Care Plus NJ: CCBHC-PDI - CPNJ’s CCBHC clinic will be located in Essex County, NJ and will serve all individuals across the lifespan with serious mental illness, serious emotional disturbance, substance use disorders, and co-occurring disorders; this population of focus will include historically underserved communities including those who self-identify as Black, Hispanic, and LGBTQ+. The catchment area (CA) is Essex County, NJ, a highly urban county with disparities in access due to a lack of behavioral and mental health services. The CA’s population is 852,720. Of the total population 323,837 self-identify as white; 329,047 as Black; 47,362 as Asian. 201,744 of the population self-identifies as Hispanic or Latino. CPNJ’s CCBHC will create a transformative behavioral health system that provides comprehensive outreach, screening, assessment, treatment, care coordination, and recovery supports. CPNJ’s CCBHC will serve 250 unduplicated individuals annually, totaling 1,000 individuals over the total project period. Goal/Objectives: Streamline, integrate and provide rapid access to expanded evidence based behavioral and mental health care through CPNJ’s Essex County CCBHC. Objective 1: By month 6 of year 1, Project Director (PD) and Project Evaluator (PE) will facilitate an inclusive community needs assessment, which will be updated in months 6-12 of year 3 to guide CCBHC services and infrastructure development. Objective 2: By the end of month 6 of year 1, establish a walk-in rapid access behavioral health center staffed by 1.0 Psychiatric Advanced Practice Nurse (PAPN), 2.0 Crisis Access masters-level licensed Therapists (CAT), 1.0 Targeted Case Manager (TCM), and 1.0 Peer Support Specialist (PSS) who will provide rapid access to screening, assessment and treatment services to 250 individuals annually. Objective 3: By month 6 of year 1, Hire an Outreach and Training Specialist who will provide 100 outreach and training encounters in historically underserved Essex County neighborhood locations to increase knowledge. Objective 4: By month 12 of year 1, the CATs and the PAPN will screen 250 individuals utilizing validated instruments; facilitate clinical assessment for 75% of those screened; assist 100% of those assessed in developing an individual recovery plan that outlines services, benchmarks and responsible staff for all domains with Targeted Case Manager and Peer Support Specialist accompanying each through service delivery, especially attending to transitions with 80% retained in treatment after 6 months. Objective 5: By month 12 of year 1, provide comprehensive SUD services to a minimum of 65 individuals via our DCO Integrity House the largest provider of SUD services in the CA; by the end of year 1, Care Plus will also secure its own license to provide SUD services in this County through the state of NJ. Objective 6: By Month 12 of year 4, APN will increase availability from 2 days per week to 5 days per week to provide a minimum of 1,000 intakes to expedite comprehensive screening assessment and diagnosis. Objective 7: By Month 12 of year 2, DCO will provide intensive psychiatric rehabilitation services to an additional 100 consumers, and an additional 200 school aged youth will receive more timely linkage to care such as psycho-educational social skills and skill building. Objective 8: By month 12 of year 1, a minimum of 250 individuals will be connected to Peer Support Services. Objective 9: By month 12, year 1 TCM will assist 100% of veterans served in establishing eligibility for VA benefits and connect them to CCBHC benefits as necessary. Objective 10: To ensure the project is meeting goals and addressing disparities, by month 4 of year 1 enlist a culturally/linguistically diverse Advisory Committee comprised of more than 55% individuals with lived experience representative of the POF; add at least one veteran receiving CCBHC services. Objective 11: Achieve full compliance with CCBHC certification and submit attestation by the end of year 1.
