Grants Dashboard

The Rosebud Sioux Tribe 988 Lifeline Project will establish a 988 Lifeline response team for the Rosebud Indian Reservation, home to 29,028 Tribal members, as well as members of federally-recognized Tribes who live on or near the Rosebud Indian Reservation. The project will address the transportation barriers to care faced by many individuals in the catchment area, many of whom have to travel over an hour to the single mental health care facility on the reservation. The team will enhance connections between federal behavioral health services, community-based behavioral health services, and off-reservation services, strengthening the network of care for users. The Sicangu Oyate (which translates to English as the “Burnt Thigh Nation”) is also known by its federally recognized name of the Rosebud Sioux Tribe (RST). It is one of the 574 federally recognized American Indian tribal governments in the United States. The Sicangu are one of the seven bands of Lakota people which, together with the Dakota and Nakota, compose the Oceti Sakowin Oyate (which translates to English as the “People of Seven Council Fires”). This group of people is also sometimes referred to as the Great Sioux Nation. Under the Indian Reorganization Act of 1934, the RST was able to re-establish its self-government and is currently a sovereign nation. The RST is located on the Rosebud Indian Reservation, which was established in 1889 after the US partition of the Great Sioux Reservation, created by the 1868 Treaty of Fort Laramie. The Rosebud Indian Reservation has a geographic area of 882,416 acres located primarily in Todd County, South Dakota and parts of the four adjacent counties in south-central South Dakota. Flanked by the Missouri River on the East and the Badlands on the West, the RST is composed of 20 communities located across the Rosebud Indian Reservation, as well as on off-reservation land known as trust land, which act as political subdivisions for the tribal government. As of 2016, there are approximately 34,150 enrolled RST tribal members. Of those, 29,028 tribal members live on the reservation. In 2010, roughly 44% of the population living on the reservation were 19 years of age or younger. Suicide prevention is a priority among the behavioral health challenges afflicting Rosebud’s tribal community. According to the Centers for Disease Control and Prevention (CDC), American Indian and Alaskan Native (AI/AN) populations had the highest rates of suicide in 2021 at a rate of 28.1 per 100,000 people, twice that of the general population. In 2018, suicide was the leading cause of death for AI/AN between the ages of 10-19 and in 2019, it was the 8th leading cause of death among all AI/AN. The goals of the project include: effectively partnering with the South Dakota 988 Lifeline program to provide culturally competent services for patients in crisis; and assessing the impact of the award, ensuring it meets relevant standards, and sustaining the program beyond the project period. The catchment area and service population for the project may be expanded to other area and regional American Indian communities in discussion with local, regional, and state partners.

Project Abstract Name of Applicant: Texas Native Health • Mailing Address: 1283 Record Crossing Road, Dallas, Texas 75235 • Contact Name and Title: Omer Tamir, Chief Executive Officer • Phone Number: (214) 941-1050 • Fax Number: (214) 946-4738 • Email: ceo@texasnativehealth.org ________________________________________ Proposed Project Title: 988 Tribal Texas Area(s) served: Texas (statewide) Project Summary: Texas Native Health, the only Urban Indian Organization (UIO) in Texas, requests support from the Substance Abuse and Mental Health Services Administration (SAMHSA) to introduce 988 lifeline linkages and support mental health services to tribal and urban Indian communities in Texas. This project addresses the urgent mental health crisis and suicide prevention needs within the Native American community, strongly emphasizing cultural continuity and collaboration with tribal partners and local crisis centers. Texas Native Health, as the applicant organization, will incorporate various evidence-based strategies such as TIP 61 and the Zero Suicide Model to deliver a comprehensive range of prevention, intervention, and treatment services as part of this groundbreaking initiative. 988 Tribal Texas aims to serve 2,000 or more tribal members annually, reaching at least 6,000 individuals over three years. The proposed project supports existing needs, data analysis, and best practices in Indian Country to achieve the following goals: 1. Expand access to the 988 Lifeline and mental health services using linkages to crisis centers and tribal-specific resources. 2. Increase awareness of the 988 Lifeline among tribal and urban Indian communities in Texas through cultural and linguistic continuity. Eligible Entity: Urban Indian Organization (UIO), as defined by 25 U.S.C. § 1603(29) Length of Project Period: 3 years Total Funds Requested: $1,100,000.00 (annually).

Abstract: Sac and Fox 988 initiative The Sac and Fox Nation will support the 988 Suicide and Crisis Lifeline in Lincoln, Payne and Pottawatomie counties in central Oklahoma. The three-county area contains 26,000 Native persons from over ten Tribal Nations who are at high risk of suicide, depression and substance use. We will increase the number of Indigenous callers to the Lifeline, facilitate partnerships with local health organizations, and implement culturally appropriate suicide prevention strategies. Our project works with the Sac and Fox Tribe and its partners in the three-county area of central Oklahoma just east of Oklahoma city. The 988 project will provide a suicide and mental health specific Lifeline to Native callers. The new system offers callers a choice to select a counselor who is a Native person and has the life experience of what it means to be Native. National, state and local data highlight two populations where Native suicide disparities are particularly severe: the first is Native Males 15-30, the second are Natives who are LGBTQ in their sexual orientation. Suicide disparities are particularly severe among both groups. Native males between the ages of 15 and 30 have more than double the rate of suicide of Whites of the same age group. Data about the LGBTQ population has been obtained by the US Census in their Pulse Survey. It indicates that LGBTQ individuals are: • 8.4 times more likely to report having attempted suicide, • 5.9 times more likely to report high levels of depression; and, • 3.4 times more likely to use illegal drugs, The Sac and Fox Nation is joined in this effort by two Indigenous organizations working in the Central Oklahoma area: namely, the Association of American Indian Physicians (AAIP) and the National Indian Education Association (NIEA). NIEA funds numerous programs throughout the nation and will provide its message of the importance of Native mental and spiritual wellness to schools, vocational centers and colleges in our Tribal Jurisdiction. AAIP funds scholarships for Native youth who wish to pursue biomedical careers and it convenes a yearly Cross Cultural Workshop that examines cultural influences in different societies. Both NIEA and AAIP will reach different sectors of Indigenous society. Individuals needing additional counseling or hospitalization will be referred to local mental health and substance abuse treatment centers. Native persons who request Native counselors will be offered culture classes to instill knowledge and pride of being Native. We will offer at least two major cultural events about Native history each year. These events will be the Gathering Of Native Americans and the Blanket Exercise. At this time most help calls from potential suicides are received by 911 dispatch centers, most of which are housed in County Sheriff’s offices. All current 911 personnel will be trained in the need for and the advantages of the 988 Lifeline over other help centers. Our work will also identify persons who are in crisis and will need a Crisis Intervention Team to perform an intervention. All information given to 988 calls are strictly confidential. We estimate we will receive over 150 new callers each year (450 over the 3 year project) and that over 10% (45 persons over the 3 year project) will be referred to further services as a result of this grant.

The Central Council of the Tlingit & Haida Indian Tribes of Alaska is a federally recognized tribe with a Community and Behavioral Health Services division that proposes a $1 million project under the Department of Health and Human Services Substance Abuse and Mental Health Services Administration's 988 Tribal Response Cooperative Agreements. This project will enable the tribe to provide culturally responsive and culturally appropriate methods of addressing behavioral health issues. This will include a critical and essential ongoing partnership with Careline (Alaska 988 Crisis Line Provider).

Mental illness increases the risk of HIV risk behaviors and acquisition by 4 to 10-fold. People experiencing homelessness (PEH) in Alameda County face multiple intersectional vulnerabilities and are amongst the most heavily impacted by the HIV, sexually transmitted infections (STI), hepatitis C (HCV), substance use, and mental illness. On any given night, >9,700 people experience homelessness in Alameda County, with an estimated >15,000 people who were without a home in the past year. The population of PEH in Alameda County increased by 241% from 2015 to 2022. While homelessness occurs across the county, it is highly concentrated in Oakland, CA (~8000 people). Almost half of (49%) of PEH are experiencing psychiatric or emotional conditions, PTSD (42%), drug or alcohol abuse (30%), and HIV/AIDS related illness (2%). Twenty-seven percent of PEH reported that mental health assistance might have prevented homelessness. The number of PEH reported as living with HIV was 98, however, the number of late diagnoses of HIV with a diagnosis of AIDS within one year, from 2019-2021 of the overall population was 21-24%. Mental illness and substance use impact HIV outcomes. There are gaps in access to and in the uptake of effective traditional mental health and substance use screening and treatment resources among the homeless population. Mobile health clinics (MHC) serve communities by delivering convenient and necessary services directly to clients in their proximal environment, overcoming barriers in access to care for those who lack resources, time, or safety to travel to traditional clinics. Therefore, we will use community-based participatory research principles and the Equity-Focused Implementation Research Framework to guide us in implementing and evaluating a portable based mental health and substance use disorder prevention and treatment intervention. This intervention will be an expansion of the HOPE MHC HIV syndemic prevention and treatment engagement services among PEH. Our project goals are to: A). Implement, refine, and evaluate a culturally tailored street-based mental health and substance use screening, treatment, referral pilot program integrated with the existing HOPE mobile status-neutral HIV, STI, and HCV prevention and treatment program for PEH in Alameda County. B). Provide an APRN clinical immersion site available to all students interested in under-served and marginalized populations. C). Document best practices and lessons learned while implementing integrated care using the enhanced HOPE model and disseminate findings from the pilot program.

Terros Health, located in Phoenix, Arizona, looks forward to continuing to meet specific community needs as they arise through the expansion of services in our Terros Health Portable Clinical Care Pilot Project to serve the U.S. Interagency Council on Homelessness’s (USICH) ALL INside Initiative Jurisdiction of the Phoenix Metro catchment area. The service focus population is racial and ethnic underserved people experiencing unsheltered homelessness, with a focus on those at high risk of HIV, SUD, or other infectious diseases. The data shows an increasing prevalence of homelessness in the Phoenix metro region. The official “Point-in-Time” count in January 2022 reported by the U.S. Department of Housing and Urban Development (HUD) shows the number of homeless people in Maricopa County, Arizona (which includes the Phoenix Metro area) surged 35% over the previous two years amid a housing crisis and economic hardship caused by the coronavirus pandemic. Of the 425 people who died of heat-related causes in 2022 in Phoenix, at least 178, or 48% of the total heat related deaths, were experiencing homelessness,. The data also demonstrates disparities which include a significantly larger proportion of the unhoused population identifying as Black (29%) compared to the overall Maricopa County population from the 2020 Decennial Census (6%). From April 2022 to March 2023, there were 20 new people experiencing homelessness for every 10 people finding housing in Maricopa County. Over the three year project period of the grant, we will address health disparities and health equity for those who are disproportionately underserved while offering outreach and case management, comprehensive and connected primary health care, evidence-based substance use disorder and mental health care, harm reduction services, (including Narcan, fentanyl testing strips, safe sex kits and other items) social determinant of health services, and transportation for more than 465 individuals who agree to ongoing, consistent care and treatment. One time services of infectious disease testing, crisis intervention, hydration, nutrition, wound care and other emergent care will be provided to many others near “The Zone,” in other encampments across the city, and in the areas of greatest need (West Phoenix, South Phoenix, Sunnyslope and the area around Sky Harbor Airport). Project goals include: 1) Provide comprehensive healthcare for medically underserved people experiencing unsheltered homelessness through portable clinical care that integrates BH and HIV treatment and prevention services 2) connect participants with SDoH resource needs including stable housing and 3) Provide community-based harm reduction services. Project objectives include 1) engage, at least three new participants each week in ongoing portable clinical care 2) for those participants that we engage in services, 100% will be offered and at minimum 20% will receive infectious disease testing 3) for those participants that we assess and identify with an infectious disease (including HIV/AIDS, STI, viral hepatitis, Mpox, or Tuberculosis), 90% will receive a referral for follow-up treatment 4) engage 75% enrolled participants with housing support through our Terros health case management team/housing specialist 5) beginning during year two, we will connect at minimum 10 participants a month with short- or long-term housing 6) provide 100 individuals each month (and 150 individuals each month beginning in year two) with at least one SDoH resource (which may include food, clothing, personal care items, or housing resources) and 7) provide weekly Narcan education and distribution (which includes safe needle exchange and education – not funded as a part of this grant) to reach at least 10 individuals each month.

In order to address the growing need in our community to provide healthcare to the unhoused, The City of Vernon is partnering with and MLK Hospital Street Medicine and Wellness Equity Alliance to implement our On-The-Streets Portable Clinical Care IBHPC+HIV Care Program. This program combines the best practices of Integrated Behavioral Health and Primary Care and HIV/AIDS prevention and treatment interventions with the promising practice of Street Medicine to provide comprehensive services to unsheltered people experiencing homelessness. On-The-Streets provides direct patient care through multi-disciplinary teams who conduct walking rounds and pop up clinics for the unsheltered homeless population in the Greater Vernon Area. Our implementation strategy for this program is built on a foundation trust-building, flexibility, and respect for the unsheltered individuals’ unique experiences and wishes. We recognize that unsheltered individuals have many of the same medical issues as the general population, we also recognize that traditional doctor-patient relationship in brick and mortar practices does not meet the needs of this population. We firmly believe that quality healthcare is a fundamental right that should be accessible to every person, irrespective of their housing situation and we are experienced in addressing the unique needs and challenges faced by unhoused individuals, particularly those who have been living on the streets or encampments for extended lengths of time and those with complex co-morbidity issues. On the Streets will improve health outcomes of those who do not readily utilize shelters or the adjunctive services co-located within shelters by providing direct patient care to unsheltered individuals experiencing homelessness. The Street Medicine Team is a roaming multi-disciplinary team will be a with “relationship-based” model including frequent/re-occurring contact with patients. The team will be comprised a Psychiatric Nurse Practitioner, a Medical Assistant, Community Health Worker SUD Counselor, Community Health Worker/HIV Counselor/Tester and a Consulting Psychiatrist.

Guam Behavioral Health and Wellness Center (GBHWC), the applicant organization, is home to the island's only 988 Suicide and Crisis Lifeline center. Guam's 988 Lifeline has morphed from a local number answered by on-shift nurses in crisis stabilization units to a formally recognized National Suicide Prevention Lifeline (NSPL) center on January 11, 2021. Through federal funding, GBHWC has been able to maintain operations by staffing the lifeline with full/part-time employees and volunteers. The Lifeline was absorbed and transformed into the 988 Suicide and Crisis Lifeline in July 2022. Since the start of 2023, Guam's Lifeline has received an average of 200 calls/month and has maintained an average answer rate of approximately 90%. The Guam Lifeline does not currently provide chat or text functionality, and there is a strong need for both workforce development and infrastructure upgrades to allow for these services. Currently, staff have the capacity to provide referrals to local resources, and the positive relationships between the 988 Lifeline and GBHWC crisis services allow for proper transitions of care. Still, Follow up care continues to wane. For the months of Nov. 2022-Jan. 2023, only 55% of Lifeline callers eligible for follow-up calls were offered a follow-up call. GBHWC's Mobile Crisis Response Team (MCRT) is the island's sole mobile crisis unit. The Lifeline has worked alongside the MCRT since its inception in June 2022 and will continue its collaborations. Through a structured follow-up process, Lifeline staff can connect with individuals with suicide ideations on a more regular basis, mitigating the need for other services on the crisis continuum. Funding will be utilized to support the following goals: 1. Develop and implement improved follow-up protocols for suicidal individuals who contact the 988 Suicide and Crisis Lifeline and provide enhanced coordination with the CBHWC Crisis Stabilization Units and MCRT. 2. Improve relationships with Guam Memorial Hospital, Guam Police Department, and Guam Fire Department to enhance the continuity of care by continual engagement post-initial 988 contacts for individuals who are at risk of suicide. 3. Improve connection with high-risk populations. Developing infrastructure for follow-up policy and procedures will force great strides and improvements in the overall service delivery for the crisis continuum of care, paving the way for increased access to services and a reduction in local suicide rates.

Compass Health, Inc. d/b/a Compass Health Network is in the process of applying for a grant offered from the Department of Health and Human Services and the Substance Abuse and Mental Health Services Administration entitled FY2023 Cooperative Agreements for 988 Suicide and Crisis Lifeline Center Follow-Up Programs (Short Title: Crisis Center Follow-Up). The three-year grant program is intended to expand efforts among Lifeline crisis centers to support individuals post-contact to provide continued support and linkages to decrease suicide risk. Ur project title, Compass Health 988 Follow Up Program, is requesting funding from SAMHSA to enhance current efforts being developed and delivered within a four-county service region in Missouri (Cass, Henry, Hickory, and Vernon Counties). The service region is predominantly Caucasian, with 91% of the service region comprising this race, with 11.75% of the population lacking access to insurance and more than 12% of the population enrolled in state Medicaid. The number served will depend on the number of regional calls made to the 988 system for this region, but we anticipate the following for those in which we will engage in clinical programming post contact with 988: YR1: 75; YR2: 100; YR3: 125. Additional individuals in crisis may be engaged and served beyond this anticipated count. With this program, it is the goal of SAMHSA and our system to significantly enhance continuity of care with engagement of hospitals, behavioral health organizations and services, as well as 911/PSAP’s (Public Safety Answering Points), MCO and police, to safeguard and ultimately improve the well-being of individuals who are at risk of suicide. Compass Health plans to support the required personnel (Project Director and Project Evaluator) as well as hire 2.00 FTE 911 Diversion Coordinators and 2.00 FTE Peer Specialists to assist in the program development and implementation of all coordination activities and follow-up care coordination. This will include direct work with local PSAP providers that directly interface with the 988 system. In collaboration with the Missouri Behavioral Health Council and selected 988/911 community partners, we are proposing to implement four regional Centers of Excellence with 988 providers and 911 PSAP providers to support engagement, collaboration, and interoperability. The Centers of Excellence in each of the four listed counties will implement 911/988 interoperability practices in their respective regions and utilize lessons learned to devise a strategy to implement and support 911/988 interoperability statewide across Missouri. Core activities of each Center of Excellence will include the following: 1) needs and opportunity assessment; 2) coordination and engagement activities – including engagement with community health care providers in each community to support follow-up care post contact; 3) implementation of 911/988 interoperability; 4) development of 911/988 training resources and tools to strengthen the existing system and for replicability; 5) sustainability planning to ensure continuity of funding and care coordination activities. The experiences that each of these centers in establishing interoperability will be utilized to create a blueprint for outreach, education, training and standards that can be leveraged by other 988 call centers, PSAP’s and CCBHC’s throughout Missouri. All required activities and objectives, as set forth by SAMHSA, will be addressed and tracked.

The First Choice Crisis Center Follow-Up Initiative expands post-contact supports to provide continued support/linkages & decrease suicide risk. The focus population is all people living in West Virginia. The focus population has high access to lethal means, is rural and suffers from high rates of suicidal ideation, substance use disorder, poverty, unemployment & poor mental health, all of which contribute to suicide. The project will serve 18,000 people (9,000/year). Project goals (interventions/strategies) include: (1) Ensure the systematic follow-up of suicidal persons who call/visit the 988 Suicide & Crisis Lifeline. by (A) Hiring 3 Crisis Case Managers to systematically follow-up with suicidal persons who call/visit the 24/7 988 Lifeline; (B) Initiating the Case Management Platform to be used by Crisis Case Managers and law enforcement to track services provided & (C) Providing training on culturally responsive care to First Choice staff. (2) Enhance coordination between entities engaged in the crisis continuum of care to improve services for suicidal persons in West Virginia by (A) Leveraging the Case Management Platform to identify needed partnerships; (B) Engaging partners in response to identified needs; (C) Conducting an annual WV 988 & Crisis Intervention Team (CIT) Summit to connect the WV crisis continuum; (D) Leveraging the annual WV 988 & CIT Summit to build the WV 988 & CIT Workgroup which will create statewide CIT policies; (E) Creating a statewide crisis training and critical incident debriefing website; (F) Initiating weekly collaboration between First Choice and the WV 988 Crisis/Disaster Coordinator; (G) Providing training on culturally responsive care to community partners; (H) Building collaborative partnerships with agencies who provide short-term crisis stabilization & (I) Establishing data sharing agreements with the WV Suicide Fatality Review Team. (3) Reduce unnecessary police engagements for West Virginians with suicidal ideation by (A) Working with law enforcement partners to leverage the Case Management Platform to measure & report on the percentage of contacts that require police engagement throughout the project period; (B) Working with law enforcement to devise data-driven processes for reducing the percentage of contacts that require police engagement throughout the project period; (C) Implementing data-driven processes to reduce crisis encounters requiring police engagement; (D) Leveraging outcomes to engage additional law enforcement partners & (E) Expanding CIT Training throughout the state. (4) Improve connections to crisis care and follow-up services for high-risk West Virginians by (A) Leveraging the annual WV 988 & Crisis CIT Summit & community partners to identify high-risk population stakeholders to participate in the WV 988 & CIT Workgroup; (B) Monitoring high-risk & disparity groups to ensure equal service use, outcomes, access & retention & (C) Identifying/engaging in training partners in high-risk and disparity group communities. (5) Improve the well-being of West Virginians who are at risk of suicide by (A) Screening 100% of individuals answering follow-up calls for suicidal ideation; (B) Referring individuals to crisis or other mental health services for suicide risk/ideation/behavior; (C) Empowering callers/visitors expressing suicidal ideation to have a statistically significant improvement in self-rated well-being at 3-month follow-up & (D) Empowering 95% of callers/visitors experiencing suicidal ideation to not have a suicide attempt at 3-month follow-up. (6) Sustain Initiative services post-grant to permanently enhance the crisis continuum of care for West Virginia residents by (A) Creating a sustainability plan for each budget line item to ensure service sustainability & (B) Working with state partners to sustain the 988 program.

Western Montana Mental Health Center (Western) is the 988 Crisis Lifeline provider for Missoula, Flathead, Ravalli, Lincoln, Mineral, and Sanders counties in western Montana. Western will use grant funding to improve follow-up care and coordination after crisis services, reduce suicides and attempted suicides, and decrease law enforcement involvement for the seven counties covered by its 988 call center. In 2022, its first full year of operation, the call center had 1025 Answered Lifeline Calls; 740 of these were repeat callers, indicating a significant need for improved follow-up care. Through the grant, Western will answer 1200 calls annually and 3600 calls over the lifetime of the project. The infrastructure development supported by this grant will impact all residents who access 988/crisis/emergency services for themselves, on behalf of others, as well as service providers; 20% are under 18, 59% are between ages 18 and 64, and 21% are 65 and older. Half are male, half are female. Approximately 7% identify as LGBTQ+. Eighty-eight percent identify as non-Hispanic White, 4% as Native American/Alaska Native, and 4% as Hispanic/Latino and 12% of residents live under the federal poverty level. The percentage of veterans in Montana (8%) exceeds the national rate (5.7%). The overall suicide rate in the service area (28.2/100,000) is twice the national rate (14.5). Suicide rates among Native Americans/Alaska Natives in the service are higher than that of the non-native population. LGBTQ+ youth are more than four times as likely to attempt suicide compared to their peers. Goal 1: Improve connection to follow-up care for 988 callers to prevent cycling back into crisis, prevent suicide attempts and completions, and promote recovery. (1.1) By end of Y1, develop a plan to confirm which calls with a disposition of "Resources given" result in callers making actual connections to resources. By end of Y2, report baseline percentage of "Resources given" calls resulting in connection; by end of Y3, demonstrate a 15% increase in connection to services over Y2 baseline. (1.2) By end of Y1, research best practices for peer specialists in crisis services; by end of Y2, develop a plan to incorporate peer specialists in follow-up care for 988 callers; by end of Y3, hire at least one peer specialist to support connection to follow-up care. Goal 2: Improve coordination of services, especially for high-risk subpopulations, to facilitate rapid connection to appropriate and culturally responsive care. (2.1) Develop four MOUs with organizations within local crisis continuum each year with at least one MOU in each of the seven counties. (2.2) Train all 988 call center staff, Western crisis services staff, and MOU partners in cultural sensitivity to identified high-risk subpopulations by end of grant period. Goal 3: Divert individuals experiencing behavioral health crises from law enforcement involvement to more appropriate crisis services by closing service gaps. (3.1) By end of Y1, complete crisis receiving center in Missoula; by end of Y2, determine baseline use, including drop-off type; by end of Y3, reduce number of law enforcement drop-offs by 15% from baseline and increase direct use by 15%. (3.2) By end of Year 1, coordinate with community partners to define Western's role in the development and implementation of a crisis receiving center in Flathead County; by end of Y2, complete crisis receiving center; by end of Y3, capture baseline use and set goal for reduction of law enforcement drop-offs. (3.3) By end of Y1, develop crisis service plan for each community. By end of Y2, complete implementation of plans through outreach, service integration and training. By end of Y3, capture baseline measurements for call dispositions and set goals for next level diversion.

Ocean WAVES (We Ask, Verify, Empathize and Support Suicide Prevention, is the comprehensive campus suicide prevention program at Ocean County College. This program is designed to respond to the transitioning demographics of OCC, building the infrastructure and programmatic systems to help prevent suicide. The following goals are a focus of the program: enhance mental health and wellness services, promote help-seeking behavior, reduce stigma, and improve the identification and treatment of at-risk students. Goal 1: Improve Student Mental Health Objective 1.1: By the end of the project period, at least 10% of the campus community will be trained in the evidence-based gatekeeper training, QPR to expand the ability of the college community to recognize and respond effectively to students at risk of suicide and mental health crises Objective 1.2: Continuously improve mental health services utilizing formalized student feedback and ensure a minimum of 95% satisfaction rating through annual review and QI processes. Objective 1.3: By the end of year 1 and on an ongoing basis, improve data collection and reporting mechanisms to inform continued expansion of services to address mental health concerns and treatment, both in-person and virtually Goal 2: Become central to campus- and community-wide unified suicide prevention network providing the necessary training and educational materials to support an evidence-based approach to prevention. Objective 2.1 Within 6 months of project and ongoing, build upon existing and develop new strategic partnerships with campus stakeholders, local community mental health providers, crisis response services, advocates, and professionals Objective 2.2 By the end of the first quarter, begin hosting monthly campus and community events raising awareness and providing community education on topics of mental health, wellness, and suicide prevention Objective 2.3 Within the first project year, partner with mental health experts for annual professional education and training As a community college, OCC serves a transitional student base that touches all ages and stages of life. A total student population of 7275 was recorded for Fall 2021 with 63% Caucasian, 5.9% Black or African American, 2.4% Asian, 7% Hispanic, 13.73% identifying as 2 or more races, and less than 1% American Indian, Alaskan Native, Hawaiian Native or Pacific Islander. Additionally, approximately one third of OCC's student population meet criteria for low-income status. Some of the most consistent clinical presenting concerns in the Counseling Center are: anxiety, depression, financial/housing/food insecurity, stress and overwhelm. Most recently in the wake of the COVID-19 Pandemic, there has been a notable increase in concern related to grief and social or family relationships. OCC students are typically managing stress at home and in relationships, taking care of children or other family members, and maintaining employment all while pursuing their degrees. Ocean WAVES is designed to comprehensively meet the needs of the student population within the context of the greater Ocean County Community, with a focus on increasing identification and services to those most at risk of suicide.

Harris County Resources for Children and Adults will implement AWARE Harris project in 3 high-need LEAs (Channelview ISD, Sheldon ISD and Waller ISD) to address social emotional, behavioral and mental health (MH) needs. The purpose is to develop a sustainable infrastructure where students have adequate access to MH resources. The designated LEAs are located in the outlying parts of Harris County. They are ethnically diverse and over 60% of their students are Hispanic. Since 2017, Harris County has experienced many adversities and traumatic events. Hurricanes, winter storms and the pandemic greatly impacted the most vulnerable; low-income families and children. Increased cost of living, poverty, lack of resources, access issues and political/social issues regarding immigration status make these three communities very vulnerable to MH and substance abuse issues. To achieve this purpose, LEAs will be provided with services based on a Multi-Tiered Systems of Supports (MTSS) framework which includes universal screening; MH promotion/prevention; targeted, early MH interventions; and intensive MH interventions. This project will work with families, teachers and the school community to support their MH and make strides towards a sustainable resiliency plan. This will ultimately lead to improved student and school outcomes, decreased disciplinary actions and better social emotional and behavioral functioning for students. Project goals and objectives are: 1. Increase MH awareness and literacy among students, families and school staff through trainings, outreach and engagement.1A. By end of Year 1, 40%, by end of Year 2, 75% of the teachers/school staff will have received training on Youth MH First Aid. 1B. By end of Year 2, 1000+ parents/guardians and community members will have attended youth MH related training. 2. Increase capacity of designated LEAs to implement trauma-informed, culturally inclusive, comprehensive school MH systems through universal prevention and supports. 2A. By end of Year 1, all schools will have been trained in Emotional Backpack Project (EBP) and will have at least 2 teachers per school implementing it. 2B. By end of Year 1, 3 schools will have received PAX Good Behavior Game training and will have at least 2 teachers per school implementing it. 2C. By March 2024, first universal screening for each district will have been conducted. 3. Increase access to high-quality, culturally inclusive, comprehensive school-based mental and behavioral health services and supports through MTSS. 3A. By February 2024, school districts will have developed a school MH referral pathway. 3B. By March 2024, all school staff will have received training in MH referral pathways. 3C. By end of Year 5, 24000 students will have received Tier 1, 2 or 3 services. 3D. By end of Year 5, 3750 students will have received substance abuse related Tier 1,2,3 services. 4.Improve LEA policies and procedures for Comprehensive School MH Systems through trainings and evaluation. 4A. By end of Year 1, 75% of school administrators will have received trainings related to student MH such as Administrators Impact on School Mental Health. 4B. By end of Year 1, each LEAs School Safety and Crisis Response plans will have been reviewed and updated.4C. By end of Year 1, all LEAs will participate in the School Health Assessment Performance and Evaluation (SHAPE) System. 5.Build and support a sustainable infrastructure with referral pathways that will continue to meet the behavioral and MH needs of school-aged youth and their families. 5A. By end of Year 2, at least 10 collaborative partnerships will have been created to support the sustainable infrastructure. 5B. By end of Year 2, each LEA will have built a sustainability plan.5C. By end of Year 5, each LEA will have established a sustainable infrastructure for student MH needs. This project will serve: 2000 students in Year 1, 5500 students in Year 2,3,4, and 5; a total of 24,000 youth over the 5-year period.

Centerstone’s Crisis Center Follow-Up Program (C-CCFP) will expand efforts within Centerstone’s 988 Lifeline Crisis Center, which provides follow-up in 20 primary, mainly rural counties and backup in 2 secondary, urban counties in Tennessee. C-CCFP will develop infrastructure to support engagement post-crisis in enhanced follow-up and support/linkages for consenting persons from an anticipated 10,010 Lifeline callers (Y1:2,730; Y2-3: 3,640/yr.). Focus population demographics/socioeconomics are expected to mirror those of the primary catchment area (e.g., nearly 50% male; 50% female; 82% White; 9% Black; 7% Hispanic/Latino individuals; 13% in poverty). The secondary area comprises a greater percentage of racial/ethnic minorities and persons in poverty. C-CCFP will serve subpopulations from among the areas’ rural residents (537,230); Veterans (148,500); minority communities (e.g., 1,028,245 racial/ethnic minorities and/or 95,570 LGBT adults/youth); and criminal justice population (e.g., 13,785 juvenile court youth; 7,530 released jail inmates). From 2016-18, catchment area calls to the National Suicide Prevention Lifeline increased by 73%, and since 988’s launch in July 2022, Centerstone has received 6,000+ calls, with 23% reporting suicidal thoughts. Catchment area populations at high-risk of suicide include an estimated 5% (96,480) of adults and 13% (24,920) of youth ages 12-17 who had suicidal thoughts. Subpopulations at heightened risk of suicide include an estimated 4,455 of Veterans, 10,983 of LGB adults, and 770 adults on probation with serious thoughts of suicide. C-CCFP’s enhanced follow-up protocols will be guided by evidence-based strategies/best practices such as SAMHSA’s standards and the National Guidelines for Behavioral Health Crisis Care and will include evidence-based approaches such as the Columbia-Suicide Severity Rating Scale for screening; Stanley Brown for safety planning; and Motivational Interviewing to encourage service access/engagement. C-CCFP’s goals include: (1) Develop a sound infrastructure and increased capacity to deliver enhanced crisis follow-up services; (2) Increase coordination between and capacity within members of the local crisis care continuum; (3) Implement systematic enhanced post-crisis follow-up services for a minimum period of 90 days up to 12 months to support suicidal individuals post-988 contact; (4) Improve continuity of care, safety, and well-being outcomes among individuals at risk of suicide following contact; and (5) Develop/disseminate a documented service model for agency-wide and national replication/ adoption. As a result of these goals, C-CCFP will achieve the following measurable crisis workforce and capacity building objectives: hire/train 3 project staff, to include peers, in culturally responsive care, intersections of service access/social determinants of health; develop/formalize partnerships with 40 local crisis continuum providers and 22 post-crisis recovery support providers; share program processes with state personnel semi-annually; establish data sharing agreements with 1 epidemiological records team; work to establish a partnership with 3 area mobile crisis outreach and 3 short-term crisis stabilization organizations; and offer training to 300 Centerstone and other crisis workforce members. C-CCFP will achieve the following measurable participant-related objectives: Enroll 100% of consenting persons in follow-up; initiate follow-up within 24 hours for and request documented consent from 100%; provide initial screening, safety planning, and referral to crisis/post-crisis recovery services for 100%; conduct 3+ follow-up attempts and complete 2+ follow-up connections per participant; increase number accessing services by 50%; achieve 0 suicide deaths and 0 attempts among those engaging in services; achieve annual percentage of contacts requiring police engagement of 5%; and improve mental health/disposition outcomes by 70%.

The Opportunity Alliance: Project Abstract Summary The Maine Crisis Lifeline Community Coordination and Follow-Up Program The Opportunity Alliance (TOA) Maine Crisis Lifeline (Maine Crisis Line and 988 Suicide Line) seeks funding to improve outcomes for suicidal individuals by addressing an often segmented system of crisis care in Maine. By harnessing the power of coordination and follow-up, while utilizing a trauma-informed, data-driven approach, suicidal persons in Maine will receive a robust continuum of care. Partnerships between the Maine Crisis Lifeline, 911, Maine's Department of Public Safety and Office of Behavioral Health (OBH), Portland Regional Communications Department (PRCC), and the Portland Police Department (PPD) will increase system-wide collaboration and use of best practices, support suicidal individuals through follow-up, decrease unnecessary police engagement, and improve crisis care for high-risk populations. The partners believe that another benefit of this project is the large sets of data that will be gathered to inform future efforts. We anticipate that at least 25% of calls into 988 will engage in the follow-up program; 1800 in the first year, and 5400 total by the end of year three. Special emphasis will be placed on engaging callers from the high-risk populations including people of color, individuals in substance use treatment programs, individuals who are homeless, and the LGBTQ+ community. The goals and objectives of the Maine Crisis Lifeline Community Coordination and Follow-Up Program are: -Increase MCL's capacity to provide critical follow-up to high-risk 988 callers who are most vulnerable after contacting the hotline by increasing staffing and interns and implementing new policies and procedures. -Improve service coordination among crisis stabilization; crisis respite; and mobile crisis outreach through convenings to improve program coordination and continuity of care for 988 callers experiencing suicidality. -Improve coordination with law enforcement, starting with the PPD behavioral health staff, to reduce unnecessary police engagement and to safeguard and ultimately improve the wellbeing of individuals who are at risk for suicide. -Improve coordination between 911 and 988, increasing statewide access to a cost-effective mental health response and decreasing unnecessary police engagement by working closely with PRCC to transfer calls between 911 and 988. -Improve connections for high-risk populations by working with partners who specialize in providing services to these populations as well as hiring a Crisis Peer Partner with lived experience. To monitor and report on the project's progress, performance assessment and program evaluation efforts will be conducted by the MCL Data Team and administrative staff. MCL already has experience successfully conducting SAMHSA funded performance assessment and program evaluations. This team also has an existing relationship with OBH in Maine's crisis system and is currently collecting data related to the project's performance measures through iCarol helpline software and Avaya Call Management System, and reporting to OBH and Vibrant.

Project Abstract Summary- Oklahoma FY 2023 Solari Cooperative Agreements for Follow-Up Programs NOFO FG-23-003. Project Summary: Solari will provide enhanced follow-up services to 988 callers in Oklahoma to reduce suicide attempts. Individuals provided enhanced follow-up services will continue to receive services for at least 90 days and potentially up to 12 months based on clinical acuity. Solari works collaboratively with other providers, including several 911 PSAP centers, across Oklahoma to assist individuals in accessing the service they need when they need it. This includes dispatching mobile crisis services when necessary as well as collaborating with higher levels of care if needed. Solari works to minimize caller involvement with law enforcement and provides diversion to allow law enforcement to return to the needs of the community. Solari will continue to educate the public and providers in Oklahoma about 988 with a focus on underserved communities, including targeted community forums. Oklahoma's callers represent a mix of rural, urban, and Tribal domains who will all be targeted in these efforts. Solari will collect demographic data on all callers to the program. Volume will be contingent on the clinical acuity of callers and is expected to rise over the three years of the program due to increased awareness and promotion of 988 in Oklahoma. Solari has established the following goals and outcomes for the program: 1. Increase acuity stability. 50.0% of follow-up participants rated as low, minimal, medium on assessments completed within the first 90 days of program participation. 75.0% of follow-up participants rated as low, minimal, medium on assessments completed within the first 180 days of program participation. 2. Increase connection to referred community support. 50.0% of follow-up participants confirm connection to at least one referred community support within 45 days of program participation. 75.0% of follow-up participants confirm connection to at least one referred community support within 90 days of program participation. 3. Enhanced outreach options by the end of year 2 by adding in other outreach methods such as text. Per SAMHSA, Solari will transition text and chat to our internal system in year 2 at which time we will begin the process of implementing alternative outreach method of text. Review and update policies and procedures to ensure compliance with necessary state and federal statutes for non-telephonic outreach from July 2024 to September 2024. Update EHR and train on new consent form and process with follow-up care coordinators from September 2024 through December 2024. Implement alternative outreach methods beginning in January 2025. 4. Increase awareness of the 988 follow-up program and goals. Educate at risk populations of the 988 and 988 follow-up services available by participating in targeted community forums at least once per quarter during year. Educate the provider community who serves at risk populations by providing presentations on Oklahoma 988 and Oklahoma 988 follow-up services available at least once a quarter during year 1.

Netcare's 988 Follow-Up initiative addresses the acute behavioral health (BH) needs of Franklin County, Ohio, home to approximately 100,000 residents with SED/SMI & 93,000 people with SUD. This region witnessed 140 suicide fatalities in 2020 & a 46% surge in drug overdoses from 2019 to 2020. The project will establish partnerships, improve follow-up protocols/BH services, & bolster culturally sensitive crisis care. Project goals/objectives include Goal 1 Improve Netcare's crisis follow-up protocols & crisis follow-up team performance. Obj. Within PY1 Q1, review & analyze current follow-up procedures post-crisis encounter & first responder intervention, identifying areas of improvement & gaps. Obj. B Within PY1 Q3, implement & train all relevant clinical staff on the 988 follow-up protocol that incorporates best practices for client engagement. Obj. C Within PY1, establish a follow-up protocol monitoring system that tracks client engagement & outcomes for 90 days to 12 months post-crisis. Obj. D Within PY2, increase follow-up rates by 20% within 90 days post-crisis relative to PY1, & 30% in PY3 relative to PY1. Goal 2 Establish formal crisis system partnerships to increase access to 988 follow-up best practices across the crisis system. Obj. A Within PY2, establish formal collaborative agreements with three additional Franklin County mobile crisis teams. Obj. B Within PY3, conduct a comprehensive training program for 100% of Netcare's frontline staff to enhance coordination with the partnered mobile crisis teams & ensure optimal crisis response. Obj. C Within PY3, provide joint crisis intervention services with the partnered mobile crisis teams to at least 30% more individuals in crisis than the previous year. Goal 3 Enhance accessibility to same-day/next-day appointment availability for people with BH crisis in the community. Obj. A Within PY2, revise the current scheduling system & procedures to allow for at least a 20% increase in same-day & next-day appointment slots, according to CCBHC guidelines. Obj B. Within PY2, achieve a 10% increase in total appointments scheduled & kept compared to the previous year. Obj. C After implementing new follow-up program components and beginning PY2, evaluate appointment availability, scheduling efficiency, & patient satisfaction to guide necessary adjustments. Goal 4 Enhance analytic capacity to monitor & reduce crisis contacts requiring police engagement in the community. Obj. A Within PY1 Q2, monitor key caller characteristics for those referred to 911 related to BH crises. Obj. B Within PY1 Q3, based on identified trends & training needs, conduct a comprehensive crisis intervention training for staff. Obj. C After PY1, achieve an annual 10% reduction in the frequency of 911 referred calls related to BH crises through effective intervention & proactive support compared to the prior year. Goal 5 Improve cultural competency across Franklin County's crisis response continuum. Obj. A Within PY1, develop a culturally responsive care training curriculum. Obj. B Within PY2 Q1, train at least 75% of the 988 follow-up service staff in culturally responsive care & demonstrate a high cultural competency (80% or better) on training post-tests. Obj. C Within PY3, through client surveys, 90% of clients receiving crisis services will indicate staff honored their cultural values & preferences. Goal 6 Enhance county crisis continuum's collaborative efforts & information sharing. Obj. A Within PY1 Q1, identify key data points that must be shared with the Franklin County Suicide Prevention Coalition (FCSPC) to improve care coordination. Obj. B Within PY1 Q3, formalize a data-sharing agreement with the FCSPC, detailing the data to be shared, the frequency of data sharing, & data security measures. Obj. C Within PY2 Q3, establish a regular review process to evaluate the efficacy & efficiency of these data-sharing agreements, ensuring they meet all parties' needs and contribute to improved outcomes.

The Mental Health and Anti-Addiction Services Administration (MHAASA) of Puerto Rico will implement the PR 988 Crisis Center Follow-Up Project to expand efforts of the PR PAS Line/988 Lifeline crisis center to support individuals post-contact and provide continued support and linkages to decrease suicide risks. The PAS Line, as the only call center/988 in PR, attended 211,323 calls, including 505 calls through the 988/Lifeline, in SFY 2022. Through April of 2023 of the current fiscal year, a total of 134,440 persons have been attended by the PAS Line, 8,998 of which showed suicide behavior. The most recent data of May 2023 from the Spanish Crisis Line reflected 2,924 calls received. the PR Crisis Continuum of Services currently guarantees access to crisis counseling services, available for all PR through one Crisis Call Center (CC), 5 Mobile Crisis Teams (MCT), and coordination of services to Crisis Stabilization Faculties. The MCT's reported 842 contacts in 2022. A total of 18,441 referrals to private hospitals were made in SFY 2022, with 15,824 for adult hospitalization and 2,617 for the hospitalization of children. The contacts also resulted in 12,061 coordination of services for psychological assessments, and 12,506 for psychiatric assessments. Based on the increase of calls received by the CC through the addition of 988 contacts, and the continuing needs to serve individuals at risk of suicide and ensure follow-up services, the MHAASA proposes a 3-year 988 Crisis Center Follow-Up Project to achieve the following summarized Goals and Objectives: G.1) Improve connections for populations at risk of suicide and ensure the systematic follow-up of suicidal persons who contact the PAS Line/988 Lifeline Crisis Center through 24/7 crisis services; G.2) Ensure enhanced coordination of crisis stabilization, crisis respite, Mobile Crisis Outreach (MCO) response services and other services on the crisis continuum of care for individuals at risk of suicide that contact the PAS Line/988 Lifeline; G.3) Reduce unnecessary police engagement by linking the individuals at risk of suicide with the PAS Line/988 personnel; and G.4) Enhance the visibility of 988 services to ensure that the PR 988 processes are known, available, and accessible statewide and nationwide. Aligned with the needs, the objectives will be directed ensure: assessment of suicide risks in at least 95% of contacts; that 95% of the individuals identified at risk of suicide are offered follow-up services for a minimum of 90 days post contact and up to 12 months after contact; 100% of the PAS Line/988 CC's protocols and procedures follow Lifeline requirements; that at least 3 formal MOU's for crisis stabilization are developed and signed for crisis stabilization; and that at least 2 formal MOU's are developed with community-based organizations that provide follow-up recovery-oriented services; to ensure that the PAS Line CC workforce receives at least 2 trainings on working with populations at higher risk of suicide; and that training is provided to 100% of the personnel of the PAS Line/988; to provide at least one training to staff of each of the organizations included in the MOU's on 988 Lifeline requirements and standards; that police engagement is maintained at 10% or less through the MCT's interventions; that the PAS Line/988 CC director is designated and participate in the Commission for Suicide Prevention; and that PAS Line processes are shared on a semi-annual (6-month) basis; and to establish connection for suicide fatality review. The project will enhance continuity of care with engagement of hospitals, BH organizations and 911/Public Safety Answering Points, MCO and police, through post-initial contact with at risk individuals through 988. Data collection, analysis and reporting will be supported by a 0.2 FTE Data Administrator to ensure EBP fidelity and GPRA/SPARS compliance. A total of $500,000 a year for a 3-year grant period.

The Help Center Follow-Up Project will serve a 13-county region in southwest Montana including Beaverhead, Broadwater, Deer Lodge, Gallatin, Granite, Jefferson, Madison, Meagher, Park, Powell, Silver Bow, Sweetgrass, and Wheatland Counties, which collectively span 28,729 square miles. The almost entirely rural service region includes approximately 233,000 people. The service area population includes a higher proportion of individuals who are veterans, males, older, and living below the federal poverty level than national averages. The Help Center Follow-Up Project will provide follow-up services to an increasing number of people annually, with a goal of supporting 3,500 people in the third year of the project. The Help Center Follow-Up Project will enhance the follow-up program by: 1. Ensuring the systematic follow-up of suicidal persons who contact the 988 Suicide and Crisis Lifeline. 2. Providing enhanced coordination of mobile crisis response, crisis receiving, crisis stabilization, and crisis respite services. 3. Reducing unnecessary law enforcement engagement. 4. Improving connections for high-risk populations. The Help Center will achieve these goals and related objectives through several key strategies, including: • Developing additional referral partnerships and MOUs with crisis providers including regional emergency departments, CIT trained law enforcement, 911, mobile crisis response services, and school-based crisis services to increase access to follow-up services. • Integrating peers and/or community health workers into the follow-up program in communities without mobile crisis response services to provide in-person follow-up support for individuals who are at high risk for suicide. • Integrate behavioral health professional network into follow-up program to increase access to these services. • Further developing relationships and MOUs with social health providers across the social determinants of health. • Enhance follow-up protocols to include enhanced referral partnerships, policies, and processes as well as in-person peer/CHW follow-up supports. • Train other Montana 988 providers on replicable follow-up protocol with common data elements to promote statewide alignment. • Provide training on culturally responsive care, intersections of service access and crisis encounters with social determinants of health, and higher risk populations to partners and community members. The Help Center Follow Up Project will enhance the current follow-up program, increasing access and use through enhanced partnerships across the crisis and broader behavioral health continuum as well as in-person follow-up options for high-risk individuals. These efforts will support more people in recovery and long-term stability, supporting improved health and safety for individuals, families, and communities.

Bienestar Human Services (BIENESTAR), a community-based provider of integrated health services, is applying for funding to address health disparities and service gaps in Los Angeles County among Latinx, with a focus on young and older LGBTQ+ adults at high-risk for SUD and HIV, Viral Hepatitis, and/or other Sexually Transmitted Infections (STIs). With roots in the HIV/AIDS crisis, BIENESTAR has always emphasized engagement with marginalized Latinx community members, including people who identify as LGBTQ+, are HIV positive or at elevated risk for HIV/AIDS, or who have SUD or co-occurring mental health conditions and SUD (COD). Through culturally sensitive bilingual/bicultural programs and high community visibility, BIENESTAR will leverage our strong presence and current programs. Geographic Catchment Area: Los Angeles County, of southern California. Specifically three Service Planning Areas (SPA) of Los Angeles County including: 1) San Gabriel Valley (Pomona, SPA 3); 2) South Los Angeles (SPA 6); and 3) East Los Angeles (SPA 7) where HIV prevalence among the population of focus remains high. Populations to be served: Racial and ethnic minority populations, specifically Latinx young and older adults (age 18+) who are at substantial risk for HIV infection, Viral Hepatitis, and other Sexually Transmitted Infections (STIs) as well as SUD, or COD. We plan to emphasize men who have sex with men (MSM) and men who have sex with men and women (MSMW) as well as those who identify as LGBTQ+. Number to be served: Year 1: 48; Year 2: 96; Year 3: 96 Year 4: 96; Year 5: 96 Life of project: 432. Project strategies/interventions: BIENESTAR will use a combination of several evidence-based- interventions, including Motivational Interviewing, Screening, Brief Intervention, and Referral to Treatment, and Medicated- Assisted Treatment. Project goals and measurable objectives: Our project goals include: increase HIV, Viral Hepatitis, and other STI prevention outreach activities to minority populations, such as those who identify as Latinx and/or LGBTQ+; increase SUD treatment, including harm reduction services, for the population of focus; increase access to HIV and other STI prevention services and SUD treatment for those who are homeless; increase access to linguistically and culturally competent HIV and other STI prevention services and SUD treatment for those who identify as Latinx and/or LGBTQ+. Measurable objectives are as follows: 1) Each grant year, screen 100% of individuals participating in the program for HIV, Viral Hepatitis, and other STIs. Of those who test positive, 75% will accept a referral for medical treatment; 2) Each grant year, offer Peer Navigation services to 100% of individuals who test positive for HIV, of these, 75% will accept our linkages to care; 3) Each grant year, of those referred for PrEP or PEP, 60% will attend the appointment and fill their prescription; 4) Each grant year, screen 85% of individuals participating in the program for substance abuse; of these, 50% with need will accept a referral for SUD treatment; 5) Each grant year, of those referred for harm reduction supplies/education, 60% will attend the appointment or obtain the referred service; 6) Each grant year, participate in or host three community events for outreach and raising awareness of services; 7) Staff will conduct community-based street outreach to high-risk homeless populations, making 100 contacts per grant year; 8) Each grant year, make four social media posts per month, to reach 500 individuals by the end of the year. Posts will be in Spanish and English; 9) Each grant year, we will distribute 5,000 printed educational materials (pamphlets, brochures, etc.) in Spanish and English at strategic outreach locations throughout the community.

Title: FY 2023 Minority AIDS Initiative: The Substance Use and Human Immunodeficiency Virus Prevention Navigator Program for Racial/Ethnic Minorities. Project Period Start: September 30, 2023. Proactive Community Services (PCS) will implement the Self-Empowerment through Engagement with Resources (SEER) Program with direct service partners (DSP): South Suburban Council on Alcoholism and Substance Abuse, Kirby Rehabilitation, Chicagoland Infectious Disease, SAJ Family Practice, and the PCS Greater Metropolitan Area Providers (GMAP), a cadre of medical psychosocial and essential service providers. The Program will provide prevention and care services to populations at high-risk for substance use disorders (SUDs) and HIV infection. The program targets ethnic and racial communities residing in Cook County, Illinois ages 18+, with a focus on transgender, cisgender, and gender nonconforming (GNC) African American men and women. The Program will use a syndemic approach to increase engagement with resources and reduce SUDs, HIV, viral hepatitis, and other blood-borne diseases, which are disproportionately high among African Americans in Cook County, especially in the communities of men who have sex with men (MSM) aka same-gender loving men (SGLM), and women -cisgender and transgender, These communities have been historically marginalized and systematically experience greater obstacles accessing medical, mental health treatment, or care services based on race, age, geographic location, socioeconomic status, justice involvement, sexual orientation, or gender identity. SEER direct service partners (DSP) will coordinate substance use, mental health, and medical services to annually provide 500 Black intergenerational men and women -cis-gender or transgender, and gender nonconforming (GNC) individuals with HIV, HCV, and STI testing/screening services, including health education, screenings and assessment, harm reduction, treatment and supportive services, and safer sex and safer consumption biomedical tools. During year one, SEER partners will focus on communities in the south and southwest districts, and in subsequent years, the program will replicate year one best practices to expand and serve underserved county communities, especially persons with limited English Proficiency. Individuals at the intersections of systemic racism, medical syndemic, and SUDs require services tailored to their unique physical, mental, and social needs. SEER partners will collaborate with interdisciplinary members of the PCS Greater Metropolitan Area Providers (GMAP) to provide culturally competent, client-centered services using Community Outreach, Peer Support Specialists, and WRAP (Wellness Recovery Action Planning). The goals of the SEER include facilitating entry into treatment and care for those with or at risk for HIV, HCV, STIs, and SUDs by annually serving 500 unduplicated Cook County residents: disseminating educational materials, providing HIV, STI, and HCV screenings, linking to Pre-Exposure Prophylaxis (PrEP) or nPEP (250 total) treatment: outpatient and residential drug treatment to 21 participants the first year and 26 participants each year thereafter (125 total); group level intervention to 25 participants the first year and 50 participants each year thereafter (225 total); and the GMAP network for medical psychosocial and essential services (600 total); and retaining clients in care. The long-term community impact is decreasing substance use, risky sexual behaviors, and mental health problems; and increasing adherence to treatment protocols and medications; and improving quality of life-related to home, health, community, economic stability, and purpose. SEER partners will employ a comprehensive strategy of engagement, education, assessment, and evidence-based practices, including individual and group-level interventions, individualized client service plans, and linkages to treatment and care.

The St. Luke’s Roosevelt Hospital Center Coming Home Program’s Prevention Navigator Program will be part of the Institute for Advanced Medicine, located at their Jack Martin Fund Center (JMFC) located in Harlem, NYC and serving Harlem/South Bronx catchment area. The population of focus is people with a history of justice involvement (PWJIH) diagnosed with substance use disorders (SUD) and/or co-occurring substance use and mental health disorders (COD) and living with or at high risk for HIV and/or Hepatitis B/C, primarily African American and Latino, many of whom are also LGBTQ. Our goal is to address health disparities among PWJIH in Harlem/SB through expanded screening and treatment services for HIV, HBV/HCV, STIs, SUDs (including OUD and IDU), and CODs. We aim to provide comprehensive care for 60 PWJIH annually and 300 over the project period, prioritizing people of color (95%) and LGBTQ individuals (25%). By fostering patient empowerment and embracing harm reduction, we strive to reduce stigma, support individuals at every stage of their recovery journey, and create a safe and inclusive healthcare environment. The Harlem/SB incarceration rate is 949/100,000 adults, with 1,347/100,000 reported in Central Harlem. This population aligns with the Minority AIDS Initiative, as NYC’s daily inmate population are 56% Black and 33% Hispanic. In Harlem/SB 83% are people of color, 26% live in poverty, 60% speak a language other than English at home (49% speak Spanish). LGBTQ people are 2x as likely to be arrested; 3x as likely to be incarcerated, and the rates are worse for LGBTQ of color. Harlem/South Bronx has high rates of alcohol related, drug related and psychiatric hospitalizations. Harlem/South Bronx has some of the highest rates of HIV diagnoses in NYC with 30.2/100,000, and 2.7% of the population is living with HIV. Nearly half of NYC inmates report substance abuse and of those with an SUD, half have a diagnosed opioid use disorder (OUD). One-third of those who use opioids pass through the criminal justice system annually. In 2021, 53.5% of NYC’s jail population had MH issues, many with a history of trauma, victimization and abuse. Inmates identified as LGBTQ are further susceptible to MH issues caused by humiliation, stigma, physical and sexual abuse during incarceration. Opioid related overdoses are the leading cause of death after re-entry, often within the first 30 days after release. The strategies and interventions we will be implementing are evidence-based prevention services such as Motivational Interviewing; Cognitive-Based Therapy; Seeking Safety; Wellness Self-Management; Screening, Behavioral Intervention and Referral to Treatment; Mindfulness Based Relapse Prevention; anger management classes; as well as other validated screening tools for substance use and mental health services. The goals will address health disparities among PWJIH in Harlem/SB through expanded screening and treatment services for HIV, HBV/HCV, STIs, SUDs (including OUD and IDU), and CODs. Goal 1: Develop a comprehensive strategic plan to address SU and HIV problems in the Harlem/SB catchment area for PWJIH; Goal 2: Increase the number of PWJIH in Harlem/SB who receive SU and MH services; Goal 3: Enhance the quality/intensity of treatment for clients with SUDs/CODs; Goal 4: Enhance and expand screening, referral and treatment for sexual health services including HIV, STIs and HBV/HCV infection among PWJIH in Harlem/SB; and Goal 5: Enhance prevention navigation services to address SDoH and barriers to care, facilitate linkages to follow-up care, and increase access to critical support services for PWJIH.

Project Abstract Agape Health & Wellness Center, Inc (Agape) a non-profit organization in Jacksonville, Duval County, FL provides primary care, behavioral health, and prevention services to residents of Duval County. Duval County is listed as one CDC’s End the HIV Epidemic Priority Jurisdictions. Agape is seeking funding to implement Project HOPE to increase engagement in substance use (SU) and HIV prevention services for racial and ethnic underrepresented individuals, with an emphasis on men who have sex with men (MSM), men who have sex with men and women (MSMW), and others who identify as lesbian, gay, bisexual, transgender, queer, questioning and intersex persons (LGBTQI+) who are not in stable housing and/or reside in communities with high rates of HIV, Viral Hepatitis (VH) and/or sexually transmitted infections (STI). Agape proposes to implement Project HOPE, in response to the great disparities faced by racial/ethnic minority adults in the community. Project HOPE will execute the work-plan by recruiting, hiring/reassigning, and training competent staff comprised of the following: Project Director (PD), Lead Navigator (LN), Two Prevention Navigator (PN), and External Evaluator (Eval). Project HOPE will utilize a prevention navigation approach aimed at expediting and enhancing outreach, access, and linkage to services. Following the five components of SPF, Project HOPE will serve the following number of at-risk minority MSM/MSMW/LGBTQI+ adults who are not in stable housing and reside in the Duval County area: Number of Unduplicated Individuals to be Served with Grant Funds Year 1 Year 2 Year 3 Year 4 Year 5 Total 60 80 80 80 60 360

The selected population focus for APPAL (Aniz Prevention Program for African-American/Minority LGBTQ+ individuals) is the disadvantaged African-American queer population including bisexual and trans, age 18-45 in Atlanta, GA under 150% AMI. In total, 2,970 individuals will be impacted by this program over a 5-year period. The goals of the project will be to conduct HIV outreach minority LGBTQ+ individuals (hereafter, always in metropolitan Atlanta) at risk for HIV/STI and SUD. The project will conduct outreach to 500 individuals in the first year and reach 600 by the end of the fifth year. To enroll and provide HIV education and prevention services to 400 minority LGBTQ+ individuals reaching 500 by the fifth year; To conduct HIV/STI testing for a total of 2,970 minority LGBTQ+ individuals; To provide navigation services including linkage and support services to 2,245 minority LGBTQ+ individuals over the course of the project. To enroll 400 individuals in the first year for SUD intervention, HIV prevention including education and PrEP, and harm reduction counseling, reaching 500 by the fifth year. It will provide counseling and access to medication for 40 HIV infected individuals in the first year and reach 100 individuals by the fifth year. It will link 400 enrolled individuals to a PCP in the first year and reach 500 individuals by the fifth year. It will provide rehousing for 40 homeless LGBTQ+ individuals in the first year and reach 100 individuals by the fifth year. The core of the Aniz wraparound service model is Assertive Community Treatment (ACT). The basis for assertive community treatment is the idea that people will receive the best care when their mental care and healthcare providers work together as a team. It is a model which provides flexible treatment with a multidisciplinary approach to support clients in all aspects of their life. This includes therapy, social support, employment, medication, and/or housing. Based on the evaluation, the treatment plan will move the individual is through the Trans-theoretical Model (Stages of Change) six stages of change: Pre-contemplation, Contemplation, Preparation, Action, Maintenance, and Termination. Social Cognitive Theory (SCT) is applied to the environment, situation, observational learning, behavioral capability, reinforcement, outcome expectancies, self-efficacy and reciprocal determinism. Brief Interventions (single or multiple sessions) is offered in the SUD treatments including a) Motivational interviewing (MI). MI is a counseling method that helps people resolve ambivalent feelings and insecurities to find the internal motivation individuals need to change their behavior; b) Motivational Enhancement Therapy, (MET). In all counseling sessions, the counselor will rely on Dialectical Behavior Therapy. Dialectical behavior therapy (DBT) is a form of cognitive behavioral therapy (CBT). Its main goals is to teach people how to live in the moment, develop healthy ways to cope with stress, regulate their emotions, and improve their relationships with others, thus “breaking” the cycle of cause and effect.

The Project seeks to reduce new HIV infections while addressing SUD and mental health issues that patients exhibit. BACH will increase access to care and promote health equity for 300 patients per year for the grant period. BACH will refer these 300 high-need, medically underserved clients in southern Alameda County and SCC to SUD services, of whom 75 will be referred to BACH’s Medically Assisted Treatment (MAT) Program. BACH will expand current and establish new services, which will increase HIV testing, resultant referrals and access to SUD services, naloxone, fentanyl detection kits, PrEP and nPEP, link persons with HIV to HIV medical care and antiretroviral therapy (ART) and provide and/or refer previously diagnosed or those at risk of HIV to HIV and SUD prevention and treatment, including mental health services. The Project seeks to reduce the impact of SUD and HIV infection and death rate, and HIV-related disparities while improving health outcomes despite HIV status. The Project will thus implement outreach and promotion in SCC and Alameda County that supports those with or at risk of HIV to access HIV testing, during which, staff will conduct client-centered, trauma-informed screenings for medical and non-medical risk factors and social determinants of health (SDOH), including SUD and mental health issues.