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The purpose of DWIHN’s Zero Suicide Initiative (ZSI) is to provide a framework for holistic, clinical suicide prevention within DWIHN’s network of 300 providers throughout Wayne County, Michigan. DWIHN is committed to patient safety and closing gaps in care management, while transforming organizational culture around suicide awareness and prevention. ZSI implementation and the clinical actions will reverse the increasing trend in the number of suicide deaths each year in Wayne County. A suicide death happens by an individual, however, each person lives in context of relationships with family, friends, colleagues, and the community, who are all greatly impacted by the suicide. Table 1 highlights the individuals directly serviced in eliminating suicide, however there are many more people impacted indirectly through DWIHN’s ZSI. The Zero Suicide framework is implemented through seven elements: LEAD, TRAIN, IDENTIFY, ENGAGE, TREAT, TRANSITION, IMPROVE. DWIHN has more than 30 years of experience with this population of focus, and has a network of 300 service providers across the geographic catchment area. The population to be served includes adults residing in Wayne County with mental health concerns, specifically suicide ideation and attempts. While DWIHN's application is not proposing to partner with other organizations via subawards, DWIHN has formal partnerships with a range of community partners, health systems, and providers. Specifically, DWIHN will work with current state and local health agencies implementing Zero Suicide (i.e., Hegira Health, American Indian Health and Family Services, and Michigan Department of Health and Human Services) as well as work with those interested in adopting the Zero Suicide model. DWIHN has been a lead agency in serving adults who are suicidal and is highly capable of further integrating the Zero Suicide model into our current behavioral health services and network. DWIHN's Zero Suicide Initiative goals include: Goal 1: Increase the capacity of DWIHN to lead in a comprehensive, multi-setting approach and system-wide culture change through the implementation of the Zero Suicide intervention and prevention model to reduce suicide ideation, attempts, and deaths in Wayne County, Michigan. Goal 2: Improve, expand, and coordinate access to and quality of suicide prevention practices, services, and infrastructure delivered across the entire system of care to advance health equity and reduce suicide ideation, attempts, and deaths in Wayne County, Michigan. Goal 3: Decrease the stigma around suicide and mental health across the entire community so each person at risk for suicide has a supportive network that recognizes the warning signs and knows to alert for help before it is too late.

Project Zero Suicide in Alabama is implementing the Zero Suicide (ZS) Model of Care - multilevel evidenced-based suicide prevention practices to clinical care with individuals who are 18 years of age or older in rural and underserved Cullman County where 13% of the population live below the federal poverty level. Project Zero Suicide in Alabama will be implemented to achieve the following three goals and associated objectives: 1) Increase access to universal suicide screening for adults in public health; (a) by the end of year one, counselors or social workers in the identified public health care settings will be appropriately assessed using the Workforce Survey and trained in the ZS approach, including ASIST Training for regular inclusion at medical and clinical practice sites; (b) develop and convene an oversight steering council to oversee the development, implementation, and quality improvement of ZS; 2) To improve patient outcomes among adults, including veterans, with a risk of suicide; (a) at least 75% of patients who are positive for suicide risk will receive a same day comprehensive assessment; (b) at least 75% of patients who are positive for suicide risk will receive a same day safety plan development; (c) at least 75% of patients who are positive for suicide risk will receive a same day counseling on lethal means; (d) at least 50% of patients who are discharged from hospitalization or emergency department will receive a follow up within 24 hours; (e) by the end of the project, reduce the rate of suicide deaths among those with a suicide care management plan by 50%; and 3) To increase education and training of professionals to better assess, engage, treat, and transition those with identified risk; (a) by the end of year one, conduct at least one ASIST Train-the Trainer session in the state of Alabama, to increase the states workforce capacity to provide suicide training; (b) by the end of year one conduct a statewide ZS Workforce Survey to evaluate provider/staff perceptions of knowledge and skill to provide suicide care to inform state-wide training needs. The unduplicated number of individuals who will be served annually is 15,000, with a total of 75,000 over the five-year project period.

Iina Bihoo’aah (the essence of life) The Utah Navajo Health System (UNHS) proposes to implement the Iina Bihoo’aah (the essence of life) to improve the mental health and wellbeing of youth and young adults ages 16 – 25 with or at risk of developing a serious emotional disturbance or serious mental illness through quick and easy access to high quality and coordinated services. The communities of focus include the Utah Strip of the Navajo Nation (UNHS Service area) and the Northern Treehouse Shelter in Shiprock, NM. Iina Bihoo’aah will accomplish the proposed purpose through a coordinated local service system that provides outreach, early identification, engagement and early intervention, treatment, and transition facilitation services. It is expected, after completion of a needs assessment, that there will be two Evidence Based Practices implemented: Wraparound and Supported Employment, and one evidence-informed practice, Supported Education. The local communities selected for implementation are both rural, designated as Mental Health Professional Shortage Areas, with low educational attainment, and higher than state average in suicide death, poverty and unemployment rate. Goal 1: Throughout the grant period, improve the functioning of 280 youth and young adults to maximize their potential assuming adult roles and leading full and productive lives. a. By 9/30/2028, enroll 280 AI youth living on and around the Utah Strip of NN and the Northern Treehouse Shelter located in Shiprock, NM on the NN (year 1: 30, year 2: 60, year 3-4: 70 each year, and year 5: 50). b. By 9/30/2028, provide evidence-based or -informed practices to 80% of enrolled youth. c. By 9/30/2028, 80% of enrolled youth will demonstrate improved adulthood functioning. Goal 2: Improve community awareness, understanding and collaboration on mental health and issues related to AI youth transitioning into adulthood. a. For each year of the grant, youth and family advocates will organize 3 social marketing activities to improve community awareness on mental health and transition issues. b. For each year of the grant, a minimum of 300 community members will receive information on mental health and AI youth-in-transition issues. c. For each year of the grant, a minimum of 5 AI youth and 5 AI family members will be trained, coached and mentored in leadership and advocacy roles. Goal 3: Enhance organizational infrastructure and community readiness to support AI youth a. By 12/31/2023, establish a Transition Team (TT) of key tribal and community decision-makers, including young people and family members to improve organizational and community support for AI youth. b. For each year of the grant, a minimum of 30 cross system staff will receive training to improve their knowledge and skills on supporting AI youth transitioning into adulthood.

Based in Grand Rapids, Michigan, Pine Rest Christian Mental Health Services (Pine Rest) is the nation's third largest free-standing behavioral health provider, annually serving over 50,000 individuals through and extensive continuum of behavioral health services, including inpatient, outpatient, residential services, community outreach, substance use treatment, telehealth services, consultation, and psychiatric urgent care. While the focused geographic area is West Michigan, Pine Rest services span the state of Michigan, treating people from 98% of Michigan's counties in 2022. Through work already completed toward Zero Suicide, Pine Rest has identified a gap in clinical education, assessment, and continuity of care for individuals with suicidal behavior. To fill this gap, Pine Rest proposes to implement the Zero Suicide model across the Pine Rest continuum, with the goal of serving over 15,000 patients over the 5 year project. Pine Rest will focus on individuals above the age of 18 who receive treatment through the Pine Rest Transition Clinic. Those who receive treatment in a psychiatric inpatient hospital have one of the highest suicide risks of any population, with suicide rates 30 times that of the general population five years after hospital discharge. Three months post-discharge, this rate is 100 times the general population. For patients hospitalized for suicidal thoughts or behaviors, this risk increases to 200 times that of the general population (Chung, et al., 2017). The Transition Clinic provides intensive behavioral health treatment for these high-risk patients for up to three months after discharge from a psychiatric crisis episode. This project will accomplish three goals: 1) Reduce suicide and suicide attempt rates within the Transition Clinic population; 2) Increase the capacity to directly treat suicidality by training the Pine Rest workforce in Evidence-Based Practices; and 3) Improve the suicide prevention rate at Pine Rest's Transition Clinic by implementing Zero Suicide framework into treatment. The three goals of the project will address three main service gaps in reducing suicide: 1) The lack of continuity in care for patients across the continuum; 2) The lack of capacity and training of the behavioral health workforce; and 3) the understanding of cultural complexities in suicide prevention. To this end, Pine Rest will fully integrate the seven elements and best practices of Zero Suicide into its health system by developing and implementing organizational policies and procedures, by providing training in Evidence-Based Practices, and by addressing barriers to treatment caused by health inequities.

The Ascension Collaborative Zero Suicide Network is a multi-state, 80-site partnership that will reduce suicide deaths by 30% by transforming primary care, behavioral health, medical, psychiatry, OB/GYN, residency clinic and emergency department services. It will serve 400,000 individuals 25 years and older (60,000 in year 1–70,000 in year 2–80,000 in year 3, 90,000 in year 4, and 100,000 in year 5) in diverse urban and rural settings, as well as Native American reservation areas. At least 5,000 people will be trained in suicide prevention techniques. Special outreach will focus on U.S. Veterans, people with substance use disorder, middle-aged men, pregnant women, LGBTQI+ community, individuals with social determinants of health barriers and other under-served populations. Ascension, the largest non-profit health system in the US, its national executive leader committees will create a leadership-driven culture that embraces recovery and the principles of Zero Suicide. Ascension is committed to delivering compassionate, personalized care to all with special attention to persons living in poverty and those most vulnerable. The purpose of the Ascension Collaborative Zero Suicide Program is to raise awareness about suicide, develop a safety-oriented culture, create robust referral processes and significantly improve care and outcomes for people who are at risk for suicide. A Zero Suicide Survivor Advisory Group will be created to ensure survivor leadership and input. The Program will implement all components of the Zero Suicide model throughout diverse settings and create an implementation guide and lessons learned that will be shared with organizations within and beyond Ascension. State Zero Suicide Champions will ensure alignment with state suicide prevention plans/committees and actively collaborate with state and local health agencies via regular updates and meetings. Primary care and emergency department professionals will have access to virtual simulations in order to practice identifying and engaging people at risk of suicide. People receiving care in primary care, emergency departments, OB/GYN clinics and other key settings will be screened using the PHQ-2 and where indicated, the PHQ9. If there is an indication that the person may be at risk for suicide, the individual will receive an assessment using the Columbia Suicide Severity Rating Scale. When an individual is identified as being at-risk, they will be enrolled in the Ascension Zero Suicide Clinical Pathway and will be engaged in Suicide Care Planning and Collaborative Safety Planning including Counseling on Lethal Means (CALM). Individuals on the pathway will receive treatment for suicidal thoughts and behaviors in the least restrictive, most appropriate level of care. Mental health therapists will be trained on Assessing and Managing Suicide Risk (AMSR). Caring follow-up will occur to ensure engagement and effective transitions of care. People discharged from the hospital after a mental health crisis will be called within 48 hours after discharge. Regular reassessments will indicate when someone no longer needs the clinical pathway follow-up. 400,000 unduplicated individuals to be served

Mennonite General Hospital (MGHPR), the largest health service organization in Puerto Rico (PR), will implement the seven elements of the Zero Suicide Framework (ZSF) to reduce suicide ideation, attempts, and deaths in 27 counties on the island. The organization, as an integrated health system, operates six general hospitals, 11 EDs, care management, health insurance, a home health agency, and a hospice. CIMA, an operating division of MGHPR, is the largest non-profit specialty BH organization in PR. It manages five Certified Community Behavioral Clinics (CCBHC), a psychiatric hospital, a stabilization unit, and five partial hospitalization programs. All these services are available, situated, and coordinated in the CA using the hub and spokes model. The organization is the only one in PR with all levels of services (BH and physical health) to provide integrated care services and transitions for individuals at risk of suicide within a single system. These 27 municipalities, which experience some of the poorest social, economic, and health conditions in PR, are Aibonito, Coamo, Las Piedras, Aguas Buenas, Comerio, Maunabo, Arroyo, Guayama, Naguabo, Barranquitas, Gurabo, Orocovis, Caguas, Humacao, Patillas, Cayey, Jayuya, San Lorenzo, Villalba, Ceiba, Juana Díaz, Santa Isabel, Yabucoa, Cidra, Juncos, Salinas, and Ponce. Overall, 98% of the population is Hispanic and primarily Spanish-speaking. HRSA classifies the entire zone as medically underserved and a Health Professional Shortage Area for mental health care providers. Two subgroups are highlighted and attended to with the project. The catchment population is declining, primarily due to the outmigration of working-age adults, while the number of adults over age 65 is growing, the only age group to do so, leaving them without social support. On the other hand, the incidence of suicide among veterans is 16.9 per 100,000, more than double the average rate in PR. In addition, men account for 80% of suicides in PR, with a rate that has been consistently above 15 per 100,000 in recent years. Over the five-year program, MGHPR will achieve the following: Goal 1 Implement the seven elements of the ZSF at MGHPR 1.a Within 90 days, complete and operationalize clinical pathways for persons with natural disaster trauma and older adults. 1.b Within 90 days, complete and operationalize a clinical and referral pathway for veterans to VA. 1.c Within 120 days, adapt the ZSF to Spanish and begin implementing the seven elements of the ZSF, including the staff education program. Goal 2 Reduce the suicide rate in the CA. 2.a By the end of the program, increase the number of consumers identified in the MGHPR EDs and refer them to its CCCBHC by 25%, from the baseline. 2.b By the end of the program, achieve 75% engagement of suicide treatment participants. 2.c By the end of the program, 90% of suicide treatment participants will reduce their suicidal thoughts. 2.d By the end of the program, reduce the suicide rate in the CA by 25%. The program will enroll 400 clients in Year 1, 1000 Year 2, 1000 Year 3, 1000 Year 4, and 1000 Year 5.

The Harris Center for Mental Health and IDD is working to bring the best practices in suicide care to those we directly serve and those who are potential clients by affecting them in an indirect way. The L.I.F.E. (Living Is For Everyone) project focuses on the continued implementation of Zero Suicide for those at highest risk in Harris County, Texas. The population chosen includes those people served within The Harris Center as well as those who encounter the Harris County Sheriff's Office in the field or in the detention environment. There were 625 deaths by suicide in Harris County in 2022 based off the most recent medical examiners data, which accounts for a 20% increase in suicide related deaths since 2017 (Harris County Institute of Forensic Sciences, personal communication, March 2023). According to the Bureau of Justice Statistics, 355 persons in local jails died by suicide in 2019 in the state of Texas. This represents an increase of 5% from 2018 to 2019 and an overall total of about 30% of deaths in local jails being suicides. The sharp increase in suicide related deaths in Harris County has highlighted a significant need for more standardized suicide risk assessment as well as more intensive approaches to evidence based interventions when risk is identified. While The Harris Center began its Zero Suicide journey in FY19, timely intervention is a core element that the agency wishes to prioritize. Suicide risk intervention is a time intensive, resource dependent practice that is proven to decrease the risk of suicide attempts and death by suicide. The Harris Center will expand its use of the Zero Suicide framework via the L.I.F.E. Program using programmatic efforts to target those at highest risk for suicide by utilizing additional clinical team members to increase the focus of the organization on suicide intervention and prevention with those individuals within our system. Using Zero Suicide principles and evidence-based training, targeted intervention would begin at recognition of initial increased risk and provide key assessment and personalized interventions based on the specific needs of the person served. These dedicated clinical individuals will work with other Harris Center clinicians and PEERS to develop a meaningful safety plan, discuss lethal means, schedule follow up appointments, facilitate referrals to therapeutic services such as CBT and DBT and provide active monitoring for a minimum of 30 days. Staff will use evidence-based training such as AS+K, CALM, ASIST or others to care for the at-risk person. The clinician will provide a warm handoff and transition to the next level of care based on the current need and situation of the individual. These services may be offered by a team member that specializes in suicide care or any other Zero Suicide informed Harris Center staff member. The Harris Center will also provide guidance and recommendations for the Harris County Sheriff's Office (HCSO) as they work to implement the Zero Suicide framework in the Harris County Jail and within the department. The Harris Center will use its partnership with HCSO and its knowledge of the Zero Suicide framework to assist with training opportunities, make evidence-based recommendations, increase the use of best practice suicide care and provide quality implementation guidance to improve suicide prevention methods within the justice system. Total anticipated to be served throughout the project's tenure (5 years): 10,250

Suncoast Center, Inc., is the organizational chair of Zero Suicide Partners of Pinellas (ZSPoP) and serves Pinellas County, Florida (FL). ZSPoP is a collective impact project which was initiated in 2016 by Suncoast Center and other organizations from the Pinellas County Behavioral Health System of Care. The purpose of this project is to prevent suicidal thoughts and behaviors, including suicide attempts and deaths through implementation of the Zero Suicide framework and a suicide prevention care pathway across multiple partnering organizations. Through this project, ZSPoP will serve 50 (unduplicated) individuals in Year 1, and 75 annually in Years 2-5, for a total of 350 individuals. The population of focus (POF) for ZSPoP is any individual in Pinellas County who may experience suicidal thoughts or behaviors, including (but not limited to) young adults, Veterans and their families, older adults, and LGBTQ+ communities, as well as individuals experiencing a mental health or substance use-related crisis. The Zero Suicide framework includes planning, implementation, and evaluation of 7 key elements: Lead, Train, Identify, Engage, Treat, Transition, and Improve. Additionally, this project expands suicide prevention efforts from the clinical setting to community settings through outreach, education, training, and safe messaging practices. We acknowledge that no one is immune to moments of crises, which may result in suicidal thoughts and behaviors, regardless of any potential mental health conditions. We also recognize there is often intersectionality within the project’s POF, which may affect their access to care and the behavioral health equity within Pinellas County. Pinellas County’s 2021 age-adjusted suicide rate (per 100,000 population) of 20.3 is higher than the state (16.9) and national (14.1) 2021 averages. In a 2021 community health needs assessments by All4HealthFL, 11.5% of Pinellas respondents indicated they had suicidal or self-harming thoughts for several days, more than half of the days or nearly every day over the past year. FL has the largest Veteran population of any state, with a Veteran suicide rate of 40.9 (per 100,000). Additionally, 16% of LGBTQ+ youth (through 24 years of age) and 20% of transgender or non-binary youth, in Florida, attempted suicide in 2021. By intentionally reaching out to individuals who may not be connected to behavioral health systems of care, in addition to implementing universal screening for suicide risk, we increase our engagement with at-risk populations This includes those who might not seek formal support due to issues of access, stigma, or cultural beliefs. The number of unduplicated individuals to be served with award funds each years are estimated to be 10% of all individuals who enter the suicide prevention care pathway. These numbers represent the individuals who will have National Outcome Measures (NOMs) reported during their time in the suicide prevention care pathway. Additionally, we expect to reach approximately 60 unduplicated individuals annually through community engagement activities. Both the 2023 – 2028 Pinellas County Community Health Improvement Plan (CHIP) and the 2022 – 2026 FL State Health Improvement Plan (SHIP) include objectives to reduce deaths by suicide. The implementation approach for this project aligns with established health priority area goals, objectives, and activities as outlined by 2023 – 2028 Pinellas County CHIP and the 2022 – 2026 FL SHIP, demonstrating strong collaborations across the ZSPoP and partnering organizations. Since 2017, over 38 organizations, agencies, companies, groups, and community members have participated in the ZSPoP project, with many providing aggregate data on metrics related to the established Suicide Prevention Care Pathway, designed using the Zero Suicide framework. Our partnering organizations for this project are all highly experienced in providing quality behavioral health services to the POF.

Implementing a Zero Suicide Project in a Behavioral Health System: The Jewish Board (TJB) proposes to implement the Zero Suicide model in its outpatient behavioral health system of care (treatment, supportive housing, care management, intake) that annually serves 11,493 New York City residents 18 years and older who have a mental illness and are primarily low-income people of color with historic disparities in accessing evidence-based services. Number of Unduplicated Individuals to be Served: Year 1 - 4,185 Year 2 - 7,605 Year 3 - 10,328 Year 4 - 12,096 Year 5 13,809 Total - 48,022 The population of focus are over 15,000 adult residents of New York City (NYC) who annually participate in/seek out mental health (MH), substance use (SU) rehabilitation, supportive housing and/or care management services provided by TJB. Virtually all will have a MH condition and/or SU disorder; with 89% having a serious mental illness (SMI). Two-thirds live in Brooklyn (34%) and The Bronx (30%). The POF reflects NYC's racial diversity with 28% Black, 34% White, 30% Hispanic, 2% Asian, and 6% other/unknown. Two-thirds (61%) identify as female. Adult clients span age cohorts with 28% young adults 18-29 years, 51% adults 30-59, and 21% older adults 60+. The POF is lower income with 17.5% on Medicaid and Medicare/Medicaid, 63% on Medicare, and 12% uninsured. From January 2018-February 2023, 20 TJB clients died by suicide and 166 TJB clients had 207 reported suicide attempts. The service area will be the 5 boroughs of NYC where TJB operates a continuum of community-based BH programs that are located in and serve New Yorkers from underserved communities. Strategies: The proposed project will implement the Zero Suicide (ZS) model on a rolling basis over the 5-year project throughout its BH system. Targeted programs are as follows: 10 NYS-licensed outpatient MH clinics serving 8,353 adults (2 are CCBHCs); 1 NYS-certified outpatient SUD program (just launching); 3 PROS (Personalized Recovery Oriented Services) programs (543 clients); 5 ACT Teams in Brooklyn/Manhattan (297 clients); supportive housing for 1,200 adults with SMI; care management for 1,1000 adult Medicaid beneficiaries with serious BH conditions and/or HIV/AIDS; and TJB's single BH point of access-One Call-that works with 3,850 individuals with emotional distress and/or crises who seek behavioral health (BH) services. Interventions: The project will enable TJB's BH system of care to change its culture with respect to suicide prevention and intervention by implementing system-wide suicide care pathways that advance three overarching goals to save lives: (1) Improve early identification of suicide ideations and other suicide risks among TJB's racially and ethnically diverse adult BH clients; (2) Expand system-wide access to evidence-based, timely interventions, including safety planning and specialty treatment modalities (e.g., CBT-SP, DBT) for those at risk of suicide; and (3) Build on-going organizational capacity that is sustainable after the grant to provide high quality suicide prevention and intervention services to adult BH clients and eventually to children/adolescents. Measurable Objectives include (1) Over 5 years, 759 clinical/non-clinical staff will be trained in suicide risk screening/assessment (S/A) Stanely-Brown Safety Planning and CALM and 80 clinical staff in CBT-SP and/or DBT; (2) 75% of clients will be S/A in the 12 months following the completion of staff training; 90%+ of clients will be S/A annually systemwide after 5 years. (3) 80%+ high risk clients will complete or have been offered help to complete safety plans; (4) 70%+ high risk clients who could benefit from treatment will be connected to TJB or other specialized clinical services. (5) TJB will reduce suicide attempts/deaths by two-thirds through system-wide implementation of suicide-related policies/protocols/suicide care pathways that are rigorously monitored for adherence and client outcomes.

Community Alliance’s Healthy Transitions project, in collaboration with our local behavioral health authority, Region 6 Behavioral Healthcare and other key partners, will improve and expand services and supports for transition-aged youth and young adults (ages 16-25) in Douglas and Sarpy counties, Nebraska who either have, or are at risk of developing serious mental health conditions. We will help maximize the potential of our population of focus (POF) to assume adult roles and responsibilities and lead full, productive lives by collaboratively working towards the following goals and objectives: (1) Through the establishment of coordinating structures at system and agency levels, the development of interagency and intra-agency agreements concerning services to the POF, and the development of a well-represented and well-informed advisory council, improve system coordination so that the POF routinely receive the services and supports they need. At least 51% of the advisory council will include youth, young adults, and family members and by Year 2, the advisory committee will establish a peer-led evaluation team. (2) Based on findings from a system needs assessment, build a multi-year plan for filling in service and care coordination/navigation gaps for the POF and identify the trainings that will be needed to support the development of services and coordination activities. (3) Develop reliable referral pathways to vital evidence-based practices and other services within the youth-serving and adult-serving behavioral health systems, including for youth aging out of child/youth systems. (4) Develop a centralized care coordination resource that draws on current best practices to ensure the POF, particularly those with multi-system involvement or who are aging out of youth systems, promptly access necessary behavioral health services, including evidence-based and team approaches such as Coordinated Specialty Care (CSC) for transition-aged youth with first episode psychosis and Critical Time Intervention. (5) Promote the dissemination and adoption of added suicide prevention best practices as well as better coordination of existing programs. (6) Enhance Community Alliance’s supported employment services to include supported education and increase supported employment service utilization by the POF. (7) Strengthen family education and family support services for individuals in the POF who are receiving behavioral health services. (8) Improve outcomes among the POF across multiple domains and increase their opportunities to enjoy meaningful adult lives in the community. (9) Develop better alignment and use of funding streams to ensure sustainability of a strengthened, better coordinated and more effective service system for the POF. Over 5 years, we will provide outreach services to at least 1,000 unduplicated members of the POF. CA and partners will screen a minimum of 80 unduplicated members of the POF in Year 1, 120 in both Years 2 and 3, and 160 in both Years 4 and 5, resulting in enrollment and service to 40 unduplicated individuals in Year 1, another 60 in each of Years 2 and 3, and then 80 in each of Years 4 and 5, for a 5-year total of 320 members of the POF.

The Successful Transition to Early Adulthood Milestones (STEAM) project aims to increase engagement with developmentally and culturally appropriate clinical and community-based supports to facilitate a transition to independence, using the Enhanced Certified Peer Specialist (ECPS) model. Building on existing infrastructure that serves youth with mood disorders in Allegheny County, and leveraging collaborations across multiple organizations, the project will serve a total of 250 transition-age youth (TAY). Transition from adolescence to adulthood is a critical developmental period that presents both opportunities and challenges, particularly for TAY with mood disorders. Severe mood symptoms, particularly if inadequately treated, can lead to poor outcomes such as substance abuse and suicidal thoughts and behaviors. Just as impactful, the experience of mood symptoms can make it difficult to meet important developmental milestones, like moving towards independence, continuing education, finding stable employment, and/or establishing meaningful and long-lasting relationships. Success during this period depends on engagement and navigation of multiple systems (e.g., mental health, education, job training). The Child and Adolescent Bipolar Spectrum Services (CABS) Clinic, Services for Teens at Risk (STAR) Center, and College Option – Services for Transition-Age Students at Risk (COSTAR) are specialty care clinics located at Western Psychiatric Hospital, University of Pittsburgh Medical Center (UPMC) are existing programs in Allegheny County that serve over 600 youth with mood disorders in the 16-25 age range, providing both evidence-based medication management and psychotherapy. The overarching focus of the proposed STEAM project is to collaborate with Allegheny County and non-profit agencies serving TAY (e.g., Youth Move PA, Partners4Work) to better support young people with mood disorders in their transition to adulthood thereby maximizing their potential to assume adult roles and responsibilities and lead full and productive lives. To this end, three Youth/Young Adult Coordinators (ECPSs) with lived experience of a mood disorder will be trained and supervised to provide peer mentorship and coaching, evidence-based crisis management (including suicide risk assessment and safety planning), service coordination, and psychoeducation. The first goal of the project, accomplished during the first year, is to leverage partnerships with the county and non-profit agencies to identify resource gaps and opportunities by conducting a needs assessment and convening a community advisory council to provide sustained input. The second goal will focus on designing and implementing a training plan for mental health professionals serving TAY (including ECPSs) to increase integration across child and adult services. Third, the STEAM project and ECPSs will engage a diverse sample in a meaningful way, through community outreach and partnerships, one-on-one scheduled meetings, crisis intervention, and groups focused on psychoeducation and transition to adulthood. Fourth, we will assess individual-level outcomes of enrollment in the STEAM project, including improved engagement in clinical treatment, improved mood symptoms, and attaining young adult milestones (e.g., meaningful education and/or employment.) Fifth, we aim to collaborate with payor organizations to build a sustainable model for ECPSs, through enhanced billing rates. Building on the evidence-based practice of peer support, STEAM will provide TAY with the valuable perspective of someone with lived experience, giving practical guidance and instilling hope. Through partnerships with the County and relevant non-profits, and collaborations with key stakeholders including family and youth, with a specific focus on enhancing outreach to underserved TAY, this project will enhance infrastructure and provide training to improve outcomes in a diverse population of TAY with mood disorders.

Puerto Rico's SSA "PUEDO" HT Project will serve 400 Hispanic youth of 16-18 years with SED and 19-25 years with SMI over 5 years to expand access to Evidence Based treatment and recovery services, in the Caguas and Guayama municipalities and surrounding Southeastern Region, where there is 46% poverty, violence prevalence related to drug trafficking and easy access to fire arms, and high suicide incidence. Project goals are to: Expand culturally competent treatment using Wraparound, WRAP, and Supportive Employment EBPs; Improve cross-system service capacity and expertise related to transition-aged youth with SED and SMI through infrastructure/ organizational improvements; and Plan and implement public awareness to increase knowledge, reduce stigma and develop support for transitional SED/SMI youth. In YR 01, 40 youth will be served, with 90 youth per year to be served in each of the last 4 years. The Mental Health and Anti-Addiction Services Administration (MHAASA) is the applicant agency through its Division for Treatment of Children and Youth and Their Families, which has carried out a successful prior PUEDO (meaning I Can in Spanish) Healthy Transitions Project in the San Juan/Ponce region. Objectives include: 1. Integrate EBP's into policies and procedures of MH services providers; Achieve Wraparound goals for 85% of youth; Use standardized evaluation tools to assess risks of suicide and improve safety planning for 80% of transitional youth served; Reduce risky and unhealthy substance use and sexual practices in transitional youth'; Integrate WRAP Model in the 4 targeted MH Treatment Centers, achieving outcomes in at least 3 of the 5 domains; Expand the established Multisector Advisory Council with new catchment area representatives for planning, oversight, problem identification and solution; Expand formal collaborative agreements with CW, JJ and other systems for expansion of MH screening, referrals of transitional youth/families, and provision of support services; Implement at least one suicide prevention/intervention approach in the catchment area; develop and implement a culturally and linguistically appropriate social marketing/communications strategic plan to identify and engage SED/SMI youth, including suicide awareness and 988 lifeline; Capacitate youth/families to use multi-agency support services; and Increase youth-serving agency representatives on the MH Council of the MHAASA. Key project personnel include an experienced Project Director, Youth and Young Adult Coordinator and Lead Evaluator. GPRA, SPARS and other required data will be collected and reported quarterly.

Schizophrenia affects 1% of the population, causing enormous suffering, disability, and substantial societal costs. Timely engagement in CSC for youth with First Episode Psychosis (FEP) is critical to improve outcomes and support functional and symptomatic recovery. In New York State (NYS), OTNY has established a unified approach to delivering CSC to adolescents and young adults with FEP. Since inception, 27 OTNY programs have been developed across NYS, including 13 in our catchment area of Manhattan, Queens, Brooklyn, and Long Island, providing CSC to over 3,000 youth statewide to date. Directed by Dr. Birnbaum, the OTNY program at ZHH is the largest and most established and has provided care to over 300 youth. However, early intervention services are time limited. OTNY programs are designed and resourced to provide CSC for approximately 2 years, after which, discharged patients (75% between the ages of 16-25 years) are usually referred to standard clinical care within the community. Critically, accumulating evidence demonstrates that the benefits of early intervention obtained during CSC do not persist post discharge after transitioning to standard care. Further, the risk of disengagement is heightened during the transition from CSC to standard care, increasing risk for medication non-adherence, symptomatic relapse, social isolation, unemployment, and substance use. Data also suggest that minority populations may be particularly susceptible to negative outcomes post-CSC discharge. Moreover, youth graduating OTNY have new clinical and developmental needs as they mature into young adults (and gain greater independence) that require dedicated supports yet receive insufficient attention in standard clinical care. Despite a clear need, effective care for youth graduating OTNY are lacking, resulting in repeated calls for innovative solutions designed to sustain gains and promote ongoing recovery. To address this critical service gap, Northwell Health, in partnership with The NYS Office of Mental Health (OMH), is proposing to develop a CSC step-down service at ZHH for youth ages 16-25 graduating from ZHH’s OTNY site as well as those referred by other local OTNY sites. Leveraging our established expertise in recovery oriented care, the LIFT team will provide evidence-based and coordinated supports, using the Critical Time Intervention (CTI) model designed to be integrated and delivered in conjunction with standard care, aiming to 1) extend and enhance the benefits of early intervention, 2) minimize disengagement during a critical time of transition (OTNY graduation), and 3) equip youth with the skills and resources they need to foster autonomy, independence, and to lead productive and fulfilling lives.

South Carolina Department of Mental Health (SCDMH), in partnership with the Joint Council on Children and Adolescents and Pee Dee Community Mental Health Center (PD-CMHC), will implement ROADS project, partnerships to support youth and young adults as they travel on multiple roads to successful adulthood. In ROADS, we will improve and expand access to services and supports specifically tailored to youth and young adults aged 16-25 (YYA) who have, or are at risk for developing, serious mental health conditions. YYA with specific challenges include those with justice involvement, homelessness, unemployment, low educational attainment and living in communities with overlapping inequities. The geographic area consists of Florence, Marion, and Darlington counties in SC's Pee Dee region. These counties are part of the Corridor of Shame, a strip of SC counties with historically low educational achievement, few job opportunities, and scant hope for the future of young people. ROADS will establish the infrastructure needed for sustainable collaborative partnerships aimed at providing a seamless array of YYA-related services and supports. Direct service staff will identify and engage YYA in need, prioritizing those at high risk for suicide and/or presenting with mental health emergencies. As a result of project participation, YYA functioning in a variety of life domains will improve. Through this funding, we will provide clinical and/or recovery support services to fifty emerging adults in Year One, with the annual number served gradually increasing (Y2-100, Y3-125, Y4-150, Y5-150). Over the five years, a total of 575 YYA will receive direct services and at least 825 will engage in individual outreach and/or screening. Demographics will reflect our region: 50.8% Black, 47.3% White, < 2% Other Races, and 3.3% Hispanic. Males and females will be equally represented, with about 5% identifying as gender non-conforming. Sexual orientation includes 80% straight, 10% bi-sexual, 5% gay/lesbian, and 5% other, mostly non-binary. Evidence-based practices/programs to be used include: 1) training for providers in the Zero Suicide approach, as well as in transition planning models such as Transition to Independence and Achieve My Plan; 2) using validated screening tools and YYA-friendly screening practices; 3) providing a wide array of direct services (motivational interviewing, cognitive behavioral therapy (CBT), trauma-focused (CBT), dialectical behavior therapy, and peer recovery support/young adult mentoring); and 4) supporting independence through access to appropriate resources such as SSI/SSDI Outreach, Access and Recovery (SOAR) and Individual Placement and Support (IPS). Each of these interventions has been implemented with emerging adults who have, or at risk for, serious mental health conditions. We expect that each of these interventions will encourage adaptive functioning and result in successful pathways to adulthood. Our objectives are many. Through ongoing needs assessment, provider training in developmentally and culturally appropriate YYA outreach, engagement, and support techniques, and intentional alignment of the child and adult behavioral health care systems, we will increase the capacity of providers in mental health and related systems to identify, screen, engage, and connect YYA to services and supports designed to foster emotional well-being. Involvement in ROADS will result in clients experiencing reduced behavioral health symptoms, decreased behavioral health related hospitalizations and emergency room visits, and lower justice system involvement. Instead, clients will experience improved social and family connections, more positive education/employment involvement, and greater degrees of housing satisfaction. Their individual and varied roads to adulthood will be filled with supportive connections and hope.

Luzerne-Wyoming Counties Mental Health and Developmental Services Program will use their experience with SAMHSA Grants to implement an effective plan with local youth and young adults and community partners to identify and refer youth and young adults who also have a serious mental illness (SMI), a serious emotional disturbance (SED), or a co-occurring disorder (COD) to our experienced, licensed mental health/substance use treatment providers. These individuals will be linked with appropriate services and supports that are trauma-informed, culturally competent, client-centered, evidence-based which are also integrated with physical health services in order that these youth and young adults may maximize their potential to assume adult roles and responsibilities and lead full and productive lives. This initiative will be called the Luzerne-Wyoming Counties Youth Revolution. Over the course of this project, Youth Revolution will enroll at least 250 youth and young adults into behavioral health services for evaluation. Concurrently, youth and young adults who are on a path to success will contribute to the youth and young adult network, where they will have the option to give back through mentoring, advocacy and potentially becoming part of the behavioral health workforce. This project will also incorporate efforts to improve crisis response, prevent suicide, and alleviate barriers to service as it relates to the target population.

Sanford Healthy Transition Project is led by the Sanford East Dickinson Clinic representing an organized council of community partners. Sanford and partners share in the mission of increasing access and reducing obstacles regarding community support and behavioral health services in Southwest North Dakota. The Sanford Healthy Transition Project plans to increase access to transition services utilizing evidence-based practices for Transition-aged youth (16-25) and their families. Sanford will provide a sustainable model of service that will allow for long-term access to project services. With help from state and local-community partners, Sanford will implement a referral network to provide access to relevant transition services for their relevant target populations. Services will primarily impact underserved rural communities that have little to no access to the current level of care. Goals and Objectives Goal 1. Create a system of care coordination between behavioral health and other existing systems – medical, education, and law enforcement. 1. Establishing monthly advisory council meetings to discuss project needs. 2. Identifying and screening at risk youth/young adults with serious mental illness and/or emotional disturbance. 3. Hiring and training Care Coordinators and Clinicians to implement project functions. 4. Hand-off of transitioned aged youth from youth-based agencies. 5. Implement suicide prevention and intervention programs. Goal 2. Create a school-based youth mentorship support program to encourage staying in school to attain a high school diploma, based on the Check & Connect program. 1. Train behavioral health providers on the delivery of evidence-based practices. 2. Check & Connect EBT site visit. 3. Recruitment and training of Mentors to assist in referrals. 4. Providing high school youth mentorship services Goal 3. Create an integrated system of community support for young adults who are out of high school to successfully manage the multiple areas of healthy adulthood – education, vocational, health and behavioral health, financial, and lifestyle. 1. Communicate with advisory council members and local agencies for a. Housing assistance adult education, vocational rehabilitation, technical training, and financial management skills training 2. Advanced training for Care Coordinators in the YouthBuild EBT to assist in providing the above services.

Project Abstract Summary PACT for Families Collaborative, a 30-year, five county children’s mental health and social services organization serving rural MN proposes Road To Success to expand support to youth ages 16-25 who have emerging mental health issues, or are at risk for SED/SMI diagnoses, and their parents by utilizing the Transition to Independence Planning (TIP) Model® and collaborating with key community, mental health providers and policy makers. Road To Success will provide services to 110 unduplicated youth throughout the five-year project term. With much to set up in the first year, an estimated 10 unduplicated youth will be served in year one with 25 unduplicated youth served per year in years two through five. Project staff and collaborative partners will develop early identification protocol, provide early intervention to prevent emerging mental health issues from progressing to SED/SMI diagnoses. Project staff will assist youth in developing greater social and emotional skills to enhance self-sufficiency and independence while emphasizing the role of parents/guardians in guiding and supporting their youth through the transition to adulthood. Using the TIP Model®, Vroon MiiWrap Wraparound, Charting a LifeCourseTM, and QPR models of intervention, the project will employ in-vivo coaching throughout five domains including employment, education, housing, life skills and wellness to enhance the target youth and young adult population’s coping skills and effectively prepare them for transition. Ensuring these youth receive wraparound support, Road To Success focuses on enhancing the skills and capacities of parents to support their youth/young adults through one-to-one support, education, and resource navigation. Road To Success proposes to serve 300 parents/guardians over the five years through the implementation of an educational seminar series, one to one support sessions, community outreach through correspondence and social media, and by facilitating parent networking groups and educational opportunities. We will teach our participants where resources can be shared amongst parents, providers, staff, and community members. Additionally, this proposal establishes a multiagency Advisory Council within six months to operate over the five-year period as a steering committee focused on collecting data and then proposing strategy to address service delivery gaps, funding shortfalls, and institutionalization of the project’s model into the structure of the counties’ social services networks. Putting sustainability at the heart of this project reinforces PACT’s commitment to changing the system of care as it exists today, thereby demonstrating to rural Minnesota communities how they can support this vulnerable population. Road To Success represents a shift in service delivery and wraparound support that will decrease SED/SMI diagnoses by increasing the resilience of our targeted rural youth, nurturing more durable parent-child bonds, and swaying communities to adopt similar systems of care. This will culminate in their recognition of the value of investing resources into addressing this particular life transition point to enhance the support network, transform the current service system model, and sustain these systems changes indefinitely.

The Prince Georges County Transition Age Youth and Young Adults (PGCTAY) Healthy Transitions project will serve 275 transition-aged youth and young adults (TAY), aged 16 to 25, in Prince Georges County (PGC), Maryland, who either have, or are at risk for developing, serious mental health conditions. The majority (85%) of the target population are Black non-Hispanics or Hispanic. The PGC Health Department will lead the project. Key partners are the PGC Departments of Social Services and Department of Juvenile Services; a child and an adult outpatient mental health clinic, respectively; a large, non-profit mental health, special education, substance use, developmental disability, and social services provider; the Maryland Coalition of Families, a family-led behavioral health advocacy non-profit; an evidence-based supported employment and homeless services provider; the Prince Georges Public County Schools; and the Local Behavioral Health Authority. Implementation strategies include ongoing TAY behavioral health needs assessment; training and technical assistance on evidence-based trauma and grief -informed behavioral health interventions for providers; interagency agreements that support the transition from pediatric to adult services and deliver case management, care coordination, supportive services, peer support, referral and linkage to substance abuse treatment and services that mitigate social determinants of health to TAY; and an awareness campaign that includes messaging on suicide prevention among TAYs. An Advisory Council, composed of TAY, their family members, health and social service providers, and other stakeholders who work with/advocate for TAY will provide guidance on project operations. The goals we will achieve by 8/31/29 are: • Goal 1: Expand and increase access to TAY treatment recovery and support services including strengthen evidenced-based practices that address all life domains for the population of focus. • Goal 2: Increase the self-efficacy and meaningful participation in transition plans of TAY aged 16-25 who have mental health and or co-occurring substance use disorder (SUD). • Goal 3: Increase community buy-in and responsiveness to TAY service needs and outcomes. • Goal 4: Develop and implement county-wide social marketing and education messaging to reduce stigma about getting help for mental health and co-occurring SUD. Key expected outcomes to be achieved by 8/31/29 are: • A cadre of local behavioral health providers will receive training on evidence-based and evidence informed interventions and promising practices; • The project will launch a TAY-led, multi-lingual, multimedia social marketing campaign to raise awareness about mental health and co-occurring SUD among TAY and the importance of accessing available services, and how to do so; • 275 TAY will receive evidence-based care coordination, case management, life skills, peer-to-peer support, positive youth enrichment activities, recovery support, and linkages to services identified in a personalized transition plan that will enable them to transition seamlessly from the pediatric to the adult behavioral healthcare systems; and • at least 20 TAY will be trained as Peer Support Specialists and 12 TAY will complete leadership training and assume positions that promote positive outcomes for TAY with serious behavioral health conditions.

In Washington State, emerging adults navigate myriad challenges, including growing independence, new relationships, educational and vocational goals, physical changes, and exposure to substances. As such, they are at greater risk for developing a behavioral health condition, and systems of care are not designed to meet their needs. Washington State Health Care Authority (HCA's) Division of Behavioral Health and Recovery (DBHR) seeks to implement a model of care tailored to support Transitions Aged Youth (TAY) ages 16-25 who have been diagnosed or are at risk of developing a serious emotional disturbance or serious engagement and evidence-based practices, such as Individual Placement Support for Youth (IPS-Y) to connect TAY with supported employment, housing, and academic opportunities while creating innovative, developmentally focused access points and care pathways to engage youth in behavioral health services. Among the array of clinical approaches, TAY team will implement Dialectical Behavioral Health Therapy, Trauma-Focused Cognitive Behavioral Therapy, Motivational Interviewing, and a wraparound approach to intensive care coordination, as well as peer support services. In addition, KMHS will partner with local community prevention and wellness initiatives (CPWIs) to create suicide risk screening and referral pathways as well as provide community outreach, education, and training through a social marketing effort. At the State level, the Prenatal-25 Lifespan Section will work with the Recovery Supports Section, as well as the Prevention team, to align funding and policy mechanisms to ensure smooth coordination between children and adult behavioral health systems while leaning into expanding early intervention programming. A youth advisory council, coordinated between state and local community partners, will provide a feedback mechanism whereby TAY and family members can collaborate to create new policy initiatives, identify gaps and challenges, and present potential solutions to be elevated to the Children's Behavioral Health Governance Structure. Goal 1: Increase and enhance interagency coordination to support cross-system collaboration, service capacity, workforce, and expertise related to TAY need through infrastructure, financing, and policy Goals 2: Increase access to services for TAY in catchment area by creating developmentally focused access points and care pathways; Goal 3: Create spaces that invite and encourage TAY leadership; Goal 4: Increase number of TAY who receive recovery support services; Goal 5: Increase workforce capacity among TAY serving agencies; Goal 6: Create a social marketing strategy to increase awareness around TAY need and suicide prevention efforts. In Year 1, the program will serve 50 TAY; In Year 2 will serve 60; 65 in Year 3, 75 in Year 4, and 75 in Year 5 for a total of 325 across the life cycle of the grant. DBHR's overall goal is to direct statewide system design the supports individuals throughout the life span, and this grant will inform the system development for TAY.

The Pascua Yaqui Tribe's Health Services Division submits this proposal for a Healthy Transitions: Improving Life Trajectories for Youth and Youth Adult with Serious Mental Disorders Program grant, in order to provide developmentally, culturally, and linguistically appropriate services to transition age youth and young adults ages 16 to 25, males and females, who are either currently experiencing or are at-risk for developing seriously emotional disturbances in their lives. The tribal Pathways program will provide an array of evidence-based and promising practice, culturally focused services while also creating the infrastructure and appropriate seamless level of care to serve our young adults. The Tribal Coalition of Sewa U'usim Community Partnership (lead agency), Centered Spirit Mental Health Center and Education and Social Services will again coordinate services and address as part of the role on the Advisory Committee and Networking Board the pressing problems that are the result of COVID isolation the availability of new powerful drugs and the equity issues which face all tribal community nationally. Approximately 1000 youth will be reached through outreach efforts annually for a total of 5,000 over the five-year grant cycle. Approx. 100 youth annually, 500 total will be screened and enrolled in the Pathway project. It is projected that after the initial screening and assessment, 10% will be referred for higher levels of care within the tribal community. Approx. 75 tribal workforce staff annually, 375 total composed of professionals and paraprofessionals will receive training on new interventions and effective program approaches to work with SEDS/SMI young adult populations. We will provide balance and community and youth input by creating, within the first year, an Advisory committee that will include at least five family or youth members, community stakeholders and providers, and members of tribal leadership interested in addressing the issues. In place is a tribal-wide provider community Networking Board created in 2016 which answers to the Tribal Council and meets quarterly to review grant activities and service issues for the targeted populations (children, youth, and families), as well as suggested changes to policies and procedures which are then brought to the Tribal Council. The group will serve as a mechanism for initiating changes to benefit service delivery and address the needs of the target population. The Pathways program will utilize the GAIN Global Inventory an evidence-based model to screen and assess our youth and young adults and will either enroll them in life, job, and social skills training or refer them as needed for higher levels of mental healthcare. The Pathways staff is culturally focused and experienced in working with the population and in providing community partnership communication and activities. The Pathways youth will be given the Casey-Ansell Life Skills inventory and staff will utilize program manuals to help them determine clients' strengths and needs in the core skills necessary to move forward with a healthy normal lifestyle. Pathways will provide a Community resiliency model CRIM/TRIM to provide youth with trauma-focused awareness and controlled insights to allow them to stabilize and move forward with their life's journey. Youth referred for higher-level services will receive evidence-based, trauma-focused Cognitive Behavioral Therapy, utilizing many of the interventions from Honoring the Children Mending the Circle treatment model. Each enrolled member will develop their own Pathways plan, laying out the goals and objectives, to work with staff in order to help them in understanding the resources in an adult system of care. Both Sewa U'usim and Centered Spirit mental health clinic programs of our tribal Health Division have over 15 years of experience providing Medicaid-certified services to children, youth, and families in the tribal community.

The Ohio Healthy Transitions Project (OHTP) will serve youth and young adults in Summit and Medina counties, aged 16 to 25, with serious emotional disturbance (SED), serious mental illness (SMI), or co-occurring mental health and intellectual developmental disabilities (IDD). The multi-system organizations serving the target population in these two counties will collaborate to promote awareness of the unique challenges faced by transitional-aged youth (TAY) with behavioral health and intellectual-developmental disabilities. OHTP will provide culturally competent services including a full continuum of life-skills, vocational, educational, and social-emotional wellness to enable youth to become healthy and productive adults. Specifically, the following Evidence-Based Practices will be expanded: Transition to Independence (TIP), Trauma-Informed Cognitive-Behavior Therapy (TI-CBT), Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) and High-Fidelity Wraparound. The key foci of the OHTP will be the following: a) Improve access to services for TAY by increasing youth and adult system coordination as measured by procedure changes, OHTP Advisory Council performance, streamlined funding, and EHR service data, and improving service capacity as measured by caseload data and procedure guidelines; b) Increase regional and state awareness of TAY needs for SED/SMI and IDD as measured by social media metrics (number of impressions, etc.), collateral information material distributed, and number of new referrals mentioning social marketing as source, and c) Increase employment, education, training, and community involvement for target population as measured by discharge records. Once fully operational, OHTP will serve a total of 350 youth over the lifetime of the project.

The proposed project, Transitioning Lives Collaborative (TLC), will foster the mental health, behavioral health, and long-term outcomes of youth and young adults by implementing best practices within an array of services and support for youth and young adults. TLC will streamline, improve, and increase the availability and quality of comprehensive behavioral/mental health services to meet the needs of transition-age youth (TAY)/young adults (age 16-25) with serious emotional disturbance (SED), serious mental illness (SMI), co-occurring mental and substance use disorders (COD), and intellectual and developmental disabilities and their families receiving services at MHMR. The project will effectively respond to the needs of this population by providing a vast array of comprehensive, evidence-based practices and services to youth and young adults aged 16-25 who are at risk of failing to transition successfully to adult services. The population of focus for this project will include transition-age youth/young adults (TAY) (age 16-25) with SED, SMI, IDD, or COD. The following service gaps will be address through TLC: (1) Bridging the gap between two distinct service systems by assigning a TAY transitional specialized provider to help in the transition to adult services; (2) Providing staff and specialized services to serve TAY to ensure the likelihood of a successful continuity of care with needed services; (3) Reduce the lack of awareness, education, and coordination of services for transition-age youth/young adults by implementing a continuum of services through appropriate navigation/collaboration of servicing agencies (i.e., employment, vocational, housing, education, medical benefits); (4) Reducing discontinuity of services, disengagement from services, and poorer clinical outcomes for transition-age youth; and (5) Assisting TAY with SMI, SED, COD, and IDD in their transition to employment, supported employment, and vocational services. The TLC project will utilize 5 FTEs who will provide direct services to TAY. These positions include a Family Interventionist (2.0 FTE) who will provide case management services and a liaison to TAY and will serve as a liaison with Adult Services for the TAY population; a Family Advocate (2.0 FTE) who will provide support and resources to youth receiving case management services; a Navigator (1.0 FTE) who will provide access and referral service coordination to TAY that calls into MHMR; a Youth Engagement Program Director (.15 FTE) who oversees and facilitates youth voice across programs and community systems of Child and Family Services (CFS); an Advanced Practice Registered Nurse (.1 FTE) who will assist clients with medication management; and a Support Specialist (.5 FTE) who is responsible for the data fidelity for all data collection systems. The Research Division of MHMRTC will evaluate this project. Following the individuals' consent to participate, the evaluator will complete a series of instruments. Individuals will be followed up at 3-months post intake with these measures. At the time of discharge, only the NOMS will also be administered.

The Spirit Lake Suicide Prevention Program (SLSP) and its project partners—including, the Spirit Lake Recovery and Wellness Center, Spirit Lake Health Center, Behavioral Health Department, Tiwahe Initiative, Cankdeska Cikana Community College, and Four Winds High School—are in the Fort Totten district in Fort Totten, North Dakota. The Spirit Lake Tribe Enrollment Office reported approximately 7,574 total Tribal Members with approximately 3,783 residing on the Reservation in Fort Totten, Crow Hill, Mission District, and Woodlake, and 3,697 residing off the Reservation. 248 Tribal youth are enrolled in the Cankdeska Cikana Community College, 181 in Four Winds High School, 66 in Warwick High School, 78 in Minnewaukan High School, and 127 in New Rockford High School. Current barriers to proper and effective intervention include transportation, lack of capacity of parents or guardians, lack of providers, no hospital beds or overnight housing for temporary homeless, low buy-in from youth over 18 years of age, and an inability to follow up with at-risk youth. The goal of this grant is to enable the Spirit Lake Suicide Prevention Department to create and codify an efficient system of programs, policies, and capacity building for the Spirit Lake Tribal Health Department, Tribal Behavioral Health Clinic, and Educational Institutions to effectively prevent suicide and mitigate suicide risk among the youth of the Spirit Lake Tribe. The objectives of the grant are: 1. Determine the community’s needs by gathering data from 80 – 100 Tribal youth, 40 Tribal parents and guardians, 10 Tribal community service providers, 5 Tribal cultural leaders, 10 Tribal Elders, and up to 20 Tribal and Non-Tribal regional youth advocates and service providers in Year 1. 2. Develop and mobilize internal capacity through a minimum of 5 annual trainings and a minimum of 4 annual advisory council meetings to improve prevention, social connectedness, and resilience. 3. Draft and obtain feedback from the advisory council for a comprehensive Spirit Lake Youth Suicide Prevention Program and Policy document through a minimum of 3 phased feedback sessions in Year 1, 3, and 5. 4. Draft and obtain feedback from the advisory council on the Performance Report through a minimum of 3 phased feedback sessions conducted at the end of each year. Number of Unduplicated Individuals to be Served with Award Funds Year 1 - 36 Year 2 - 48 Year 3 - 60 Year 4 - 60 Year 5 - 60 Total - 264 The SLSP will provide Safety Planning Intervention (SPI+), an Evidence-Based Intervention (EBI) and Indigenous Support Groups, a Practice-Based Intervention (PBI) to build resiliency, promote positive development, and increase self-sufficiency behaviors among adults (25+ age) who are at risk for suicidal behaviors. The Safety Planning Intervention (SPI+) will provide rapid follow-up for adults who have attempted suicide, experienced a suicidal crisis, or have experienced domestic violence. SLSP’s wraparound strategy will begin with an initial meeting with the individual and family and will utilize traditional knowledge associated with healing ceremonies with primary services provided by Recovery & Wellness and Behavioral Health and secondary "recovery support services" being provided by Tribal services providers such as Victims Assistance Program, Social Services, Public Health Nursing, etc. SLSP will work with the patient and the Behavioral Health Clinic to create a program for recover support.

The focus of the population for the Onondaga County Healthy Transitions project is Onondaga County youth and young adults aged 16-25 that are identified as having or being at risk for serious emotional disturbance or serious mental illness. The Healthy Transitions Project intends to serve a total of 300 transition age youth over the course of the grant. The overall goal of the project is to support youth and young adults through the following: (1) increase the use of peers, credible messengers and natural supports to effectively engage transition age youth in behavioral health and other community based services and supports; (2) expand direct case management / care coordination services to all TAY with any systems involvement to ensure that they are successfully transitioning to adulthood; (3) enhance best practices to meet the needs of the TAY; and (4) develop infrastructure within the behavioral health provider network to support TAY moving from the children's to the adult system. SMART objectives related to each goal will align with Onondaga County's Results-Based Accountability framework and help monitor progress towards meeting project goals. Specific, time-bound objectives for this project are related to formalizing partnerships, provision of training for clinical and non-clinical providers in evidence based practices for engaging and service delivery for TAY, increasing service capacity and developing sustainable infrastructure to support TAY with behavioral health needs transition to adulthood.

Our project is titled Healthy Transition Mississippi. In this project we aim to aid transition age youth and young adults who are 16-25 who are at risk of or experiencing mental health and substance use problems and are not involved in school or work. We aim to do this through increasing capacity at three key Mississippi State University clinics, providing training on transition-aged youth to other providers, and conducting a statewide needs assessment which will aid us in synergizing our grants and programs to better serve our youth. Based on census data, there are 446,135 of these youth in MS (51.3% female; and 58.8% white; U.S. Census Bureau, 2022). Mississippi is the 4th most rural U.S. state, with 60.0% residing in rural areas. Per Mississippi's 2022 Uniform Reporting System (URS) submission, the current demographics of those receiving mental health and substance use services by DMH certified programs in Mississippi (July 1, 2021 - June 30, 2022) included: 25.6% (16,573) of 64,658 Mississippians served are between 13-24 years of age and retain either an SED or SMI designation; 52.1% female; and 51.1% Black or African American. Approximately 63,911 of the 64,658 Mississippians were served in the community. Of the 24,892 children under 18-years old with an SMI or SED designation, 11,797 reported living in a Private Residence. Additionally, 44 children and adolescents were cared for in a therapeutic foster care setting. There are three primary unmet needs that will be met with the current project: 1. Needs assessment, 2. Identification and outreach, 3. Reducing barriers and providing care. Needs assessment: First and foremost, we will conduct a statewide needs assessment to learn how many of our youth and young adults are eligible for these services, how many are receiving mental health services and from where, and what are the barriers that are preventing those who are not from engaging in services. Identification and outreach: once we have completed our assessment of needs, we will look for the gaps where youth are failing to be identified and referred for treatment. We will then tailor our outreach to these groups that are being missed to double the proportion of those youth who are referred and also subsequently receive mental health services. Overall, we will provide treatment to at least 500 youth, 100 for each year, though we expect more to be identified and treated as we improve our identification with our needs assessment. Third, we realize there are many barriers to receiving care including the care often not being available, not being culturally or linguistically suitable, or not supporting individuals with developmental disabilities. We will increase the mental health capacity in the state through providing training as well as increasing our clinics' capacity, particularly in the middle of the state which is comparatively under-served by programs like this, to help improve access to care. In addition, we will provide new treatments, such as the family-focused services, which we believe will be a better fit for many of the diverse residents of our state who may not prefer to receive mental health support via traditional routes.