Health in Action Project at Richard Hall Community Health and Wellness Center - The Health in Action Project at Richard Hall Community Health and Wellness Center will reduce disparities for persons with SMI/SED and complex health needs by improving access and availability to behavioral/primary healthcare. The project will serve 1000 persons by delivering coordinated and integrated services with a focus on: management of hypertension, obesity and diabetes; and LGBTQ persons at risk for: suicide, depression, anxiety and substance use. The population of focus are Somerset County residents in need of behavioral health services including veterans/armed forces members who experienced complex trauma. The project will focus more specifically on persons with serious mental illness and severe emotional disturbance with complex health needs including obesity, diabetes and hypertension and Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) persons who encounter stigma, bias and discrimination in their daily lives and are at increased risk for suicide, anxiety, depression and substance use. The Project will reduce disparities among persons who are cost burdened, uninsured or Medicaid/Medicare recipients by integrating recovery supports, case management, 24/7 crisis intervention and stabilization and health education in community-based settings which will improve the health outcomes for the population of focus. Project goals include: increasing availability and accessibility to care through meeting new CCBHC criteria, prioritizing hypertension, obesity and diabetes to prevent adverse health outcomes and improve service delivery to address depression, anxiety, suicide and substance use impacting LGBTQ persons. Project objectives include: developing and executing collaborating organization partnerships, instituting person-centered treatment plan meetings, expanding addiction medication management by hiring an Advanced Practice Nurse - Addiction Specialist, mitigating suicide risk and improving care to create an inclusive environment for LGBTQ persons by reviewing policy, documentation, language (CLAS) and implementing staff training through consultation. The Project will implement evidence-based practices including Cognitive Behavioral Therapy, Motivational Interviewing, Chronic Disease Self-Management Program, Nutrition and Exercise for Wellness and Recovery, Zero Suicide Protocol, AFFIRM and health education and outreach delivered by the Nurse Health Educator, Peer Specialists and Bilingual Integrated Case Manager. The Health in Action Project at Richard Hall Community Health and Wellness Center is necessary due to the unprecedented demand for integrated services by the population of focus. Service capacity of the existing integrated model must be expanded to address the complex needs of the population of focus to improve availability, accessibility and affordability of comprehensive care.