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Delivering Integrated On-site Primary Health Care at Recovery Resources (RR), a community-based behavioral health services provider in Cleveland, Ohio, will exponentially expand physical and behavioral health integration, increase on-site primary care, and develop a sustainable model for on-site integrated physical and behavioral health care in perpetuity. The project will draw participants from a pool of approximately 1,200 clients with serious mental illness (SMI) currently served by RR, and will provide primary care and support services to 780 unique individuals over the four-year term of the grant (120 in year 1, 300 in year 2, 480 in year 3, 600 in year 4). It is anticipated that of the total 351 will be white, 421 will be black, and 8 will be from another race or multiple races. This population has an elevated risk of early death from co-morbid health problems including heart disease, overweight/obesity, diabetes, asthma, and tobacco use, with an average life span of 25 years less than those without SMI. RR will partner with the MetroHealth System, Northeast Ohio Neighborhood Health Services, Visiting Nurse Association of Ohio, Neighborhood Family Practice, and the Free Medical Clinic of Greater Cleveland. They will provide on-site, integrated primary care through a combination of prescriber-level providers (MD, NP) and nursing care, as well as dental care, and off site referrals when appropriate. This program has three main goals: 1) Improve the physical health status of adults with SMI and those with co-occurring substance use disorders who have or are at risk for co-morbid primary care conditions and chronic diseases through the delivery of on-site primary care; 2) Enhance the consumer experience of care; and 3) Reduce/Control the per capita cost of care.

Delivering Integrated On-site Primary Health Care at Recovery Resources (RR), a community-based behavioral health services provider in Cleveland, Ohio, will exponentially expand physical and behavioral health integration, increase on-site primary care, and develop a sustainable model for on-site integrated physical and behavioral health care in perpetuity. The project will draw participants from a pool of approximately 1,200 clients with serious mental illness (SMI) currently served by RR, and will provide primary care and support services to 780 unique individuals over the four-year term of the grant (120 in year 1, 300 in year 2, 480 in year 3, 600 in year 4). It is anticipated that of the total 351 will be white, 421 will be black, and 8 will be from another race or multiple races. This population has an elevated risk of early death from co-morbid health problems including heart disease, overweight/obesity, diabetes, asthma, and tobacco use, with an average life span of 25 years less than those without SMI. RR will partner with the MetroHealth System, Northeast Ohio Neighborhood Health Services, Visiting Nurse Association of Ohio, Neighborhood Family Practice, and the Free Medical Clinic of Greater Cleveland. They will provide on-site, integrated primary care through a combination of prescriber-level providers (MD, NP) and nursing care, as well as dental care, and off site referrals when appropriate. This program has three main goals: 1) Improve the physical health status of adults with SMI and those with co-occurring substance use disorders who have or are at risk for co-morbid primary care conditions and chronic diseases through the delivery of on-site primary care; 2) Enhance the consumer experience of care; and 3) Reduce/Control the per capita cost of care.

LifeStream is proposing to establish a second integrated health care program, along with enhancements borne out of its prior experience, to 941 or more consumers living in the more densely populated areas of South Lake County. The project will target adults with serious mental illness who do not have a relationship with a primary care provider or other health home and who have had a history of repeated hospitalizations or involvement with the criminal justice system, or are returning veterans or their families. Over the past five years, the goal of the Wellness Integration Network II (WIN II) clinic is to provide an integrated system of care that addresses needs of the whole person (body and mind). Failure to recognize and treat substance use disorders and mental health needs, along with the primary health care needs, of consumers greatly compromises their overall health and ultimately increases the burden placed upon the health care system and society in general. The projected outcomes of WIN II include: (1) Improved access to primary care services; (2) Increased individuals receiving less costly early intervention/prevention services before they progress to a chronic state; (3) Decreased utilization of acute, crisis services as the primary source of behavioral health and primary care and fewer incarcerations; and (4) Better overall health status (physical and psychological) of those served by the project, all resulting in improved cost effectiveness in the service delivery system.

LifeStream is proposing to establish a second integrated health care program, along with enhancements borne out of its prior experience, to 941 or more consumers living in the more densely populated areas of South Lake County. The project will target adults with serious mental illness who do not have a relationship with a primary care provider or other health home and who have had a history of repeated hospitalizations or involvement with the criminal justice system, or are returning veterans or their families. Over the past five years, the goal of the Wellness Integration Network II (WIN II) clinic is to provide an integrated system of care that addresses needs of the whole person (body and mind). Failure to recognize and treat substance use disorders and mental health needs, along with the primary health care needs, of consumers greatly compromises their overall health and ultimately increases the burden placed upon the health care system and society in general. The projected outcomes of WIN II include: (1) Improved access to primary care services; (2) Increased individuals receiving less costly early intervention/prevention services before they progress to a chronic state; (3) Decreased utilization of acute, crisis services as the primary source of behavioral health and primary care and fewer incarcerations; and (4) Better overall health status (physical and psychological) of those served by the project, all resulting in improved cost effectiveness in the service delivery system.

LifeStream is proposing to establish a second integrated health care program, along with enhancements borne out of its prior experience, to 941 or more consumers living in the more densely populated areas of South Lake County. The project will target adults with serious mental illness who do not have a relationship with a primary care provider or other health home and who have had a history of repeated hospitalizations or involvement with the criminal justice system, or are returning veterans or their families. Over the past five years, the goal of the Wellness Integration Network II (WIN II) clinic is to provide an integrated system of care that addresses needs of the whole person (body and mind). Failure to recognize and treat substance use disorders and mental health needs, along with the primary health care needs, of consumers greatly compromises their overall health and ultimately increases the burden placed upon the health care system and society in general. The projected outcomes of WIN II include: (1) Improved access to primary care services; (2) Increased individuals receiving less costly early intervention/prevention services before they progress to a chronic state; (3) Decreased utilization of acute, crisis services as the primary source of behavioral health and primary care and fewer incarcerations; and (4) Better overall health status (physical and psychological) of those served by the project, all resulting in improved cost effectiveness in the service delivery system.

Goodwill Industries of Greater New York proposes to implement the Goodwill Integrated Health and Wellness Center (GIHWC), with the intent of providing services for adults (18+) in Western Queens who have been diagnosed with Serious Mental Illness (SMI). We will prioritize enrolling individuals with SMI who need a primary care physician and are disconnected from care. Goodwill aims to provide for these individuals with SMI, many of whom have co-occurring substance use disorders, physical disabilities, and/or have experienced trauma. The number of people to be served annually and throughout the lifetime of the project is 100 clients in the first year, 250 clients in the second year, 400 clients in the third year, and 500 clients in the fourth year. Through the GIHWC program, Goodwill looks to fulfill the following objectives: 1) Provide co-located primary medical and behavioral health care for SMI individuals; 2) Increase long-term recovery-oriented, pro-social resources (PROS services) for clients with co-occurring behavioral health and medical conditions. Strategies/interventions expected to be implemented include (but are not limited to) Wellness Self-Management (WSM), Chronic Disease Self-Management Program (CDSMP), Integrated Dual Disorder Treatment (IDDT), Tobacco Cessation, and Individual Placement Services (IPS). GIHWC will provide onsite primary care services within its currently operating PROS program through a partnership with The Floating Hospital (TFH) in order to create a true one-stop shop for an array of primary care and behavioral health services. GIHWC's onsite Nurse Care Coordinator (NCC) and Integrated Care Manager will coordinate to develop, monitor, and continuously refine each client's Individualized Recovery Plan (IRP), while the Integrated Care Manager will work closely with all of the service providers delivering care as part of each individual's plan in order to ensure that care is closely coordinated.

Goodwill Industries of Greater New York proposes to implement the Goodwill Integrated Health and Wellness Center (GIHWC), with the intent of providing services for adults (18+) in Western Queens who have been diagnosed with Serious Mental Illness (SMI). We will prioritize enrolling individuals with SMI who need a primary care physician and are disconnected from care. Goodwill aims to provide for these individuals with SMI, many of whom have co-occurring substance use disorders, physical disabilities, and/or have experienced trauma. The number of people to be served annually and throughout the lifetime of the project is 100 clients in the first year, 250 clients in the second year, 400 clients in the third year, and 500 clients in the fourth year. Through the GIHWC program, Goodwill looks to fulfill the following objectives: 1) Provide co-located primary medical and behavioral health care for SMI individuals; 2) Increase long-term recovery-oriented, pro-social resources (PROS services) for clients with co-occurring behavioral health and medical conditions. Strategies/interventions expected to be implemented include (but are not limited to) Wellness Self-Management (WSM), Chronic Disease Self-Management Program (CDSMP), Integrated Dual Disorder Treatment (IDDT), Tobacco Cessation, and Individual Placement Services (IPS). GIHWC will provide onsite primary care services within its currently operating PROS program through a partnership with The Floating Hospital (TFH) in order to create a true one-stop shop for an array of primary care and behavioral health services. GIHWC's onsite Nurse Care Coordinator (NCC) and Integrated Care Manager will coordinate to develop, monitor, and continuously refine each client's Individualized Recovery Plan (IRP), while the Integrated Care Manager will work closely with all of the service providers delivering care as part of each individual's plan in order to ensure that care is closely coordinated.

"Building Integration in the Ozarks" is an integration project between Burrell Behavioral Health, a community mental health center, and Jordan Valley (JV) Community Health Center (CHC), a federally- qualified health center, in Springfield, Missouri, to provide primary care services to at least 2,000 seriously mentally ill (SMI) adults (approximately 60% females, 50% males) with co-occurring disorders and chronic diseases enrolled in BBH's Healthcare Home. Three additional community partners, Lester E. Cox Medical Centers, CoxHealth Family Medical Care Clinic, and Mercy Health Springfield Community, will also provide services to the population of focus through a referral system at the patient's request. Using the Four-Quadrant model and nine evidenced-based practices, the project will provide comprehensive coordinated care to the population of focus. The objective of this project is to offer a person-centered treatment approach that embraces the recovery dimensions of home, purpose, and community.

Services for the Underserved, Inc. (SUS) has 36 years' experience in serving the vast needs of New York City's most vulnerable citizens. Via its 1000+ staff, annual operating budget of $100 million, and 80 locations, SUS provides services to more than 7,000 persons annually, including residential services, outpatient treatment and rehabilitation programs, peer advocacy, case management, recovery supports, employment services, rapid rehousing and homelessness prevention, linkages to benefits programs, and other wraparound services that foster health and independence. SUS clients exhibit the following demographic characteristics: 100% have a history of homelessness, 71% are male, 93% are heterosexual, 68% are African American, 13% are Caucasian, and 19% are Latino. The average age is 51. Almost 60% are current smokers, and 70% have a history of nicotine addiction. Further, 74% have a history of chemical dependency; 34% are diagnosed with major depressive disorders; 32% are diagnosed with schizophrenia or schizoaffective disorder; and 23% are diagnosed with bipolar disorder. A high percentage of clients have the following conditions: 15% are HIV+; 17% have asthma; 19% are diagnosed with diabetes; 19% are diagnosed with Hepatitis C; 22% have high cholesterol; 29% have hypertension and 33% are anemic, have arthritis, or are obese. These statistics are based on self-reports and are predicted to be higher In December 2014, SUS merged with Palladia, one of NYC’s leading substance abuse providers for the past 44 years, which provided a continuum of outpatient and residential treatment services to more than 2,000 individuals per day (over 17,000 per year).

Services for the Underserved, Inc. (SUS) has 36 years' experience in serving the vast needs of New York City's most vulnerable citizens. Via its 1000+ staff, annual operating budget of $100 million, and 80 locations, SUS provides services to more than 7,000 persons annually, including residential services, outpatient treatment and rehabilitation programs, peer advocacy, case management, recovery supports, employment services, rapid rehousing and homelessness prevention, linkages to benefits programs, and other wraparound services that foster health and independence. SUS clients exhibit the following demographic characteristics: 100% have a history of homelessness, 71% are male, 93% are heterosexual, 68% are African American, 13% are Caucasian, and 19% are Latino. The average age is 51. Almost 60% are current smokers, and 70% have a history of nicotine addiction. Further, 74% have a history of chemical dependency; 34% are diagnosed with major depressive disorders; 32% are diagnosed with schizophrenia or schizoaffective disorder; and 23% are diagnosed with bipolar disorder. A high percentage of clients have the following conditions: 15% are HIV+; 17% have asthma; 19% are diagnosed with diabetes; 19% are diagnosed with Hepatitis C; 22% have high cholesterol; 29% have hypertension and 33% are anemic, have arthritis, or are obese. These statistics are based on self-reports and are predicted to be higher In December 2014, SUS merged with Palladia, one of NYC's leading substance abuse providers for the past 44 years, which provided a continuum of outpatient and residential treatment services to more than 2,000 individuals per day (over 17,000 per year).

Services for the Underserved, Inc. (SUS) has 36 years' experience in serving the vast needs of New York City's most vulnerable citizens. Via its 1000+ staff, annual operating budget of $100 million, and 80 locations, SUS provides services to more than 7,000 persons annually, including residential services, outpatient treatment and rehabilitation programs, peer advocacy, case management, recovery supports, employment services, rapid rehousing and homelessness prevention, linkages to benefits programs, and other wraparound services that foster health and independence. SUS clients exhibit the following demographic characteristics: 100% have a history of homelessness, 71% are male, 93% are heterosexual, 68% are African American, 13% are Caucasian, and 19% are Latino. The average age is 51. Almost 60% are current smokers, and 70% have a history of nicotine addiction. Further, 74% have a history of chemical dependency; 34% are diagnosed with major depressive disorders; 32% are diagnosed with schizophrenia or schizoaffective disorder; and 23% are diagnosed with bipolar disorder. A high percentage of clients have the following conditions: 15% are HIV+; 17% have asthma; 19% are diagnosed with diabetes; 19% are diagnosed with Hepatitis C; 22% have high cholesterol; 29% have hypertension and 33% are anemic, have arthritis, or are obese. These statistics are based on self-reports and are predicted to be higher In December 2014, SUS merged with Palladia, one of NYC's leading substance abuse providers for the past 44 years, which provided a continuum of outpatient and residential treatment services to more than 2,000 individuals per day (over 17,000 per year).

As the third largest public healthcare system in the nation, South Broward Hospital District, d/b/a Memorial Healthcare System (MHS) will implement the Mind/Body Wellness Project to provide effective, co-located primary care and behavioral health services. The goal is to improve the physical health status of adults with serious mental illness and co-occurring substance use disorders who have or are at risk for co-morbid chronic diseases. Population(s) to be served: It is expected that 40% of the population will be diagnosed with Major Depressive Disorder, 19% substance use disorder, 15% Anxiety/Panic Disorder; 10% Schizophrenia; 9% Bipolar Disorder; and 3% PTSD. Gender: 58% Female, 41% Male and .05% Transgender. Race/Ethnicity of the population will be 45% White; 34% Hispanic, 18% Black and 3% Other. Sexual orientation is 85% heterosexual and 15% LGBTQ.

As the third largest public healthcare system in the nation, South Broward Hospital District, d/b/a Memorial Healthcare System (MHS) will implement the Mind/Body Wellness Project to provide effective, co-located primary care and behavioral health services. The goal is to improve the physical health status of adults with serious mental illness and co-occurring substance use disorders who have or are at risk for co-morbid chronic diseases. Population(s) to be served: It is expected that 40% of the population will be diagnosed with Major Depressive Disorder, 19% substance use disorder, 15% Anxiety/Panic Disorder; 10% Schizophrenia; 9% Bipolar Disorder; and 3% PTSD. Gender: 58% Female, 41% Male and .05% Transgender. Race/Ethnicity of the population will be 45% White; 34% Hispanic, 18% Black and 3% Other. Sexual orientation is 85% heterosexual and 15% LGBTQ.

As the third largest public healthcare system in the nation, South Broward Hospital District, d/b/a Memorial Healthcare System (MHS) will implement the Mind/Body Wellness Project to provide effective, co-located primary care and behavioral health services. The goal is to improve the physical health status of adults with serious mental illness and co-occurring substance use disorders who have or are at risk for co-morbid chronic diseases. Population(s) to be served: It is expected that 40% of the population will be diagnosed with Major Depressive Disorder, 19% substance use disorder, 15% Anxiety/Panic Disorder; 10% Schizophrenia; 9% Bipolar Disorder; and 3% PTSD. Gender: 58% Female, 41% Male and .05% Transgender. Race/Ethnicity of the population will be 45% White; 34% Hispanic, 18% Black and 3% Other. Sexual orientation is 85% heterosexual and 15% LGBTQ.

The purpose of COPE Primary Care Integration (ICOPE-PC) is to ensure the provision of coordinated and integrated services through the co-location of primary care (PC) anti-health promotion services in a community based behavioral health (BH) setting, with the goal of improving the physical health status of adults in New Mexico (NM) with serious mental illnesses (SMI) and co-occurring substance use disorders (COD) who have or are at risk for co-morbid PC condition and chronic diseases. ICOPE-PC will support the triple aim of improving the health of individuals with SMI; enhancing the consumer experience of care (including quality, access, and reliability); and reducing/controlling the per capita cost of care. ICOPE-PC services will create a person-centered system of care that addresses an individual's holistic health and wellness, and is trauma-informed and culturally and linguistically responsive. ICOPE-PC will be located at the University of New Mexico's Mental Health Center UNMMHC), a community mental health center (CMHC) serving adults with SMI in Bernalillo County, the largest urban area in the state.

The purpose of COPE Primary Care Integration (ICOPE-PC) is to ensure the provision of coordinated and integrated services through the collocation of primary care (PC) anti-health promotion services in a community based behavioral health (BH) setting, with the goal of improving the physical health status of adults in New Mexico (NM) with serious mental illnesses (SMI) and co-occurring substance use disorders (COD) who have or are at risk for co-morbid PC condition and chronic diseases. ICOPE-PC will support the triple aim of improving the health of individuals with SMI; enhancing the consumer experience of care (including quality, access, and reliability); and reducing/controlling the per capita cost of care. ICOPE-PC services will create a person-centered system of care that addresses an individual's holistic health and wellness, and is trauma-informed and culturally and linguistically responsive. ICOPE-PC will be located at the University of New Mexico's Mental Health Center UNMMHC), a community mental health center (CMHC) serving adults with SMI in Bernalillo County, the largest urban area in the state.

The purpose of COPE Primary Care Integration (ICOPE-PC) is to ensure the provision of coordinated and integrated services through the colocation of primary care (PC) anti-health promotion services in a community based behavioral health (BH) setting, with the goal of improving the physical health status of adults in New Mexico (NM) with serious mental illnesses (SMI) and co-occurring substance use disorders (COD) who have or are at risk for co-morbid PC condition and chronic diseases. ICOPE-PC will support the triple aim of improving the health of individuals with SMI; enhancing the consumer experience of care (including quality, access, and reliability); and reducing/controlling the per capita cost of care. ICOPE-PC services will create a person-centered system of care that addresses an individual's holistic health and wellness, and is trauma-informed and culturally and linguistically responsive. ICOPE-PC will be located at the University of New Mexico's Mental Health Center UNMMHC), a community mental health center (CMHC) serving adults with SMI in Bernalillo County, the largest urban area in the state.

Cherry Health is a Federally Qualified Health Center based in Grand Rapids, Michigan that provides primary care, dental, vision and behavioral health services to over 60,000 patients. We are serving a total of 3,390 consumers who qualify as seriously mentally ill at all of our locations. Sixty percent of the SMI consumers are Caucasian, 26% are African American, Hispanics, Latinos, and Asian make up the majority of the remaining 14%. Ninety-six percent speak English, 2% speak only Spanish; however 4% consider language to be a barrier to receiving care. Fifty-four percent of the SMI population is female and 46% are male. The majority of the SMI consumers are between the ages of 31 and 60 (22% between 31 - 40, 26% between 41 - 50, 27% between 51 - 60), 16% are below age 31, and 9% are over 61. Only 14% are homeless.

PrimeCare is an initiative to establish coordinated and integrated primary and behavioral health care services in Detroit, MI. The target population is low-income African American Detroit-Wayne County residents with serious mental illness (SMI) or SMI with Co-Occurring Disorder and who have or are at risk of co-morbid physical health problems including chronic disease. A subpopulation of focus is those living in Adult Foster Care homes. An estimated 61% will be males; 39% female; 10% will identify as gay, lesbian, bisexual or transgender. At least 80% will come from Detroit. Nearly one-quarter have less than a high school education. African American adults are 20% more likely to report serious psychological distress than Whites, and those living below poverty are two-to-three times more likely to report serious psychological distress than those living above poverty. Diagnoses such as schizophrenia, bipolar disorder, major depression and severe anxiety are common and are exacerbated by obesity, poor nutrition, inadequate physical activity, smoking, co-occurring substance use disorder and lack of family or other natural supports. Nearly three-fourths of adults with SMI in Detroit-Wayne County have at least one chronic physical health problem. More than half have two or more. Those with SMI are more than twice as likely to smoke and over 50% more likely to be obese compared to the general population. Persons with SMI are also more likely to use an emergency room or to be hospitalized, driving up health care costs.

Psychiatric Integrated Treatment/Collaborative Health (PITCH), the PITCH program will serve patients with serious mental illness who have or are at risk of poor health, to connect them to and keep them in primary health care, link them to specialty services and engage them in wellness programs and health promotion and education. In partnership with Maimonides Medical Center, OHEL will also provide integrated wellness programming supported by trained Peer Specialists. The service area is the borough of Brooklyn, NY. The population to be served are area residents with DSM IV diagnoses of serious mental illness. The program will provide integrated primary and behavioral care in the PBHCI model. Goal 1: To provide a health care home that offers continuity and comprehensiveness of care for people with serious mental illness and other mental health barriers to improving their health. Goal 2: To empower people with barriers to health care because of mental illness to make informed and healthy decisions about their own health care and wellness by offering a holistic lifestyle management approach to combat the clear physical health inequalities they now experience. Goal 3: To improve the efficiency, cost effectiveness and quality of service delivery by more accurately targeting services. Measurable performance goals entail improvements to HB A1C and lipid levels, reduced BMI, waist circumference, Breath CO, blood pressure and reduction of the range of health-related risk behaviors.

Psychiatric Integrated Treatment/Collaborative Health (PITCH), the PITCH program will serve patients with serious mental illness who have or are at risk of poor health, to connect them to and keep them in primary health care, link them to specialty services and engage them in wellness programs and health promotion and education. In partnership with Maimonides Medical Center, OHEL will also provide integrated wellness programming supported by trained Peer Specialists. The service area is the borough of Brooklyn, NY. The population to be served are area residents with DSM IV diagnoses of serious mental illness. The program will provide integrated primary and behavioral care in the PBHCI model. Goal 1: To provide a health care home that offers continuity and comprehensiveness of care for people with serious mental illness and other mental health barriers to improving their health. Goal 2: To empower people with barriers to health care because of mental illness to make informed and healthy decisions about their own health care and wellness by offering a holistic lifestyle management approach to combat the clear physical health inequalities they now experience. Goal 3: To improve the efficiency, cost effectiveness and quality of service delivery by more accurately targeting services. Measurable performance goals entail improvements to HB A1C and lipid levels, reduced BMI, waist circumference, Breath CO, blood pressure and reduction of the range of health-related risk behaviors.

Psychiatric Integrated Treatment/Collaborative Health (PITCH), the PITCH program will serve patients with serious mental illness who have or are at risk of poor health, to connect them to and keep them in primary health care, link them to specialty services and engage them in wellness programs and health promotion and education. In partnership with Maimonides Medical Center, OHEL will also provide integrated wellness programming supported by trained Peer Specialists. The service area is the borough of Brooklyn, NY. The population to be served are area residents with DSM IV diagnoses of serious mental illness. The program will provide integrated primary and behavioral care in the PBHCI model. Goal 1: To provide a health care home that offers continuity and comprehensiveness of care for people with serious mental illness and other mental health barriers to improving their health. Goal 2: To empower people with barriers to health care because of mental illness to make informed and healthy decisions about their own health care and wellness by offering a holistic lifestyle management approach to combat the clear physical health inequalities they now experience. Goal 3: To improve the efficiency, cost effectiveness and quality of service delivery by more accurately targeting services. Measurable performance goals entail improvements to HB A1C and lipid levels, reduce BMI, waist circumference, Breath CO, blood pressure and reduction of the range of health-related risk behaviors.

Care Plus NJ's application for Primary and Behavioral Health Care Integration will provide a new capacity of primary care services fully integrated in the behavioral healthcare setting in partnership with Turning Point and serving adults in Northern New Jersey with co-occurring serious mental illness and substance use disorders, with or at-risk of healthcare needs. Our project is proposing to serve 600 consumers over the project, building the caseload each year (120, 300, 480, 600 consecutively). Services will be consistent with a patient-centered medical home, the Triple Aim, and SAMHSA's guiding principles of recovery. The targeted adult population has rates of depression and anxiety higher than national trends. They are all substance abusers with heroin (or other opiates) as their primary substance of choice followed by alcohol. Chronic health conditions typical to the population include Hepatitis C, liver disease, asthma, heart disease, respiratory disease, and more. Nearly all are smokers. Pre- dominant demographic characteristics include: male (68%), 25-29 year of age (24%), Caucasian (65%), non-Hispanic (90%), English speaking (100%). 95% are unemployed

Care Plus NJ's application for Primary and Behavioral Health Care Integration will provide a new capacity of primary care services fully integrated in the behavioral healthcare setting in partnership with Turning Point and serving adults in Northern New Jersey with co-occurring serious mental illness and substance use disorders, with or at-risk of healthcare needs. Our project is proposing to serve 600 consumers over the project, building the caseload each year (120, 300, 480, 600 consecutively). Services will be consistent with a patient-centered medical home, the Triple Aim, and SAMHSA's guiding principles of recovery. The targeted adult population has rates of depression and anxiety higher than national trends. They are all substance abusers with heroin (or other opiates) as their primary substance of choice followed by alcohol. Chronic health conditions typical to the population include Hepatitis C, liver disease, asthma, heart disease, respiratory disease, and more. Nearly all are smokers. Pre- dominant demographic characteristics include: male (68%), 25-29 year of age (24%), Caucasian (65%), non-Hispanic (90%), English speaking (100%). 95% are unemployed

Care Plus NJ's application for Primary and Behavioral Health Care Integration will provide a new capacity of primary care services fully integrated in the behavioral healthcare setting in partnership with Turning Point and serving adults in Northern New Jersey with co-occurring serious mental illness and substance use disorders, with or at-risk of healthcare needs. Our project is proposing to serve 600 consumers over the project, building the caseload each year (120, 300, 480, 600 consecutively). Services will be consistent with a patient-centered medical home, the Triple Aim, and SAMHSA's guiding principles of recovery. The targeted adult population has rates of depression and anxiety higher than national trends. They are all substance abusers with heroin (or other opiates) as their primary substance of choice followed by alcohol. Chronic health conditions typical to the population include Hepatitis C, liver disease, asthma, heart disease, respiratory disease, and more. Nearly all are smokers. Pre- dominant demographic characteristics include: male (68%), 25-29 year of age (24%), Caucasian (65%), non-Hispanic (90%), English speaking (100%). 95% are unemployed