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The Utah Partnership for Success 2023 (PFS 23) Project in Utah utilizes a science based, proven to be effective system called the Strategic Prevention Framework (SPF) to deploy prevention services in Utah for underage drinking and marijuana use prevention. The SPF drives communities and the state to effective prevention programming and strategies that meet unique community needs. Utah’s goal is to continue the efforts of utilizing SPF model and enhancing our capacity, assessing, planning, implementing and evaluating our prevention efforts, specifically underage drinking and marijuana use among youth at the state, local, and community level. Measurable goals and objectives were established by considering Utah’s population, need, culture and ethnic makeup. Our overarching goal is to decrease 30 day alcohol use by 10% and decrease 30 day marijuana use among youth by 10%. Utah’s population is approximately 3.2 million. Utah has a population that is 77.2% white alone, 14.8% Hispanic or Latino, 2.7% Asian, 1.6% American Indian and Alaska Native, and 1.5% Black or African American. 28.4% of the population is under age 18. 8.4% of students in 12th grade have used alcohol in the past 30 days, and 4.9% report heavy (binge) drinking. 9% of students in 12th grade report having used marijuana in the past 30 days. PFS 23 will reach the general population of parents and students. There are approximately 675,000 students, with environmental and universal programs and strategies. Indicated programs will reach 10,000 students annually, selective programs will reach 42,000 students, delivered mostly through the school system. In the lifetime of the project, we aim to reach 3,000,000 in a universal population, 200,000 selective and 50,000 with indicated services. Previous SAMHSA/CSAP Grants have improved Utah’s prevention system in the strategic process to the point where the state and communities follow the Strategic Prevention Framework and utilize best practice programs and strategies. With PFS 2018, Utah strengthened the Prevention Network by continuing the Regional Director system and built capacity by implementing Community Centered Evidence Based Prevention (CCEPB) services that are implemented by local coalitions. PFS 23 will continue to build capacity by continuing to add coalitions statewide. The communities are tied to performance measures and a rigorous ongoing evaluation will immediately begin at the start of this project that includes process and outcome data. Because the Utah system is inherently connected, existing resources will be leveraged to support these communities and assist them in their sustainability efforts.

Ohel Children's Home and Family Services' proposed CCBHC will expand and enhance access to comprehensive, trauma-informed, and integrated care to all individuals living experiencing behavioral health (BH) conditions and comorbid conditions in Rockaway, Queens (CD14). We will prioritize children and pregnant and postpartum women (PPW) from diverse backgrounds; we aim to address significant disparities among children with a disproportionate number of ACEs, and among PPW with peripartum depression. We anticipate that many of our CCBHC clients will be white and from the Orthodox Jewish community, as Ohel has a particular cultural competence in serving faith-based communities. Through our geotargeted outreach based on data from the city's Taskforce on Racial Inclusion and Equity, we will actively engage individuals from diverse backgrounds, including Veterans. According to US Census data, CD14 is 36% White, 30% Black, 29% Hispanic, 2% Asian, and 3% Other. Ohel currently provides most of the CCBHC required services and will complete its community needs assessment by month 6, and its staffing and sustainability plans by month 12. Through the PDI grant, Ohel will extend our mobile outreach to 24/7, hire 4 additional on-call clinicians, and train all crisis workers to respond to pediatric BH crises. We will begin using new evidence-based screening tools for children (PEARLS) and adults (RODS, MAST). We will hire 1 CASAC; 1 RN to provide onsite primary care; 1 RN with SUD experience to expand our SUD services, including MAT; and 1 peer specialist with lived SUD/MH experience. We also plan to expand our CFTSS program to include PSR, and our TCM program to serve more individuals in the community, including uninsured and those with commercial insurance. In addition to enhancing our EHR to capture more assessment data, we will train our staff to better capture client demographic data in our EHR. With this grant, we will increase our total unduplicated individuals served annually from 647 to 1147 by the end of year 4. Our goals and measurable objectives include: (1) Expand access to BH services for PPW via the following objectives: 1.a: Increase number of PPW treated for SMI, SUD, or COD by 20% by year 4; 1.b: Increase number of individuals, including PPW, with SUD who are receiving individual or group therapy by 20 each year of the program; and 1.c: Increase number of providers prescribing MAT by 2 by year 4. (2) Increase BH crisis services via the following objectives: 2.a: Expand mobile crisis hours to 24/7 by the end of year 1; 2.b: Implement Safety Planning Interventions for Children (C-SPI) to expand crisis services to include children 6-12 years old by the end of year 1; and 2.c: Increase number of crisis interventions by 20% by year 4. (3) Increase community-based services for high acuity children and youth and PPW via the following objectives: 3.a: Increase number of children 0-17 and transitional youth 18-21 treated for SCP, SED, or SUD by 20% by year 4; 3.b: Increase enrollment in CFTSS for 20% by year 2; and 3.c: Increase number of PPW we are treating with an EBP by 20% by year 4. (4) Develop partnerships and create referral pathways for children from diverse backgrounds across the entire SA via the following objectives: 4.a: Outreach to new community partners and provide children's BH educational sessions in 2 new community settings in our SA each year of the grant (8 total); and 4.b: Outreach to Black, Hispanic/Latino, and Asian families (populations historically underrepresented in our client base) through culturally specific social media pages by the end of year 1. (5) Improve pediatric BH outcomes and reduce health disparities via the following objectives: 5.a: Improve documentation of client self-reported race, ethnicity, sexual orientation, and gender identity by 50% by the end of year 1; and 5.b: For children ages 4-17 with a high PSC-17, 25% will have a decrease of 4 points within a year across all races and ethnicities.

AWARE's Certified Community Behavioral Health Clinic (CCBHC) Planning, Development and Implementation Project will provide the full continuum of CCBHC services to individuals of all ages in Lewis & Clark County. Lewis & Clark County has been experiencing ongoing gaps in service and unmet behavioral health needs. Closure of Helena's crisis stabilization facility in 2020 and ongoing development of crisis services present critical issues for the community. AWARE's CCBHC project is poised to meet the pressing, unmet health needs and gaps in Lewis & Clark County by facilitating services for a community identified as high risk for suicide, opioid overdose, and other deaths of despair. AWARE plans to serve 500 individuals through the implementation of CCBHC services and collaborations. Revitalizing community-based services, under the comprehensive CCBHC model will springboard services into a community with proven need. As one of Montana's largest providers of human services, AWARE is ready and able to become the sole provider of comprehensive CCBHC services and to fill essential needs in the county and its surrounding rural regions. AWARE will coordinate healthcare services for our community's most vulnerable individuals by investing in a network designed to provide a seamless, integrated process to address each person's unique health needs. This integrated approach will leverage community collaborations to support physical and behavioral health care while offering broader connection to supports not traditionally provided by primary care by connecting clients with housing, employment, and other social services. AWARE's CCBHC will provide care to all with special attention to increasing care for historically disenfranchised people living with a disability, identifying as LGBTQIA+, members of a tribal nation, and underserved veterans. By increasing access and decreasing stigma, it is hoped health outcomes for Lewis and Clark County will improve.

For over 100 years, Pillars Community Health (PCH) has provided innovative health, and social services in western Cook County, Illinois. PCH will utilize the CCBHC grant funding to establish a CCBHC site at our “Fillmore Center” in Berwyn Illinois. Our CCHBC will serve the seven municipalities of Bedford Park, Berwyn, Bridgeview, Cicero, Justice Stickney and Summit. Our population of focus is Latine adolescents, ages 13-18 who reside in this area. PCH will also serve individuals with a behavioral health (BH) diagnosis, with emphasis on those with serious emotional disturbance (SED), serious mental illness (SMI), substance use disorder (SUD), opioid use disorder (OUD), and co-occurring mental and substance disorders (COD). We estimate serving 700 new clients over the four-year grant period. Unmet needs and BH disparities remain a challenge, especially for Latine adolescents in our catchment area. Our population of focus primarily attend two high schools (Morton HS District 201 and Argo-Summit District 217). 82% of these students identify as Latine, 25% are English language learners, and 74% are from low-income households. In recent years, rates of sadness and suicidality have increased significantly for our population of focus. In 2019, 42% of Illinois high school students reported “feeling so sad or hopeless almost every day for two weeks or more in a row”, compared to 28% in 2007. 12% of Latine high school students self-reported attempting suicide, among the highest rates in IL. Our project goals are directly aligned with the need in our catchment area. Goal 1: Enhance data collection & analysis to improve population health management and meet CCBHC criteria. Objectives: Complete assessment of HIT; establish and launch centralized data collection processes. Goal 2: Increase and diversify BH access points and workforce for Latine adolescents and their families. Objectives: Implement “Parent Café” at high schools; increase self-identified Latine staff by 20%; implement Teen Advisory Subcommittee to Client Advisory Council. Goal 3: Improve health outcomes for Latine adolescents by enhancing access to culturally appropriate treatment and reducing overall symptoms experienced. Objectives: Implement Culturally Modified Trauma Informed Cognitive Behavioral Therapy and Interpersonal Therapy – Adolescents treatment teams; demonstrate 20% reduction of depression and anxiety symptoms; implement Community Crisis Response Team. Goal 4: Expand collaborative relationships to enhance delivery of services and reduce health disparities. Objectives: Establish MOUs with local schools; execute MOU with Hines VA, implement teen mental wellness programming. PCH already provides all CCBHC required clinical services. Combined with our FQHC medical, dental, psychiatry, and integrated BH services, we offer individuals and families a continuum of care to support both physical and mental health, enabling them to access care and participate in community life. We continue to build on a “no wrong door” approach to connecting residents with the appropriate level of care and method of service provision to best address their needs.

The purpose of Lincoln Behavioral Services proposed CCBHC planning, development and implementation project is to increase access to integrated, holistic, evidence based practices and quality care, program expansions and pathway improvements. Services are designed for individuals who are in crisis, experiencing a substance use or opioid use disorder, chronic health conditions, and are at risk for suicide and/or violent behaviors. Wayne County serves over 75,000 individuals with some of the highest poverty rates, suicide and school violence rates, poor mental health and decreased follow-through on chronic physical health conditions than other counties in Michigan. These combined factors represent a higher demand for integrated services. LBS will invest in infrastructure to facilitate care coordination, population health analytics and monitoring, increased access and engagement into services through targeted interventions to address health disparities and social determinants of health. Evidence based treatment, staff training and expanded staffing will increase integrated health services (mental health, prevention and engagement, SUD/OUD and/or physical health) to 1500 individuals over four years (Y1 250, Y2 350, Y3 425, Y4 475). LBS populations of focus are youth, veterans, LGBTQI+, and African Americans individuals lacking fully integrated, coordinated care, residing in the city of Detroit and all remaining communities in Wayne County, Michigan. LBS will use the CCBHC-PDI funding to advance three primary goals: (1) reduce barriers to access for veterans, LGBTQI+ and African American communities, including medication assisted treatment for SUD and OUD, and suicide prevention; (2) reduce school violence and school avoidance by decreasing/eliminating bullying/cyberbullying, homicide and threats of violence among students K-12, including LGBTQI+ and African American youth; and (3)reduce health inequities and improve access to primary care among veterans, LGBTQI+, youth, and African-American communities with mental illness. Anticipated outcomes include improved treatment retention and recovery, increased professional competency (including culturally competent interventions), decreased school avoidance, threats of violence and suicide rates; improved management of chronic health conditions, and improved access for the identified populations of focus. Care coordination and staffing will focus on screening, prevention, connection to resources, follow-up and intervention on health concerns, SUD/OUD support services and crisis stabilization. Screening and ongoing primary care needs will be provided on site by LBS. The provision of crisis services will be accomplished through LBS, Designated Collaborating Organizations and community stakeholders. LBS will develop an Advisory Council with membership represented by clients, family members, community stakeholders, and other advocates to obtain input and feedback on the identified goals and outcomes. LBS will enhance data collection and reporting to demonstrate improved access, engagement of target populations and increase care coordination through LBS's EHR and the Health Information Exchange.

The vision for Serenity Behavioral Health Systems, as a CCBHC, will be to provide trauma informed, person and family-centered services supporting recovery for individuals with, or at risk for, mental illness and/or substance use disorders, regardless of the individual’s ability to pay. Serenity is currently a Community Service Board (CSB) for the state of Georgia which is a Safety Net provider tasked with providing a comprehensive bundle of services to promote recovery in crisis residential, outpatient, and community-based settings. Serenity will be targeting coordinated services to persons in need of care to include those with limited or no access to ongoing mental health and/or substance use services living in Richmond, Columbia, and McDuffie counties in East Central Georgia including children ages 5-17 with diagnoses of depression and veterans or uniformed service members at risk of suicide. The most recently published Census data shows that those three counties have a combined population of 390,772 with 14.75% of that population being uninsured. Within those three counties, 15.48% of families live below the poverty level. Richmond county reflects the highest percentage of families living in poverty (21.4%) and the highest number of uninsured (16.5%). McDuffie County has the 2nd highest number of uninsured individuals, at 16.3% while Columbia County has the second largest population at 162,419 with 7.3% living in poverty and 12.3% uninsured. Results from previous needs assessments completed by community hospitals serving the three counties lists deaths due to despair (which include suicide, drug and alcohol poisoning, and alcoholic liver disease) and poor mental health days as higher than the state and national averages in Richmond and McDuffie counties. It also indicated access to mental health care including inpatient, outpatient, and low-cost care were three of the five most important items for improving the health of community members and mental health was also noted as a problem (lack of resources), cause (trauma, lack of knowledge of resources) and solution (collaboration, telehealth) to the overall health of community members. Mental health and lack of access to mental health services and veterans with PTSD were noted as major issues facing McDuffie County. A need for expanded access and services to rural areas were also noted as a need. Currently serving 2,321 people, Serenity expects to increase access to services and serve two hundred people in year one, two hundred fifty people in year two, three hundred people in year 3 and three hundred fifty people in year 4. The goals of this project include Goal 1: Expand access to mental health and SUD care for individuals in SBHS’ catchment area who are uninsured, have Medicaid and/or are at 150% of the federal poverty level. Goal 2: Establish an integrated primary care program that includes the provision/offering of primary health screening and monitoring, health education, and medication administration while simultaneously initiating the offering of care coordination to reduce care fragmentation for individuals served through the CCBHC. Goal 3: Elevate standards of care through implementation of an outcome-based treatment model that includes staff training in population health management, outcomes-based treatment models, and the use of client-level outcomes measures. Goal 4: Increase veteran engagement and experience of care by providing organization-wide training on military culture and implementing evidence-based practices tailored to veterans and their families. We will also establish key treatment outcomes for clinical programs using tools such as the PHQ-9 and the DLA-20 and develop dashboards and analytics for ongoing tracking of performance indicators.

McLean County Center for Human Services (MCCHS) serves McLean County Illinois (catchment region). The purpose of this project is to transform the service system provided by MCCHS to improve health and behavioral health outcomes for individuals with serious mental illness, serious emotional disturbance and substance use disorders in McLean County. This project will allow MCCHS to meet criteria as Certified Community Behavioral Health Clinic (CCBHC). MCCHS will ensure access to recovery-oriented, trauma-informed behavioral health services including client-centered, evidence based behavioral health care. MCCHS currently provides most of the required CCBHC services, including crisis mental health services, behavioral health screening with risk assessment, outpatient mental health and substance abuse services, patient-centered treatment planning, targeted case management, psychiatric rehabilitation services, peer support, counselor services, family supports, and intensive, community based mental health services for members of the armed forces and veterans. Services that will be implemented and improved as part of this project are staffing for the walk-in crisis stabilization center to be open 24/7/365, primary care and health indicator screening with a nurse practitioner, expanding substance use services including medication assisted treatment and services for youth, expanding the role of consumers and families including integrating the Consumer/Family Advisory Council into the board of director's structure, and developing an internship program with local colleges and universities to address the mental health provider shortage long-term. MCCHS will create a detailed action plan to achieve CCBHC certification. The action plan will include activities and strategies for developing and meeting the CCBHC criteria, including the integration of CCBHC culture and principles into agency policies and procedures and updating our electronic health information systems, processes, and protocols. MCCHS will also develop procedures for regular monitoring and evaluation of CCBHC standards and adherence.

WellLife Network (WLN) proposes to provide comprehensive, high-quality coordinated behavioral health care in Nassau County, NY by planning for, developing, and implementing a new Certified Community Behavioral Health Clinic (CCBHC) that meets SAMHSA’s updated CCBHC Certification Criteria. WLN will provide a comprehensive range of person- and family-centered outreach, screening, assessment, treatment, care coordination, crisis services, and recovery supports based on a community needs assessment. WLN’s CCBHC will serve Nassau County’s more than 1.38 million residents, including children, adults, families, and veterans diagnosed with serious emotional disturbance (SED), serious mental illness (SMI), and co-occurring (COD) mental health (MH) and substance use disorders (SUD) experiencing isolation and loneliness post-COVID-19 pandemic. Residents’ median age is 42 years and 50.8% of the population identifies as female. Its racial distribution is 72.2% White, 17.6% Latino, 11.9% Asian, and 13.1% Black. More than 22% are foreign-born and 28.8% speak a language other than English at home. More than 38,000 are veterans. While county-level data is not available, more than one million adults in NY identify as LGBTQ+. Nassau’s primary care provider-to-population ratio is 143:100,000 and the mental health (MH) provider-to-population ratio is 314:100,000. One-quarter of Long Island families are unable to find a mental health provider who takes their insurance and 3.6% of Nassau County residents are uninsured. Recent studies show the COVID-19 pandemic has exacerbated SUD and MH issues among youth, children, and adults, with approximately 25% of residents indicating that drug and alcohol abuse and mental health depression/suicide are two of Nassau County’s biggest ongoing health concerns. Despite its affluence, Nassau County lacks sufficient services to address the myriad needs of child and adult residents with SMI, MHD, SUD, and COD, including community-based services that support peer connection, medication-assisted treatment (MAT), and 24/7 mobile crisis services. To offer a comprehensive array of services to Nassau County residents, WLN will: 1) Develop a staffing and training plan reflective of community needs; 2) Increase availability and accessibility of service to the population of focus by developing and implementing a service delivery plan based on the community needs assessment and hiring and training the appropriate staff to deliver those services; 3) Improve care coordination for clients to ensure seamless transitions across myriad health services by implementing electronic health record (EHR) improvements for data collection and analysis, executing Memorandums of Agreement with Designated Collaborating Organizations (DCOs), and updating care coordination protocols; and 4) Increase compliance with CCBHC Certification Criteria by providing mobile crisis services, incorporating screening tools in the EHR, providing primary care screening and monitoring, developing and implementing a targeted outreach plan to veterans, and establishing a clubhouse model of psychosocial rehabilitation for children/youth in WLN’s pediatric community residences and in its supported housing for adults with SMI. Evidence-based practices include Assertive Community Treatment, the Clubhouse Model, Cognitive Behavioral Treatment (CBT), Family Psychoeducation, Integrated Dual Diagnosis Treatment, MAT, Motivational Interviewing, Seeking Safety, and Trauma-Focused CBT. Five of nine CCBHC Certification Criteria will be in place within 6 months of the grant award and all criteria will be met within 12 months of award. WellLife Network’s CCBHC will provide a continuum of evidence-based approaches to 415 unduplicated individuals: 75 in Year 1, 100 in Year 2, 115 in Year 3, and 125 in Year 4.

Tessie Cleveland Community Services Corporation (TCCSC) is a 501(c)3 non-profit behavioral health agency and has been providing services to children, adolescents, adults, and families since 2005. TCCSC’s CCBHC-PDI project will serve the Southeast Los Angeles area, designated by LA County as Service Planning Area 7. SPA 7 includes multi-generational poverty, unemployment/under-employment, limited English proficiency, illiteracy, low-to-no self-efficacy, and geographic deprivation of services and resources readily available in more affluent neighborhoods (job opportunities, safer parks and recreation, quality stores, and choices). The specific focal population will be Latino men and women (18+), adolescents (12-17), children (0-11), and LGBTQIA with SMI, SED, co-occurring mental and physical health problems, SUDs, experiencing homelessness, and living at or below 100% of the FPL. Through this grant, TCCSC will provide services to 75 clients annually and 300 throughout the lifetime of the project. TCCSC provides services that are individualized based on the unique dynamics of each client and family and tailored to address their strengths, needs, and desired outcomes. In addition to our clinic services, TCCSC utilizes in-home services including psychotherapy; counseling; crisis response; case management; linkage; and parenting education to increase child safety in the home and prevent child abuse, maltreatment, and neglect. TCCSC provides clients and families with exposure therapy to increase their comfort level in seeking resources outside the community. TCCSC’s service delivery plan includes programs and events that incorporate strengthening a family’s protective framework. In addition to these services, TCCSC uses a myriad of Evidence-Based Practices (EBP’s) enabling our clinicians to become self-directed, problem-based, treatment providers who can integrate the results with their clinical expertise. TCCSC selected EBP’s proven to be effective with our focal population such as Dialectical Behavioral Therapy (DBT), Motivational Interviewing (MI), and Seeking Safety (SS). physical health problems, SUDs, experiencing homelessness, and living at or below 100% of the FPL. The grant will allow TCCSC to address behavioral health disparities for Southeast LA (SPA 7) including: 1) lack of access to care; by a) opening a center in an area designated as health, mental health and primary care professionals shortage areas by HRSA; b) providing services in Spanish where 38.5% of the population are monolingual Spanish speaking (LA County KIH, 2017); c) providing services regardless of ability to pay, especially for undocumented individuals, with 44% representing the total population in Southeast LA (SELA Nonprofit Needs Assessment: Landscape Analysis, 2019); 2) higher rates of chronic diseases by offering primary care screenings to address significantly higher rates of diabetes (5% higher than the LA County rate at 28%) and obesity (39% of the population); 3) lack of educational attainment by offering information using written, verbal or other alternative methods of communication, including visual aids, audio recordings, and hosting community forums; and 4) lack of coordinated care by hiring five bilingual FTE providers (therapists, care coordinators, nurse practitioner, psychiatrist, SUDs counselor, and peer specialist) to manage care for individuals.

BayCare Behavioral Health (BCBH) is the comprehensive behavioral health provider for the BayCare Health System with 53 years of experience in providing effective recovery-oriented, trauma-informed, evidence-based, culturally, linguistically, and equity-based behavioral health care within Pasco County. In 2022, BCBH served 11,768 individuals from Pasco County. BCBH currently provides all nine CCBHC required core services and will use grant funding for the planning, development, and implementation of the Pasco-Certified Community Behavioral Health Clinic (P-CCBHC). The project will provide a full continuum of enhanced and coordinated mental health, addiction, primary care screening and monitoring, and outreach activities. The population for this project will serve four targeted groups who are uninsured, underinsured, and from under resourced communities and include consumers with a mental or substance use disorder, including those with serious mental illness or opioid use disorder, children and adolescents with serious emotional disturbance, consumers with a co-occurring mental and substance use disorder and, active military/veterans and their families. P-CCBHC will serve 1600 unduplicated consumers (Yr. 1: 250; Yr. 2: 350; Yr. 3: 450; Yr. 4: 550). The extent of the problems in Pasco County includes a need for urgent behavioral healthcare access, effective care coordination from inpatient settings, an ongoing opioid epidemic, and an increase in crisis incidents related to suicide, overdose, and mental health issues. The project will establish the P-CCBHC as a CCBHC through the enhancement of operations, infrastructure, availability and accessibility of services, scope of services, quality/performance reporting, staffing, and authority to operate as a CCBHC. The primary enhancement for this project will be the development of an Urgent Care Center as part of the crisis system of care and transition point for inpatient crisis and emergency department discharges to outpatient care. Key enhancements to operations would include (1) placing qualified clinicians and peers at the point of initial contact and/or transition (2) offering a hybrid approach; (3) standardizing access, screening, transition; (4) increasing acquisition, engagement, and retention; (5) reducing uncoordinated care; (6) increasing consumer perception; and (7) decreasing time from contact to clinical care. P-CCBHC will accomplish the following five goals through seventeen measurable objectives: 1) Increase access/availability to high-quality services that are responsive to community needs. 2) Support recovery from mental health and substance use disorder challenges via a comprehensive community-based mental health and substance use disorder treatment and supports. 3) Use evidenced-based practices that address the needs of the consumers served. 4) Measure and improve the quality of service. 5) Involve consumers/family members in their care and broader governance.

The Westbrook CCBHC-PDI Initiative will provide comprehensive, coordinated behavioral health care for all people in need of behavioral health services at Westbrook’s Jackson County Clinic which serves Jackson, Calhoun & Roane Counties in West Virginia. The focus population suffers SUD, poor mental health, low mental health workforce capacity, poor social determinants of health & poor disparity group outcomes. The Initiative will serve 1,600 clients (400/year). Project goals (interventions/strategies) include: (1) Plan, develop & implement The Jackson County Clinic CCBHC to meet the CCBHC Certification Criteria by (A) initiating a Project Director to manage the CCBHC Initiative; (B) hiring an Evaluator to support processes & procedures for collecting, reporting & tracking required CCBHC encounter, outcome & quality data; (C) ensuring agency participation in CCBHC Technical Assistance Center activities; (D) implementing health information technology to support care coordination; (E) working with West Virginia University to gain access to the WVU Medicine EHR; (F) developing community partnerships; and (G) implementing the Westbrook CCBHC-wide data-driven continuous quality improvement (CQI) plan for clinical services and clinical management. (2) Design the Jackson County Clinic CCBHC to address community needs of the target population by (A) contracting with a consultant to conduct the required needs assessment; (B) implementing the needs assessment driven CCBHC staffing plan; (C) implementing the needs assessment driven CCBHC training plan; (D) implementing the needs assessment driven CCBHC service delivery plan; and (E) completing the CCBHC Attestation after each needs assessment. (3) Provide a comprehensive range of outreach, screening, assessment, treatment, care coordination, and recovery supports to the target population based on a needs assessment that aligns with the CCBHC Certification Criteria by (A) ensuring that the Jackson Clinic provides all 9 core CCBHC services; (B) ensuring that the Jackson Clinic operates in compliance with the CCBHC Criteria; (C) hiring Care Coordinators to coordinate the nine core CCBHC services; (D) hiring a Mental Health Peer to serve clients discharging from the crisis unit; (E) designating a Veteran’s Care Coordinator to serve the veteran population; (F) designating a Tobacco Cessation Care Coordinator to initiate a clinic-wide tobacco cessation program; (G) expanding Medical Director & Nurse Practitioner time; and (H) initiating an SDOH screener to be conducted & addressed by the Care Coordinators. (4) Support recovery from mental illness & SUD for the target population by providing access to high-quality mental health and SUD services by (A) serving a total of 400 clients annually; (B) clients having a statistically significant decrease in illicit substance use at 6-month NOMs follow-up; (C) clients having statistically significant improvement in mental health outcomes at 6-month NOMs follow-up; (D) clients having statistically significant improvement in social connectedness at 6-month NOMs follow-up; (E) having 100 clients engage in the smoking cessation program throughout the duration of the grant; (F) having 80% of clients remain in treatment for at least 6-months throughout the life of the grant; (G) monitoring disparity group data to ensure equal access/use/outcomes/retention; and (H) identifying culturally competent referral pathways for disparity group communities. (5) Sustain Jackson County Clinic CCBHC services post grant funding to serve the target population by (A) having the peer-led Board of Directors serve as the CCBHC Board; and (B) creating a sustainability plan.

Horizon Health and Wellness (HHW) plans to implement the Certified Community Behavioral Health Center (CCBHC) program in our outpatient clinic in Yuma, Yuma County, AZ. We will provide a comprehensive array of integrated outpatient services embracing the principles of the CCBHC model to improve the health outcomes of the people we serve. We will build on our community based mental health and substance use disorder services to more consistently and broadly incorporate evidence-based practices, engagement of at-risk individuals including military/veterans and the most vulnerable community members, accessible services, and improved coordination of care with the greater system. We will provide improved access to high quality care even in the most rural clinic, addressing social determinants of health barriers. HHW is a non-profit 501(c)(3) integrated health care agency licensed by the State of Arizona. Our Yuma clinic is a Federally Qualified Health Cent and we have been providing services there for over 40 years. Originally services focused on behavioral health (BH) and substance use (SU) disorder treatment primarily, but over the years has expanded to include, integrated primary care, residential treatment and more. In addition to service expansion, we have also been improving upon the quality of care provided, adding best practices including Trauma-Informed care, Medically Assisted Treatment (MAT) for SU disorders, wrap-around services for children and families and community-based programs for improved access to care. Our CCBHC clinic will serve Yuma which is a large rural county located on the border of Mexico and the United States. Yuma has a population of 95,550 per the 2020 census. Yuma has a high poverty level and high unemployment rate. The goals of this project are to: 1) improve patient health outcomes through improved evidence-based services and care coordination and 2) increase the number of at risk community members, (including military/veterans, youth, and individuals who experienced a crisis episode) who access BH, SU and primary care services 3)decrease the number of drug overdoses in Yuma County by 25% through provision of evidence based practices for substance use treatment. Objectives include: 1) 25% increase in patients receiving MAT treatment; 2) 25% increase in individuals receiving suicide prevention training; 3) 50% increase in veterans/military engagement after crisis episodes; 4) 25% increase in outreach and engagement to individuals after a crisis episode; 5) 20% increase in patients receiving integrated behavioral and primary care services; 6) 10% per year increase in BH/SU patients served. Interventions will include SU and MAT treatment, family centered service planning, peer and family support combined with clinical and/or psychiatric services, trauma-informed evidence based clinical programs, suicide prevention, school-based programs, mobile crisis and crisis outreach and engagement, case management, primary care and care coordination. Over the 4-year period we will serve 6500 patients, starting at 1000 in year 1 and expanding to 1500 year 2, 2000 year 3 and 2000 year 4.

Rosecrance Jackson’s CCBHC Planning, Development, and Implementation (PDI) initiative will seek to improve access to critical, community-based behavioral health (BH) care for individuals of all ages with mental (MH) conditions and substance use disorders (SUD) in Woodbury County, Iowa. Our CCBHC’s catchment area in Woodbury County is approximately 880 square miles on the western edge of Iowa, located in the Siouxland Region. We anticipate that our CCBHC client population will be 69.8% white, 9.5% American Indian or Alaskan Native, and 6.6% Black, and 6% will identify as Hispanic or Latino. Further, 56% will be male and 44% will be female, with less than 1% of clients being transgender. We expect 3.6% will identify as LGBTQ+. Most (90%) of our CCBHC clients will be over the age of 18, with only 10% being minors. The majority of clients (72%) will be Medicaid enrollees living at or below 133% of the Federal Poverty Line, and 25% of our CCBHC client population is expected to be experiencing homelessness. Based on their low access to BH care and complex, intersecting needs, we will seek to reduce disparities for two priority populations through our CCBHC program: 1) women with SUD who also have children, who we expect to represent about 20% of our CCBHC clients served; and 2) individuals of any age with BH needs and are involved with the Criminal Justice (CJ) system, which we expect to be about 40% of our CCBHC clients served. We will serve 1,700 individuals over the grant period, including 300 in Y1, 400 in Y2, and 500 in Ys 3 and 4, respectively. Through our CCBHC-PDI initiative, Rosecrance Jackson seeks to achieve the following: Goal 1: Build capacity to align with the newly revised CCBHC Criteria within one year of grant award, including: 1.A: Onboarding two clinicians, two case managers, two peer specialists, and a Medical Assistant to support our CCBHC services; 1.B: Attaining Chapter 24 accreditation from Iowa Department of Health and Human Services to deliver outpatient MH services; 1.C: Entering into a DCO agreement with Siouxland MH for CCBHC mobile crisis and specialty MH services; and 1.D: Completing an attestation illustrating how our CCBHC meets all criteria, as measured by program records. Goal 2: Increase access to integrated BH care for individuals who are involved with the CJ system, including: 2.A: Annually conducting six outreach and educational sessions with partners serving the CJ-involved population (e.g., probation, Dept. of Corrections, SUD and Juvenile courts), to educate them about our CCBHC; and 2.B: Establishing an agreement with the Woodbury County Sheriff’s Department to provide universal MH and SUD screening and connection to care for individuals being released from the County jail. Goal 3: Increase access to integrated BH care for individuals who are women with SUD, including 3.A: Annually conducting six outreach and educational sessions with partners serving women with SUD (e.g., hospitals, child welfare, housing provides, WIC), to educate them about our CCBHC; and 3.B: Establishing a partnership with Siouxland Community Health Center to provide training to their OBGYN and primary care providers to screen women for SUD and connect individuals to our CCBHC for care when risks are identified. Goal 4: Improve BH outcomes for Woodbury County residents living with BH needs served by our CCBHC, including: 4.A: Improving retention in our CCBHC services; 4.B: Offering overdose response training and Narcan to 100% of clients with OUD and their families to reduce risk of death from overdose; 4.C: Supporting clients to decrease their depression-related risks; and 4.D: Supporting clients to improve their overall quality of life.

Through the CCBHC PDI Grant, CCAOH seeks transform its New Haven Family Service Center, a community-based behavioral health clinic, into a CCBHC. The CCBHC will increase access to and availability of high quality behavioral health services for low income individuals in New Haven CT. CCBHC will target individuals across the lifespan with Any Mental Illness (AMI), Serious Mental Illness (SMI), Substance Use Disorder (SUD) and Co-Occurring Disorders (COD) in New Haven, CT. 2021 Census data show that the target population ages 5 and up is 128,598; 47% are male and 53% are female; 32% are Caucasian; 33% are Black, 31% are Hispanic of any race, 5% are Asian. Approximately 22% (28,079) are ages 5-19, 11% (14,486) are ages 20-24, 49% (63,046) are ages 25-59 and 18% (22,987) are age 60+. Some 23.3% of the city’s population lives below poverty, with the highest poverty among Hispanics at 33%, 22% among African Americans, 28.5% among some other race, 33.2% among people of 2+ races and 17.6% among whites. 3.6% of people identify as LGB (4,692) and .03% (386) as transgender. GOAL 1: To create the infrastructure, staffing and management capacity for full implementation of the CCBHC. Objectives: By 10/15/23, the PI/PD will convene a 7 member Project Management Team (PMT). By 1/31/24, DataHaven will conduct a community needs assessment. 2) By 2/28/24, the PMT will develop a plan for staffing, service delivery and staff training. GOAL 2: To implement the operational and infrastructure changes needed to meet CCBHC certification criteria and improve the quality care. Objectives: By 11/15/23, the PMT will adapt its existing CCBHC processes and procedures for collecting, reporting and tracking encounter, outcome and quality data. By 11/30/23, the PI/PD will develop formal care coordination partnerships with 3 Mobile Crisis DCOs and 1 Psychosocial Rehabilitation DCO. By 1/31/24 obtain an outpatient psychiatric clinic license. By 5/4/24, connect the agency EHR with CT’s Health Information Exchange. By 1/31/24, integrate the CCBHC into existing CQI systems. By 1/31/24 convene a 6-8 member project advisory board, composed of 51% of persons receiving services. By 9/29/24, complete a CCBHC certification attestation. GOAL 3: To improve behavioral health functioning, decrease mental health symptoms and reduce risk of self/other harm among adults and children with MI, SMI, COD. Objectives: Beginning 10/1/23, improve mental health symptoms/ functioning among at least 60% of 120 adults (10-15 who are veterans/military) in year 1 and 240 (20-30 who are veterans/military) annually, clinic staff will provide outpatient behavioral health services. Beginning 12/15/23, prevent unnecessary hospitalization/ER visits among 1,200 adults and 1,200 children annually, CCBHC clinicians and supervisors and DCO Emergency Mobile Crisis clinical staff will work collaboratively. Beginning 2/2824, a peer recovery specialist will provide individual and group support services for 75 participants and their families (35 in year one). Beginning 2/28/24, to reduce drug use and overdose risk among 50% of 64 adults with SA/COD annually (32 in year 1) by providing an IOP. Beginning 3/15/24, to improve behavioral health symptoms and functioning among a minimum of 60% of 70 children annually, (30 in year one), by providing children’s outpatient care. Beginning March 3/1/24, 60% of 35 participants will show increases in daily living skills through psychosocial rehabilitation services offered by Fellowship Place (DCO). Beginning 5/1/24, to promote a tobacco use quit rate of 30%, offer tobacco cessation and MAT, respectively, to 20 persons in year 1 and 30 annually thereafter. Beginning 4/15/24, to increase daily living skills and reduce the impact of SDHs among 60% of 20 adults with SMI/COD (30 annually) through TCM services. The project will serve 180 adults/children in year 1 and 375 adults/children in years 2-4, for a total of 1,305.

Project Name: Enhancing Mental Health and Substance Use Services for the Diverse Population of Youth, Families and Residents of the South Bronx. Summary: This project aims to address the pressing and unmet mental health and substance use needs faced by the diverse population residing in the South Bronx. The target population includes residents of Mott Haven, Morrisania, Hunts Point, Highbridge, East Tremont, and Melrose. These neighborhoods exhibit socioeconomic disparities, with a high percentage of Hispanic residents and limited access to quality healthcare. The project's goals include improving access to comprehensive mental health and substance use disorder services, reducing behavioral crises, and enhancing overall health outcomes. Throughout the project's four-year duration, it is anticipated to serve 1,484 individuals, with an equal distribution between children (ages 5-18) and adults (ages 19 and older). The projected number of unduplicated individuals to be served annually is as follows: Year 1: 275, Year 2: 342, Year 3: 415, Year 4: 452. Strategies and Interventions: The project will implement a range of core services, such as crisis mental health services, early intervention/prevention, crisis response services, stabilization services, screening, assessment, diagnosis, patient-centered treatment planning, outpatient mental health services, targeted case management, service referral and linkage, psychiatric rehabilitation services, intensive community-based mental health care for armed forces and veterans, and substance use services. The service delivery will be tailored to meet the specific needs of the population, taking into account cultural and linguistic considerations and access to care. Project Goals and Measurable Objectives: Become fully compliant with CCBHC requirements by the end of Year 1. Objectives: (1) Implement at least 5 of 9 core services by March 2024 and complete all core services by September 2024. (2) Establish a robust data infrastructure integrated with Electronic Medical Records (EMR) for efficient data collection, analysis, and utilization. (3) Maintain adherence to certification criteria for enhanced Medicaid reimbursement. Increase equitable access to comprehensive mental health and substance use disorder services for youth, families, and adults in the Bronx. Objectives: (1) Provide Social Determinants of Health (SDOH) assessments to 100% of CCBHC patients. (2) Offer targeted case management services to 100% of CCBHC patients. (3) Facilitate warm hand-offs and care coordination with local health, social, and human service agencies. (4) Engage 100% of CCBHC patients in peer support services. (5) Enhance cultural responsiveness through staff trainings. (6) Collaborate with local Department of Veterans Affairs facilities to better serve veterans and their families. (7) Enroll eligible patients with lapsed Health Home eligibility in the VNS Health Behavioral Health CCBHC. Decrease the risk and occurrence of behavioral crisis events among the population served. Objectives: (1) Conduct substance use disorder screening for 100% of CCBHC patients. (2) Ensure enrollment of CCBHC patients with substance use disorder in treatment. (3) Provide suicide risk assessments to 100% of CCBHC patients. (4) Reduce the risk of suicide by 75% using the Zero Suicide model. (5) Deliver Medication Assisted Treatment to 100% of CCBHC patients in need. (6) Establish robust care coordination with external agencies for seamless transition and integration of care. Improve overall health outcomes for youth, families, and adults in the Bronx. Objectives (1) Conduct primary care screenings and health monitoring for 100% of CCBHC patients. (2) Screen patients for tobacco/electronic cigarette use and enroll 80% of CCBHC patients in cessation intervention.

Axis Health System CCBHC Project: Southwest Colorado Mental Health Center Inc., d.b.a. Axis Health System (Axis), is requesting SAMHSA funding to become the first CCBHC in rural southwest Colorado. Axis is a 501(c)(3) incorporated in 1959, with three unique designations: a licensed Community-Based Behavioral Healthcare Entity, a licensed Substance Use Disorder (SUD)Treatment Provider, and a HRSA-funded Community Health Center. As a CCBHC, Axis will improve behavioral health (BH) access, treatment, and outcomes for people in rural La Plata County (LPC) regardless of ability to pay, with a specialized focus on the following subpopulations experiencing health disparities: 1) adults 17+ with a need for higher-intensity SUD treatment; 2) people of all ages who identify as LBGTQI+; 3) Latinx people of all ages; and 4) veterans and members of the armed forces (MAF). Axis will serve over 100 people annually in these groups and a total of 580 by the end of the 4-year project period. LPC has a population of 55,638, and a median household income of $75,089. Over 10% of people in LPC live below 100% of the FPL, 26.8% receive Medicaid, and 12% of people do not have health insurance. Currently, 13% of the population is Latinx (a 15.7% increase since 2010), 8.4% speak only Spanish, 6.8% are veterans, and 12.37% of people identify as LGBTQI+. There are higher behavioral health needs in LPC than in Colorado overall. In 2023, LPC residents reported 4.8 poor mental health (MH) days in the past 30 days, compared with 4.3 in the state. LPC has a significantly higher suicide rate than the national average. The suicide rate in LPC is 24 per 100,000 compared to the nation at 14 per 100,000 people, and 14% of LPC residents reported experiencing frequent mental distress, slightly higher than 13% in the state. Substance use is also a significant BH concern in Colorado and in LPC. Statewide, among adults ages 18+, 11.03% of people needed but did not receive specialized SUD treatment in the past year, compared to 7.18% in the nation, a higher percentage than any other state. Despite the high need, LPC has fewer outpatient SUD and intensive outpatient SUD services available than the rest of the state. Additionally, data indicate that there is a lack of equitable access to BH care in LPC but significant BH needs in three subpopulations: Latinx, Veterans, and people who identify as LGBTQI+, due in part to a lack of resources to focus on the unique needs of these subpopulations that require specialized outreach and engagement support. Axis will implement strategies to increase access to care and improve BH outcomes for the population of focus: use trauma-informed approaches to recovery through outreach, program development, and EBPs; address health disparities and advance BH equity through culturally competent care coordination; and encourage recovery-oriented systems of care by involving family, peers, and the community in program participants’ recovery. Axis will focus on five goals and associated objectives to increase access to care and improve BH outcomes: Raise the standard of care by achieving 100% of the CCBHC standards; conduct a community needs assessment to inform Axis’ CCBHC project plan; increase access to high-quality and affordable health care services and supports for all populations, especially adults 17+ with a need for higher-intensity SUD treatment, people of all ages who identify as LBGTQI+, Latinx people of all ages, and veterans and MAF; and improve infrastructure and capacity to measure and continually improve the quality of services.

COPE Community Services, Inc. (COPE) proposes to implement the comprehensive CCBHC model through the COPE All-Access Team (CAAT) in Pima County, AZ, to provide high quality mental health and SUD services informed by a local needs assessment. With a 24/7 point of entry into behavioral health care, the CAAT will provide crucial treatment expansion, agency-wide improvements, and will aim to reduce substance use and improve mental health symptoms. The CAAT will serve populations with or at risk for mental illness and/or substance use disorders in Pima County, AZ. The extent of the problem in Pima County is aptly characterized by the four health priority areas identified by Pima County Health Department (PCHD): behavioral and mental health, substance use disorder (SUD), access to care, and social determinants of health (CHNA, 2022). The interacting priorities emphasize the critical need for comprehensive, coordinated behavioral health care. Access to timely, culturally, and linguistically appropriate mental health and SUD care is an urgent service gap in Pima County. Compounding this, the COVID19 pandemic caused both MH symptoms and SUD rates to skyrocket in Pima County. Overdose deaths in Pima County have doubled from 176 in 2017 to 335 in 2022. Non-fatal overdoses have also doubled; there were 297 in 2017 compared to 607 in 2022 (AZDHS, 2023). Additionally, areas with high social vulnerability (based on the CDC Social Vulnerability Index) experience disproportionate overdose deaths, emphasizing the disparities between under-resources communities and the general population. The CAAT will serve as an efficient physical and digital 24/7 entry point for COPE's treatment programs and will implement several strategies to achieve its objectives. The team will consist of a Project Director, Program Manager, Behavioral Health Medical Professional (BHMP), and six Behavioral Health Technicians Specialists (BHTS) staff, all comprehensively trained to provide targeted case management and behavioral health treatment services. COPE will also make agency-wide infrastructure improvements to enable full implementation of the CCBHC model. The goals of the CAAT are 1) To provide comprehensive and coordinated behavioral health services by planning and implementing the CCBHC model system-wide within COPE Community Services Inc; 2) To provide comprehensive outreach, screening, assessment, treatment, care coordination, and recovery support services to individuals in need of behavioral health care; and 3) To increase timely access to behavioral health care, supporting recovery and improving outcomes among individuals served by the CCBHC. These goals are reinforced by specific and measurable objectives designed to measure progress in program implementation and the outcomes of interest: increased access to care, improved mental health systems, and decreased substance use. The CAAT will serve 300 clients per year (1050 total, 150 in year one). The CAAT will provide crucial treatment expansion and essential agency-wide improvements, increasing timely access to coordinated behavioral health care in Pima County, AZ. COPE currently offers most of the core CCBHS services, and the proposed program will supplement those services and nearly eliminate the delay between first contact and full intake through immediate same-day provision of services, regardless of benefit enrollment status or ability to pay. Rapid initiation of services will allow staff to intervene quickly to address the needs of the whole person: medial, mental health, substance use, and social determinants of health.

Project Abstract Through SAMHSA’s Certified Community Behavioral Health Clinic (CCBHC) Planning, Development, & Implementation Grant, Community Mental Health Affiliates, Inc. (CMHA) will focus on increasing access to mental health treatment for children and youth and expanding intensive care coordination for adults and children in order to effectively address the needs of adults and adolescents with Serious Mental Illness (SMI), Substance Use Disorder (SUD), and Co-Occurring Disorder (COD) and children with Serious Emotional Disturbance (SED) in the targeted service area. CCBHC service population includes individuals and families across New Haven and Litchfield County, specifically residing in: Watertown, Waterbury, Middlebury, Goshen, Naugatuck, New Hartford, Winsted, Southbury, Wolcott, Thomaston, Litchfield, Barkhamsted, Torrington, Harwinton, Morris, and Bethlehem. US 2020 Census data shows a target population of 278,401: 219,603 ages 18+; 43,840 ages 6-17; and 14,958 under age 5. CMHA is an Enhanced Care Clinic (ECC) and provides an array of services to the historically underserved population of adults, children and families in the region. Last year, CMHA served 2,306 consumers in this target area: 531 children in our Outpatient Child Guidance Clinic; 656 youth via ongoing school-based services; 470 adults in Outpatient/Intensive OP; 1,305 families through our home-based programs. More than 10% of our clients are primarily Spanish-speaking, and the number of Portuguese-speaking clients has increased by 400% since 2019. A majority (65%) identify as female, and 1% are transgender/non-binary. The majority are heterosexual (81%), with 12% indicating LGBTQ+. Nearly all (93%) fall at/below 200% of the Federal Poverty Level, and most (90%) have been affected by trauma. Agency and community data indicates a need for more Open Access hours; continued services and supports for Veterans/Military; Targeted Case Management (TCM) and intensive care coordination for adults and children; and increased access to treatment for children and youth. Our CCBHC will reduce disparities by enhancing access to culturally and linguistically appropriate services for Black, Hispanic and Spanish speaking women, children, and their families affected by violence, trauma, and poverty. CCBHC goals include: 1) Support recovery from mental illness and/or SUD among target population adults, children and families through an expansion of Clinic Services and contracted 24/7 Mobile Crisis Services; 2) Reduce behavioral health issues, trauma symptoms, and substance abuse among target population children, adolescents, and adults through wraparound support and community-based services and outreach; 3) Reduce the likelihood of chronic disease and premature death among target population adults and children through CCBHC’s Behavioral Health Home and contracted primary care; 4) Promote wellness and recovery among CCBHC consumers by providing psychiatric rehabilitation, peer and family recovery supports; 5) Equip CCBHC staff with the skills to continue offering evidence-based practices through additional training; 6) Meet CCBHC goals/objectives by creating project management and governance structures.; 8) Implement infrastructure activities and assessments to implement and sustain CCBHC services. CMHA’s CCBHC will serve a total of 600 individuals over four years.

The purpose of the boone county ccbhc-pdi project is to expand access to community-based mental health and substance use disorder treatment and support as well as integrated care for individuals with mental or substance use disorders who seeks care, including those with serious mental illnesses (smi), substance use disorders (sud), including opioid use disorder; children and adolescents with a serious emotional disturbance (sed); individuals with a co-occurring disorder (cod); and individuals experiencing a mental health or substance use-related crisis by implementing a new ccbhc clinic in boone county, Arkansas. Ozark guidance center (ogc) an affiliate of arisa health is the state contracted community mental health center serving 8 counties in northwest Arkansas. Ogcs catchment area is inclusive of the ozark mountains region, an area plagued with many problems such poor health, and myriad issues related to substance use and mental illness. The proposed project will target boone county. Boone county is located in the north-central part of the state. The primary site for services provided through the proposed project is 103 e. Crandall Ave., harrison are 72601. In boone county, social determinants of health contribute to a wide variety of health disparities and inequities and have significantly affected residents well-being and quality of life. With an estimated population of 37,890, boone county has a 13.6 % poverty rate and has a disability rate of 14.2%. The county's challenges are further complicated by factors that influence the county's overall population health including smoking (22.6%), adults with frequent mental distress (19.0%), deaths of despair (50.5/100k), adults in poor general health (23.6%), prevalence of heart disease (6.8%), diabetes prevalence (10.1%), obesity prevalence (33%), preventable hospital admissions among Medicare beneficiaries (3,939/100k), and 10% of the population with no health insurance. Additionally, boone county has a documented homeless population of 390 and boone county's violent crime rate (551.2/100k) over doubles the national violent crime rate of 204.5/100k, opioid dispensing rate of 81.20 per 100 people, and 464 narcotic arrests in 2020-2021. Through the boone county ccbhc-pdi project ozark guidance center aims to improve behavioral health care for children and adults. To this end, ozark guidance has identified 4 project goals. Goal 1: increase access to, and availability of, high-quality comprehensive behavioral health services that are responsive to the needs of boone county residents with smis, seds, suds and cods. Goal 2: support recovery from mental health and substance use disorder challenges by providing ccbhc services and supports in boone county. Goal 3: deliver integrated care for behavioral health and physical health risks and needs. Goal 4: ensure sustainability of ccbhc services in the targeted areas. The project will have a specific focus on addressing behavioral health disparities that exist for racial, ethnic and gender minorities including marshallese, latin americans, and members of the lgbtqia+ community. Moreover, the project will improve outcomes through the provision of evidence-based services and measurement-based care which will help ensure sustainability of services. It is expected that 75 individuals will be served annually and 300 individuals over the project period. Ogc is requesting $4 million to implement this project.

SHIELDS for Families (SHIELDS)’ CCBHC project focuses on one of the poorest and most under-resourced areas in South Los Angeles, including the Athens, Compton, Crenshaw, Florence, Hyde Park, Lynwood, Paramount, and Watts neighborhoods. Through targeted outreach SHIELDS will address social health needs and expand access to community-based behavioral health services for Latinx and Black adults and children experiencing disparities. Our CCBHC will provide person-centered, family-centered, and trauma-informed behavioral health services, including outpatient mental health and substance use treatment and crisis services; primary health care screening and monitoring; peer supports; psychiatric care, and community-based mental health care for members of the armed forces and veterans, with plans to serve 2,750 individuals over the four-year period. Project goals are inclusive of 1) expanding access to community-based BH services, 2) improving data informed care delivery; 3) deepening local engagement; and 4) addressing social health barriers to care. SHIELDS is a nationally and internationally recognized organization that offers award-winning services in Los Angeles’ most challenged communities. Since 1991, SHIELDS has offered a comprehensive continuum of culturally sensitive services that empower and advocate for high-risk families in South Los Angeles. Our geographic catchment area is a HRSA designated medically underserved area, and access to care is severely limited for our population of focus. Residents of our catchment area experience a high rate of behavioral health and SUD intervention need and face significant barriers to accessing care. According to the 2021 CHIS, in South Los Angeles, 17.5% of teens and adults likely have had serious psychological distress during the past year; 13.5% of adults have seriously thought about committing suicide, 50.5% of teens have had adverse childhood experiences (ACEs), 37.9% of teens reported needing help for emotional/mental health problems, and 19.5% of adults reporting needing help for emotional/mental health problems or use of alcohol/drug. Methamphetamine use is a particular challenge in the community, and according to Los Angeles Substance Abuse Prevention Control (SAPC), methamphetamine-related hospitalizations and ED visits increased in Los Angeles County from 2010-2017 and remained high through 2020. Additionally, methamphetamine-related deaths increased 1,185 percent between 2010 and 2020. To address these complex issues and health disparities, SHIELDS will utilize CCBHC funding to expand access to community-based behavioral health care services, improve data informed care delivery and enhance continuous quality improvement. Through the project, SHIELDS intends to deepen local engagement and promote local awareness of and access to CCBHC services and address social barriers to care. SHIELDS will increase local outreach, expand access to care through hiring and community partnerships, modify internal data analytics and information technology infrastructure to better understand and address the community’s growing needs, and address social needs by supplying transportation, employment supports, and on-site childcare.

Howard Center proposes to enhance and expand its array of programs and services to meet Certified Community Behavioral Health Clinic certification criteria. Adding to Howard Center’s already robust programming will provide comprehensive, coordinated behavioral health care that is person- and family-centered and will include a range of outreach, screening, assessment, treatment, care coordination, and recovery supports in alignment with CCBHC certification criteria. This project will serve the people of Chittenden County, Vermont.

Improving Access to Care in Southern Maine Sweetser seeks to provide increased access to all CCBHC core services for individuals in central and western York County, Maine through its Sanford, Maine clinic site. Sweetser aims to decrease the prevalence of hopelessness and consideration of suicide, particularly among youth, as well as increase the screening and access to evidence-based treatment for substance misuse in all ages. Sweetser offers a statewide network of comprehensive mental and behavioral health, development, and education services to children, adults, families, and military. Through this project, Sweetser intends to increase access to quality services in York County, Maine. Sweetser intends to serve a total of 750 individuals throughout four years; serving 150 individuals in Year One, and 200 individuals in each of the subsequent three years. Through this project, Sweetser aims to decrease the prevalence of youth hopelessness and consideration of suicide by increasing risk screening and access to evidence-based treatments. Sweetser also aims to increase screening and access to evidence-based treatment for substance misuse in youth and adults. Sweetser aims to expand access, availability, and quality of services through increased provider resources, enhanced trainings of evidence based and evidence informed practices, and ongoing evaluations.

Sound will establish a Certified Community Behavioral Health Center in the Capitol Hill neighborhood of Seattle, Washington. By establishing a CCBHC Sound will provide comprehensive integrated care to meet the behavioral health, substance use and co-occurring disorder treatment needs in underserved and marginalized communities. In King County Washington both the BIPOC, and LGBTQ communities experience disproportionately higher incidence of mental health distress and substance use. Sound will directly provide services to the un/underinsured individuals experiencing serious mental illness, severe emotional distress, and substance use disorders, with a specific focus on reaching the BIPOC and LGBTQ communities. Sound’s CCBHC is a step forward in increasing access to timely, high-quality care for communities that have been left behind by the wealth and health gap. Over the four years of the CCBHC-PDI grant project Sound aims to serve 500 unique individuals annually for a total of 2,000 unique individuals served through the life of the grant. Sound has identified the following project goals as being instrumental to meeting the unique needs of the communities we serve to instill hope and foster recovery. To address community access to services Sound will increase timely access to integrated healthcare services for those experiencing SMI, SUD, and COD diagnoses in King County. By 3/29/24, Sound will implement and maintain a pre-intake risk assessment to prioritize and meet the treatment needs of high-risk individuals. By 9/30/24 Sound will meet, or exceed the 1-, and 10-day intake timeline by increasing intake capacity by 25% by enhancing recruitment efforts and increasing intake staffing to meet demand. To ensure Sound is meeting the needs of marginalized and underserved people and communities Sound will increase the penetration and utilization rates of behavioral health; substance use and co-occurring disorder treatment including Buprenorphine in underserved populations. Sound will help support treatment engagement and connection by providing culturally appropriate and trauma informed care to the BIPOC, LGBTQ, and Veteran populations in KC. By 12/30/23 Sound will enhance and target hiring practices with the goal of building a clinical workforce even more representative of the BIPOC and LGBTQ population being served. Sound will stabilize and improve the health outcomes of medically marginalized populations by increasing access to integrated healthcare in King County. By 3/29/24 Sound Primary Care Sound will contact CCBHC clients identified as needing Primary Care services for engagement. By 6/28/24 Sound will conduct health screenings and routine monitoring for all CCBHC clients. By 6/28/24 Sound CCBHC staff will support clients with chronic health conditions in setting health goals and connecting with Primary Care services. To address the devastating effects the opioid crisis is having on King County and the increasing rate of opiate overdose deaths Sound will increase support for opiate addiction recovery by increasing rapid access to Buprenorphine treatment in King County. By 3/29/24 Sound will begin outreach services to jail and hospital release and discharge planers notifying them of priority Buprenorphine appointment availability for maintaining people that have received induction and are at increased risk for overdose in the community. Sound will decrease the rising number of opiate deaths in King County by providing those at the highest risk for overdose with Naloxone. By 5/31/24 Sound will begin providing Naloxone to all clients. By 5/31/24 Sound will create and implement a program to train all staff and clients receiving Naloxone in the administration of it.

The Seneca County Integrated Wellness Center of the Seneca County Mental Health Department (SCMHD) will establish a Certified Community Behavioral Health Center at the Seneca County Community Counseling Center (Seneca County Mental Health Department) in Waterloo, NY. Seneca County is a small rural county in the Finger Lakes Region of Upstate New York. The county experiences high rates of poverty and ranks among the lowest counties in New York State for health outcomes and health factors which considers health behaviors, clinical care, social and economic factors, and physical environments. Seneca County is designated by HRSA as a Health Provider Shortage Area for Mental Health-Medicaid Eligible Populations and Primary Care. The rural nature of this area, along with few behavioral health providers, high poverty rates and a limited public transportation system presents challenges for access to care. This requires a comprehensive approach to address the needs of those with behavioral health challenges, along with trauma related to poverty and/or the effects of adverse circumstances. The Population(s) of focus for this project is adults, youth and children in need of behavioral health services, including individuals with SMI, SUD, COD and people experiencing a mental health or substance use disorder related crisis. The populations to be serviced will be primarily individuals with limited/no income, uninsured/underinsured or Medicaid recipients. The project will provide comprehensive CCBHC services directly and through Designated Collaborating Organizations. A total of 2,300 individuals will be served by the Project over the 4-year period - 350 individuals in year 1 and 650 individuals annually in years 2-4. The project goals are to: - Establish and operate a CCBHC in the rural community of Seneca County, New York that fully meets the CCBHC Criteria. - Increase the availability of, and access to, comprehensive CCBHC services for persons with SMI, SED, SUD, COD in the rural community of Seneca County, New York. - Support recovery from mental health and substance use disorder challenges through comprehensive community based CCBHC services for persons with SMI, SED, SUD, COD in the rural community of Seneca County, New York. - Provide evidence-based mental health and substance use interventions across CCBHC services that address the needs of populations of focus to improve participant retention and outcomes. - Conduct comprehensive continuous quality improvement processes to measure and improve the quality of services. - Ensure meaningful involvement of people with lived experience of mental health and substance use conditions, individuals who have received/are receiving services from the clinic, and family members in their own care and the broader governance of the CCBHC. As a small, rural community, there is a strong emphasis on partnership and collaboration to meet the behavioral health needs of the population, with integrated approaches across behavioral health, primary care, recovery support providers and crisis response systems (including law enforcement). The CCBHC will use integrated approaches across its outreach, engagement, and service delivery to fully address the needs of the populations of focus. As the CCBHC is further developed, enhancements will focus on strategies to address underserved populations, with CQI processes in place for continued modifications as disparities are identified and as new populations and/or needs emerge through needs assessment.

Community Health of South Florida, Inc. (CHI), a non-profit primary and behavioral health care provider in Miami-Dade County, submits this proposal to plan for, develop, and implement services and meet Certified Community Behavioral Health Clinic (CCBHC) certification criteria. The population of focus is individuals in this geographic catchment area with mental health and/or substance use needs who seek care, including those with serious mental illness (SMI), substance use disorder (SUD), children and adolescents with serious emotional disturbance (SED), those with co-occurring mental and substance disorders (COD), and those experiencing a mental health or substance use-related crisis. CHI will specifically focus on individuals with low socio-economic status and populations historically and presently underserved: young adults ages 18-25 years with low socio-economic status and the migrant population. CHI plans to serve 500 unique individuals in Year 1, 100 in Year 2, 120 in Year 3, and 144 in Year 4, for a total of 864 unique individuals over the 4-year grant period. The goals and objectives are as follows: Goal #1: Increase the capacity of CHI to engage historically underserved populations in integrated behavioral and primary healthcare services. Objective 1.1: By September 29, 2027, increase the number of clients served between the ages of 18-25 by 30%. Objective 1.2: By September 29, 2027, increase the number of clients served from migrant populations by 30%. Objective 1.3: By September 29, 2027, decrease the gap in health outcomes between Blacks/African Americans and other racial/ethnic groups, as demonstrated by CCBHC quality measures. Objective 1.4: By September 29, 2027, decrease the gap in health outcomes between the Hispanics/Latinos and other racial/ethnic groups, as demonstrated by CCBHC quality measures. Goal #2: Increase the service capacity of CHI to meet the criteria of becoming a CCBHC. Objective 2.1: By January 31, 2024, strengthen the partnership with The Village South (WestCare) through the development of a Designated Collaborating Organization (DCO) agreement and formal plans around mobile crisis services provision. Objective 2.2: By February 29, 2024, increase staffing capacity through the addition of seven positions.