The Kentucky Department for Behavioral Health/Developmental and Intellectual Disabilities will implement Kentucky Care Integration (KCI), promoting primary and behavioral health care integration between selected providers, Centerstone of Kentucky and Mountain Comprehensive Care Center (MCCC), and federally qualified health centers, Family Health Centers and HomePlace Clinics. KCI will serve Kentucky focus populations who have behavioral health conditions and physical health conditions or chronic diseases.
Centerstone will serve a total of 625 adults (Yr 1: 75; Yrs 2-3: 125, annually; Yrs 4-5: 150, annually) with substance use disorder (SUD) who have/are at risk for co-occurring physical health conditions/chronic diseases in Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer, and Trimble counties. The focus population is predominately male (52%) and white (84%), with 67% unemployed and 27% acquiring less than a high school education. Nearly 70% of clients with SUD use opioids; prevalent physical health conditions include hypertension (21%).
MCCC will serve a total of 500 individuals (Yrs 1-5: 100, annually), including adults with mental illness, serious mental illness, and SUD, and children/adolescents with serious emotional disturbance who have/are at risk for physical health conditions/chronic diseases in Floyd, Johnson, and Pike counties. MCCC’s focus populations are primarily white (99%) and disproportionately impacted by poverty. Among those with SUD, 58% are male, 89% live below poverty, 35% are unemployed, and 38% have less than a high school education. The focus population with mental illness is 51% female, and 77% live in poverty, 14% are unemployed, and 25% have attained less than a high school education. Among the focus population with SMI, 60% are female, 82% live in poverty, and 42% have less than a high school education. The focus population with SED is 61% female and 78% live in poverty. Approximately 34% of MCCC clients experience anxiety disorders, 36%, hypertension, and 16%, diabetes.
KCI will provide bidirectional and co-located integrated services related to the screening, diagnosis, prevention and treatment for the focus populations, implementing the Chronic Care Model and the following evidence-based/informed practice strategies/interventions: Integrated Dual Disorders Treatment, Twelve-Step Facilitation, The 4 R’s and 2 S’s for Strengthening Families Program, Whole Action Health Management, Nutrition and Exercise for Wellness and Recovery, and DIMENSIONS. Project goals include: establishing comprehensive health homes and wellness services; enhancing infrastructure/capacity to sustain services; improving client health status/outcomes; and developing/disseminating a replicable service model. Measurable objectives include: decreased risk factors related to hypertension, diabetes, hyperlipidemia, nicotine dependence, obesity, etc. for 30% of clients; decreased mental health symptomatology by 35% for SMI, 60% for mental illness, and 45% for SED clients; substance use abstinence by 45% for clients with SUD; and improved functional outcomes for 80% of clients with SMI and SUD. A multidisciplinary, integrated care team, including an integrated care manager, primary care provider, care coordinators, counselors/clinicians, peer wellness specialists, etc., will help clients develop/implement individualized care plans. KCI will utilize a meaningful-use certified EHR, population management tools, and data-sharing protocols across providers. KCI has obtained and will continue to pursue key community partnerships with other behavioral/primary health care providers and supports, nonprofits, and faith-based organizations.