Peace River Center (PRC) is a community behavioral health center serving Central Florida which will implement the Certified Community Behavioral Health Clinic (CCBHC) Initiative to improve the overall health of the community it serves by transforming the organization to meet CCBHC criteria. The CCBHC Initiative will increase availability and accessibility of integrated primary care and behavioral health services for vulnerable populations.
The population of focus are individuals with serious mental health and/or substance use disorders, with specific subgroups in the population of focus prioritized for certain services. To better serve all individuals seeking service, PRC will redesign their access system to ensure all recipients are thoroughly screened, assessed, and linked to the services that best meet their needs in a timely manner. Peace River Center currently offers primary care services for adults only in one outpatient clinic, which will be expanded to rural areas and to children and veterans. People with behavioral health conditions are at increased risk for diabetes, obesity, heart disease, HIV, and other diseases, so it is vital that they have access to preventive and primary care. Integrating behavioral and primary healthcare will ensure that all health providers are communicating and planning treatment together. For adults diagnosed with an opioid use disorder (OUD), PRC will enhance its medication assisted treatment capacity by adding provision of buprenorphine products. With the alarming increases in overdose deaths primarily due to fentanyl, PRC must ensure access to the gold standard of care for OUDs. Lastly, care coordination activities will be expanded from only serving adults exiting crisis settings to anyone with a SED, SUD, or SMI who is not connected to needed services and psychosocial supports. It is anticipated that the project will serve 120 unduplicated individuals in Year 1, 135 in Year 2, 145 in Year 3, and 150 in Year 4, for a total of 550 individuals over the lifetime of the project.
Primary focus of PRC’s CBHC Initiative is to expand its service array to fully meet the CCBHC criteria, which in turn will improve service delivery in the catchment area. The first goal of the project is to improve timely access to the appropriate service level(s) by reducing time from screening to initial intake assessment from 18 to under 10 days and lowering recidivism related to inpatient stays through active service engagement to 15% or less. The project also aims to improve health outcomes for individuals with SMI, SED, and SUD by integrating primary care and behavioral health with the objectives of screening and monitoring at least 90% of patient’s key health indicators and health risks, ensuring at least 95% of those who need additional health care services are linked, and at least 90% of tobacco users receive counseling on smoking cessation. The third project goal is to decrease adult opioid misuse and its negative consequences by implementing buprenorphine treatment and community NARCAN® distribution. It is anticipated that 65% of patients served will decrease opioid use, thereby decreasing drug-related mortality and increasing recovery capital. Lastly, the project aims to increase access to integrated, high-quality care coordination services with the objectives that 75% of patients will receive a follow-up contact within 3 days of a pending outpatient appointment and within 1 day of a missed (non-show) outpatient appointment, 90% of patients will be assessed for eligibility for enrollment in health insurance coverage options and of those, 65% will successfully achieve enrollment, and 90% of individuals and families served will rate their participation in care coordination as positive through quarterly satisfaction surveys. A CCBHC Advisory Board composed of community stakeholders, family members , and individuals with lived experience will oversee project implementation and quality improvements.