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The Start Certified Community Behavioral Health Clinic (CCBHC) will provide comprehensive, coordinated, person- and family-centered behavioral health care to children, youth, and families in need of support recovery for serious mental illness (SMI); substance use disorder (SUD) including opioid use; serious emotional disturbance (SED); cooccurring mental and substance disorders (COD); and to individuals experiencing a mental health or substance use-related crisis regardless of an individual’s place of residence, ability to pay, or age. The CCBHC will address the behavioral health disparities of specific populations including Veterans and people experiencing homelessness. The CCBHC will serve Assumption, Lafourche, St. Charles, St. James, St. John the Baptist, St. Mary, and Terrebonne parishes in the Bayou Region of Louisiana. The total population of the seven-parish service area is 469,438 and 2.2% identify as American Indian/Native Alaskan; 0.9% Asian; 23.7% Black or African American; 6.3% Hispanic or Latino; 55.2% White; and 4.9% two or more races. There are 63,394 individuals living below the poverty line in the service area and 22,998 are uninsured. The service area is home to 17,623 Veterans. There are 4,731 homeless individuals in the service area. Start will enhance and expand outreach, screening, assessment, early intervention, comprehensive treatment, care coordination, and recovery support services for all individuals in the service area. The following table identifies the program goals and measurable objectives. Goal 1: Increase access to and availability of behavioral health and substance use services for individuals across the lifespan for the population of focus. Objective 1.1: By month 3, hire project staff to enhance behavioral health and substance use crisis services; screening & assessment; treatment; outpatient primary care screening; outpatient mental health and substance use services; case management; rehabilitation & recovery supports; and peer support. Objective 1.2: By month 5, complete staff training on using EBPs that address the needs of the individuals the CCBHC serves; follow the staff training plan for annual refresher training throughout the funding period. Goal 2: Support recovery from mental health and substance use disorder challenges via comprehensive community-based mental and substance use disorder treatment and supports. Objective 2.1: Provide evidence-based treatment & comprehensive supportive services for 250 individuals in Year 1; 400 in Years 2; 700 in Year 3; and 1,000 in Year 4 for a total of at least 2,350 individuals. Objective 2.2: By month 6, ensure that a mental health screening is embedded into the FQHC primary care visit. Goal 3: Continually work to measure and improve the quality of services. Objective 3.1:By month 2, develop a CCBHC-wide data-driven Continuous Quality Improvement (QCI) plan for clinical services and clinical management; implemented beginning month 4. Objective 3.2: Develop a Data Collection Plan & partnership logic model by month 3. Begin collecting and tracking encounter, outcome, and quality data by month 4. Goal 4; Meaningfully involve people with lived experience of mental 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. Objective 4.1: Complete a community needs assessment by month 6 and a follow-up by month 42 that will integrate input from consumers and family members into the assessment using feedback from client surveys and the CCBHC Board. Objective 4.2: Conduct recruitment of CCBHC Board members following CCBHC Certification Criteria 6.B: Governance Option 1 beginning month 1. Commence quarterly CCBHC Board meetings month 6. Objective 4.3: Develop a comprehensive, person-centered Individualized Treatment Plan (ITP) that includes needs, strengths, abilities, preferences, and goals, expressed.

Boundary Regional Community Health d/b/a/Kaniksu Community Health’s (KCH) CCBHC application will develop and certify a CCBHC in Northern Idaho serving Boundary and Bonner counties. KCH intends to build upon its comprehensive service delivery options through the planning, development, implementation, and certification process required of the SAMHSA CCBHC-PDI opportunity. By grant end, KCH will be delivering high-quality mental health disorder and substance use disorder (SUD) treatment, recovery supports to individuals in the target service area with a SUD, serious mental illness (SMI), children and adolescents with a serious emotional disturbance (SED), individuals with a co-occurring mental health and SUD disorder, and individuals experiencing mental health or substance use-related crisis. KCH intends to fill a needed mental health, substance use disorder, and primary care treatment gap in Northern Idaho. Through the CCBHC development, KCH will improve the access and overall health of the residents, whether they are insured, under insured, and regardless of ability to pay for services. POPULATION TO BE SERVED: KCH will serve individuals in Boundary and Bonner counties with mental health, substance use disorder, and who are also women of child bearing age (15-44) and pregnant women at risk for depression, anxiety, and suicide. STRATEGIES/INTERVENTIONS: KCH’s strategy to CCBHC implementation is to expand upon its current outpatient mental health and integrated behavioral health services. The additional funding will allow KCH to develop a reverse integration model that incorporates population health management to integrate primary care, substance use disorder, and 24-hour crisis treatment and services to not only meet the nine core CCBHC criteria but to increase access to health services in rural communities. PROJECT GOALS AND MEASURABLE OBJECTIVES: KCH will serve new, unduplicated patients in each grant year: 75 year 1; 125 year 2; 125 year 3, and; 175 in year 4, for a total of 500 new patients and 1,112 total unduplicated patients served during the four-year project. The project goals include 1)Increase access to and availability of high-quality behavioral health services that are responsive to the needs of individuals with qualifying behavioral health diagnosis residing in Boundary and Bonner counties.2)Support recovery from mental health and substance use disorder challenges via the implementation of a comprehensive community-based mental and substance use disorder treatment program and supports. 3)Implement evidence-based practices that address the behavioral health needs of the residents of Boundary and Bonner counties. 4)Measure and improve the quality of behavioral health services delivery within KCH.5)Involve consumers and family members in their own care and the broader governance of KCHs CCBHC services. 6)Establish a Project Evaluation and Quality Improvement Process to monitor the implementation of the CCBHC and ensure quality of services and supports. 7)Promote sustainability and expansion of CCBHC best practices by sharing key lessons learned, effective strategies, and beneficial outcomes with key stakeholders.

Region IV Mental Health Services, a qualified public behavioral health authority with 50 years of proven expertise serving the populations of focus in North Mississippi and Designated Collaborative Organizations (DCOs) will implement a CCBHC to transform community behavioral health systems in Region IV and expand access to quality care in 5 rural, medically underserved counties by strengthening infrastructure and advancing trauma-informed integrated care delivering comprehensive person-centered coordinated behavioral health services. Populations of focus: All individuals across the lifespan who are in need of behavioral health services, including those with SMI; individuals with SUD, including opioid use disorders; children and youth with SED; individuals with COD; and individuals experiencing a mental health or substance use related crisis; and members of the armed forces/veterans/families. Health care access will be prioritized for racial, ethnic and LGBTQI+ underserved groups addressing health disparities. Goals: 1) Advance Health Equity with Expanded Access to Care Across the Lifespan; 2) Expand Peer Recovery Oriented Care; 3) Provide Person-Centered Care; 4) Measure Quality Care; 5) Ensure Collaborative Consumer Leadership; 6) Provide Whole-Person Care. Objectives: 1) 100% timely submission of Disparities Impact Statement, Needs Assessment and CCBHC Attestation; 2) Increase DCOs by 5% annually; 3) 100% accurate diagnosis and access to person-centered treatment; 4) 80% report high perception of care; 5) 51% consumer involvement in board governance; 6a)100% will receive physical health measurements and physical examination; 6b) 100% will receive evidence based behavioral health services; 6c) 55% will improve mental health functioning; 6d) 55% will reduce substance use; 6e) 55% will improve employment status; 6f) 55% will improve housing stability; 6g) 55% will reduce use of emergency room services; and 6h) 55% will reduce inpatient psychiatric admissions. #Served: Years 1-4 150, = 600 total.

Project Summary: South Central Alabama Mental Health Board (SCAMHB), a public, non-profit, comprehensive community mental health center, is applying for CCBHC-PDI funding as there is greater demand for acute behavioral healthcare care in Covington County than can be provided by existing resources. This service gap, specifically for the treatment of low-income individuals with Severe Mental Illness (SMI), Severe Emotional Disturbance (SED), Substance Use Disorders (SUD), and co-occurring disorders (COD), can be reduced with our proposed CCBHC. Geographic Catchment Area: Covington County, of south central Alabama. Project Name: South Central Mental Health Board CCBHC Program. Populations to be served: Low-income children, adults and seniors, with high rates of being uninsured, and with behavioral health (BH) needs, specifically individuals with SMI, SED, SUD, and COD. Number to be served: Year 1: 100; Year 2: 150; Year 3: 200 Year 4: 250; Life of project: 700. Project strategies/interventions: SCAMHB will use a combination of several evidence-based- interventions, including Cognitive Behavioral Therapy (CBT), Trauma-Informed Care (TIC), and Medicated-Assisted Treatment (MAT). Project goals and measurable objectives: Our goals include: Decrease symptoms of psychological distress by increasing access to mental health (MH) care; Screen for ACEs among children, and screen for trauma among adults and refer to MH services; Increase access to SUD care and reduce use of substances. Measurable objectives are as follows: 1) Each grant year, screen 90% of those projected to be served by the CCBHC for MH conditions, including depression and anxiety; 85% of those at-risk will accept referral to MH services; 2) Each grant year, 65% of CCBHC patients will have reduced risk for MH conditions, including depression and anxiety, as indicated by improvements in PHQ-9 scores and GAD-7 scores between assessments; 3) For each grant year, screen 90% of those projected to be served by the CCBHC for suicide risk using C-SSRS; 85% of CCBHC patients screened at-risk for suicide will develop a crisis plan; 4) Each grant year, screen 90% of children/adolescents projected to be served by the CCBHC for ACEs; 60% of those at-risk will accept referral to services; 5) Each grant year, screen 90% of adults projected to be served by the CCBHC for trauma; 60% of those at-risk will accept referral to services; 6) Each grant year, screen 90% of those projected to be served by the CCBHC for substance use, using UNCOPE and CRAFFT; 75% of those at-risk will accept referral to SUD services; 7) Each grant year, 65% of CCBHC patients will have reduced substance use, as indicated by improvements in screening scores between SUD assessments. As a decades-long BH provider, SCAMHB is already providing comprehensive MH and SUD services, so we will be excited to formalize these services into the CCBHC model of care.

Thresholds Kankakee CCBHC will serve children with SED and their families, adults with SMI, and individuals with SUD or COD in Kankakee County, Illinois. The CCBHC will increase access to a comprehensive array of evidence-based, recovery-oriented services; address the physical health concerns of people receiving services; and coordinate care with other service providers to address social determinants of health, reduce disparities, and increase engagement in services. Our geographic service area in northeastern Illinois has a population of 106,601; 17% of youth and 12% of adults live below the federal poverty line (US Census Bureau, 2021). The county includes two designated Health Professional Shortage Areas and has higher rates of mental health-related hospitalizations than the state average. With grant funding, Thresholds Kankakee CCBHC will build upon our current programs for adults with SMI by expanding outpatient therapy services for children, youth, families, and adults; providing SUD treatment; and addressing the physical health risks that contribute to repeat hospitalizations and medical comorbidities. The goals and objectives of the Thresholds Kankakee CCBHC will focus on 1) achieving compliance with CCBHC certification criteria and implementing all required activities, 2) improving health indicators for individuals at risk for or experiencing physical health comorbidities, 3) increasing access to evidence-based behavioral health services, and 4) establishing substance use services for youth and adults. Thresholds Kankakee CCBHC will serve an unduplicated total of 650 individuals across the four-year grant period: 200 in Year 1, 125 in Year 2, 150 in Year 3, and 175 in Year 4. Using evidence-based practices such as Assertive Community Treatment Trauma-Focused Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Illness Management and Recovery, Individual Placement and Support, Integrated Dual Diagnosis Treatment, and Wellness Recovery Action Planning, Thresholds Kankakee CCBHC will meet the behavioral health needs of individuals and families, and improve their physical health outcomes.

Special Health Resources for Texas, Inc. (SHR), a Federally Qualified Health Center in the heart of East Texas, is seeking funding to transform its community clinic and service compendium into a newly established Certified Community Behavioral Health Clinic (CCBHC) delivering high-quality behavioral health services that are person- and family-centered, integrated, comprehensive, and coordinated. To accomplish this, SHR proposes to implement Project East Texas – Behavioral Health Improvement Program (BHIP) to establish a CCBHC offering services including, mental health, substance abuse, primary care, and mobile 24-hour crisis intervention unit. Project BHIP’s population of focus will be all individuals with a mental or substance use disorder who seek care, including those with serious mental illness (SMI), substance use disorder (SUD) including opioid use; children and adolescents with serious emotional disturbance (SED); individuals with co-occurring mental and substance disorders (COD); and individuals experiencing a mental health or substance use-related crisis. Project BHIP will utilize a multidimensional crisis intervention approach that links clients to an array of services and a compendium of evidence-based practices designed to specifically improve the lives of the population of focus. A pivotal aspect of Project BHIP will be to strengthen collaborative community partnerships to efficaciously overcome the challenges underlying the delivery of integrated substance abuse, mental health, and primary care services. Project BHIP will establish a project-specific advisory workgroup, The Community Crisis and Behavioral Health Coalition to work with project staff in executing the work plan. Project BHIP will achieve its goals and objectives by recruiting, hiring/assigning, and training a competent and multidisciplinary team that is comprised of a Project Director, Psychiatric Medical Director, Family Nurse Practitioner, Licensed Professional Counselors, Licensed Vocational Nurse, Substance Abuse Counselors, Recovery Support Specialist, Patient Navigators, and Evaluator. The following table describes the proposed measurable goals of the project: • GOAL 1. Develop and strengthen organizational capacity to successfully become a Certified Community Behavioral Health Clinic. • GOAL 2. Develop a comprehensive mobile crisis intervention program that will be accessible 24/7 to increase access to integrated care to the population of focus. • GOAL 3 Provide culturally tailored treatment services that are based on evidence-based practices. • GOAL 4. Provide ongoing monitoring and performance assessment of project activities and effectiveness in accomplishing goals and objectives.

The Thresholds South CCBHC population of focus includes children with SED and their families, adults with SMI, and individuals with SUC or COD in Chicago's South Side neighborhoods. The CCBHC will provide a comprehensive array of evidence-based services to fill service gaps and treat behavioral health needs, monitor the physical health concerns of people receiving services, and coordinate care to address social determinants of health and increase engagement in services. Our geographic service area comprises neighborhoods that are densely populated and diverse; of the 798,361 individuals living in the service area, 34% of youth and 21% of adults live below the federal poverty line, 3% are veterans, and 12% have limited English proficiency (US Census Bureau, 2021). Over 88% of Thresholds South's current clients with SMI identify as Black/African American, an estimated 45% have obesity, and over 25% have type 2 diabetes. The CCBHC service area is in the 95th percentile for behavioral health related hospital admissions and emergency department visits in the state, and has high rates of opioid overdose, hypertension, heart disease, and stroke, all of which can be attributed to structural racism, public safety concerns, food insecurity, lack of preventative care, and cultural stigma associated with seeking behavioral health treatment. With CCBHC grant funding, Thresholds South CCBHC will build upon our current programs for adults with SMI by initiating services for children and families, expanding outpatient therapy services, providing SUD treatment, and addressing the physical health risks that contribute to repeat hospitalizations, medical comorbidities, and early mortality among our population of focus. The goals and objectives of the Thresholds South CCBHC will focus on 1) achieving compliance with CCBHC certification criteria and implementing all required activities, 2) increasing access to evidence-based behavioral health services for the population of focus, 3) improving health indicators for individuals at risk for or experiencing physical health comorbidities, and 4) increasing client engagement across CCBHC services. Thresholds South CCBHC will serve an unduplicated total of 825 individuals across the four-year grant period: 300 in Year 1, 150 in Year 2, 175 in Year 3, and 200 in Year 4. Using evidence-based practices such as Assertive Community Treatment, Trauma-Focused Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Illness Management and Recovery, Individual Placement and Support, and Integrated Dual Diagnosis Treatment, Thresholds South CCBHC will meet the behavioral health needs of individuals and families, improve their health outcomes, and reduce disparities in access to care.

Centerstone will plan, develop, and implement a new CCBHC in Tullahoma, Tennessee (C-CCBHC), to provide comprehensive, integrated, coordinated, person-centered behavioral health care; improve access to community-based mental health and substance use disorder treatment; and support 24/7 crisis services, regardless of an individual’s ability to pay or place of residence. C-CCBHC will serve 700 unduplicated individuals (Y1: 80; Y2: 150; Y3-4: 235/yr.). C-CCBHC will serve any individual with a mental or substance use disorder who seeks care at Centerstone’s Tullahoma CCBHC, including those with serious mental illness (SMI); substance use disorder (SUD), including opioid use disorder; children and adolescents with serious emotional disturbance (SED); individuals with co-occurring mental and substance disorders (COD); and individuals experiencing a mental health or substance use-related crisis. C-CCBHC’s focus population demographics are expected to mirror area individuals and current clinic clients: 84% White; 10% Black; 6% Hispanic/Latino, with roughly 50% male and 50% female. Of the area’s roughly 146,950 adults, 23% are expected to have AMI; 5.5%, SMI; 17%, SUD; 2%, OUD; and 8%, COD. Among the 44,080 youth, 20% are expected to have major depressive episode; 5%, SUD; and 3%, COD. Key C-CCBHC strategies include increasing access/availability of services responsive to community needs (e.g., crisis services; screening/assessment/diagnosis, including risk assessment; treatment/crisis planning; outpatient mental health/substance use services; primary care screening and health monitoring; targeted case management; psychiatric rehabilitation; peer and family supports; and community-based mental health care for Armed Forces/Veteran populations); meaningfully involving service recipients/families in their care; and applying a continuous quality improvement (CQI) approach. C-CCBHC will integrate SAMHSA’s TIP 59: Improving Cultural Competence and 57: Trauma-Informed Care in Behavioral Health to implement evidence-based interventions addressing the full array service recipients’ behavioral health needs (e.g., Cognitive Behavioral Therapy, Motivational Interviewing, Dialectical Behavior Therapy, Assertive Community Treatment, Multi-Systemic Therapy, Parent Management Training, Seeking Safety, Hazelden’s Co-Occurring Disorders Program, MAT, Illness Management and Recovery, and DIMENSIONS). C-CCBHC will accomplish the following goals: 1) Establish comprehensive, integrated, coordinated, and person-centered community-based services via the CCBHC; 2) Enhance infrastructure/capacity for a full continuum of quality/inclusive coordinated care; 3) Increase access to/availability of timely/high quality services; 4) Implement a measurement-based care process to ensure a comprehensive scope of evidence-based services/supports; 5) Improve health status/outcomes for treatment service recipients across the lifespan; and 6) Apply a CQI approach to drive systems, improve the quality of services, and ensure ongoing service delivery. As a result of these goals/improvements, the project will achieve the following measurable service recipient-related objectives: Decrease symptomatology among 45% with mental health disorders; decrease substance use among 45% of those with SUD/OUD/COD; provide ITPs for 100% of service recipients; improve housing stability among 80% who are homeless/marginally housed; provide 100% with employment case management services per ITPs; improve health indicators among 75% of participating service recipients; reduce past 30-day tobacco use by 30% among tobacco cessation activity participants; achieve no past 30-day criminal justice system involvement among 60% with criminal justice histories; achieve no past 30-day ER/hospitalizations among 60% of service recipients with hospitalization histories; achieve/maintain an 80% follow-up rate; and achieve satisfaction of experience/care among 80% of service recipients/families.

Centerstone will establish a new CCBHC in Carbondale, Illinois (C-CCBHC), to expand access to/quality of community behavioral health services, including 24/7 crisis services, for individuals with serious mental illness (SMI), substance use disorders (SUD), opioid use disorders (OUD), co-occurring disorders (COD), youth with serious emotional disturbance (SED), and those experiencing a mental health or substance use related crisis. C-CCBHC will serve 1,000 unduplicated individuals (Y1: 100; Y2-4: 300/year). Focus population demographics and clinical characteristics are expected to mirror those of individuals in the 5-county geographic catchment area (i.e., Franklin, Jackson, Perry, Union, and Williamson counties, Illinois) and of current clinic clients. Those under 18 are expected to comprise 48% male, 52% female, 75% White, 10% Black/African American, and 2% Hispanic/ Latino individuals. Those 18+ are expected to comprise 38% male, 62% female, 77% White, 9% Black/African American, and 2% Hispanic/Latino individuals. Of the catchment area’s population of 197,430, 4% (6,250) of adults are expected to have SMI, and 2,140 youth ages 12-17, SED. Roughly 17% (26,560) of area adults have SUD, including 2% (3,125) with OUD, and 11% (1,690) of area youth ages 12-17 have SUD. Within the catchment area, 8% (12,500) of adults have COD and 4% (615) of youth ages 12-17 have co-occurring SUD/major depressive episode. Chronic health conditions disproportionately impact the focus population: An estimated 16% of area adults with a mood disorders will have diabetes versus 10% in the general population. C-CCBHC will provide an array of integrated primary/behavioral health services (e.g., crisis care; screening, assessment, and diagnosis; person-/family-centered treatment planning; mental health/substance use services; primary care screenings and monitoring of key health indicators/ risks; targeted case management; psychiatric rehabilitation services; peer supports, counseling services, and family supports; intensive, community-based mental health services for past/current members of the Armed Forces). C-CCBHC’s evidence-based interventions include Cognitive Behavioral Therapy (CBT), Trauma-Informed CBT, Motivational Interviewing, Dialectical Behavior Therapy, Assertive Community Treatment, Integrated Dual Disorder Treatment, and more. C-CCBHC will accomplish the following goals: a) Establish the CCBHC and address infrastructure/capacity for care coordination, ensuring services address focus population’ physical, behavioral, and social service needs; b) Ensure the timely, integrated, age/culturally appropriate evidence-based scope of services are accessible/available regardless of ability to pay/residence; c) Address whole-person recovery needs, measuring recipient outcomes in mental, substance use, etc. domains; and d) Apply a quality improvement approach to drive outcome improvement and ensure ongoing service delivery/sustainability. To support these goals, C-CCBHC will achieve the following measurable objectives: Decrease mental health symptomatology among 45% of those with mental health disorders; Decrease substance use among 45% of those with SUD/OUD/COD; Improve housing stability among 80% who are homeless/marginally housed; Improve physical health indicators among 75% of service recipients; and Achieve satisfaction in care experience among 80% of service recipients/family. Key C-CCBHC strategies include conducting 2 needs assessments (1 by Month 6 of Year 1 and another 6 months prior to Year 4) and meeting full compliance with the CCBHC Certification Criteria by the end of Year 1; establishing/enhancing access/services; establishing/convening the Advisory Work Group; collaborating with community providers to promote whole-person wellness and recovery; utilizing an experienced evaluation team; and applying a continuous quality improvement approach to drive improvements and sustainability.

Van Buren Community Mental Health Certified Community Behavioral Health Clinic will provide CCBHC services to adults with Serious Mental Illness, children with Serious Emotional Disturbance, individuals with Substance Use Disorders, and adults and children with mild-to-moderate mental health conditions who may be at risk for more serious behavioral health conditions. Grant funds will be used to: Provide all CCBHC services; enhance infrastructure and capacity for improved care coordination for those at risk for poor health outcomes; Increase provision of evidence-based practices due to high rates of PTSD, Depression, Anxiety, and suicide; and Increase screening and follow-up for specific health risk behaviors including alcohol and tobacco. Under this grant, VBCMH proposes to serve 585 individuals with grant funds over the next 4 years, with additional broad community and population impacts (Year 1=180, Year 2=125, Year 3=135, Year 4=145). Van Buren County is a rural county in southwest Michigan with a population of 75,692. Per the 2020 US Census population estimates, over 13% of people in the county live in poverty. The racial and ethnic composition of the county is 81.2% white, non-Hispanic, 3.8 % Black or African American, 1.2% American Indian or Alaskan Native and less than 1% Asian, Native Hawaiian or Other Pacific Islander. 2.8% of the population identifies as two or more races. 12.3% of the county population is Hispanic. Of the 2,500 individuals served by VBCMH in FY22, 49% were female, 48% were male. 2% identified with one of the following: agender, androgynous, bigender, questioning, fluid, non-binary, or transgender. 8.2% of VBCMH service recipients identify as gay, lesbian, bisexual or another sexual orientation other than heterosexual. 23.1% of county residents are under the age of 18 and 18.7% are over the age of 65. In FY22, 26.9% of individuals served by VBCMH were under the age of 18 and 9.4% were aged 65 and older. 80% of the individuals served by VBCMH are at or below the poverty line. Based on internal data, while VBCMH has seen an increase in the number of veterans served each year, (up 61% from FY20 to FY22), This represents only a small percentage of the Van Buren County's veteran population (6% of the civilian population 18+). Specific program objectives include: 1) Increase provision of TF-CBT by 20% in year 1 and an additional 10% each subsequent year 2) Increase number of staff trained in Seeking Safety and Motivational Interviewing 3) Increase screening and follow up for specific health risk behaviors including alcohol (50% in year one, increasing by 5% each subsequent year) and tobacco use (60% in year 1, increasing by 10% each subsequent year), 4) Implementation of an EMR module to track external referrals to providers (50% year 1, increasing by 5% each subsequent year, 5) Increase percentage of individuals connected to a primary care provider (40% in year 1, increasing by 5% each subsequent year, and 6) Increase screening for social drivers of health (SDoH), 40% post implementation followed by an additional 10% each subsequent grant year. VBCMH CCBHC seeks to increase access to and availability of high-quality services that are responsive to the needs of the community, using evidence-based practices including Trauma-Focused CBT, Motivational Interviewing, Seeking Safety, Screening, Brief Intervention, Referral and Treatment (SBIRT) and Question, Persuade, Refer (QPR) to address targeted community needs and risk factors. VBCMH will continue to build on the foundations of person-centered/family-centered supports and services that are recovery-oriented, trauma-informed, and equity-based, involving those with lived experience in all aspects of the CCBHC. During the grant period, VBCMH will partner with the community to complete a comprehensive Community Needs Assessment to inform future program design and enhancements, staffing, and clinical practices.

Legacy Behavioral Health Services (LBHS), a public safety net provider based in Lowndes County, the Metropolitan Statistical Area (MSA) center of a 10-county non-MSA area of southeast Georgia, proposes to establish a Certified Community Behavioral Health Clinic. LBHS currently delivers person-centered, evidence-based prevention, treatment, and recovery services and pursues this opportunity to increase behavioral health and reduce poor outcomes. Our proposal has three goals: 1) reduce crisis contacts through expanded criminal justice partnerships, expanded crisis care and aftercare and consistent application of trauma informed EBPs 2) increase physical health care access for people with behavioral health issues, who frequently have complex chronic conditions, particularly minorities, and who often lack access to traditional healthcare provider settings 3) Reduce poor behavioral health outcomes for people of Hispanic ethnicity through expanding access and engagement. Our CCBHC will deliver quality screening, assessment, and treatment, 24/7 crisis services, person centered care coordination, physical health screenings and coordination, psychiatric rehabilitation and peer support, targeted case management and integrated care for veterans for children and adults. We are partnering with our local FQHC, working closely with our VA partners, providing co-response with the police, and delivering services in schools. To support this work, we will hire additional nurses, therapists, case managers, and outreach and peer staff. We propose to reduce crisis contacts by expanding available services to people who are incarcerated and supporting them in their transition out of jail, following up on people leaving local EDs, providing peer services 7 days a week at our Behavioral Health Crisis Center and consistently delivering trauma focused EBPs: Seeking Safety, EMDR Training for Trauma, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and QPR. We will increase physical health care access through adding resources to do our own screenings as well as primary care visits for those who wish. Lastly, we will reduce poor behavioral health outcomes for people of Hispanic ethnicity by expanding access and engagement. We will facilitate access to transportation through partners in the local Hispanic community who will help identify those in need. We will also conduct outreach and education to non-traditional behavioral health partners, e.g., barber shops and groceries to inform the community of services available. Our efforts will be conducted using evidence-based and emerging practices to support care for behavioral health conditions. In addition to the trauma-focused interventions mentioned above, LBHS will use Screening, Brief Intervention, and Referral to Treatment (SBIRT); Motivational Interviewing, a recognized engagement practice for structured communication to assess readiness and/or promote behavior change; Collaborative Problem Solving (CPS) and Parent Management Training (PMT), both practices recognized to support parents coping with a children’s’ behavioral challenges; Dialectical Behavioral Therapy (DBT), effective for youth and adults with suicidal ideation and risk; Multidimensional Family Therapy (MDFT), a recognized intervention for youth substance use and antisocial behaviors; and Acceptance and Commitment Therapy (ACT), an evidence-based practice for behavioral health disorders in adults. Throughout all CCBHC services, we will ensure that consumers receive client-centered care that is free from stigma and that is culturally and linguistically appropriate to meet the consumer’s individual context and care needs.

Champlain Valley Family Center (CVFC) CCBHC will target individuals in need of BH care in rural northeastern New York's high poverty counties of Clinton, Esses, and Franklin with a focus on adults experiencing serious mental illness (SMI), children experiencing serious emotional disturbance (SED), those who have substance use disorders (SUD), and/or co-occurring mental health/substance use disorders (COD), especially those discharged from the regional hospital following a psychiatric admission, justice-involved individuals, and individuals and families representing the military/Veteran population. Our area includes four mental health HPSA designations, its average per capita income is $26,348 annually, 22.7% of the region's population is on Medicaid, and 5.1% do not have health insurance. The average suicide rate is 13.6 per 100,000. In 2021 our area's opioid overdose rate had increased by 637% since 2015 and our local hospital has 200 adolescents and 40 adults boarded in the ER for more than a day at any given time; 50% were diagnosed with SUD yet only 42.2% received an outpatient follow up appointment within 7 days of release and only 11.1% of youth up to age 17 diagnosed with SUD received a follow up care appointment within 7 days. As well, 70% of this population requires MAT that they do not receive. Our region's six adult correctional facilities, release apx. 138 individuals annually who have an SUD and 1,250 individuals are on probation or parole, yet we are seeing only a few of these high risk clients. Veterans comprise 8.4% of the population within our region, in contrast to a NYS average of 3.9%, however the two clinics meant to serve them are not presently able to provide timely access to clinical assessment and Veterans and their families require information and support related to SUD and suicide prevention. The CCBHC model offers a vital framework and critical expansion funding for CVFC's integrated mental health and substance use treatment services for children and adults. Our goals include expanding access and timely initiation of community-based BH services, reducing overdose and suicide, providing transportation support to treatment from the hospital and upon release from jail integrating primary care to address co-occurring chronic conditions, and establishing a process to monitor Continuous Quality Improvement. To accomplish these goals, we will expand our peer and clinician capacity, hire a Nurse Practitioner capable of prescribing MAT, implement Dialectical Behavioral Therapy in our clinic and school-based services, co-locate services in our local hospital and jail, partner with Homeward Bound a Veteran Peer organization to serve Veterans, and establish DCO collaborations with primary care clinics and our regional mobile crisis provider. As a result, we will expand access to care for 50 new, unduplicated children and adolescents each year via school-based DBT training and 75 new unduplicated children and adolescents with SED and 200 adults with SMI/SUD/COD will engage in DBT to avoid overdose/suicide, 160 individuals with an Opioid Use Disorder will receive MAT, 300 clients will be provided with transportation to care and services, and we will provide pre-discharge assessments and warm handoffs from the hospital for 45 new adult and adolescent patients annually, conduct 75 BH screenings for justice involved individuals each year, and increase our BH care for veterans by 5% in Y1 and 5% each year thereafter. As well, 70 % of clients served at the CCBHC will be connected to a PCP in year 1. Additionally, we will integrate care to track and monitor client health, medication adherence, and areas for needed improvement in Year 2 and each year thereafter. CCBHC funding will allow CVFC to serve an additional 980 individuals over the grant period, including 180 in Y1, 225 in Y2, 265 in Y3, and 310 in Y4.

Finger Lakes Area Counseling & Recovery Agency (FLACRA) proposes to expand its current integrated care service delivery model through the Certified Community Behavioral Health Clinic (CCBHC) Planning, Development, and Implementation (PDI) Grant. Currently, FLACRA's East Ave Clinic provides services for individuals with serious mental illness (SMI) and substance use disorders (SUD) and is in the approval process for the expansion of services for children and adolescents with serious emotional disturbances (SED) and is currently designated to provide services for individuals with co-occurring disorders (COD) and is seeking support to expand its service. A total of 2,761 unduplicated individuals (across grant years) will be served over the 4-year period through this CCBHC: Year 1- 596, Year 2- 665, Year 3- 720 and Year 4- 780. The East Ave Clinic is approved for the NYS OMH Integrated Outpatient Services (IOS) designation and is providing fully integrated substance use disorder treatment and mental health services and is pending approval to serve children ages 5 and older for mental health treatment and psychiatric support. As a result of obtaining the current IOS designation, services already offered include several of the required CCBHC Core Services including care coordination and primary care services. We will expand our CCBHC services through Designated Collaborating Organizations (DCO) partnerships to extend crisis care, psychiatric emergency and inpatient care and primary care services. Since the pandemic, the socio-economic and environmental factors in the City of Rochester service area populations have widened health disparities and inequitable access to care, as well as compounded trauma and stressors exacerbating behavioral health (BH) and substance use disorders (SUD). The residents of the most significantly impacted zip codes in the City of Rochester will benefit from the addition of a CCBHC that is integrated, trauma-informed, recovery-oriented and operates from an evidence-based and equity focused approach. FLACRA has extensive experience providing treatment and recovery support for mild to serious mental illness and serious emotional disturbances, SUDD and co-occurring disorders. The CCBHC PDI Grant will be used to build on existing comprehensive services and expand support for adults and children with the clinic and through school-based services and collaborations. Services will be grounded in evidence-based care, person-centered planning approaches, attention to cultural norms and beliefs and trauma-informed practices. The goals and objectives of the PDI Grant include: (1) implementing and enhancing services aligned with a CCBHC model; (2) increasing the number of providers with diverse specialty areas and cultural skillsets, trained in evidence-based interventions such as Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy for Adults (DBT) and Adolescents (DBT-A), Trauma Focused CBT (TF-CBT), CBT for Psychosis (CBTp), Family Psychoeducation, Social Skills Training (SST), Functional Family Therapy (FFT), Matrix Model for Teens and Young Adults, Peer Advocacy/Support, Seeking Safety, Living in Balance, Community Reinforcement and Family Training (CRAFT), Motivational Interviewing (MI) as well as Medication Assisted Therapy (MAT); (3) expanding off-site services to meet the BH needs of children and families in high need school settings; (4) increasing peer and recovery support services; (5) augmenting technology to support EMR data extraction to make data-driven decisions that identify and improve practice patterns, drive quality and promote and interdisciplinary Team-Based Care approach; and (6) adhering to SPARS and NOMS requirements and accuracy through tracking performance and clinical quality metrics that help improve quality of life perceptions, improve outcomes and reduce disparities in both access and outcomes.

As one of the largest nonprofit providers serving individuals living with substance use disorders (SUD) and co-occurring disorders (COD) in the mid-Atlantic region, Gaudenzia is applying to become a CCBHC at our Park Heights, MD clinic. Through our CCBHC, we will serve individuals of all ages in need of behavioral health (BH) services who are living in our catchment area of Baltimore City, including individuals with serious mental illness (SMI), SUD, serious emotional disturbance (SED), COD, and those experiencing a mental health (MH) or substance use related crisis. The cornerstone of our CCBHC will be a harm reduction, recovery-oriented approach that meets each individual where they are and engages them around their own, self-identified recovery goals. Through our CCBHC, we will seek to address disparities for two priority populations: homeless individuals/families and individuals living with BH needs who are involved in the criminal justice (CJ) system. We will serve 2,100 clients over the four year program, including 300 in Y1, 400 in Y2, 600 in Y3, and 800 in Y4. We will achieve the following goals and objectives: Goal 1: Become a CCBHC in alignment with all 2023 CCBHC Criteria, including: 1.a: Hire our CCBHC team within 4 months of award; 1.b: 100% of client-facing CCBHC staff will be trained in our CCBHC core curriculum, including our selected Evidence Based Practices (EBP) within 6 months of award; 1.c: Initiate a Community Advisory Board (CAB), inclusive of individuals representing our target populations within 6 months of award; 1.d: Begin delivering the following 5 services within 6 months of award: Screening/Assessment, Treatment Planning, Primary Care Screening/Monitoring, Targeted Case Management, and Peer Support; and 1.e: Begin delivering the remaining 4 services within 12 months of award: Crisis response, Outpatient MH/SUD treatment, Psychiatric Rehabilitation, and Services for Veterans. Goal 2: Improve the health and BH of individuals with SMI, SUD, SED, and COD served by our CCBHC, including: 2.a: 100% of clients served with SUD who are clinically appropriate will be offered MAT, in combination with psychotherapy support services; 2.b: 75% of clients will complete their care plan by the time they are discharged from our CCBHC; 2.c: 60% of clients served who score 8 or more on the Generalized Anxiety Disorder-7 (GAD-7) during their initial assessment will reduce their risks related to anxiety after six months of engagement; 2.d: 60% of clients served with SUD will decrease their substance use/risks and increase their protective factors after six months of engagement; and 2.e: 60% of clients served who score over 5 on the Patient Health Questionaire-9 (PHQ-9) during their initial assessment will reduce their PHQ-9 score after six months of engagement. Goal 3: Reduce disparities in service access and BH outcomes for our priority populations of homeless individuals and families and those impacted by the CJ system who are living with BH needs, including 3.a: Partner with 4 external partners during each grant year serving these priority populations, providing them with information about our CCBHC program and how to refer individuals to the program; 3.b: 100% of individuals who are homeless and/or unstably housed, as well as individuals who are being discharged from CJ settings, will be offered a connection to our Care Coordinators to address their housing related needs; 3.c: 100% of individuals in our priority populations will be offered a connection to Peer-led group sessions; and 3.d: 70% of CCBHC clients who are mandated to treatment due to CJ involvement will successfully complete their treatment mandates.

Maine Behavioral Healthcare (MBH) is proposing to plan, develop, and implement (PDI) a Certified Community Behavioral Health Clinic (CCBHC) in Midcoast Maine (ME) encompassing Waldo and Knox Counties, which include the island communities of Islesboro, Matinicus, Monhegan, North Haven, and Vinalhaven (the Islands). MBH has established clinics in the Midcoast area: one in Rockland (Knox County) and one in Belfast (Waldo County). Each works closely with Coastal Healthcare Alliance (Waldo County General Hospital and Pen Bay Medical Center) the local hospital system and members of MaineHealth. These two clinics, collectively led by a leadership team comprised of a Regional Medical Director, Practice Manager, and Clinical Director, will form the Midcoast CCBHC. The population of focus (POF) for the Midcoast CCBHC will include those that are rural, low income or living in poverty, seniors, youth, pregnant or parenting, living with disabilities, and housing insecure. The disparities the CCBHC project will impact are access; health inequities based on race, poverty especially in the coastal fishing community, ethnicity, or culture; stigma; and the lack of availability of a continuum (screening through ongoing recovery) of integrated mental health, substance use disorder, and primary care services and supports. The Midcoast CCBHC will serve 625 over the lifetime of the project (Y1=75, Y2=150, Y3=200, Y4-200). MBH has a history of implementing recovery-oriented, trauma-informed, and equity-based programs, practices, and policies that are the primary means for improving behavioral health. MBH currently provides, directly or through its DCO partner (Sweetser), many of the core CCBHC services. MBH under the guidance of the Project Director (PD) and the Clinical Leadership of the Regional Medical Director and Clinical Director, will implement infrastructure activities to address the operational changes needed to meet the certification criteria and improve the quality and effectiveness of services including strategies to address behavioral health workforce shortages and improve access to care by implementing a two-year advanced clinical training program. Goals for the funding period: 1) Increase access and availability to behavioral health services, 2) Improve integration of SUD, MH, and COD programming, and 3) Continually work to measure and improve the quality of services. Objectives include recruitment, hiring, training, and retaining staff positions; implementing team-based care; expanding the existing Hub and Spoke model for SUD to include all behavioral health populations, improving protocols and processes; and developing and implementing systems to track clinical and programmatic data including referral, services, workflow, and outcomes.

The Jewish Board of Family and Children's Services (the JB) is one of the largest BH service providers in New York City (NYC), with expertise in trauma informed, culturally appropriate care. The population of focus is people of all ages with SMI/SED/SUD/COD and other BH challenges. The JB will implement a CCBHC to serve Taskforce on Racial Inclusion and Equity (TRIE)-defined high BH inequity areas in Manhattan. The service area (SA) is: Morningside & Hamilton Heights (TRIE 2), Central (TRIE 3) and East (TRIE 4) Harlem, and Washington Heights/Inwood (TRIE 5). The SA has 588,776 residents, 34-59% of whom speak a language other than English at home, generally Spanish; 27 - 68% are Latinx, 7 - 44% are Black and 11 - 36% are white, and 3-10% are Asian, with 21% under 18. 7.9% of adult NY state residents and 12% of Latinx and 9% of non-Latinx NYC high schoolers are LGBTQ+. The SA has higher than NYC average rates of poverty, substance use, drug related deaths, psychiatric hospitalizations, premature mortality, avoidable hospitalizations, new HIV diagnoses, uninsurance, going without needed care and other indicators of chronic lack of access to consistent, linguistically and culturally appropriate, affirming BH, primary, reproductive and other health care. NYC was an epicenter of Covid-19, with mortality doubled for Black and Latinx New Yorkers, increasing BH need while reducing the BH workforce. Black, Latinx and LGBTQ+ New Yorkers have higher rates of unmet BH need, with significant health and BH inequity and access gaps in the SA. The JB has expertise in BH equity, LGBTQ+ affirming care, serving diverse, underserved populations and linguistically and culturally appropriate care, with representative, bilingual staff who can provide all services in Spanish, reducing access barriers. The proposed CCBHC will integrate services currently provided at two main SA sites into a single service hub. We will serve a total of 1035 unduplicated individuals (225 YR1, 248 YR2, 270 YR3 & 293 YR4). Goal 1 is to increase access to/availability of a continuum of integrated BH services in order to reduce BH crisis, psychiatric hospitalization, suicide attempts and overdose deaths. Objectives and activities: 1.1 Improve timely access to BH care via staff hiring; expanding the Facilitated Intake Team (FIT, completes intake activities, initial care planning); Bridges to Care Team (B2C, provides crisis response, follow up and bridge clinical services while arranging for outpatient care), with OP wait times reduced to 10 business days by month 12. 1.2 Reduce inpatient admissions & crisis incidence; by month 12, 75% of crisis clients who are admitted inpatient will have an OP appointment scheduled, and 90% of all clients will have a crisis prevention plan documented. 1.3 Increase outpatient service offerings and availability to adults via staff hiring. 1.4 Training in SUD/COD/harm reduction, MAT, IDDT for 100% of relevant staff by month 12, with the SUD team to be expanded in year 2. 1.5 Increase timely identification of SUD/COD and facilitate access to services via enhanced SUD screening & diagnosis; By month 12, 100% of clients age 12+ will be screened, with 80% of positive screens to receive diagnosis & 75% to receive follow up. 1.6 Improve suicide screening, with 95% of clients screened by month 9, and 90% of positive screens receiving risk assessment & care navigation. By month 12, 95% of clients will be re-screened at treatment review, and 100% of relevant staff will be trained in evidence-based suicide prevention (CAMS). Goal 2 is to reduce historic BH and health disparities in the SA via increased health screening, monitoring, follow up and care coordination. Objectives and activities are: 2.1 Improve capacity for health screening by hiring a nurse & a Patient Navigator by month 6. 2.2 Improve health screening rates; by month 9, 70% of clients will be screened, 95% screened by M12 and 85% of positive screens have f/u included in treatment plans.

The Jewish Board(JB) is applying for a 4-year, $1 million annual CCBHC PDI grant to increase access to and fill gaps in care at its New York State (NYS)-licensed Grand Concourse Mental Health Outpatient Treatment Program(GC MH Clinic) located at 2488 Grand Concourse, Bronx, NY 10458 (and co-and near located mental health (MH) services) which currently serves 1,443 diverse, primarily low-income New Yorkers ages 0 and older annually. JB's Service area is the contiguous economically disadvantaged Fordham-Bronx where the JB GC MH programs are located (zip codes 10458, 10467, 10468); Crotona-Tremont (zip codes 10453, 10457, 10460); and Highbridge-Morrisania (zip codes 10451, 10452, 10456). The population primarily Hispanic (53%) and Black (34%). Most (90%) are low income on Medicaid and/or Medicare. Children ages 0-17 years are a third (34%) of the population; and those with serious mental illness are 77%. People with co-occurring substance use disorders (SUD) ) are 8% and will increase significantly when JB secures certification for an outpatient SUD Clinic. Many Bronx residents have economic and social challenges: 10% are uninsured; 34% are foreign-born; 59% speak a language other than English. Over 4 years, JB will serve 7,215 individuals (Yr. 1-1,587, Yr. 2-1,732, Yr. 3-1,876, Yr. 4-2,020) Strategies/Interventions: JB currently provides 8 of the 9 CCBHC core services. CCBHC grant funds will be primarily used to improve timely access to care and achieve CCBHC certification by expanding (1) clinical intake (screening/assessment) to reduce wait times; (2) crisis services to increase capacity to provide crisis stabilization care; (3) primary care screening/monitoring to offer services to more at-risk clients; and (4) peer services to better support recovery. These improvements will be implemented within 6 months of award. Funds will be used to open a new outpatient SU Treatment Program within a year of award co-located with JB MH Clinic that will add SU treatment capacity at the proposed CCBHC. Also, intensive, community-based MH for members of armed forces/veterans will be implemented within a year Project Goals/Measurable Outcomes: (1) Improve timely access to evidence-based outpatient MH care: Within 12 months of award, JB will reduce the wait time for initial routine intake appointments to 5 business days and urgent intake appointments to 1 day; and reduce the wait time for consumers waiting for an initial treatment visit by a clinician to 20 business days for routine needs and one day for urgent needs. (2) Improve Primary Care Screening & Follow-Up: 6 years: JB will increase annual age and risk appropriate primary care screening of CCBHC consumers to 45% in year 2 and 60% in Years 3-4 from 5% currently; and increase follow-up and interventions for clients who have medical condition identified by CCBHC staff (3) Improve Tobacco Use Cessation Intervention 14 years+: JB will progressively increase evidence-based tobacco use cessation interventions among consumers screened positive for tobacco use from 10% in 2022 to 60% by Year 4. (4) Improve timely access to evidence-based SUD services for adults: JB will commence offering SUD services in Year 2 to 50 adults and increase capacity in Years 3-4 to 70 adults annually. Today, MH Clinic/PROS clients needing SUD care are referred to other Bronx providers that may not have capacity to assist them and/or individuals may not follow-up with the referral. Additionally, JB will increase the number of clients newly diagnosed with a SUD who initiate SUD treatment within 14 days of diagnosis to 60%, compared with no initiation currently.

Sound will establish a Certified Community Behavioral Health Center in Auburn, 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 3/29/23 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 CCH BHS Certified Community Behavioral Health Clinic Planning, Development, and Implementation (CCBHC-PDI) project has been developed to expand behavioral health services in Campbell County, Wyoming. CCH BHS has been providing mental health (MH) and substance use disorder (SUD) services to residents in the area for 35 years. Over the years our services have grown and adapted. It is now necessary to expand further to meet the needs of the community. The population of focus for the CCH BHS CCBHC-PDI project includes individuals across the lifespan in Campbell County, from all demographics, who need behavioral health services. As of July 1, 2022, there were 47,058 individuals living in Campbell County. Based on the National Alliance on Mental Illness’s US statistics, there are approximately 6,870 adults and 1,524 kids between the ages of 6 and 17 adults in Campbell County experiencing mental health (MH) issues. The demographics of Campbell County’s population include: White, not Hispanic 86.9%: Persons in Poverty 8.5%: Hispanic Latino 8.8%; Veterans 6.6%; American Indian and Alaska Native 1.7%; Male 51.1%; Female 48.9%; Asian 0.7%; Disabled under 65 years old 6.9%; Black 0.7%; No Health Insurance under 65 years old 13.0%; Pacific Islander 0.1%; Persons under 18 years of age 27.0%; Multiracial 2.3%; Persons over 65 years of age 12.2%; Per Capita Income $36,568; and 3.3% of the people living in Wyoming identify as lesbian, gay, bisexual, or transgender (LGBT)-9.3% of LGBT Wyoming residents identify as transgender. To align with the population of focus and address disparities in access to MH and SUD services, CCH BHS will expand its services in the following ways: • Expand telemedicine to increase access to crisis care, MH services, and SUD care for individuals who are in crisis or cannot get to appointments. • Implement crisis education programs in the community to decrease suicide rates among all patient demographics. This is essential to the community as Campbell County specifically had a record number of twenty-one suicides in 2022. • Implement MH programming specific to veterans and members of the armed forces. • Implement educational programs about MH and SUDs to decrease stigma and encourage individuals to seek help when they need it. In calendar year 2022 CCH BHS provided 582 in-person crisis assessments and behavioral health services were provided to 2,115 patients. In that same year, Campbell County’s suicide rate was almost triple the national rate and the Health Resources and Services Administration has identified Campbell County as a Health Professional Shortage Area for MH. As it is a rural area, many northeast Wyoming residents encounter barriers to accessing MH and SUD care. Examples of those barriers include provider shortages, longer distances from services, and stigmas about MH and SUD services. The combination of the extensive need for MH and SUD services and the barriers referenced above equates to significant gaps in MH and SUD services in the area. The CCH BHS CCBHC-PDI project will help close some of those gaps and expand the services they provide to the community.

ABSTRACT Project Name: Integrated Hope and Healing Certified Community Behavioral Health Clinic (CCBHC) Project Summary: The Integrated Hope and Healing CCBHC is a neighborhood-centric mobile and physical clinic in 2 westside neighborhoods and 3 eastside neighborhoods, using harm reduction, evidence-based practices, innovative recovery supports, and warm transfers to Designated Collaborating Organizations, to measurably reduce health disparities, while increasing positive social determinants of health. Population To Be Served (Demographics And Clinical Characteristics): BFDI targeted western zip codes are 48228 and 48235, and the eastern zip codes are 48205, 48224, and 48234. The targeted zip codes have 12-20% of Detroiter’s who have not accessed health insurance and/or access to services; 90% of the target population is Black, and 8% Latino; 30% of residents are below the federal poverty level, with 47% of residents being 50% below poverty standards; and 17% of work-age residents are unemployed. Furthermore, 7% of the population identify as LGBTQIA2+. Selected zip codes are negatively impacted by lack of transportation to access care. Strategies And Interventions: Evidence-Based Screening and Assessment Tools. Project will use assessment tools deemed effective with the target population: UNCOPE, Drug and Alcohol Problem (DAP) Quick Screen, Patient Health Questionnaire (PHQ), Generalized Anxiety Disorder-7 (GAD-7), Child and Adolescent Functioning Assessment Scale (CAFAS), Mental Illness and Addiction Screening (MIDAS), and LOCUS (Level of Care Utilization System), the Columbia-Suicide Severity Rating Scale, the Drug Abuse Screening Tool, and the Michigan Alcohol Screening Test. Evidence-Based Interventions. Evidence-based clinical interventions include, but are not limited to: Cognitive Behavioral Therapy (CBT), Trauma – Focused CBT, Parent Management Training – Oregon, Parenting Through Change, Wraparound, contingency management, Restorative Practices, and motivational interviewing, Measurement-based Care screens and assessments. Project Goals and Measurable Objectives: Goal 1: Decrease behavioral health disparities through accessible, high quality, community-connected continuums of care to mobility-limited residents in 5 Detroit neighborhoods. Objectives: (1) 1500 behavioral health and physical health screenings and recovery plans as evidenced by completed screenings and plans in the BFDI Electronic Health Record. (2) 80% of uninsured individuals will acquire health insurance, as evidenced by results of their health screens, completed consents for ongoing services, and post-service access questionnaire. (3) 75% of individuals not receiving treatment services and screen positive for behavioral health will consent to services. Goal 2: Improve health outcomes within 5 resource-limited neighborhoods. Objectives: (1) Establish medical and behavioral health homes for underserved residents. (2) 70% of individuals in active treatment will measurably increase their level of functioning. Number Of People Served Annually And During Project Duration: 375 annually; 1500 total.

Migrant Health Center Western Region, Inc. (MHC) is a Community Based 330 (g) (e) (h), non-profit, 501c3, program. MHC is requesting funding ($1,000,000 per year/4 years) to establish a new CCBHC program. The proposed program would be called Clinica BIENESTAR (MHC Wellness Clinic). The overall goal is to increase access to integrated care to ensure consumers have immediate and timely access to comprehensive, coordinated and evidence-based behavioral health care through a single point of entry by establishing the first CCBHC program in the Western Region of Puerto Rico (PR). The populations to be served are individuals with serious mental illness, substance use disorder, including opioid use; children and adolescents with serious emotional disturbance; individuals with co-occurring mental and substance disorders; and individuals experiencing a mental health or substance use-related crisis in the Western Region of PR. The Western Region of PR is home of 408,184 residents, of which 99% are Hispanic/Latino and nearly 55% live under the Federal Poverty Level. There is a high prevalence of substance use and mental health conditions among the target population and often these conditions go undiagnosed and untreated. Through this funding MHC will: 1) hire 22 additional leadership, clinical and supportive staff to expand access; 2) implement comprehensive assessment utilizing validated screening and assessment tools, inclusive of those for adverse childhood experiences (ACEs), suicide risk, and behavioral health disorders, as indicated; 3) develop tailored service and treatment plans; and 4) provide a range of evidence-based prevention and treatment services that address a combination of immediate and long-term needs. To meets the CCBHC Certification Criteria, within one year of grant award, MHC will provide at least five of the nine required services by the 6 month after award (Screening, assessment, and diagnosis; Treatment Planning; Targeted Case Management; Psychiatric rehabilitation services; and Peer support counseling services); and provide all the required nine core CCBHC services within twelve months (adding Crisis mental health services, Outpatient mental health and substance use services, Outpatient clinic primary care screening and monitoring, and Community-based mental health for members of the armed forces and veterans). Some of the EBPs evidence-informed, that will be used and the proposed CCBHC are: Motivational Interviewing, SBIRT, Peer and Family Support Specialists, Medication-Assisted Treatment, Solution-Focused Therapy, Cognitive behavioral therapy, and Trauma-Focused Cognitive Behavioral Therapy, among others. The objectives of the proposed project are: 1) By 9/29/27 the project will have provided services to at least 1,500 (Y1 250, Y2 350, Y3 400, and Y4 500) unduplicated individuals from the western region of PR. 2) By 9/29/24 MHC will obtain the CCBHC designation, complying with all certification criteria established in the compliance checklist. 3) By 03/31/24 the project will have conducted a community assessment, presented its results to SAMHSA, and will be providing at least 5 required services. 4) By 9/29/24 MHC will develop a sustainability plan to support delivery of services. 5) By 12/31/23 MHC will have hired all of the proposed 22 CCBHC program staff. 6) By 9/29/27 the project will have increased initiation and engagement in treatment by at least 25% (from baseline). 7) By 9/29/27 the project will have reduced the time between screening and treatment initiation by at least 25% (from baseline). 8) By 9/29/27 100% of program participants will have completed a comprehensive intake and integrated treatment plan development process. And 9) By 9/29/27 the project will have increased the number of consumers initiated on medication-assisted treatment by at least 20% (from baseline).

Summary: Portage Path Behavioral Health (PPBH), located in Akron, Ohio (Summit County), seeks CCBHC PDI funding to increase access to help transform the community behavioral health (BH) system and provide comprehensive, coordinated BH care. DCOs include AxessPointe Community Health Center, Genoa Pharmacy, and Child Guidance & Family Solutions. Population of Focus: The population of focus will be indigent, low- and moderate-income individuals who are experiencing SMI, SED, or CoD. This focus includes increasing services to racial minorities, including immigrants and refugees in North Hill and other vulnerable populations such as the LGBTQ+ persons. Total number served over four years: 1,650. Goals and Objectives: Goal 1 of PPBH's CCBHC is to transform the community BH system and provide comprehensive coordinated BH care to individuals across the lifespan. Goal 2 is to increase access to care through mobile service and targeted co-location of staff. Goal 1, Objective 1: 75% of CCBHC participants who receive at least four of the core services will report a 50% improvement in their perceived health and well-being between the administration of the baseline NOMS and their six-month follow-up NOMS. Goal 1, Objective 2: 100% of CCBHC participants who identify as having a housing need at the time of their assessment will receive a referral to PPBH's case managers who will link them to housing resources within 30 days of this need being identified. Goal 1, Objective 3: 100% of CCBHC participants will be offered linkage to recovery support services (RSS), including peer services, within 10 days of their enrollment to increase their connection to recovery and to the recovery communities. 75% will report utilization of RSS in the community at the time of their six-month reassessment. Goal 1, Objective 4: 100% of CCBHC participants will be offered targeted case management and psychiatric rehabilitation services to assist them in pursuing education and/or vocational needs, improve their daily living skills, and help them engage in wellness activities that support recovery. Goal 2, Objective 1: 100% of CCBHC participants will receive services that support multiple pathways of recovery that are culturally competent, and patient centered. Goal 2, Objective 2: By the end of Y1, provide mobile BH services throughout the catchment areas to decrease disparities and increase access to care to populations in need, serving at least 25% of the population through the mobile unit. Goal 2, Objective 3: By the end of Y2, establish 8 co-locations of staff within non-traditional settings to increase equity and access to care.

Westchester Jewish Community Services (WJCS) will establish a CCBHC in Hartsdale, New York, Westchester County, to increase community access to high-quality, community based integrated behavioral health services, including mental health, substance use treatment services and primary care screenings, as well as provide seamless connection to additional services to address Health Related Social Needs for underserved populations. Our population of focus is low-income populations across the lifespan, especially Blacks and Hispanics who are disproportionately impacted by income and BH disparities in Westchester. As part of the project, WJCS will leverage its existing services as a certified MH and SUD provider in Hartsdale, 2 miles from White Plains, New York’s tenth largest city. Primary care screening and monitoring of key health indicators and health risks will be provided through the project and delivered in an integrated manner to allow for more comprehensive assessment and treatment of physical, mental health, and substance use disorders in a manner that is less likely to be stigmatizing, more consistent with the target community’s help-seeking behaviors, and relatively seamless in care. Over the grant period, we expect to serve 3,500 unduplicated clients. Four overarching goals guide this work. Goal 1: Improve access for individuals with or at-risk for MH or SUD through enhanced integration of culturally and linguistically responsive BH, physical, and social services; Obj. 1: During the grant period, LPNs will complete the health review form in our EHR for 90% of all consumers and capture demographic data to identify and address BH disparities. Obj. 2: During the grant period, CCBHC staff will complete and conduct an HRSN screening administered in our EHR for 80% of people receiving services. Obj. 3: During the grant period, 60% of individuals from our focus population receiving services to address needs from HRSN screening will have improvements in employment, food insecurity, or housing. Obj: 4 During the grant period, increase outreach efforts in community-and employment settings to increase treatment access for hard-to-reach, low-income, and underserved populations. Obj. 5: Maintain a No-Show Rate at or below 10% across the 4 years of the grant. Goal 2: Improve BH outcomes by addressing socioeconomic disparities experienced by low-income priority populations through peer supports and comprehensive IBH treatment; Obj. 1: During the grant period, our new Peer/Family Support Specialist will meet with all consumers who score low on the HSRN screening tool. Obj. 2: Increase the number of community partnerships with providers that address HRSN. Obj. 3: Achieve and surpass an engagement rate of more than 50% after 4 treatment sessions. Obj. 4: Implement and integrate NY State OASAS license to increase number of consumers in our focus population receiving culturally responsive evidence-based integrated SUD services by 60% in year 4. Goal 3: Implement culturally and linguistically responsive Evidence-Based Practices (EBP) for our focus population’s needs. Obj. 1: Increase staff trained in culturally responsive SUD EBPs (Encompass and CRAFT) by 60% by year 2. Obj. 2 Increase staff trained in culturally responsive Cognitive Processing Therapy (CPT) by 50% by year 2. Obj. 3 Train Employment Specialist on culturally responsive Individualized Placement and Support by year 1. Obj: 4 Implement /increase diversity, equity and inclusion training for all new employees.

LUK Crisis Center, Inc. (LUK) proposes to develop a Certified Community Behavioral Health Clinic (CCBHC), serving residents of the 27 communities that comprise the North Central Massachusetts region. LUK’s CCBHC will serve individuals throughout the lifespan in home-, clinic-, community-, and school-based settings. Services will be provided to children and youth who have a serious emotional disturbance (SED), adults with a serious mental illness (SMI), individuals with a substance use disorder (SUD), individuals with co-occurring mental health and substance use disorders (CODs), and people experiencing a mental health or substance use crisis, regardless of ability to pay. LUK’s CCBHC will provide rapid assessment and triage into behavioral health services and targeted case management as needed. LUK’s CCBHC will utilize evidence-based models such as High Fidelity Wraparound and Motivational Interviewing. With our Designated Collaborating Organization (DCO), Community Health Connections, we will achieve the goals of the project, which include development of the infrastructure to support the CCBHC, completing required activities to achieve CCBHC status, and supporting consumers’ recovery from mental illness and/or substance use disorders. The number of unduplicated individuals to be served each year is as follows: Year 1 – 250, Year 2 – 350, Year 3 – 400, Year 4 – 500, for a total of 1,500 CCBHC consumers over the four years of funding.

All Faiths Children’s Advocacy Center (AFCAC) has been serving families in the New Mexico community since 1956, offering a variety of quality behavioral health services. There is a need to increase services to address substance use, suicidality, and mental health in New Mexico. New Mexico continues to have unmet needs and behavioral health disparities for serious mental illness, substance use disorder (SUD), individuals with co-occurring disorders (COD) and children and youth with serious emotional disturbances. Service gaps include lower accessibility to services, lack of substance use disorder and mental health providers, and lack of transportation. CCBHC PDI funds will be used to increase outreach and access to behavioral health treatments and build our capacity to provide comprehensive, higher acuity care for adults, adolescents, and children and increase the number of patients we serve. In CY2022 we served 2,931 patients. We anticipate 775 individuals to be eligible for CCBHC services in Year One, 825 in Year Two, 925 in Year Three, and 1,125 in Year Four. By the end of the four year grant period, we expect to serve 1,325 unduplicated patients. Our goals are to decrease health disparities for SUD and COD, enhance access to behavioral health services for families, and commence substance use disorder services. We will do this by establishing a school district partner in Valencia County, increasing services for veterans, closing racial/ethnic disparities affecting access to behavioral health services, hiring nine culturally reflective staff to reduce our current waitlist, enhancing our data collection of sexual orientation and gender identity (SOGI) information, expanding our delivery of telehealth services, applying for and obtaining our SUD license, launching SUD services and beginning referrals for SUD services.