The PCMH CCHBC Program will reduce the number of re-hospitalizations for PCMH clients by creating a menu of culturally and linguistically appropriate expanded behavioral health services - The Postgraduate Center for Mental Health (PCMH) proposes to provide a full continuum of co-located, clinical, residential and rehabilitation services to homeless (medically engaged), mentally ill, low-income individuals, families, veterans and children ages 5-17 living in the Bronx, Brooklyn, Queens and Manhattan boroughs. Unmet mental health needs were identified among these community's top five priorities. In Bronx County, poverty (31%) is one of the major trigggers for homelessness among the mentally ill. Also, drug related hospitalizations of 1761 and 1025 per 100,000 population, respectively in the Bronx and Manhattan, as well as alcohol related hospitalizations of 1633 and 1084 per 100,000, respectively, in the same areas and overdose deaths, which have risen by 66% over the past five years, document a disproportionate impact in low-income areas. Thus, the proposed goal of the CCBHC Program is to reduce the number of re-hospitalizations for PCMH clients by creating a menu of culturally and linguistically appropriate (CLAS) expanded behavioral health services that address and/or impact each client's psychological functioning, social functioning, therapeutic engagement and social network supports. A secondary goal is to monitor the client's performance and psychosocial changes during treatment as an indicator of their ability to master these measures, at their own pace and without the disruption of being re-hospitalized. The objectives supporting the above goals are: 1. By 9/29/2020 improve and enhance the menu of CLAS mental health and crisis services e.g., an ACT Team by 10% to reduce the number of critical incidents experienced by current clients. 2. By 9/29/2020 access to comprehensive, fully integrated primary care/behavioral health services at the Bronx (Adult and Child) and Manhattan (CAP) clinics will be improved by 20% thereby decreasing the incidence of homelessness and re-hospitalizations. 3. By 9/29/2020 add an ACT Team to reduce the number to reduce the number of hospitalizations/re-hospitalizations attritubed by exacerbations of poorly managed/coordinated diabetes and hypertension by 10%. 4. By 9/29/2020 implement 30 evidence based emergency interventions, including adding a RN to the Mobile Crisis Team, telepsychiatry and an EmPath Unit, to prevent hospitalizations. 5. By 9/29/2020 reduce re-hospitalizations by 20% with the addition of targeted case managers and/or navigators to ensure proper discharge comprehension and better post-care follow up. 6. By 9/29/2020 the use of medication assisted therapy (MAT) such as Buprenorphene, to prevent the effects of medication non-compliance will be increased by 10%. 7. By 9/29/2020, outcomes for child-age (5-17) clients of the Bronx Clinic will be improved by 15% through implementation of an evidence based surrogate support system for parents in crisis, such as the Family-Based Treatment Program or the Teaching Family Homes Program. NOTE: Baselines numbers = values present prior to implementing mental health expansion. PCMH proposes to serve a total of 1,200 unduplicated clients: 1,100 adults and 100 children - 45 SED adults , 425 SU/MH/COD adults and 630 SMI/COD adults - by the end of Year 2: 9/29/2020.
