Ibn Sina Foundation Mental Health Screening, Assessment, and Treatment (SAT) Project - PROJECT NAME: Ibn Sina Foundation Screening, Assessment, and Treatment (ISF SAT) Project POPULATION TO BE SERVED: The ISF SAT Project will serve uninsured and low-income residents of Harris, Fort Bend, and Brazoria Counties ages 18 and older with substance use and/or mental health disorders. ISF patients are predominantly Hispanic/Latino, Black, and other people of color, who are more to behavioral health problems and less likely to seek treatment than their White counterparts and people with higher incomes. A pilot project, the ISF SAT will take place at Wilcrest and South Post Oak Medical Centers. Upon successful completion of the pilot, the project will be expanded to all six ISF sites. SERVICES TO BE PROVIDED: ISF will hire two Community Health Workers (CHWs) to screen all patients for depression, anxiety, and/or substance misuse, three major causes of disability. CHWs will also screen for health-related social needs and make needed referrals to community-based resources (e.g., for housing, food, income supports, and employment). Patients screening positive for behavioral health problems will be referred to one of six Behavioral Health Care Managers (BHCMs) trained to provide evidence-based interventions. The. BHCMs will be supported by a psychiatrist or psychiatric nurse practitioner with whom they meet regularly, and will use an automated patient registry tracking system to monitor patient outcomes. They will work closely with other members of the primary care team to coordinate the delivery of medical and behavioral health services. Each BHCM will carry an average caseload of 60 to 80 patients, for a total of up to 480 patients. The University of Washington AIMS Center will provide training, technical assistance, consultation, and mentoring. GOALS AND MEASUREABLE OBJECTIVES: Goal 1: Integrate the CoCM into adult primary care practices at Wilcrest and South Post Oak Community Medical Centers. Objectives: 1.1. No later than 8/31/2023, execute a one-year contract with the AIMS Center at the University of Washington for training and technical assistance; 1.2. No later than 12/31/2023, complete pre-implementation planning in collaboration with the AIMS Center to facilitate the effectiveness and sustainability of practice change, including cultivation of leadership buy-in and development of clinical and operational workflows, billing/financing strategies, metrics, and the patient registry, 1.3. No later than 12/31/2023, complete online training of BHCMs, primary care providers, psychiatrists/ psychiatric nurse practitioners, and ancillary staff; 1.4. Beginning 1/1/2024, monitor project implementation using registry reports and with technical assistance from the AIMS Center; 1.5. No later than 3/31/2024, complete training of BHCMs in evidence-based therapies and training of primary care providers in behavioral health conditions and psychopharmacology; 1.6. No later than 9/29/2024, complete preliminary evaluation and plans for scaling and sustainability. Goal 2: Screen 75% of Wilcrest and South Post Oak adult patients for substance misuse, depression, and anxiety. Objectives: 2.1 No later than 8/31/2023, develop and pilot-test screening methods and workflow, to include automated administration of the PHQ-9, GAD-7, and ASSIST in clinic waiting areas; 2.2 No later than 9/29/2023, recruit and select CHWs to begin work on 9/30/23; 2.3 No later than 10/31/2023, train CHWs in motivational interviewing, clinical workflow, and administration of automated screenings; 2.4. No later than 9/29/2024, screen 75% of patients (4,500 of 6,000) for substance misuse, depression, and/or anxiety and refer them as indicated to BHCM. Goal 3: Engage 75% of patients screening positive for behavioral health problems in evidence-based treatments. Objectives: 3.1. No later than 9/29/2024, refer at least 675 patients screening positive to BHCMs; 3.2. No later than 9/29/2024, engage 75% of patients (506 of 675) in treatment.
