MLCC, a PA CCBHC & Expansion Grant awardee will further increase access and capacity & enhance and expand services to SUD, SMI through complex care coordination, partnerships & enhanced clinical teams - Through the CCBHC-IA (Improvement and Advancement Grant) project, Mercy Life Center Corporation's (MLCC) goal is to increase access to and improve coordination of primary care and CCBHC services at MLCC to provide comprehensive patient screening and effective treatment services to people from four identified vulnerable populations (homeless, justice informed, veterans, and at-risk co-occurring behavioral health and SUD clients not engaged in behavioral health services in Allegheny County, Pennsylvania. This will be accomplished through collaborative partnerships, enhanced clinical treatment teams, and comprehensive care coordination. MLCC proposes utilizing a data driven framework that defines and measures the clinical interventions, processes and workflows that support the objectives related to this goal that will ensure a high degree of fidelity. Therefore, system-wide practices will be implemented to collect and utilize individual and population-based data to inform decision that improve quality, efficacy and value. Provision of services will include 1) outreach to clients from vulnerable populations leading to enrollment to MLCC's primary care services and nine core CCBHC services, screening, monitoring and tele-psychiatry and tele-consultation 2) Care management and care planning focused on risk stratification and using predictive risk analytics to guide intervention activities and evidence-based practices 3) Coordination and linkage to housing stability resources 4) Measurement of utilization and effectiveness of EBPs utilized to treat the target populations. Population focused services will 1) effectively engage , screen, assess and coordinate care through a complex Care Management Model, 2) provide increased access to MH, SUD and COD treatment and primary care as will as ancillary services 3) institute a safety net for community providers to coordinate and access care across systems, 4) provides access to tele-psychiatry and teleconsultation services to address gaps in care related to readiness to engage, social disparities and provider shortage areas. These key areas address several risk factors that affect the target populations including the lack of care coordination for the most vulnerable person in our communities as well as the significant mortality gap in which people with mental illness are more likely to die earlier, be incarcerated, experience homelessness, and have co-occurring health conditions than the general population. Better outcomes will be accomplished by improving access to the primary care and nine CCBHC core services which includes SUD treatment and homeless services as well as addressing access to provider shortage and barriers to accessing traditional behavioral health care. Throughout the life of the grant 540 unduplicated individuals from the target populations will be served with 2,566 assessments completed. The project will utilize the Evidence-Based Practices (EBPs) of illness management and recovery (IMR), Motivational Interviewing (MI), Harm Reduction, and trauma informed approaches and interventions, to engage and maintain individuals in services. MLCC, by building upon the CCBHC model, will increase capacity and outcomes for the target vulnerable population by meeting the following objectives: (1) MLCC, will increase access to physical health care services for person from our identified vulnerable populations of homeless, justice informed, veterans and at-risk clients not engaged in co-occurring MH and SUD who are referred to or receive one or more of our nine CCBHC core services by 5% each year and 20% over the life of the grant. (2) MLCC will screen 540 unduplicated clients and increase the number of persons linked each year by 10% (40% over the lifetime of the grant) from vulnerable populations of homelessness, justice informed, veterans, and at risk co-occurring behavioral health and SUD clients not engaged in services to one or ore of the nine CCBHC core services.
