Achieve, serving Rockland and Orange counties in NY, has participated in the CCBHC demonstration project since 2017. It has dramatically reduced hospitalization and emergency department (ED) utilization despite increasing clinical complexity and severity. Through this CCBHC improvement and advancement (CCBHC-IA) grant, we will extend our highly effective crisis hotline and mobile crisis team services to all individuals in the community. Thereby addressing the failure of BH crisis services unable to keep pace with demand for service, population growth, and the strain of service capacity.
We will use our successful existing CCBHC protocols and models to create a community-based crisis response system accessible to all individuals in our catchment area. Community crisis response services provide crisis de-escalation, stabilization, assessment, and linkage to care through a 24/7/365 crisis hotline and mobile crisis response team that brings crisis services to the person where and when they need them. Crisis hotline calls are triaged and responded to by trained staff (peer, psych rehab, or clinician) and assessed for severity, risk, and needs. If a mobile crisis response is warranted, we will dispatch a two-person mobile crisis team comprised of a licensed clinician and certified peer specialist. Based on each persons social context, we will build on strengths congruent with culture, race, age, sexual orientation, and health needs throughout the crisis. Person-centered and trauma-informed care, recovery, and behavioral health equity are core values of the program. Clinical supervisors and psychiatrist/nurse practitioners in psychiatry will always be available for telehealth consultation and are part of the team.
Once the situation is assessed and stabilized, a safety plan is in place; the team ensures continuous care with the clients provider through a warm handoff by the care manager (CM), who will also address service gaps. Suppose the individual does not have an identified provider or treatment system. In that case, the CM ensures rapid warm handoff to Achieve, or another appropriate service provider of the clients choice, for an expedited intake to begin services without barriers. To ensure they receive and are engaged in services, follow-ups with the client and receiving providers will be made within 3-5 days. Peers remain engaged with the client until participating in the new treatment.
If an imminent risk to oneself or others is identified, the team will engage EMS and/or law enforcement and proceed accordingly. In the unusual situations where ED or hospitalization is necessary, we will support families, set expectations, and facilitate access to available inpatient beds. Achieve will work closely with EMS and law enforcement and provide cross-system training for emergency responders and partners on recognizing MH symptoms and how (and when) to refer or connect people to mobile crisis teams. To ensure meaningful involvement in the design, monitoring, and evaluation of program services and provide meaningful input to our board, Achieve will convene stakeholder meetings and discussion groups with the community (consumers, family members, community leaders, and advocates).
We will increase our offerings of culturally responsive and sustainable BH and SUD services and expand access to more than 1,079 unique individuals across the lifespan, including a five percent increase each grant year. In alignment with community needs, our goals and measurable objectives include fully implementing the 24/7 crisis response team by the fourth month of the project, advancing the teams skillsets using EBPs, improving community health outcomes, lowering ED and psychiatric hospitalization, enhancing data interoperability and data utilization, and strengthening community partnerships and collaborations with EMS and healthcare providers.
