The Community Health Center of Buffalo, Inc. (CHCB) will transform behavioral health services in Erie and Niagara Counties by establishing a Certified Community Behavioral Health Clinic within a Federally Qualified Health Center. New services will fill major gaps in access to culturally sensitive person-centered, recovery-focused care targeting low-income Black, Indigenous, and People of Color (BIPOC), service members/veterans, refugees, and the re-entry populations. Behavioral health is a critical but frequently unaddressed concern for low-income BIPOC. The targeted population is at higher risk for behavioral health disorders and trauma with symptoms that are undiagnosed, under-diagnosed or misdiagnosed for cultural, racial or linguistic reasons. Patients seek out CHCB’s services “because staff look like us and respect us.” Number to be served: Year 1 (1,000); Year 2 (1,100); Year 3 (1,200); Year 4 (1,200). Total = 4,500 (> 60% BIPOC).
Goal 1: Within 4 months, complete a community needs assessment (& during the third year).
Objective 1: Within 3 months, complete assessment of behavioral services in Erie/Niagara.
Objective 2: Within 4 months, conduct focus groups in Buffalo and Niagara Falls to identify cultural, linguistic, and treatment needs and understand racial disparities.
Objective 3: Within 4 months, conduct interviews with 20 representatives of the target population.
Objective 4: Within 4 months, conduct a consumer and family member survey (50 people).
Objective 5: Within 4 months, complete a behavioral health workforce assessment and select at least one job title to include in CHCB’s workforce training program.
Outcome: Utilize the needs assessment to inform staffing and CCBHC services development.
Goal 2: Increase access to collaborative, person-centered culturally competent CCBHC nine core services buttressed by care coordination and community partners for 4,500 individuals (4 years).
Objective 1: Within 4 months form a CCBHC Advisory Board consisting of 51% consumers.
Objective 2: Within 4 months, develop a plan, hire X new staff, and begin transforming existing behavioral health services by expanding existing services and adding new CCBHC services.
Objective 3: Within 4 months, initiate CCBHC performance measurement framework (CQI).
Objective 4: Within 4 months expand health behavior and medication adherence assessments Objective 5: Within 6 months, begin implementing CCBHC 9 core services.
Objective 6: Within 12 months, develop, and implement a sustainability plan.
Goal 3: Reduce health disparities by working with diverse partnerships to develop programming.
Objective 1: Within 60 days, initiate outreach plans to work with work community organizations serving people of color and overcome stigma by disseminating testimonials.
Objective 2: Provide services for at least 60 service members/veterans annually (work with VA).
Objective 3: Enter into arrangements with the Tuscarora Indian Health Services and the Urban Indian Institute to serve at least 40 Native Americans annually and provide education.
Objective 4: Provide cultural/linguistically competent CCBHC for at least 100 refugees annually.
Objective 5: Provide CCBHC services for at least 100 Criminal Justice re-entry citizens annually.
Goal 4: Reduce behavioral health hospital admissions/30-day readmissions.
Objective 1: Reduce suicide attempts and deaths by providing: suicide safer care training, community screenings; early intervention; treatment, and Mental Health First Aid Training.
Objective 2: Track when admissions and discharges from psychiatric inpatient facilities and schedule appointments within 7 days or sooner based on the discharge plan.
Objective 3: Create a dedicated CCBHC Interdisciplinary Transitions of Care Team, that includes peer specialists to reduce 30-day readmissions by working with high risk individuals.
Outcomes: Increased access to collaborative behavioral health services will reduce disparities.