CREOKS CCBHC Expansion Project (C-CEP): Mobile Crisis, Health Home Teams, and Primary Care for Rural Oklahoma, Prioritizing Veterans and Welfare/Juvenile Justice Involved Children - The "CREOKS CCBHC Expansion Project (C-CEP): Mobile Crisis, Health Home Teams, and Primary Care for Rural Oklahoma, Prioritizing Veterans and Welfare/Juvenile Justice Involved Children" addresses unmet psychiatric, substance use, and medical needs for seven rural counties with an area population over 310,000 that have suicide rates nearly twice the national average, drug overdose deaths 33% higher, and death due to coronary artery disease three times higher.
These conditions appear disparate but effective interventions for all three lie in detection and early intervention through assertive outreach as well as the management of risk factors and the promotion of supports that lead to improved functioning and quality of life. To this end, C-CEP has adopted the following goals: (1) increase access to services for adults with serious mental illness (SMI), adults with substance use disorders (SUD), including opioid use disorders; children and adolescents with serious emotional disturbance (SED); individuals with co-occurring disorders (COD); and, prioritizing veterans and welfare/juvenile justice involved children by assertive engagement, augmenting needed services, and increasing enrollment; (2) reducing emergency department, hospital utilization, and suicide through improving depression screening and treatment as well as post hospital/crisis center follow-up care; (3) improving the functioning of families with children at risk of out of home placement, school suspension, and law enforcement involvement through wraparound services; (4) improve preventive care with screening and early intervention; and (5) improve chronic disease management through effective risk factor control. C-CEP employs mobile crisis teams to engage people in the community who need services and the project works to reduce the wait times between first contact and treatment. Services have been augmented to provide for Health Home teams. Theses interdisciplinary teams provide wraparound supports that can address psychiatric, substance use, and medical needs at the same time. Due to vulnerabilities and an acute lack of services in our communities, veterans and welfare/juvenile justice involved children are prioritized for Health Home team care. There is an emphasis on detection and early intervention. C-CEP conducts a variety of screens to identify substance use, depression, suicidal ideation, metabolic syndrome, and other risk factors for treatment. Primary care screening and monitoring of key health indicators and health risk are offered to all persons and medications are made available to treat psychiatric, substance use, and coronary artery disease. Outcomes are measured in numbers of new adults and children served, number of persons receiving mobile crisis services, numbers of veterans and welfare/juvenile justice involved children receiving Health Home services, screening and documented follow ups for risk factors, reduction in PHQ-9 depression scores, reduction in school days missed, reduction in law enforcement contact, reduction in self-harm, controlling HbA1c < 8%, controlling blood pressure < 140/90, and maintaining LDL-C < 100 mg/dL. C-CEP will serve 5,000 adults and children in year one and 10,000 over the course of the two-year project.
