In Linn County, IA, Abbe Center CCBHC Project will implement strategies to engage individuals who over-utilize or are "at-risk" for presenting at the emergency department (ED) instead of utilizing more cost-effective community-based services due to lack of engagement, timely access to services and/or understanding how to navigate the service system.
Current populations served are children and adults with mental illness, serious mental illness, serious emotional disturbance, substance use disorders & co-occurring disorders. In 2019, Abbe Center served 7,144 individuals in these categories. It is estimated that 15% of these individuals will be determined "at-risk."
The population of focus for this grant is "at-risk" individuals as determined by the following criteria: 1) being recently discharged from the ED or inpatient unit after a behavioral health visit; 2) utilizing a mobile crisis or crisis stabilization service; 3) having an interaction with law enforcement due to a behavioral health reason; or 4) having an urgent social determinant of health need. Abbe Center CCBHC will serve 1,072 unduplicated individuals determined to be "at-risk" each year (1,608 unduplicated over the 2-year grant project period).
Project Goal 1: Decrease ED utilization by CCBHC clients by 20% by providing timely access to services and enhancing care coordination to individuals identified as "at-risk".
Objective A: Engage "at-risk" individuals and coordinate behavioral health services.
1. By January 1,2021, Implement a "One Step" referral process for quick engagement of clients from the ED to Abbe. 75% of the people referred from the ED will engage by having a service with Abbe.
2. By August 29, 2021, 60% of individuals "at-risk" will receive outreach/care coordination.
Objective B: Provide timely access to services through urgent care services and Access Center.
1.By April 30, 2021, Abbe Center will expand an established urgent care track to include 20 hours per week availability of Prescriber services.
2. By August 29, 2021, increase by 50% law enforcement "drop-offs" at an Access Center.
Project Goal 2: Integrate the management of physical health and behavioral health by creating and implementing care pathways for clients with diabetes, smoking, and cardiovascular disease.
Objective A: Increase the number of clients who are actively engaged with their PCP.
1. By July 1, 2021, implement tracking of primary care visits and work with clients identified as "at-risk" to ensure at least 70% have had at least one primary care visit with in the last year.
2. By April 1, 2021, Abbe will co-locate a primary care provider within the CMHC setting and develop an integrated workflow to co-manage healthcare needs.