Bridge Of Central Massachusetts Inc

OPEN SKY RAPID RESPONSE HUB - THE BRIDGE OF CENTRAL MASSACHUSETTS, INC., (THE BRIDGE), DBA OPEN SKY COMMUNITY SERVICES, PROPOSES TO IMPLEMENT A TRANSFORMATIVE APPROACH TO SERVICE DELIVERY CALLED THE OPEN SKY RAPID RESPONSE HUB (OSRRH) WHICH WILL PROVIDE REAL TIME ACCESS TO INTEGRATED BEHAVIORAL HEALTH TREATMENT SERVICES AND REHABILITATIVE SUPPORTS. SERVICES WILL BE ACCESSIBLE 24/7 AND DELIVERED BY AN INTERDISCIPLINARY TEAM. SERVICE DELIVERY IS NOT BOUND TO THE FOUR WALLS OF THE CLINIC AND WILL BE DELIVERED FLEXIBLY IN A VARIETY OF SETTINGS. AS A HOUSING AUTHORITY, THE OSRRH WILL EMPLOY HOUSING FIRST AND RAPID REHOUSING MODELS AS VEHICLES FOR STABILIZATION AND ENGAGEMENT IN CCBHC SERVICES. THE BRIDGE WILL BE THE LEAD AGENCY IN PARTNERSHIP WITH ITS DCO’S: FAMILY HEALTH CENTER OF WORCESTER, EDWARD M KENNEDY COMMUNITY HEALTH CENTER AND LUK, INC., WHO WILL PROVIDE PRIMARY CARE AND SPECIALIZED SERVICES FOR YOUTH AND FAMILIES. OVER TWO YEARS, THE OSRRH WILL SERVE 800 INDIVIDUALS AND FAMILIES WITH KNOWN AND CHRONIC CONDITIONS (SMI, SED, SUD, COD) AS WELL AS THOSE WHOSE WELLBEING HAS BEEN NEGATIVELY IMPACTED BY THE COVID-19 PANDEMIC. POPULATIONS OF FOCUS WILL INCLUDE THE HOMELESS, JUSTICE-INVOLVED, VETERANS, LGBTQIA+ YOUTH AND YOUNG ADULTS, AND SENIORS. WORCESTER COUNTY IS ONE OF THE MA COUNTIES HARDEST HIT BY THE OPIOID EPIDEMIC, ACCOUNTING FOR OVER 13% OF MA OVERDOSES IN 2019 (WWW.MASS.GOV). AMONG THE COUNTY’S JUSTICE-INVOLVED AND HOMELESS POPULATIONS THERE IS HIGH PREVALENCE OF MENTAL HEALTH CONDITIONS AND OVERDOSE, AS WELL AS LACK OF FOLLOW-UP CARE FOLLOWING AN OVERDOSE (UMASS MEDICAL, 2020). IN MASSACHUSETTS, LGBT YOUTH REPORT HAVING CONSIDERED SUICIDE AT FIVE TIMES THE RATE OF NON-LGBT YOUTH. PRIOR TO THE PANDEMIC, UNDOMICILED WORCESTER COUNTY RESIDENTS TOTALED NEARLY1,600 (2019 PIT COUNT). THE BRIDGE’S MISSION ALIGNS WITH THAT OF SAMHSA’S AND READS: BLENDING BEST PRACTICES WITH THE POWER OF COMMUNITY, WE PARTNER WITH INDIVIDUALS AND FAMILIES TO SEE BEYOND AND LIVE BEYOND PERCEIVED LIMITATIONS TO PURSUE FULFILLING LIVES. WE HAVE IDENTIFIED THREE OVERARCHING OUTCOMES FOR THE INDIVIDUALS AND FAMILIES WE SUPPORT THAT ARE TIED TO OUR AGENCY’S THEORY OF CHANGE: WELLNESS, OPPORTUNITIES, AND RELATIONSHIPS. THE GOALS OF THE OSRRH ARE TO EMPOWER INDIVIDUALS AND FAMILIES TO ACHIEVE WELLNESS, BUILD RELATIONSHIPS, AND REALIZE OPPORTUNITY. WELLNESS OBJECTIVES INVOLVE EXPANDING OPEN ACCESS AND OUTREACH MODELS FOR DELIVERING EVIDENCE-BASED CLINICAL INTERVENTIONS THAT EQUIP PARTICIPANTS WITH THE SKILLS TO IMPROVE THEIR NEAR AND LONG-TERM BEHAVIORAL AND PHYSICAL HEALTH. BY ADDING CAPACITY FOR INTEGRATED PEER SERVICES, THE OSRRH WILL CREATE CONNECTIONS, NATURAL SUPPORTS, AND RECOVERY CAPITAL THAT WILL LEAD TO LASTING RELATIONSHIPS. TO ENABLE PARTICIPANTS TO REALIZE OPPORTUNITY, THE OSRRH WILL INTEGRATE HOUSING, EDUCATION, EMPLOYMENT, AND CASE MANAGEMENT SERVICES INTO PERSON-CENTERED CARE PLANS, OPENING PATHWAYS TO SELF-DETERMINATION AND SELF-SUFFICIENCY.

OPEN SKY RAPID RESPONSE HUB. - THE BRIDGE OF CENTRAL MASSACHUSETTS, INC., DBA OPEN SKY COMMUNITY SERVICES (OPEN SKY) PROPOSES TO IMPROVE AND ADVANCE OUR CCBHC SERVICE DELIVERY CALLED THE OPEN SKY RAPID RESPONSE HUB (OSRRH) WHICH PROVIDES REAL TIME ACCESS TO INTEGRATED BEHAVIORAL HEALTH TREATMENT SERVICES AND REHABILITATIVE SUPPORTS. CURRENTLY THESE SERVICES ARE ACCESSIBLE 24/7 AND DELIVERED BY AN INTERDISCIPLINARY TEAM. SERVICE DELIVERY IS NOT BOUND TO THE FOUR WALLS OF THE CLINIC AND IS DELIVERED FLEXIBLY IN A VARIETY OF SETTINGS. WE UTILIZE PRACTICES THAT INCLUDE TRAUMA INFORMED CARE AND HOUSING FIRST PRINCIPLES AS VEHICLES FOR STABILIZATION AND ENGAGEMENT IN CCBHC SERVICES. OPEN SKY IS THE PRIMARY CCBHC AGENCY WORKING IN PARTNERSHIP WITH DESIGNATED COLLABORATIVE ORGANIZATIONS (DCO): FAMILY HEALTH CENTER OF WORCESTER, EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, YOU, INC., RIVERSIDE COMMUNITY CARE, COMMUNITY HEALTHLINK INC., AND SPECTRUM HEALTH SYSTEMS, THAT WILL PROVIDE PRIMARY CARE, SPECIALIZED SERVICES FOR YOUTH AND FAMILIES, STATE-SANCTIONED CRISIS SERVICES AND SUBSTANCE USE TREATMENT, AS INDICATED, FOR THOSE ENGAGED IN OPEN SKY’S CCBHC. OPEN SKY RRH SERVES INDIVIDUALS THROUGHOUT WORCESTER COUNTY (POP. 862,11, US CENSUS), PROVIDING OFFICE BASED IN THE CITY OF WORCESTER OR THROUGH MOBILE OUTREACH. ACCORDING TO THE US CENSUS, 37% OF WORCESTER RESIDENTS SPEAK A LANGUAGE OTHER THAN ENGLISH IN THEIR HOME (2017-2021 AVERAGE), 23.9% ARE HISPANIC OR LATINO, AND 19.3% ARE IN POVERTY. OTHER PROVIDERS OFFER MENTAL HEALTH AND SUBSTANCE USE SERVICES BUT WITHOUT THE ARRAY OF HOUSING AND OTHER SERVICES DESIGNED TO ADDRESS HEALTH RELATED SOCIAL NEEDS OFFERED BY OPEN SKY. DURING EACH YEAR OF THE GRANT, THE OSRRH WILL SERVE 150 UNDUPLICATED INDIVIDUALS AND FAMILIES (600 THROUGHOUT THE LIFETIME OF THE PROJECT) WITH KNOWN AND CHRONIC CONDITIONS (SMI, SED, SUD, COD) AS WELL AS THOSE WHOSE WELLBEING HAS BEEN NEGATIVELY IMPACTED BY THE COVID-19 PANDEMIC. POPULATIONS OF FOCUS WILL INCLUDE THE HOMELESS, JUSTICE-INVOLVED, VETERANS, LGBTQIA+ YOUTH AND YOUNG ADULTS, AND SENIORS. WORCESTER COUNTY IS ONE OF THE MA COUNTIES HARDEST HIT BY THE OPIOID EPIDEMIC, ACCOUNTING FOR OVER 12% OF MA OVERDOSES IN 2021 (WWW.MASS.GOV). AMONG THE COUNTY’S JUSTICE-INVOLVED AND HOMELESS POPULATIONS THERE IS HIGH PREVALENCE OF MENTAL HEALTH CONDITIONS AND OVERDOSE, AS WELL AS LACK OF FOLLOW-UP CARE FOLLOWING AN OVERDOSE (UMASS MEDICAL, 2020). IN 2023, UNDOMICILED WORCESTER COUNTY RESIDENTS TOTALED 963, 45% OF WHOM ARE HISPANIC/LATINX AND 58% BIPOC (2023 PIT COUNT). OPEN SKY’S MISSION ALIGNS WITH THAT OF SAMHSA’S AND READS: BLENDING BEST PRACTICES WITH THE POWER OF COMMUNITY, WE PARTNER WITH INDIVIDUALS AND FAMILIES TO SEE BEYOND AND LIVE BEYOND PERCEIVED LIMITATIONS TO PURSUE FULFILLING LIVES. WE HAVE IDENTIFIED THREE OVERARCHING OUTCOMES FOR THE INDIVIDUALS AND FAMILIES WE SUPPORT THAT ARE TIED TO THE OPEN SKY APPROACH: WELLNESS, OPPORTUNITIES, AND RELATIONSHIPS. THE GOALS OF THE OSRRH ARE TO EMPOWER INDIVIDUALS AND FAMILIES TO ACHIEVE WELLNESS, BUILD RELATIONSHIPS, AND REALIZE OPPORTUNITY. WELLNESS OBJECTIVES INVOLVE EXPANDING OPEN ACCESS AND OUTREACH MODELS FOR DELIVERING EVIDENCE-BASED CLINICAL INTERVENTIONS THAT EQUIP PARTICIPANTS WITH THE SKILLS TO IMPROVE THEIR NEAR AND LONG-TERM BEHAVIORAL AND PHYSICAL HEALTH. BY ADDING CAPACITY FOR INTEGRATED PEER SERVICES, THE OSRRH WILL CONTINUE TO CREATE CONNECTIONS, NATURAL SUPPORTS, AND RECOVERY CAPITAL THAT WILL LEAD TO LASTING RELATIONSHIPS. TO ENABLE PARTICIPANTS TO REALIZE OPPORTUNITY, THE OSRRH WILL INTEGRATE HOUSING, EDUCATION, EMPLOYMENT, AND CASE MANAGEMENT SERVICES INTO PERSON-CENTERED CARE PLANS, OPENING PATHWAYS TO SELF-DETERMINATION AND SELF-SUFFICIENCY.

MOBILE COMMUNITY RESPONSE TEAM - THE BRIDGE OF CENTRAL MASSACHUSETTS (THE BRIDGE), DBA OPEN SKY COMMUNITY SERVICES PROPOSES TO IMPLEMENT A MOBILE COMMUNITY RESPONSE TEAM (MCRT) PARTNERING WITH HOSPITAL EMERGENCY DEPARTMENTS (ED’S). THE TARGET POPULATION IS 100 ADULTS AND CHILDREN ANNUALLY FROM WORCESTER COUNTY, MASSACHUSETTS, EXPERIENCING SERIOUS EMOTIONAL DISTURBANCE (SED), SERIOUS MENTAL ILLNESS (SMI), OR SED/SMI AND SUBSTANCE USE DISORDERS, ALSO CALLED CO-OCCURRING DISORDER (COD). IN ADDITION, THE TARGET POPULATION INCLUDES INDIVIDUALS WHO FREQUENTLY UTILIZE THE ED, MAY BE BOARDING IN THE ED, OR WHO EXPERIENCE FREQUENT PSYCHIATRIC HOSPITALIZATIONS. TO REACH THIS POPULATION, MCRT STAFF WILL BE DEPLOYED TO AND RESPOND TO THREE LOCAL HOSPITAL AND ACUTE PSYCHIATRIC UNITS. THE PARTNER HOSPITALS ARE HARRINGTON HEALTHCARE SYSTEMS IN SOUTHBRIDGE AND WEBSTER, MA, AND ST. VINCENT’S HOSPITAL IN WORCESTER, MA. THE BRIDGE IS HIGHLY SKILLED IN WORKING WITH PEOPLE PRESENTING WITH SEVERE AND PERSISTENT MENTAL ILLNESS AND SUBSTANCE USE DISORDERS AND HAS SPECIALIZED EXPERTISE IN SERVING CHILDREN, ADOLESCENTS, YOUNG ADULTS AND THEIR FAMILIES, THE LGBTQIA+ POPULATION AND THOSE EXPERIENCING HOMELESSNESS OR CRIMINAL JUSTICE INVOLVEMENT. THE PROJECT GOALS ARE TO ESTABLISH THE MCRT, CONNECT 200 INDIVIDUALS OVER THE TWO-YEAR PROJECT WHO ARE EXPERIENCING SED, SMI AND COD TO BEHAVIORAL HEALTH SERVICES, AND TO IMPROVE ACCESS TO COMMUNITY-BASED SUPPORTS FOR THESE INDIVIDUALS. THE MEASURABLE OBJECTIVES FOR THE PROJECT INCLUDE SERVING 80 ADULTS AND 20 YOUTH PER YEAR, SUPPORTING THE DELIVERY AND ACCESS TO TELEHEALTH WHEN NECESSARY, ENSURING THAT 80% OF ENROLLED PARTICIPANTS RECEIVE EVIDENCE-BASED INTERVENTIONS FOR TREATMENT OF SMI/SED AND/OR COD, THAT 75% OF MCRT PARTICIPANTS ACHIEVE/MAINTAIN HOUSING STABILITY, AND THAT 65% OF MCRT PARTICIPANTS INDICATE SOCIAL CONNECTEDNESS. OTHER OBJECTIVES INCLUDE 75% OF ENROLLED INDIVIDUALS ARE CONTACTED BY A MCRT TEAM MEMBER WITHIN 24 HOURS OF RECEIPT OF REFERRAL, 80% OF INDIVIDUALS ARE ACTIVELY ENGAGED IN BEHAVIORAL HEALTH SERVICES THAT MEET THEIR NEEDS, AND THAT UPON DISENROLLMENT, 70% OF ENROLLEES GRADUATE (COMPLETE IDENTIFIED TREATMENT GOALS) OR LEAVE BEFORE COMPLETION WITH THE AGREEMENT OF TREATMENT STAFF. THROUGH THESE SERVICES, ACCESS TO BEHAVIORAL HEALTH CARE WILL BE IMPROVED AND INCREASED FOR THE COMMUNITY. WITH THE MCRT, INDIVIDUALS CAN BE PROVIDED ADDITIONAL SUPPORTS TO IMPROVE OUTCOMES, SUCH AS RECOVERY COACHING, HOUSING ASSISTANCE AND CASE MANAGEMENT, AMONG OTHERS. WHEN NECESSARY, TELEHEALTH AND VIRTUAL CONFERENCING WILL AMELIORATE BARRIERS TO IN-PERSON SERVICES. DURING THE PANDEMIC, NUMBERS OF AVAILABLE BEDS IN ED’S AND OTHER PSYCHIATRIC UNITS HAVE BEEN REDUCED TO ALLOW FOR GREATER SOCIAL DISTANCING, OR BECAUSE BEDS HAVE BEEN ASSIGNED TO COVID-19 PATIENTS WHO REQUIRED ISOLATION. BY DIVERTING BEHAVIORAL HEALTH PATIENTS IN THE ED, MORE BEDS WILL BE AVAILABLE FOR THE COMMUNITY FOR OTHER MEDICAL PURPOSES, AND BEHAVIORAL HEALTH OUTCOMES WILL IMPROVE.