Egyptian Health Department’s (EHD’s) CCBHC will ensure people living with SMI/ SED/ SUD/COD in Gallatin, Saline, and White counties have access to comprehensive, evidence-based behavioral health (BH) and primary care (PC) services needed to attain recovery and well-being. The CCBHC will increase access to a comprehensive array of evidence-based practices (EBPs) to address the needs of the rural community. EHD will serve 2,500 clients annually with CCBHC-required screenings and coordination with primary care. Over the two-year grant, EHD will expand intensive services to 800 clients with complex needs (600 adults and 200 youth). The intensive service array will include ACT, IPS, Supported Education, High-Fidelity Wraparound, integrated care coordination for complex BH/physical health (PH) conditions, case management and AOT for court-ordered individuals, crisis follow-up and stabilization for adults, targeted veteran services, and telehealth for clients discharged from psychiatric hospitals.
EHD’s primary goals and highlighted objectives include: 1) Implement CCBHC criteria: a) By month 4, hire a psychiatric nurse practitioner and establish an ACT team; recruit, hire, and train all other project staff; b) Establish an advisory work group comprised of at least 51% CCBHC enrollees and family members. 2) Universally screen and monitor health: a) Screen and monitor health indicators for 100% of enrollees; b) Screen and monitor prevalence and risk of diabetes for 100% of enrollees on psychotropic medications; c) Document that 100% of enrollees receive routine follow-up. 3) Ensure access to PC and continuity of care: a) 100% of enrollees with complex BH/PH needs will have a designated care coordinator; b) All existing clients will have a designated PC provider within 4 months; c) Pilot telehealth services to follow hospital discharge by month 4, and provide integrated telehealth to at least 50 people post-discharge by year 2.
4) Provide coordinated care for clients with complex BH needs: Identify and enroll 100% of eligible adults in ACT or Community Support; b) Provide or ensure referral to Wraparound services for 100% of eligible children. 5) Expand psychosocial rehabilitation services: a) Refer and enroll at least 5 adult clients into IPS and 5 youth clients into supported education each month in year 1; b) At least 25% of participants receiving IPS will obtain employment after 1 year of participation and at least 40% will have obtained employment after 2 years; c) Enroll 75% of court-ordered individuals into case management and AOT. 6) Increase services to veterans: Serve at least 100 Veterans with SMI/SUD by year 2. 7) Decrease health risk: 50% of enrollees with elevated health indicators at enrollment will experience a clinical improvement after 12 months. 8) Decrease substance use: a) Refer 100% of enrollees who screen positive for tobacco or substance abuse to intervention or treatment; b) 75% will participate in intervention or treatment within 30 days; c) 40% of enrollees with SUDs at baseline will reduce substance use after 12 months. 9) Decrease use of restrictive settings: Monitor and develop QI plans to address the use of restrictive settings, and reduce high utilization by month 21.