Southeast CCBHC IA - Southeast Healthcare (SE) provides a comprehensive range of community-based integrated behavioral and physical health care services as a CCBHC-E grantee in eight diverse Ohio counties (Franklin, Delaware, Morrow, Belmont, Harrison, Monroe, Tuscarawas & Carroll). Through the Southeast CCBHC IA project, SE intends to improve and advance the CCBHC model throughout the organization and service area, with specific enhancements in care coordination, accessibility, trauma-informed care, and suicide risk response. SE primarily serves those living with severe mental illness (SMI), and/or substance use disorders (SUD) with low socioeconomic status and facing health disparities. The population of focus covers the lifespan, from children and youth with severe emotional disturbances through older adults with SMI, and/or SUD with a specific focus on the homeless population, those involved with the criminal justice system, and the Appalachian population in the service area. SE intends to address disparities and other barriers typically faced by these populations. SE will serve 1,500 individuals total during the four-year period (350 in years 1 and 4, and 400 in years 2 and 3).Goal 1: Enhance access to and availability of services to members of historically underserved subgroups and to those most urgently in need of care. Objectives: 1.1- 25% of enrollees will represent one or more of the four target populations. 1.2- Take immediate action on behalf of 100% of individuals who identify an emergency need, and provide services within 1 day for individuals who identify an urgent need, within 10 days for individuals who identify routine needs. Goal 2: Increase integration of comprehensive PH, BH and adjunct service delivery. Objectives: 2.1- Attendant to domains 1 (screening, referral, and follow-up) and 7 (linkages with community and social services) of the Comprehensive Healthcare Integration (CHI ) Framework, 80% of individuals in each annual enrollment cohort will be screened for SDoH. 2.2- Attendant to domains 1 and 7 of the CHI Framework, 75% of individuals who screen positive for an SDoH will receive a timely referral and follow-up. 2.3- Attendant to domain 4 (self-management support) of the CHI Framework, 45% of individuals will report increased self-efficacy to manage chronic healthcare conditions. 2.4- Attendant to domain 5 (multidisciplinary teams) of the CHI Framework, 100% of SE staff requests for multidisciplinary care conferences will be fulfilled by CCBHC staff. Goal 3: Expand and advance care coordination to achieve improved health outcomes. Objectives: 3.1- Launch a risk-stratification system to improve alignment between individual needs and care coordination services. 3.2- Implement organization-wide Case-to-Care Training for case managers and team leaders/supervisors in collaboration with a trainer affiliated with the National Council CCBHC success center. 3.3- 100% of individuals discharged from inpatient acute-care hospitals will have a contact attempt documented within 24 hours of discharge. 3.4- 100% of all individuals hospitalized for a suicide attempt will have a multi-disciplinary care team meeting within 7 days of discharge, led by an independently licensed staff member to produce an enhanced care plan. 3.5- 50% of individuals in the annual enrollment cohort will demonstrate improvement in self-reported BH symptoms, overall health and/or clinic measured PH indicators. Goal 4: Strengthen the organizational climate for integrated, wholistic, person-centered, trauma-informed care. Objectives: 4.1- SE will conduct at least one organization-wide EBP/promising practice training, which addresses one or more core IHC element and which includes an experiential component and follow-up. 4.2- During the course of each EBP/promising practice training, SE and project leadership will identify staff champions to provide in situ support and reinforcement to staff engaged in delivering the focal EBP/promising practice.
