Thursday, January 2, 2025
1/2/2025
Tapestry 360 Health (T360H)—H80CS00215—proposes to increase the number of individuals receiving mental health services and substance use disorder (SUD) services by addressing current gaps in care for patients and expanding outreach in the community. T360H is a Chicago-based community health center that served 28,384 patients in CY2023. T360H offers a full continuum of trauma-informed and culturally and linguistically appropriate care through an integrated Primary Care and Behavioral Health (BH) Care model. The model includes a warm hand off from primary care to licensed behavioral health consultants (BHCs) to address mental health, SUD, and health related social needs. BH services encompass psychiatry, mental health screenings, individual and group counseling, Medicated Assisted Treatment for Opioid Use Disorder (OUD), peer support, wellness classes, care coordination and case management. The majority of T360H patients are people of color, uninsured, many are refugees and immigrants with limited English proficiency, and 89% live in poverty. These demographics result in a higher prevalence of mental health issues and a greater need for a higher level of care and social supports. Patients and residents residing in the T360H service area are targeted by this intervention. The homeless population and communities on Chicago’s west side adjacent to the T360H service are also targeted given the high prevalence of SUDs and OUDs in this population and geography. There are twenty-one contiguous zip codes that make up the T360H’s service area: 60053, 60076, 60077, 60202, 60613, 60614, 60618, 60625, 60626, 60630, 60639, 60640, 60641, 60645, 60647, 60651, 60657, 60659, 60660, 60712, and 60714. The west side, whose zip codes—60612, 60623, 60624, 60644—are adjacent to T360H’s service area, has among the highest overdoses and mortality rates in Chicago. There is also a high unmet need for individuals experiencing psychological distress. In two-thirds of th e zip codes the need is worse than the average for Chicago (74.3%) overall. Other health indicators affecting these communities include adult loneliness, binge drinking, alcohol related mortality, physical inactivity, fruit and vegetables consumption, education level, poverty, and limited English-speaking population. Care coordination and case management has been identified as a significant gap at T360H. BHCs currently provide both mental health counseling and care coordination/case management. Given the demand for counseling, BHCs have limited availability to provide care coordination and case management causing a gap in support for patients to obtain needed follow-up care and supports. T360H proposes to create a new behavioral health care coordination and case management role to improve patient care and increase access. This will allow the BHCs to focus on counseling and to see new counseling patients, and better helping patients access specialty care, higher-levels of care, and health-related social needs. T360H will partner with local community groups to promote community awareness of T360Hs BH services and increase access to care by creating referral arrangements and engaging their clients in group classes and programming. T360H will also partner with Street Samaritans, a non-profit focused on street outreach and access to care and supports for the homeless population, to increase the number of individuals with SUDs and OUDs receiving treatment and services from T360H. Funds will be used to support two BH case managers, one BH consultant, instructors for group classes, two staff dedicated to street outreach to the homeless, a peer recovery specialist, and to support salaries of existing team members to carry out the objectives of the plan.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).