Sunday, November 24, 2024
11/24/2024
The Family Center of Brooklyn, NY CCBHC Service Improvement project will serve all populations of focus, improving behavioral and health outcomes through enhanced trauma-informed screening and behavioral health treatment, expanding care coordination for vulnerable CCBHC clients wit multiple chronic health conditions and risks, and implementing targeted case management, engagement, and follow-up services using the Critical Time Intervention model to ensure continuity of care after in-patient MH and SUD treatment episodes and overdoses. Demographic characteristics of the high-risk Central Brooklyn populations served will be: Over 90% will be members of underrepresented minority groups, 76% African American, nearly 13% Hispanic, less than 10% non-Hispanic white. Twenty percent of residents are foreign born, mostly from the Caribbean or Central America, with 90% being English proficient from Trinidad, Jamaica, and Guyana. The median age is 32.8 (slightly younger than NYC overall). Nearly 58% of the population 18 years and older is female. The clinical profile will be: 40% of adults above the 80th percentile of disability on the WHODAS, 20% above the moderately severe level for depression, 15% severely anxious, 6% homeless, and 55% unemployed and not seeking work. The majority of TFC-CCBHC consumers have primary diagnoses of SUD/COD; 13% of adults have "substantial" or "severe" drug abuse and indicate hazardous or harmful alcohol use; 23% of children/youth screen into the medium to high-risk range for substance abuse. High rates of pre-diabetes, diabetes, HIV, and other co-morbidities mirror community rates. Goals and measurable objectives include: Goal 1: Reduce the impact of trauma, including COVID-related trauma, on the behavioral health of those enrolled in the CCBHC and their families. Objectives: screen 100% of the CCBHC enrolled population for the impact of trauma on behavioral health (BH) and well-being; initiate a mindfulness intervention for consumers with positive trauma screens to enhance coping skills for anxiety, depression, emotional distress, using DBT mindfulness groups mindfulness-based cognitive therapy (MBCT); implement routine telehealth Peer/Case Manager check-ins for 100% trauma-impacted consumers/those in significant distress; conduct BH needs assessment of catchment area. Goal 2: Improve health and treatment outcomes via enhanced health screening, emphasis on medical outcomes in treatment planning, wellness education/support, and coordination with primary/specialty medical care. Objective: By Project Month [PM] 5, 85% of consumers determined to have or be high-risk for metabolic disease, HBP, HIV and other co-morbidities will receive monthly medical monitoring/support; 75% will show health marker improvements after 6 months and show significant BH treatment gains compared to those with no improvement. Goal 3: Provide new team-based intensive transitional care during high-risk care transitions, including post-release from in-patient psychiatric or residential SUD treatment, using the Critical Time Intervention model. Objectives: By PM 5,initiate intensive transitional care; 70% of consumers enrolled in intensive transitional care will remain engaged in care for at least 3-months following each transition, as measured by service data; For SED and SMI clients receiving team-based transitional care following discharge from in-patient settings, reduce the 30-day psychiatric hospital readmission rate to 15% below area baseline; By PM 3, implement enhanced pre-release collaborative discharge planning for 100% CCBHC adults and youth completing residential SUD treatment. A total of 800 adults and 300 children/youth will be served, with 200 adults and 75 children/youth served each of the 4 Project Years.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).
