Overview: Health Care and Rehabilitation Services of Southeastern Vermont, Inc. (HCRS) proposes CCBHC Planning, Development, and Implementation (PDI): Addressing Health Disparities in the Rural Setting. With CCBHC-PDI funds, HCRS will serve more than 2,500 children, adolescents, and adults with mental health or substance use disorders each year in Vermont’s rural Windham and Windsor counties.
Project Title: CCBHC Planning, Development, and Implementation (PDI): Addressing Health Disparities in the Rural Setting
Population: The populations of focus are children, adolescents, and adults with mental health or substance use disorders in two adjacent rural counties of southeastern Vermont.
Strategies: Transform and improve the local community behavioral health system, (2) provide comprehensive, coordinated behavioral health care, and (3) enhance care coordination in order to improve care access and healthcare outcomes for the project’s population of focus.
Summary overview of goals and objectives:
Goal 1: Identify and create a plan to address the healthcare needs of adults and children in the catchment area with a focus on those experiencing disparities in access to, and outcomes from, mental health and substance use disorder services.
- Complete Community Assessment (CA).
- Create a written staffing, training, and service plan.
- Update CA and adjust CCBHC plan.
Goal 2: Improve access to services for the populations of focus by enhancing care coordination infrastructure and partnerships.
- Establish an Enhanced Care Coordination program to standardize partnerships and provide enhanced care coordination to clients with complex needs.
- Develop a platform for its Electronic Health Record (EHR) to track external hospital admissions and discharges.
- Identify active and potential care coordination partnerships.
- Standardize care coordination agreements with 50 of the partner organizations.
- Establish care coordination partnerships with five Medication Assisted Treatment (MAT) providers, the VA, and 15 primary care practices.
Goal 3. Provide comprehensive, coordinated mental health and substance use care aligned with CCBHC certification criteria and SAMHSA funding requirements to the population of focus.
- Finalize data collection, performance measurement, and data reporting processes with EHR integration.
- Ensure 100% of HCRS policies and procedures align with requirements.
- Complete an organizational project to increase frequency of client assessments.
- Create a written sustainability plan.
- Expand primary care screening to all clients.
Number served: CCBHC Planning, Development, and Implementation (PDI): Addressing Health Disparities in the Rural Setting will serve 2,600 individuals in year one, 2,750 in year two, 2,850 in year three, and 3,000 in year four, or 11,200 over the lifetime of the project.