Amherst H. Wilder Foundation: Improving access to and quality of CCBHC services to low-income, underserved cultural and ethnic communities via direct services and practice transformation in Minnesota - Through a FY24-27 CCBHC IA Grant, Wilder will improve access, affordability, and quality of mental health and substance use services to residents in Ramsey County, MN who are underserved and experiencing substantial disparities related to mental health and substance use disorder service access and outcomes – especially culturally and linguistically specific care. Wilder’s project will prioritize residents who are below 200% of the federal poverty line, speak a primary language other than English, and/or are from cultural and ethnic minority communities, with specific efforts to deepen engagement with Black/African American, East African, Afghan, and Southeast Asian communities. The project will reach 2,000 clients annually and 3,500 clients total. This project addresses financial, cultural, and language barriers and overall accessibility to be responsive to clients’ needs, including high-acuity co-occurring mental health and substance use needs, comorbid physical health conditions, and coinciding social determinants of health (e.g. housing, transportation, immigration benefits, civil legal services, government benefits, and food access concerns). Our project proposes the following services to improve our CCBHCs impact in our community: - Expand accessibility and affordability of core CCBHC services by growing our provider base, diversifying provider types, and offering uncompensated care coverage for clients - Refine population health strategies and care management pathways by improving our patient health registry, analyzing trends, and supporting clinicians in data-driven clinical decision-making - Redesign care coordination processes and implementation by engaging community to inform meaningful, whole-family, multilingual/multicultural care coordination needs and shaping our assessments, communications, referrals, and follow-ups on this basis. - Deepen integration and development of our workforce, to reflect these newly-improved strategies for care and to increase our ability to train and team collaboratively/interprofessionally Through these activities, we will accomplish the following goals and measurable objectives: 1. Increase capacity and affordability of culturally-responsive behavioral health services for clients in Ramsey County to reduce current disparities in access among our focus population. a. By end of Y2, Wilder will increase clinical staff capacity from 120 to 134 FTEs and at least 50% of new staff will be representative of our focus population. b. By end of Y2, Wilder will have eight FTE certified peer specialists/cultural brokers (we currently have four FTE) and 75% will represent our focus population. c. By end of Y4, Wilder will increase capacity from 48,824 to 54,683 CCBHC encounters annually (12% increase) with 75% serving our focus population. d. By end of Y4, Wilder will support uncompensated care costs of >3,500 CCBHC encounters for ~500 individuals with 75% from our focus population. 2. Increase and improve care management and care coordination practices to reduce outcome disparities among high-complexity/acuity behavioral health clients in our focus population. a. By end of Y1, 90% of clients will have current CMS Social Determinant of Health screens and follow-up plans in place for client-prioritized social needs. b. By end of Y2, 65% of direct service staff will use data from a refined population health management and care management strategy to inform their client care, documented in EHR and measured by management case audits. c. By end of Y3, 75% of direct service staff will use new care coordination pathways in client care, documented in EHR and measured by management case audits. d. By end of Y3, 75% of clients will self-report that their whole-family care is being successfully coordinated. e. By end of Y4, 75% of clients will maintain or improve functioning as compared to their previous measurement.
