 5.b: For children ages 4-17 with a high PSC-17, 25% will have a decrease of 4 points within a year of initiating treatment across all races and ethnicities.

The Seneca CCBHC-IA Initiative will provide comprehensive, coordinated behavioral health care for all people in need of behavioral health services at Seneca’s Nicholas County Clinic which serves Nicholas, Pocahontas & Webster Counties in rural WV. The focus population suffers from SUD, poor mental health, low mental health workforce capacity, poor SDOH & poor disparity group outcomes. The Initiative will serve 2,800 clients (700/year). Project goals (interventions/strategies) include: (1) Increase access to & availability of community-based mental health/SUD Tx and support for the focus population by enhancing SHS’s CCBHC program by (A) hiring the CCBHC Project Director to lead the program & advisory board; (B) ensuring agency compliance with the CCBHC Certification Criteria; (C) collaborating with the state to obtain CCBHC certification; (D) maintaining existing & adding new service provider & community stakeholder partnerships; (E) conducting the needs assessment; (F) initiating, analyzing & addressing concerns identified via client satisfaction surveys; (G) advancing and monitoring agency training in response to the needs assessment; and (H) enhancing training via a focus on cultural competency & implicit bias training. (2) Increase access to and availability of community-based mental health and substance use disorder treatment and support for the focus population by enhancing SHS’s CCBHC services by (A) continuing to provide the 9 core CCBHC services; (B) enhancing crisis services by hiring 2 Youth Crisis Specialists; (C) advancing physical health screening, assessment & diagnosis services; (D) improving treatment plan quality via training and EHR improvements; (E) expanding mental health services via hiring a Therapist to initiate intensive outpatient programs; (F) expanding primary care services to the Nicholas County Clinic; (G) hiring two Case Managers; (H) expanding peer & family support services to include two mental health peers; (I) initiating a veteran’s support group; and (J) developing and implementing a tobacco cessation program. (3) Increase access to and availability of community-based mental health and SUD treatment and support for the focus population by improving SHS’s CCBHC infrastructure by (A) facilitating care coordination by initiating medical EHR upgrades; (B) implementing health information exchange software to facilitate health information exchange; (C) initiating and maintaining care coordination agreements with identified partners; (D) supporting processes and procedures for collecting, reporting & tracking encounter, outcome, and quality data; (E) updating and implementing a CCBHC-wide data-driven CQI plan for clinical services & management; and (F) leveraging the patient portal to conduct measurement-based care. (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) ensuring that marketing products are culturally competent; (B) conducting community outreach & SDOH screening; (C) serving a total of 700 clients annually; (D) clients having a statistically significant decrease in illicit substance use at 6-month NOMs follow-up; (E) clients having a statistically significant decrease in tobacco use at 6-month NOMs follow-up; (F) having clients experience statistically significant improvement in NOMs mental health outcomes at 6-month; (G) clients having statistically significant improvement in social connectedness at 6-month follow-up; (H) having 80% of clients remain in treatment for at least 6-months throughout the life of the grant; and (I) monitoring disparity group data to ensure equal access/use/outcomes/retention. (5) Sustain CCBHC services beyond grant funding to serve the focus population by (A) having the Project Director lead the CCBHC Board which is made up of 51% people with lived experience; (B) creating a sustainability plan & (C) improving primary care billing.

Talbert House (CCBHC-TH) met the attestation requirement on May 4, 2022 and is seeking funds to continue to transform our community behavioral health systems and provide comprehensive, coordinated health care by a) enhancing and improving CCBHC to meet the CCBHC Certification Criteria; b) providing a comprehensive range of outreach, screenings, assessment, treatment, case management, care coordination, and recovery supports based on needs assessment with fidelity to CCBHC Certification, and c) supporting recovery from mental illness and/or substance use disorders by providing high quality mental health and substance use services regardless of an individual's ability to pay. CCBHC-TH will improve access to community-based mental health and substance use disorder treatment and support including the nine required services for individuals seeking care for mental health, substance use, opioid use, children and youth with serious emotional disturbance, and individuals with co-occurring disorders and those experiencing related crisis. CCBHC-TH will focus on groups facing health disparities as identified in the community needs assessment. The project will improve behavioral health care for individuals across the lifespan by supporting providers in accordance with CCBHC criteria and 1) increase access to and availability of high-quality services that are responsive to the needs of the community;2) recovery from mental health and substance use disorder challenges via comprehensive community-based treatment and supports; 3) use evidence based practices to address the needs of individuals; 4) continually work to measure and improve quality of services; and 5) meaningfully involve consumers and family members in their own care and the broader governance of CCBHC. CCBHC-TH will continue to offer integrated behavioral health and primary care at three sites- Walnut Hills and Western Hills clinics in Hamilton County, Ohio and Mt. Orab clinic in Brown County, Ohio a rural Appalachian area. CCBHC-TH has made progress in workforce diversity, the integration of primary care into behavioral health and care coordination. The CCBHC Improvement and Advancement Grant funds are needed to continue the support and progress to meet the needs of individuals and reduce the persistent disparities of healthcare services for underserved populations.

Project Summary: Zepf Center seeks CCBHC-IA Grant funding to improve upon its existing CCBHC services by increasing access to and improving the quality of community mental health and substance use disorder treatment in Toledo ,Ohio. The CCBHC is located in Toledo's historic Junction Neighborhood and has allowed Zepf to expand its service offerings further into the community to offer the full array of CCBHC services to persons in need. Zepf Center was awarded a previous CCBHC-E grant through SAMHSA in 2021. The Designated Collaborating Organization (DCO) for this project is the UTMC Ryan White Program. Population of Focus: The Junction Neighborhood (zip code 43607) is home to 20,854 people, 66.3% of whom are Black, 24.2% are White, and 5.2% are Hispanic or Latino. The current unemployment rate in 43607 is 7.3%, which is higher than the current county unemployment rate of 4.9%, the state unemployment rate of 5.2%, and the national unemployment rate of 6.7%. Zepf Center is one of the only service providers in this neighborhood, operating a two-building campus which provides integrated care for co-occurring disorders with co-located primary care services. The most common diagnoses amongst the target population served through Zepf's CCBHC were major depressive disorder, bipolar disorder, and anxiety disorders. Goals and Objectives: Goal 1: Improve access to and availability of high-quality services that are responsive to the needs of the community and continually work to measure and improve the quality of services. Objectives: (1) 100% of individuals seeking services through Zepf's CCBHC will be screened and assessed within 10 days of initial inquiry. (2) Within 5 working days of an assessment at Zepf Center, ensure that 90% of interested individuals are enrolled in the CCBHC to increase access to care. Goal 2: Use evidence-based practices that address the needs of the individuals the CCBHC serves. Objectives: (1) By the end of Y1, ensure that the fidelity assessments for the EBPs of Peer Support Services and EMPath Mobility Mentoring are conducted to ensure that quality services proposed by the CCBHC are being delivered to fidelity. (2) On an annual basis, review the EBPs offered at Zepf Center to CCBHC participants and compare them to the needs assessment to ensure that the needs of those served are reflected in the practices. (3) Ensure that ongoing training is provided to staff on EBPs in conjunction with the CCBHC requirements for 100% of CCBHC staff who provide clinical services on an annual basis. Total Number Serves: Y1: 200, Y2: 250; Total: 850 unduplicated persons. Contact: Deb Flores, CEO; dflores@zepfcenter.org.

South Shore Guidance Center (SSGC) is an outpatient behavioral health (BH) clinic licensed by New York (NY) to provide mental health and substance use disorder (SUD) services for children and adults in Nassau County. SSGC serves individuals of all ages, regardless of their ability to pay and was certified as a Certified Community BH Clinic (CCBHC) in 2021. In 2022, SSGC provided BH services to more than 3,500 children and adults in the most diverse and economically distressed communities of Nassau County. SSGC's population of focus (POF) consists of the large number of foreign born children and adults in the towns of Baldwin, Freeport, Hempstead, Roosevelt and Uniondale who lack English proficiency and are underserved for BH treatment for Severe Emotional Distress (SED), Serious Mental Illness (SMI), SUD MH, and trauma. Our project will specifically target the needs of our POF to increase access and address their BH and social determinants of health (SDOH) disparities. Our CCBHC Improvement and Advancement project will further increase access, patient engagement, and care coordination for children and adults in Nassau County's most underserved communities, particularly for those who are foreign born and lack English proficiency. Our measurable objectives align with three main goals: (1) increase access to integrated services for individuals with complex needs including SDOH needs; (2) further expand access to culturally appropriate services, particularly for children and their families; and (3) expand meaningful consumer involvement in CCBHC programming and planning efforts. Under this project, SSGC will implement all required activities, including (1) looking across current CCBHC services to adopt and comply with revised criteria published by SAMHSA; (2) provide all nine core CCBHC services directly or in partnership; (3) conduct required community needs assessments; (4) complete an attestation demonstrating SSGC has met all CCBHC certification criteria; (5) implement strategies to meaningfully involve consumers and family members in the planning and development of CCBHC programming and services; (6) implement additional CCBHC sustainability strategies: and (7) participate in SAMHSA CCBHC technical assistance activities. SSGC will also implement the allowed activity of Measurement Based Care for all patients served by our CCBHC.

LifeStream Behavioral Center, Inc. (LifeStream) is a fully-licensed and accredited behavioral health and social services organization with a mission of "Creating Hope, Supporting Recovery, and Promoting Health." Tis mission is accomplished by providing a continuously improving quality continuum of care that is cost-effective, culturally competent, and includes quality treatment, education, care and case management, and rehabilitation services to children, adolescents, and adults. LifeStream operates using the following principles: promoting quality; improving efficiency; and assuring growth. We are a comprehensive care facility that focuses on the all-around health and wellness of children and adults living with severe and persistent mental illness (SMI), substance use disorder (SUD), serious emotional disturbance (SED) as well as co-occurring disorders (COD) and living below the federal poverty index. Being a Certified Community Behavioral Health Clinic (CCBHC) will allow LifeStream to provide care coordination services, primary health integration, and crisis management in order to treat our consumers' health and wellness needs, not just part of their illnesses. The CCBHC grant funding will assist in linking families to recommended services, help remove barriers to engagement, complete ongoing assessment and intervention plans to reach attainable goals, and to assess for additional services or resources that will promote whole family wellness, collaboration with community partnerships to meet the needs of families, and advocate for families. LifeStream sees a continuing need within Lake County, FL for care coordination services and a need to improve access to care for individuals living in poverty who have been diagnosed with a mental health and/or substance use disorder. LifeStream currently offers a comprehensive care continuum including improves access to care for veterans in need of services. From our previous CCBCH grant, we've adopted engagement techniques to reach veterans within the community to offer same day crisis and routine care, including primary care as needed. Data and information sharing with primary care providers is another way LifeStream will be able to treat our consumers and give them the best possible outcomes for recovery and sustainability in the community. LifeStream will utilize the National Outcome Measures determined by SAMHSA to monitor and determine increases in the four dimensions of recovery - home, health, purpose, and community. This program will provide care coordination and therapeutic services to those who may benefit from counseling and family engagement. Project goals include improved timely access to services, including initial and comprehensive evaluation along with person-centered and family-centered treatment plans. We provide an array of services from prenatal care to geriatric care utilizing evidence-based practices such as Motivational Interviewing and Cognitive Behavioral Therapy in order to foster positive changes and thinking patterns for our consumers. If awarded, this program will serve 300 unduplicated individuals in the first year; 350 unduplicated individuals for year 2; 375 unduplicated individuals for year 3; and 400 unduplicated individuals for year 4; for a combined total of 1425 unduplicated individuals served over the four-year grant period.

The Westbrook CCBHC-IA Initiative will provide comprehensive, coordinated behavioral health care for all people across the lifespan in need of behavioral health services at Westbrook’s Wood County Clinic which serves Wood & Wirt Counties in West Virginia. The target population suffers from SUD, poor mental health, low mental health workforce capacity, poor social determinants of health & poor disparity group outcomes. The Initiative will serve 1,600 clients (400/year). Project goals (interventions/strategies) include: (1) Provide a comprehensive suite of CCBHC services for the focus population with fidelity to the CCBHC Certification Criteria and based on regular needs assessments by (A) initiating a Project Director to manage the CCBHC Initiative; (B) Ensuring agency compliance with the CCBHC Certification Criteria; (C) Collaborating with the state to obtain CCBHC certification; (D) Contracting with a consultant to conduct the required needs assessment; (E) Completing the CCBHC Attestation post needs assessment; (F) Supporting processes & procedures for collecting, reporting & tracking encounter, outcome, and quality data; (G) Collaborating with the Westbrook Change Team in new policy/procedure implementation; and (H) Ensuring agency participation in CCBHC Technical Assistance Center activities. (2) Enhance Westbrook’s Wood County Clinic CCBHC service provision for the target population by (A) Hiring Care Coordinators to enhance the nine core CCBHC services; (B) Hiring a Mental Health Peer to serve clients discharging from the crisis unit; (C) Designating a Veterans Care Coordinator to serve the veteran population; (D) Designating a Tobacco Cessation Care Coordinator to initiate an agency-wide tobacco cessation program; (E) Expanding Medical Director and Physician’s Assistant time; and (F) Initiating an SDOH screener to be conducted & addressed by the Care Coordinators. (3) Enhance CCBHC infrastructure development at Westbrook’s Wood County Clinic CCBHC by (A) Implementing health information technology to support care coordination; (B) Working with West Virginia University to gain access to the WVU Medicine EHR; (C) Managing care coordination agreements with service partners; (D) Developing community partnerships; and (E) Working with the Westbrook GRIT Diversity Team to provide cultural competency and implicit bias reduction training. (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) Serving a total of 400 clients annually; (B) Clients having a statistically significant decrease in illicit substance use at 6-month NOMs follow-up; (C) Clients having statistically significant improvement in mental health outcomes at 6-month follow-up; (D) Clients having statistically significant improvement in social connectedness at 6-month follow-up; (E) Having 100 clients engage in the smoking cessation program throughout the duration of the grant; (F) Having 80% of clients remain in treatment for at least 6-months throughout the life of the grant; and (G) Monitoring disparity group data to ensure equal access/use/outcomes/retention. (5) Sustain CCBHC services beyond grant funding to serve the target population by (A) Having the peer-led Board of Directors serve as the CCBHC Board; and (B) Creating a sustainability plan.

COLUMBIA WELLNESS CCBHC IMPROVEMENT AND ADVANCEMENT PROGRAM PROJECT ABSTRACT SUMMARY Columbia Wellness is a nonprofit 501c3 community behavioral health agency located in SW Washington State who will implement Comprehensive Community Behavioral Health Clinic (CCBHC) Improvement and Advancement services through funding provided by SAMHSA. Our mission is to provide a fully-integrated continuum of care that addresses the whole person through prevention, early identification, and treatment of MH, SUD, and physical health needs using evidence-based practices in one location. Targeting 850 new, unduplicated individuals annually or 3,400 throughout the lifetime of this 4-year project, we designed our continuum based on a catchment area primarily within Cowlitz County for adults with SMI, children with SED and all individuals with SUD and a subpopulation of veterans and youth where improvement and advancement in SUD services, designed to address specific needs of veterans and youth, will work to increase engagement, retention and recovery for this subpopulation. We have developed goals and measurable objectives which are aimed at improving access to services, reducing unnecessary hospital admissions, expanding harm reduction strategies of education and early intervention to improve overall health and recovery. Measurement based care will be used to improve client rate of engagement and satisfaction. No individual presenting for CCBHC IA services is turned away due to ability to pay, insurance or place of residence. Summary of Services to be Provided: We provide fully-integrated, person- and family-centered, recovery-oriented, culturally-competent, and evidence-based services that address the entire person through screening, assessment, prevention, early identification, and treatment of mental health, substance use, and physical health disorders in one location. We provide 24-hour crisis services, outpatient mental health and substance use disorder therapies, peer support services, medical and prescriber services, residential services and a residential treatment facility that offers psychiatric crisis stabilization and acute withdrawal management services. Staff provide these services in the office setting, in the community, in schools, juvenile/jails, face-to-face or via telehealth or telephonically. Initial screening and assessments determine the scope of overall client health. Care coordination serves as the very center of this program. Columbia Wellness has many longstanding community partnerships with committed and experienced providers who work together to provide intentionally coordinated care that targets the overall health needs of individuals with a goal to safely achieve more effective care through cooperative agreements and shared data. Our services use targeted case management and client voice within the treatment planning process. Providers use evidence-based and best practices that focus on addressing the needs of the individual which guide their participation in their treatment and recovery path. Our project will be supported by our CCBHC Board (formerly the Advisory Work Group (AWG)) that includes consumers with mental health and substance use disorders and their family members who provide input and guidance on project direction, services, and policies. This team approach enables our project to maintain a strong momentum and implement a public health approach across all populations using an integrated perspective that is person- and family-centered and culturally and linguistically competent. Columbia Wellness’ CCBHC IA staff will also work to set the foundation and procedures in place to develop policy, expand referrals, share data, and reduce duplicative services.

Sinnissippi Centers (SCI) is the primary provider of mental health, substance use, child and family treatment, and prevention services for Carroll, Lee, Ogle, and Whiteside counties. Our primary population of focus for the CCBHC-IA grant will be children, youth, and adults with SED, SMI, and chemical dependency, or co-occurring disorders. We will continue to prioritize outreach to individuals identifying as Hispanic/Latino, as well as members of the LGBTQ+ community. SCI uses a strategic planning process for service expansion to respond to community needs. Our 2022 CCBHC community needs assessment identified a need for more outreach to people who identify as LGBTQ+, who identify as Hispanic, and who speak Spanish. Through this needs assessment and our work over the past 2 years to implement the CCBHC model, we have identified a need to support better primary care coordination, outreach, and targeted case management for veterans and people experiencing homelessness with SMI or COD. We also recognize that to improve the quality and effectiveness of our CCBHC services, we need to advance our Health Information Technology (HIT) infrastructure and utilization to collect and report on Behavioral Health Clinic (BHC) quality measures and move toward measurement-based care. This includes educating staff around the importance of accurate and consistent collection and recording. The CCBHC-IA grant will allow us to continue expanding access to CCBHC services to additional populations in our core service area. Further, we will use grant support to advance our work in primary care screenings and access to primary care for marginalized communities, improve care coordination, improve consumer and family engagement in service assessment and delivery, and advance our data reporting capabilities. Our goals for this project include (1) maintain compliance with all CCBHC requirements and improve consumer and family engagement in CCBHC planning, implementation, services, and evaluation activities and advance data capabilities for BHC quality measure reporting; (2) increase access to and improve primary care screening, monitoring, and care coordination through hiring for primary care positions and increasing our capacity to offer MAR; (3) increase engagement with marginalized and vulnerable populations through targeted outreach; (4) and improve care coordination, case management, and peer support to better address the social determinants of health for clients—particularly those with SMI, SED, COD, are veterans, or have unstable housing.

The Centers for Youth and Families (CFYF) will improve and enhance its current slate of CCBHC services to 530 new clients in the target population - children (0+) with SED and persons of all ages who are at risk of: 1) SMI 2) SUD, 3) COD and 4) individuals with mental health issues also at risk for chronic health conditions in Little Rock, Arkansas - Pulaski County. The geographic region is primarily designated urban and is the most populous county in Arkansas (Pop 397,931; US Census). Pulaski County is HRSA-designated both Medically Underserved and a Health Professional Shortage Area in the primary and behavioral health domain. Despite its urban setting, the county ranks low on many Health Behaviors, Clinical Care, Social & Economic Factors, and Physical Environment (County Rankings, 2022). The population of the catchment area is 54% NH White, 6% Hispanic, 37% NH Black / African American, 2% Asian, < 1% Native American, and 4% Multiracial and 8.5% are veterans. Across the county, about 16% of people are in poverty, 17% are experiencing severe housing problems, 25% of children are in poverty and nearly 75% are eligible for free/reduced lunch. Further, 17% drink alcohol excessively, 15% are food insecure, 18% are in poor to fair health, 11% experience frequent physical duress, 16% experience frequent mental duress, and 10% are uninsured. The county has an Index of Dissimilarity (Black / White) score of .49, suggesting nearly half of the residents would need to relocate with in the county to create a uniform distribution of the population. Minorities living in segregated and isolated neighborhoods have lower housing quality, higher poverty, less access to education and employment, nutritional deficiencies, and less access to health care. Addressing inequity in access to quality healthcare is a pathway to reducing racial inequalities in health outcomes. CFYF is uniquely situated to address persistent integrated behavioral health inequalities as they are in southern Pulaski County, a predominantly minority area, with a client composition that is 56% Black and 9% Hispanic (CFYF, 2022). To meet the continued needs of the clients of the CCBHC and individuals in Pulaski County we have identified 4 main goals. Goal 1: Improve and enhance the current slate of services for the target population in the catchment area through targeted behavioral health equity activities including the retention of PCC staff (Y1-4) and the mobile mental health unit (Y1-4). We will increase the provision and scope of services offered by CFYF through Management Based Care and other EBPs (Y1-4). Increase general wellness exams through the PCC to include treatment and care for chronic conditions as well as screen for SED, SMI, SUD, and COD (Y1-4). Provide additional and on-going EBP training, including trauma informed care, recovery care, targeted case management, SUD treatment to all clinical staff involved in the care of the target population (Y1-4). Provide workforce development that specifically addresses Diversity, Equity, Inclusion and Accessibility, Cultural Competency, and Implicit Bias Reduction Training (Y1-4). Ensure EBPs are appropriate for specific populations for use in their care (Y1-4).Goal 2: Expand telehealth services to the target populations. Specifically, telehealth will be expanded at the outpatient west facility to include telehealth capable rooms and additional telehealth therapists. Goal 3: Increase accessibility for historically underrepresented and under resourced communities through mobile mental health services (Y1-4) in targeted areas of Pulaski County to create a continuum of care. Goal 4: Identify and improve underlying social determinants of health (SDOH) for target population through the implementation of assessment of SDOH (Y1-4) and Measurement Based Care (Y2-4).

NorthCare's Logan County CCBHC IA project will focus on developing enhanced crisis intervention services and community support services. Guthrie’s CCBHC project seeks to improve access to community-based mental health and substance use disorder treatment and support, including 24/7 crisis services, to anyone in their service area who needs it, regardless of their ability to pay or place of residence. To address this gap in care, a 24/7 triage and crisis assessment center will be established within the existing Certified Community Behavioral Health Clinic. The population served by the Logan County CCBHC IA are low-income, uninsured, and underinsured residents of Logan County, Oklahoma (population 51,933), with serious mental illness (SMI) and complex needs such as co-occurring substance use disorder (SUD), serious emotional disturbance (SED), and other co-occurring disorders (COD) across the lifespan. The 5 largest ethnic groups in Logan County are White (non-Hispanic) (77.6%), Black or African American (non-Hispanic) (8.16%), White (Hispanic) (5.35%), Two+ (non-Hispanic) (4.16%), and American Indian & Alaska Native (non-Hispanic) (3.48%). Logan County, designated a high-needs Health Professional Shortage Area (HPSA), is the 5th lowest in access to treatment in Oklahoma, with a ratio of behavioral health providers to the population of 640:1. This project will seek to address disparities among adult and adolescent males particularly among BIPOC (Black, Indigenous, and People of Color). 2) Serious mental illness among young adults (18-25 years old) in Oklahoma increased dramatically from 4.4% in 2008-2010 to 8.7% 2017-2019. 3) Youth in transition, as an age group, have the highest prevalence of serious mental illness (SMI) (8.6%) compared to adults aged 26-49 years (6.8%) and aged 50 and older (2.9%). NorthCare was established as a community mental health provider to the citizens of Oklahoma in 1980. As a safety net provider of behavioral health services, NorthCare's priority populations are individuals experiencing a psychiatric crisis, adults with SMI, adults and children with substance use disorder, co-occurring disorders, and children with SED. The project will serve 325 unique individuals over the four-year period, with an average of 81 new clients enrolled annually. As a result of the grant, 67% of individuals will report improved self-care, 94% will receive a tobacco screening or tobacco education, 30% or more will receive peer recovery services. The clinic will offer case management, therapy, wellness, peer support, and community-based services. Goals of the project include: Increasing access to high-quality crisis services, supporting recovery from mental illness and substance use disorders, using evidenced-based practices, measuring and improving the quality of care, and meaningfully involving consumers and family members in program planning and development.

Family Service of Rhode Island (FSRI) is a statewide, full-service nonprofit behavioral health (BH) and social service organization with a long history and deep presence in Providence, RI. Our CCBHC, which is centrally located at 55 Hope St. in Providence, RI, serves children and youth with serious emotional disturbance (SED), as well as individuals of all ages with serious mental illness (SMI), substance use disorders (SUD), and co-occurring disorders (COD) who live in Providence. Our current CCBHC and other programs provide access to those facing the greatest BH inequities in our region, including low-income people of color, immigrants, LGBTQIA+ individuals, and veterans and their families. Approximately 50% of those served will identify as Hispanic or Latino, with most being of Dominican descent. Unfortunately, Providence’s existing complex and under-resourced service system cannot fully meet our catchment area’s BH needs. Through our CCBHC-IA, FSRI seeks to expand our capacity to offer 24/7 access to community based BH services; treatment of COD; and physical healthcare (PH) services. We will prioritize access for individuals who are monolingual Spanish speaking by conducting targeted outreach to these communities in Providence. Additionally, FSRI seeks to expand access to a range of SUD services, enhance care coordination for transition aged youth (TAY), strengthen our recruitment of bilingual staff to ensure monolingual Spanish speaking individuals receive services in their preferred language, and modify our existing infrastructure to ensure the space is accessible and trauma informed. Our goals and objectives include the following: 1) Increase our capacity as a CCBHC in alignment with the revised CCBHC criteria, by demonstrating the following objectives a) Within 4 mos. of grant award, hire additional clinical staff to support the growing BH needs in Providence, including a Clinical Supervisor, a CPST Case Manager, and a bilingual clinician; b) Train 75% of CCBHC staff as Trainers in overdose response and Narcan administration within 4 months of contract award; c) Engage 100% of CCBHC consumers using Screening-Brief Intervention-Referral to Treatment (SBIRT), screening them to identify SUD and connect those with risks to treatment within 30 days; d) Offer access to MAT to 100% of consumers identified as using opioids within 5 days of identification; e) 100% of consumers with identified substance use risks will be offered participation in the Seven Challenges EBP or SUD counseling within 7 days of screening; f) Meet all revised CCBHC criteria by July 1, 2024, as measured by FSRI’s Attestation Statement documentation. 2) Increase access to CCBHC services for people who are monolingual Spanish speaking, by demonstrating the following objectives: a) Annually, host 4 stakeholder educational sessions with external community agencies serving Hispanic individuals in Providence; b) Conduct targeted recruitment to ensure our team reflects our community; within 4 mos. of award, 50% of our CCBHC team will be bilingual; c) Within 4 mos. of award and annually thereafter, provide 100% of CCBHC staff with culturally and linguistically competent care training, 3) Enhance services to Transition-Aged Youth (TAY) to reduce hospitalizations and suicide risk, by demonstrating the following objectives: a) Within 7 days provide targeted case management to 100% of TAY that we serve; b) 3.B In the first grant year, we will establish a baseline for hospital utilization among our CCBHC clients. In the second grant year, we will achieve a 10% decrease in hospital utilization from the established baseline; c) By the end of Y1, train 100% of CCBHC staff in Zero Suicide; d) By the end of Y1, train 50% of CCBHC staff in First Episode Psychosis to better respond to the needs of transition-aged youth.

Volunteers of America Massachusetts (VOAMASS) proposes a CCBHC Improvement & Advancement (CCBHC-IA) program to build upon its inaugural 2021 CCBHC-PDI award. In 2021 and 2022 the VOAMASS Integrated Care Center of MetroBoston (ICC-MB) met all criteria for SAMHSA Certification as a Community Behavioral Health Center serving MetroBoston, specifically Boston neighborhoods of Lower Roxbury, Dorchester, Jamaica Plain, and bordering communities of Quincy and Somerville to the south and north. MetroBoston, concentrated in Suffolk County, is the catchment area for the proposed CCBHC-IA program. The primary population includes unhoused individuals/families, veterans, justice-involved persons, and individuals experiencing co-occurring mental health and substance use disorders. The target population is at greater risk of suffering poor health outcomes from complex factors, including higher rates of co-morbid medical and behavioral health conditions, and lower access to resources that support social determinants of health (SDOH). Housing, financial stability, behavioral health, and access to services remained key priorities in the catchment area's 2022 Community Health Needs Assessment (CHNA). The proposed approach builds on lessons learned over the first two years of CCBHC implementation and focuses on measurable goals and objectives for continuously improving the ICC-MB whole-person integrated care model. The most recent CHNA findings reinforce the continued need to provide rapid access to behavioral health care alongside support for housing and homelessness; employment, education, and job training through an integrated, no-wrong-door community-oriented approach. Metro-Boston CCBHC improvement goals include (1) Improve upon current no-wrong-door approach to reaching the focus population of veterans, individuals experiencing housing instability, justice-involved persons, and/or individuals living with SUD and CoD populations in MetroBoston with CCBHC services; (2) Implement system, workflow, and staffing changes to improve rapid access to screening, assessment, and referral to services that address the needs of the whole-person and to better reach individuals who require additional support initiating or remaining engaged in services; (3) Improved infrastructure for managing staff development and enhancing training curricula to hold all staff accountable for delivering interventions to fidelity with evidence-based practices, clinical guidelines, and professional standards of practice across all disciplines; (4) Enhance existing VOAMASS crisis care model by integrating 988-referrals, adding 24/7 on-call nursing support, and tracking of referrals to state-funded mobile crisis services provider; and (5) Improve initiation and engagement of individuals with recovery and health-related social needs in person-centered, evidence-based case management, peer coaching, and rehabilitative housing and employment services. VOAMASS will serve 1,000 unduplicated individuals, 250 each funding year. The agency will implement sustainability strategies for resources to maintain service delivery once funding ceases.

Los Angeles Centers for Alcohol and Drug Abuse (L.A. CADA) is the behavioral healthcare safety net for very low-income residents of L.A. County. Using the scope of experience gained in the 2021 development of our CCBCH in Santa Fe Springs -- The Wellness Center -- together with our community partners and a local Consumer Advisory Board, L.A. CADA will use the IA grant to improve and advance CCBHC services in L.A. County Service Planning Area (SPA) 7. The IA grant will allow us to double current capacity from 150 to 300 patients served annually, including addition of two satellite offices to serve Youth and Families and LGBTQ+ consumers. The IA grant will also facilitate delivery of crisis services in full alignment with 2023 CCBHC Certification Criteria. The catchment area of L.A. County SPA 7 has the largest Latino population in L.A. County (74% Latino overall and up to 96% in some SPA 7 cities). We are also home to 03% Black; 09% Asian/PI; and 14% white residents. Over 33% of our population of 1.3 million have less than a high school diploma (compared to 24% in L.A. County); 17% live below the poverty level; and 30% are food-insecure. Other treatment barriers faced by our community are fragmented services delivered in multiple systems, lack of health equity, and long wait times for treatment. People with little means have vastly reduced access to evidence-based behavioral healthcare, particularly people of color. A study found that 39% of L.A. County Latinos could not access mental healthcare at all, and only one in three Black people who needs mental health services receives them. Disadvantaged people are often placed on wait lists for publicly-funded treatment, including services provided by the L.A. County Department of Public Health and the Department of Mental Health. Wait lists have long been identified as a significant barrier to treatment – studies show that up to 50% of substance users will drop off a wait list between assessment and treatment entry. L.A. CADA’s CCBHC advancement and improvement project will address grassroots needs to be identified by an updated Community Needs Assessment. Our 2021 assessment revealed three community needs that have anchored CCBHC services: 1) Close Local Disparities; 2) Provide Timely Access to Care; and 3) Provide Consumer-driven Care. With IA funding, L.A. CADA will achieve full adherence to 2023 CCBHC Certification Criteria by 9/30/2024.

Recovery Consultants of Atlanta, Inc. (RCA) proposes an advancement of its Certified Community Behavioral Health Clinic (CCBHC) to include community-based behavioral health services for underserved children and families in Dekalb and Fulton counties, Georgia including those with chronic health diseases, serious mental illness (SMI), substance use disorder (SUD), and co-occurring disorders (COD). RCA currently provides evidence-based interventions to adults within the service area including primary and preventative care, behavioral health services, peer support, transitional housing, and recovery support services. Through partnerships with Corners Outreach, CBOs and other community locations, RCA will extend evidence-based interventions to where children and families are most comfortable, and services are desperately needed. Within these community-based settings, RCA will provide outreach, engagement, case management, and behavioral health services to metro-Atlanta children and families for 100 individuals in Year 1, 115 in Year 2, 125 in Year 3, and 140 in Year 4 for a total of 480 individuals served during the grant period. The goals of this CCBHC advancement are to: (1) provide children and families with access to a fully integrated care team including case management, primary care, behavioral health care, peer support, and recovery support services; (2) continue to operate the CCBHC program in compliance with all certification criteria; (3) provide physical health care through screening, monitoring, and follow-up of key health indicators to decrease health risks and improve physical health outcomes of the population of focus; (4) provide behavioral health screening, assessment, diagnosis, and develop recovery-oriented treatment plans for behavioral health, SUD, and COD; and (5) demonstrate consistent, person and family-centered approach in delivery of behavioral health and primary care services.

The Harris Center seeks to transform our existing CCBHC system by expanding and improving on a comprehensive range of outreach, screening, assessment, treatment, and care coordination for underserved communities and populations within greater Houston, Texas that have experienced: 1. Barriers in outpatient behavioral health treatment resources for underserved children and adult populations and communities; 2. Poor access to integrated health screening and treatment for high-risk adults and children with complex co-morbid conditions; and 3. Iniquities and disparities in social determinants of health that are drivers of poor health and behavioral health outcomes within undeserved communities and populations. Underserved Communities and Population to Be Served: 1. Adults and children with SED, SMI, SUD who are appropriate for outpatient treatment services delivered from a comprehensive CCBHC system of care. 3. Adults and children with co-occurring substance use disorder and serious mental illness. Extrapolating data from the Harris Center's existing participant population an target communities indicates an estimated 85% of participants will be low-income persons of color (< 200% of poverty), with equal shares of male and female; 10% will identify as LGBTQI; and 75% will be between the ages of 25 and 45. Strategies/ Interventions: 1. Expand provision of comprehensive, quality-focused, patient-centered, outreach, enrollment, and coordinated comprehensive behavioral health care to underserved communities and populations with SED, SMI, and SUD needs. 2. Enhance community outreach efforts for the identified population by partnering with faith-based organizations and neighborhood communities and social agencies in targeted underserved areas. 3. Expand outpatient treatment of substance use disorders or co-occurring disorders by introducing clinic-based individual counseling, group counseling, medication management, and case management. 4. Increase the availability of outreach care coordination in underserved communities and populations to address social determinants of health disparities, assist with resource navigation and enhance retention in care. 5. Conduct risk stratification and trauma screenings to inform treatment plans within underserved populations and communities. 6. Respect and incorporate participant voice, cultural and ethnic needs, strengths, and social determinants of health needs into all services and treatment planning. Project Goal and Objectives: Goal: Improve and Advance the Harris Center's existing CCBHC care model and narrow treatment and care gaps in underserved communities and populations by increasing outreach and access to care to underserved communities and populations. Objective A. Increase access to CCBHC comprehensive services to underserved communities and populations. Objective B. Increase access to integrated outpatient treatment of co-occurring substance use and mental health disorders. Objective C. Increase outreach efforts and the availability of care coordination to address the social determinants of health, assist participants with resource navigation and enhance retention in care. Objective D. Implement measurement-based care processes in all clinics. Number of People to Be Served in the 4-year period: 4,800 children and adults will receive comprehensive CCBHC services: 750 children and adults receive crisis care; 4,800 adults and children receive outreach and case management; 4,800 adults and children receive social determinants of health social support services, food and nutrition, recovery support, peer support, and/or employment or housing connections.

As a CCBHC-IA grant awardee, Horizon Health Services (HHS) will expand and enhance our CCBHC services to serve all individuals across the lifespan in need of behavioral healthcare in the East Side of Buffalo City (East Buffalo), Erie County, New York (NY), with a particular focus on addressing BH disparities for Black individuals with criminal justice (CJ) involvement and/or transitioning from inpatient, emergency department (ED), or residential treatment. HHS' project goals are to: (1) Improve targeted case management (TCM) for those who are non-Health Home (HH) eligible or refuse to participate in HH; (2) Increase the capacity of the clinic to meet the medical and medication needs of our patients; and (3) Reduce the rate of never events (Overdose/Suicide Attempt/Patient Death). We will address these goals by strategically and proactively outreaching and engaging patients, especially those coming from a higher level of care or the CJ system. Specifically, we will: (1) hire 1 FTE targeted case manager; (2) offer TCM to 90% of eligible patients; (3) provide targeted outreach to 90% patients coming from a higher level of care; and (4) screen 90% of new patients for health-related social needs (HRSN). We expect that 50% of eligible patients will receive TCM in each year of the grant period. To improve patient access to medication and medical monitoring, we will hire 1 FTE Nurse, 1 FTE Population Health Specialist, and 1.3 FTE psychiatric nurse practitioner (PNP) to provide medication consultation/education to 75% of patients prescribed BH Rx and primary care screening and monitoring, including referral to ongoing primary care, to 75% of patients who are not consistently connected to primary care. Through improved monitoring and TCM, HHS aims to reduce the rate of never events by 20% as well as improve HEDIS rates for Follow-Up After Hospitalization for Mental Illness (FUH), High-Intensity Care for SUD (FUI), ED Visit for Mental Illness (FUM), and ED Visit for Alcohol and Other Drug Abuse or Dependence (FUA) rates by 25% over the grant period. We will collaborate with two FQHCs, Evergreen Health and Community Health Center of Buffalo (CHCB), to provide primary care services to HHS patients in need of further treatment for medical conditions, including ongoing monitoring of health needs and HIV and HEP screenings and care. We will also partner with the Crisis Services of Erie County (CSE) to offer the full range of 24/7 crisis services; Restoration Society to provide psychosocial rehabilitation (PSR) and other peer-supported services; Horizon Village's Terrace House to provide SUD crisis stabilization; and Endeavor Health Services to provide Clubhouses and Personalized Recovery Oriented Services (PROS) to HHS patients. The project will serve 300 unduplicated individuals in the first year of the project and 450 individuals for each year thereafter, for a total of 1,650 individuals over the course of the project.

Abstract: Bridgeway Certified Community Behavioral Health Clinic in Hudson County, NJ Bridgeway Behavioral Health Services (BBHS) will use SAMHSA Certified Community Behavioral Health Clinic (CCBHC) Improvement and Advancement funding to enhance the programming of its CCBHC which launched in Hudson County (HC), NJ in 2021. The CCBHC will be able to increase its offerings to include 8 of the 9 required CCBHC services on-site, and at a single location, improving access and continuity of care for its consumers. Our populations of focus (POF) will be children/adolescents; senior citizens; those with substance use disorder (SUD); the Hispanic/Latino community, particularly those for whom Spanish is their primary language and are not English proficient; the Black community; and the LGBTQ+ population. The CCBHC will address the following health disparities among subpopulations of focus in HC: rate of psychiatric hospitalizations among Black individuals which is 70% higher than the county average for all individuals in the catchment area (CA);2 chronic depression among Hispanic/Latino individuals in HC, 51% of whom reported symptoms vs. 42% of the general population;4 chronic depression among the LGBTQ+ population, 70% of which reported symptoms;4 seniors who are “particularly affected by anxiety and depression” and have a higher rate of comorbid chronic conditions than the general population;2 anxiety and depression in youth as identified by a 2022 needs assessment; 2 and persons with SUD who are without sufficient treatment resources.2 We plan to serve 75 consumers in year 1; 125 in year 2; 175 in year 3; 200 in year 4 and a total of 575 people throughout the funding period. Our goals for the catchment area include (1) Improve the mental health (MH) and physical health of the Black population, (2) Improve access to care MH/SUD/physical health care for the Hispanic/Latino population, especially Spanish speakers with limited English proficiency, (3) Improve whole-person outcomes for the LGBTQ+ population, (4) Improve whole-person health for Seniors ages 65+, (5) Provide high-quality MH care to children and adolescents, (6) Improve access to SUD treatment, (7) Improve access to care for all of our Populations of Focus (POF). These goals will be accomplished by adding, on-site for the first time, outpatient SUD treatment for adults and seniors; outpatient MH treatment for children/adolescents; primary care screening and services across the lifespan; peer services; Spanish-language options in all our service lines. We will tailor our services to be effective, responsive, and evidence-based in relation to our POF. BBHS is committed to delivering culturally and linguistically appropriate and accessible care. This is driven through the QI Dept., an internal Diversity, Equity, Inclusion, and Belonging (DEIB) committee, charged with ensuring all BBHS programs adhere to the National Standards for Cultural and Linguistically Appropriate Services, and that all staff are trained annually on cultural competency. We will prioritize the recruitment and hiring of practitioners who have similar identities/demographics as our POF including those who are bilingual, practitioners who are Black and/or Latino, and those who identify as part of the LGBTQ+ community. This service expansion will significantly improve access to comprehensive care for the community in Hudson County. We intend to ensure that all our clients have their whole-person health and recovery needs met through our CCBHC program. Through this effort, our agency will reduce health disparities in our POF and improve the MH/SUD/physical health outcomes for our consumers.

Acenda Integrated Health proposes to expand CCBHC services in Gloucester County NJ which currently include an accessible person-centered integrated system designed to reduce unnecessary hospital utilization, increase treatment engagement and adherence, and promote long-term wellness. The additional funding will allow the agency to expand an integrated care solution for mental health and substance misuse to more individuals who are currently not receiving access. The current model only includes resources sufficient enough to support clients with a higher acuity of need or more serious illness. Though care for this population is important, the current capacity means that the many individuals who need care but are not as high acuity as others, aren’t able to access the integrated supports of the CCBHC which can include case management, peer supports, health assessment screenings and nurse support, psychiatry, and substance use disorder treatment. Those clients are instead redirected to other Acenda’s programming, including outpatient mental health where they often are waitlisted, and go without additional supports to keep them stable, which could result in more severe escalation and even emergency room admissions. Acenda proposes to utilize expanded funding to more fully integrate the CCBHC into the agency’s robust service offering to ensure individuals in need are connected to necessary support services in a much more expeditious manner. Funding would specifically be applied to expanded staffing such as therapists, peer supports and SUD counseling. Most importantly, the funding would support the additional of a clinical supervisor, a care navigator, and front desk personnel to ensure a coordinated and seamless care management process acuity. The agency proposes to serve 2,600 individuals over the course of the grant period. The project goals include: 1. Increase access to integrated health services for individuals in need of behavioral health and/or co-occurring services through the CCBHC as the initial point of access; 2. Reduce emergency department utilization by increasing first appointment follow through and treatment adherence for individuals who are discharged from screening, hospital, or mental health urgent care; 3. Develop implementation plan to provide Medication Assisted Treatment (MAT); 4. Increase access to integrated treatment for Veterans; 5. Increase access to services for those who identify as LGBTQ+. Acenda currently administers over 120 programs and is positioned to provide and/or support all of the required CCBHC services, with limited need for DCO’s. For purposes of the Gloucester County CCBHC, Acenda will be engaging DCO’s within the county including Inspira Health (hospital system and physician practices), Jefferson Health (hospital system and physician practices), Complete Care (FQHC), Maryville Addiction Treatment Centers (substance withdrawal management, inpatient recovery), New Hope Integrated Health (substance withdrawal management, inpatient recovery), and additional partnerships Gloucester County Workforce Development, Gloucester County One Stop (employment).Although the Veterans Administration previously declined to formally partner as a DCO, Acenda intends to attempt to re-engage the VA. Acenda is actively involved with the Community Veterans Engagement Board (CVEB), which integrates local service provides and stakeholders with the local VA offices to address gaps in services, information sharing, and serves as a voice for Veterans and their families.

Centerstone will enhance and improve the CCBHC in Alton, Illinois (C-CCBHC), supporting recovery from mental illness and/or substance use disorders (SUD) by providing access to a comprehensive range of high-quality behavioral health services (e.g., outreach, screening, assessment, treatment, care coordination, recovery supports), regardless of an individual’s residence or ability to pay. C-CCBHC will serve 1,900 unduplicated individuals (Y1: 400; Y2-4: 500/yr.). C-CCBHC will serve individuals across the lifespan seeking care at Centerstone’s Alton CCBHC, including those with serious mental illness (SMI); SUD, including opioid use disorder (OUD); serious emotional disturbance (SED); co-occurring mental and substance disorders (COD); and/or experiencing a mental health (MH) or substance use (SU)-related crisis. Focus population demographics are expected to mirror those of the Illinois catchment area, comprising Calhoun, Greene, Macoupin, Madison, St. Clair, and Jersey counties. Those under age 17 are expected to comprise roughly 52% male; 48% female; 67% white; 19% African American; and 6% Hispanic/Latino individuals; and those ages 18+ comprise 48% male; 52% female; 76% white; 15.5% African American; and 3% Hispanic/Latino individuals. Of the area’s 470,964 adults, 6% are expected to have SMI; 17%, SUD; 2%, OUD; and 5%, co-occurring SUD/any mental illness. Of the 137,154 children/youth, 10% are expected to have SED; 4%, co-occurring SUD and major depressive episode; and 9% of youth ages 12-17, SUD. Key C-CCBHC strategies include expanding access/availability of services responsive to community needs (e.g., crisis services; screening/assessment/diagnosis, including risk assessment; treatment/crisis planning; outpatient MH/SU services; primary care screening and health monitoring; targeted case management; psychiatric rehabilitation; peer and family supports; and community-based MH care for Armed Forces/Veteran populations); meaningfully involving service recipients/families in their care; and applying a continuous quality improvement (CQI) approach to drive improvements and sustainability. C-CCBHC will implement evidence-based interventions addressing service recipients’ behavioral health needs (e.g., Cognitive Behavioral Therapy, Motivational Interviewing, Dialectical Behavior Therapy, Illness Management and Recovery, Parent Management Training, Seeking Safety, MAT, Integrated Dual Disorders Treatment). C-CCBHC will accomplish the following goals: 1) Expand and improve delivery of comprehensive, integrated, coordinated and person-/family-centered community-based behavioral services; 2) Enhance infrastructure/capacity for a coordinated care continuum; 3) Increase access to/availability of timely services; 4) Implement a measurement-based care (MBC) process to ensure comprehensive, evidence-based services, supports, and practices; 5) Improve health status and outcomes for service recipients; and 6) Apply a CQI approach to drive outcome improvement and ensure ongoing service delivery. Planned improvements include expanded care coordination, enhanced crisis planning, increased workforce capacity, and enhanced infrastructure for data-driven care improvements/MBC efforts. The project will achieve the following measurable service recipient-related objectives: Decrease symptomatology among 45% with MH disorders and SU among 45% of those with SUD/OUD/COD; provide/offer ITPs for 100%, employment case management for 100% per ITPs, and follow-up to 100% receiving linkages/referrals to MH services/supports; improve housing stability among 80% who are homeless/marginally housed and physical health indicators among 75% of participating service recipients; achieve no past 30-day criminal justice system involvement among 60% with criminal justice histories, no past 30-day ER/hospitalizations among 60% with hospitalization histories, an 80% follow-up rate, and satisfaction of experience/care among 80% of service recipients/families.

CarePlus New Jersey (CPNJ) provides integrated Behavioral Health (BH) treatment and related services to adults and children in Bergen County, NJ. It will expand services to include additional integrated primary and specialty health care to 700 individuals over 4 years with BH needs including adults who are not securely connected to primary care and children/adolescents (5-17) with serious emotional disturbance (SED) and/or substance use disorder (SUD). Project goals and objectives are as follows: Goal 1: To improve outcomes of BH services through better integration with primary care and specialty health care for children/adolescents (5-17) with SED and/or SUD, and adults with SMI, SUD and/or COD who are not securely connected to healthcare and a general population including active military and veterans in the CA. Objective 1.1: In year 1, hire 1.5 FTE Masters-level Licensed Therapists (MLTs) and a 1.0 FTE Family Nurse Practitioner (FNP), Credentialing Specialist, Clinical Supervisor, Administrative Support, and Outreach and Training Specialist trained in project evidence-based practices (EBPs) who will provide consistent contact to 100% of individuals served. Objective 1.2: Targeted case management will be provided to 100% of individuals served to streamline coordination between BH and physical health services provided by CPNJ directly and by linkage to other providers. Objective 1.3: By month 12 of year 1, Clinical Staff (Clinical Supervisor, MLT, FNP) 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; and accompany each individual through the care planning and service delivery, especially transitions with 80% of individuals retained in treatment after 6 months. Objective 1.4: In year 1, an Outreach and Training Specialist will expand effective coordination of healthcare with external providers as evidenced by participant tracking and provide training to at least 100 school-based and psychiatric rehabilitation providers on integrating BH and primary care. Objective 1.5: Over 4 years, provide training on integrated care to 200 individuals including internal and external providers. Objective 1.6: In year 1, add 1 active-duty military or veteran, and 1 physical health provider, to CPNJ’s Consumer Advisory Workgroup. Objective 1.7: Within 6 months, CPNJ will submit to SAMHSA an attestation that it has met the CCBHC Certification Criteria. Objective 1.8: Within 1 year, enhance CPNJ’s electronic health record system (EHR) to include a module for integrated primary and specialty health care services. Objective 1.9: Within 1 year, CPNJ will create new partnerships with at least 70 specialty medical providers including neurologists, cardiologists, and/or nutritionists. Objective 1.10: In year 1, reduce appointment no-shows by 20% by adding appointment tracking to CPNJ’s EHR. Objective 1.11: Within 6 months, and updated during months 6-12 of year 3, complete a Community Needs Assessment and year 1, develop a detailed Sustainability Plan. For over 45 years, CPNJ has provided integrated mental healthcare, substance abuse treatment and primary care in Northern New Jersey. CPNJ serves approximately 14,000 adults and children annually through 80 programs. CPNJ is accredited by The Joint Commission and currently licensed by the NJ Department of Health for primary care services, and NJ Department of Mental Health and Addiction Services for partial care, outpatient, residential, intensive outpatient mental health care, ambulatory detox, intensive outpatient care, standard outpatient substance abuse treatment and co-occurring treatment services. CPNJ is a mature CCBHC.

Counseling Associates, Inc. (CA) will improve and advance its current slate of CCBHC services to 405 new clients in the target population - children (0+) with SED and persons of all ages who are at risk of: 1) SMI 2) SUD, 3) COD and 4) individuals with mental health issues also at risk for chronic health conditions in 4 counties in Central Arkansas - Conway, Faulkner, Pope and Perry. Specific attention will be given to individuals who identify as veteran or minority (race, ethnicity, gender, and economic). All 4 counties are HRSA-designated (2023) Medically Underserved and Health Professional Shortage Areas in the primary and behavioral health domain. Most of the diverse geographic area is predominately rural with urbanization concentrated in Faulkner County, particularly in Conway (city), the 7th largest city in AR (Pop 67,882). The 4-county area ranks low among many Health Behaviors, Clinical Care, Social & Economic Factors, and Physical Environment (County Rankings, 2022). The population of the catchment area is 80% Non-Hispanic White, 6% Hispanic, 9% Non-Hispanic Black / African American, 1% Asian, 1% Native American, and 4% Multiracial, 7.5% are veterans and about 3.3% of Arkansans identify as part of the LGBTQIA+ community. Additionally, Faulkner County has approximately 1,200 Marshallese residents. Across the 4 counties, about 16% of people are in poverty, 17% are experiencing severe housing problems, 20% of children are in poverty and 57% are eligible for free /reduced lunch. Further, 17% drink alcohol excessively, 15% are food insecure, 19% are in poor to fair health, 12% experience frequent physical duress, 17% experience frequent mental duress, and 6% are uninsured. To meet the continued needs of the clients of the CCBHC we have identified 4 main goals. Goal 1: Improve and enhance the current slate of services for the target population in the area through targeted behavioral health equity activities including the retention of PCC staff (Y1-4) and the mobile physical health unit (Y1-4). Increase the provision and scope of services offered by CA to the target population through a mobile crisis team, Management Based Care (MBC), and other EBPs (Y1-4). Provide additional and on-going EBP training, including trauma informed care, recovery care, targeted case management, SUD treatment to all clinical staff involved in the care of the target population (Y1-4). Provide workforce development that specifically addresses Diversity, Equity, Inclusion, and Accessibility, Cultural Competency, and Implicit Bias Reduction Training (Y1-4). Ensure EBPs are meting fidelity standards (Y1-4). Goal 2: Expand PCP services to the Russellville campus, to children ages 5+ (Y2-4), to include general wellness exams (Y2-4) and assessing for, and treatment of, chronic health conditions (Y2-4). Goal 3: Increase accessibility for historically underrepresented and under resourced communities through mobile physical health services (Y1-4) in targeted areas, specifically Conway and Perry counties, to create a continuum of care. Goal 4: Identify and improve underlying social determinants of health (SDOH) for target population through the implementation of assessment of SDOH (Y1-4) and MBC (Y2-4). We will raise awareness about the social challenges that our clients are facing and action that can be taken to create more supportive environments for health across our area and the State. Finally, to sustain our CCBHC we are implementing more EBPs and assessing for fidelity to reduce the use of costly resources, hospitalizations, and jail time for clients using the most behavioral health services.