In Linn County, IA, Abbe Center CCBHC Project will implement strategies to engage individuals who are "at-risk" for readmission to the Behavioral Health inpatient. "At-risk" is determined by a hospital admission within the last year 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 and co-occurring disorders. In 2021, Abbe Center served 8,351 individuals in these categories, estimating 5% "at-risk."
Abbe Center CCBHC will serve 350 unduplicated individuals determined to be "at-risk" each year, for an unduplicated four-year total of 800 individuals served.
Nature of the problem: High incidence of people being readmitted to the hospital due to lack of engagement, timely access to services and/or understanding how to navigate the service system.
Goal 1: Decrease inpatient behavioral health readmission rate for CCBHC clients by 25% by providing timely access to services, enhancing engagement and care coordination to individuals identified as "at-risk."
Objective A: Engage "at-risk" individuals and coordinate behavioral health services.
- By January 2023, 60% of individuals "at-risk" will receive outreach/care coordination.
- By April 2023, conduct a literature review and environmental scan for research informed practices related to transitions of care.
- Based on literature review, use implementation science to evaluate at least one transition of care research informed best practice by September 2026.
- By September 2023, the outreach team will facilitate connecting 75% of their eligible clients to a community based or Integrated Health Home program for longer term support.
Objective B: Provide timely access to prescriber and community-based services.
- By September 2024, Abbe Center will expand an established urgent care track to include 24 hours per week availability for urgent timeslots in the clinic and through the Access Center.
- By September 2025, 50% of clients referred by Outreach will be enrolled in community-based service within 15 days from referral.
Nature of the problem: Individuals have more risk factors than are being identified.
Goal 2: Increase comprehensive screening activities to ensure individuals receive the resources needed to maintain their health and well-being.
Objective A: Increase health screenings to provide more integrated care.
- By September 2024, increase primary care screening and monitoring by 50%
- By September 2025, increase primary care services onsite by 25%
- By September 2024, increase screening and referrals for substance use disorder by 50%
- By September 2025, increase substance use disorder services onsite by 25%