Thursday, November 21, 2024
11/21/2024
Bridge Health Services will improve care for and health outcomes of 300-600 adults per year with Serious Mental Illness by co-locating primary care services at Sonoma County mental health program sites. The target population for Bridge Health Services is low income adults living with severe mental illness and chronic medical conditions who access mental health services at one of Sonoma County Department of Health Services behavioral health programs. The majority is white (83%); Latino patients make up 6% of the target population, black patients make up 4%, and the remaining 7% are a combination of other non-white ethnicities. Bridge will link patients to a patient-centered medical home as their ongoing source of primary care, provide medical services in the home, patient navigation, and behavioral and mental health services. Program goals are to (1) improve patient experience by delivering care when and where it is most needed, providing 24/7 access to clinical support and activating patients and their care givers in their health care; (2) improve the health status of the target population as defined by specified care quality and health outcome indicators through adherence to guidelines and protocols for chronic disease management; and (3) lower the total cost of care by reducing avoidable hospital admissions and re-admissions. Measurable objectives include serving 300 patients in Year 1, 400 in Year 2, 500 in Year 3 and 600 in Year 4. Patients will improve blood pressure, weight and Hga1C control, and hospital readmissions and ER utilization will decrease. The Bridge project will serve 1,800 patients over four years and is located in Sonoma County, California
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).
