Ohel Children's Home and Family Services' Brooklyn CCBHC will expand and enhance access to comprehensive, trauma-informed and integrated care to all individuals living experiencing behavioral health (BH) conditions and comorbid conditions in the service area (SA). We will prioritize children and pregnant and postpartum women (PPW) from diverse backgrounds; we aim to address significant disparities in the SA among children with a disproportionate number of adverse childhood events (ACEs), and among PPW with peripartum depression. We anticipate that many of our CCBHC clients will be white and from the Orthodox Jewish community, as Ohel has a particular cultural competence in serving faith-based communities. Through our geotargeted outreach we will actively engage individuals from diverse backgrounds, including Veterans. According to US Census Data, Brooklyn residents are 49.9% White, 33.3% Black, 12.9% Asian, 3.9% Other, and 18.8% identify as Hispanic/Latino.
Through our CCBHC expansion, Ohel will train all crisis workers to respond to pediatric BH crises. We will begin using new evidence-based screening tools for children (PEARLS) and adults (RODS, MAST). We will begin providing ancillary withdrawal management and will expand our tobacco cessation program. We also plan to expand our targeted case management (TCM), Children and Family Treatment and Support Services (CFTSS), and Community Oriented Recovery and Empowerment (CORE) programs to serve more individuals in the community, including the uninsured and those with commercial insurance. We will hire one additional peer specialist and expand our training program for existing staff. In addition to enhancing our EHR to capture more assessment data for measurement-based care, we will also train our staff to better capture client demographic data in our EHR to identify and eliminate disparities in services and outcomes. We served 1320 patients in 2022, and we will increase our total unduplicated individuals served by 600 by the end of year 4. Our goals and measurable objectives include:
(1) Expand access to BH services for PPW via the following objectives: 1.a: Increase number of PPW treated for SMI, SUD, or co-occurring disorders by 20% by the end of year 4; 1.b: Increase the number of individuals, including PPW, with SUD who are receiving individual or group therapy by 20 each year of the program; and 1.c: Increase the number of providers prescribing MAT by 1 by year 4. (2) Increase BH crisis services via the following objectives: 2.a: Implement Safety Planning Interventions for Children (C-SPI) to expand crisis services to include children 6-12 years old by the end of year 1; and 2.b: Increase number of crisis interventions to 20% by year 4. (3) Increase community-based services for high acuity children and youth and PPW via the following objectives: 3.a: Increase number of children 0-17 and transitional youth 18-21 treated for Suicide Care Pathway, SED, or SUD by 20% by year 4; 3.b: Increase enrollment in CFTSS by 20% by the end of year 2; and 3.c: Increase the number of PPW we are treating with an EBP by 20% by the end of year 4. (4) Develop partnerships and create referral pathways for children from diverse backgrounds across the entire SA via the following objectives: 4.1: Outreach to new community partners and provide children's BH educational sessions in 2 new community settings in our SA each year of the grant; and 4.b: Outreach to communities in the SA through social media that have high health and socioeconomic disparities by the end of year 1. (5) Improve pediatric BH outcomes and reduce health disparities via the following objectives: 5.a: Improve documentation of client self-reported race, ethnicity, sexual orientation, and gender identity by 50% by the end of year 1; and 5.b: For children ages 4-17 with a high PSC-17, 25% will have a decrease of 4 points within a year of initiating treatment across all races and ethnicities.