Pesach Tikvah CCBHC will provide a broad range of accessible, affordable, culturally appropriate, bilingual integrated outpatient MH, physical health monitoring, SUD services and care coordination.to serve an unduplicated 800 individuals with CCBHC IA grant funding (200 annually). Services will be delivered in the Williamsburg and Borough Park neighborhoods in Brooklyn, New York to adults with serious mental illness (SMI), substance use disorders (SUD), opioid use disorders (OUD) and co-occurring disorders (COD), as well as children and teens with serious emotional disorders (SED) and their family members. PT will focus on people of Orthodox Jewish/Hasidic (Orthodox) ethnic group to reduce disparities in healthcare access and outcomes. Orthodox typically have large family sizes and struggle with significant disparities in income, healthcare access and outcomes. They experience heightened barriers to accessing care due to high rates of stigma, low socioeconomic status, cultural and language barriers. Grant goals include 1) Expand access to well-coordinated, integrated services by increasing availability and capacity of behavioral health services, integrating substance abuse services, and integrating primary care screening/monitoring; 2) Support recovery by improving the quality of care and clinical outcomes for high-risk individuals by implementing evidence-based integrated mental and SUD treatment and programming, targeted care management (TCM), community-based care and enhanced use of data; and 3) Reduce total cost of care for highest risk clients (reducing usage of inpatient admissions, days in hospital, ED visits) by increasing access to integrated care and using real-time data to drive decision-making and prevent relapse and worsening of symptoms.
Strategies/Interventions for Improvement/Advancement include: 1) Improving Mobile Crisis by hiring 2 EMTs affiliated with a local volunteer first responder organization that is a trusted resource in the population of focus. 2) Fully implement, improve and integrate standalone SUD services using EBP for 70 individuals in Year 1, 3) Engage in additional patient motivation and outreach to increase patient participation in primary care screening and 4) Continue to expand TCM program to 100 patients using NYS HH model (Year 4) so it can reach break-even and become sustainable, 6) Continue to expand community based services and peer supports by hiring at least 8 additional psychosocial rehab and/or peer providers, 7) Implement additional supervision and coaching to 75 staff to ensure fidelity to EBPs, 8) Train 75 staff and make goal of supervision to increase use of screening instruments to enable measurement based care (MBP), 9) Leverage PSYCKES and Healthix (NYS/NYC electronic health information exchanges) to improve care transitions, 10) Maintain Outreach Coordinator to update and maintain Care Coordination agreements with at least 20 partners/required care settings, per criteria, 11) Maintain Data Analyst to utilize business intelligence and add Data Dashboards to enable rapid access to data and meaningful use of data, 12) Update and implement a data-driven CQI plan by year 2 of the grant, 13) Increase use of measurement-based care by 25% from baseline through use of screening instruments (i.e. PHQ9, GAD7, AUDITC), 14) Plan and complete a Needs Assessment that will inform further development of programs and supports to fill service gaps in 2024.