Bikur Cholim

ADDRESSING BEHAVIORAL HEALTH DISPARITIES DUE TO COVID-19 BY STRENGTHENING AND SUPPORTING THE SYSTEM OF CARE. - ACHIEVE BEHAVIORAL HEALTH (ACHIEVE) WILL EXPAND OUTREACH AND ACCESS TO BEHAVIORAL HEALTH SERVICES (BH) FOR INDIVIDUALS DISPROPORTIONATELY IMPACTED BY COVID-19 IN ROCKLAND AND ORANGE COUNTIES, WITH A FOCUS ON CHILDREN (>18), WOMEN (18+), AND THE HISPANIC COMMUNITY. WE WILL ACCOMPLISH THIS BY ENHANCING OUR TELEHEALTH INFRASTRUCTURE, INCREASING STAFF SUPERVISION, TRAINING, AND SUPPORT, AND IMPLEMENTING A ROBUST OUTREACH AND SCHOOL CONSULTATION PROGRAM. ACHIEVES CMHC PROJECT GOALS ARE TO: 1) ENHANCE OUR TELEHEALTH INFRASTRUCTURE TO INCREASE ACCESS TO BH AND SPECIALTY CARE SERVICES; 2) INCREASE PATIENT MONITORING AND ASSESSMENTS TO IMPROVE QUALITY OUTCOMES; 3) STABILIZE STAFF BURNOUT AND TURNOVER; 4) INCREASE ACCESS TO BH SERVICES FOR SCHOOL-AGED CHILDREN; AND 5) INCREASE ACCESS TO BH SERVICES FOR THE HISPANIC COMMUNITY. WE PLAN TO ADDRESS THESE GOALS BY ESTABLISHING EIGHT VIRTUAL PODS TO PROVIDE PRIVATE, FLEX-SPACE FOR TELEHEALTH OR FACE-TO-FACE SERVICES AND HIRING 1 FTE TELEHEALTH/IT COORDINATOR TO SUPPORT AND EXPAND ACHIEVES TELEHEALTH INFRASTRUCTURE. WE SEEK TO INCREASE USE OF TELEHEALTH BH SERVICES BY 12% WITHIN 6 MONTHS OF AWARD AND TELEHEALTH BH SPECIALTY CARE BY 15% WITH 9 MONTHS OF AWARD. WE WILL IMPLEMENT A REMOTE PATIENT SCREENING AND MONITORING TOOL, COMPLETING 30,000 SCREENINGS/ASSESSMENTS OVER THE TWO-YEAR PROJECT TO REDUCE SUICIDALITY AMONG 45% OF CLIENTS WITH POSITIVE SCREEN FOR SUICIDAL IDEATION UPON INTAKE AND REDUCE PHQ-9 SCORE AMONG 40% OF CLIENTS WITH POSITIVE CLINICAL PHQ-9 DEPRESSION SCREEN WITHIN FIRST 90 DAYS OF TREATMENT. ACHIEVE WILL ALSO CREATE A CONSULTATION AND GUIDANCE CENTER FOR SCHOOLS THAT EACH YEAR WILL TRAIN AND SUPERVISE 30 TEACHERS IN PROVIDE RAPID CRISIS RESPONSE AND DE-ESCALATION, AS WELL AS 50 FACULTY/ADMINISTRATIVE STAFF ON SOCIAL SKILLS, ANXIETY, EARLY IDENTIFICATION OF CHILDREN AT RISK OF SERIOUS EMOTIONAL DISTURBANCE (SED), AND REFERRAL TO SERVICES. WE SEEK TO INCREASE IDENTIFICATION AND REFERRALS OF CHILDREN FROM SCHOOLS BY 25% OVER THE 2-YEAR PROJECT PERIOD. TO ADDRESS THE MENTAL HEALTH NEEDS OF OUR STAFF AND PREVENT FURTHER BURNOUT, WE WILL ESTABLISH A TRAINING CENTER THAT OFFERS TRAINING, PROFESSIONAL SUPPORT AND DEVELOPMENT FOR STAFF, HIRE TWO FTE CLINICAL SUPERVISORS WITH EXPERTISE IN TRAUMA AND SUBSTANCE USE FOR ADDITIONAL STAFF SUPPORT, AND OFFER FOUR FULL-DAY WORKSHOPS TO INCREASE STAFF SKILLS, SUPPORT STAFF, PREVENT BURN-OUT, AND INCREASE STAFF COHESION POST-COVID. FINALLY, WE WILL HIRE 1 FTE OUTREACH DIRECTOR TO DEVELOP AND IMPLEMENT OUTREACH STRATEGIES AND REFERRAL PATHWAYS FOR THE HISPANIC COMMUNITY, SEEKING TO INCREASE BH SERVICE PROVISION TO THIS POPULATION BY 100% OVER THE TWO-YEAR GRANT PERIOD. THE PROJECT WILL SERVE 1,768 UNDUPLICATED INDIVIDUALS IN THE FIRST YEAR OF THE PROJECT AND 2,334 THROUGHOUT THE LIFETIME OF THE PROJECT.

CREATE A COMPREHENSIVE CRISIS RESPONSE SERVICES BY INCORPORATING PATIENT-CENTERED CARE UTILIZING EVIDENCE-BASED MODALITIES, THEREBY REDUCING THE NEED FOR ER VISITS AND HOSPITALIZATION. - ACHIEVE, SERVING ROCKLAND AND ORANGE COUNTIES IN NY, HAS PARTICIPATED IN THE CCBHC DEMONSTRATION PROJECT SINCE 2017. IT HAS DRAMATICALLY REDUCED HOSPITALIZATION AND EMERGENCY DEPARTMENT (ED) UTILIZATION DESPITE INCREASING CLINICAL COMPLEXITY AND SEVERITY. THROUGH THIS CCBHC IMPROVEMENT AND ADVANCEMENT (CCBHC-IA) GRANT, WE WILL EXTEND OUR HIGHLY EFFECTIVE CRISIS HOTLINE AND MOBILE CRISIS TEAM SERVICES TO ALL INDIVIDUALS IN THE COMMUNITY. THEREBY ADDRESSING THE FAILURE OF BH CRISIS SERVICES UNABLE TO KEEP PACE WITH DEMAND FOR SERVICE, POPULATION GROWTH, AND THE STRAIN OF SERVICE CAPACITY. WE WILL USE OUR SUCCESSFUL EXISTING CCBHC PROTOCOLS AND MODELS TO CREATE A COMMUNITY-BASED CRISIS RESPONSE SYSTEM ACCESSIBLE TO ALL INDIVIDUALS IN OUR CATCHMENT AREA. COMMUNITY CRISIS RESPONSE SERVICES PROVIDE CRISIS DE-ESCALATION, STABILIZATION, ASSESSMENT, AND LINKAGE TO CARE THROUGH A 24/7/365 CRISIS HOTLINE AND MOBILE CRISIS RESPONSE TEAM THAT BRINGS CRISIS SERVICES TO THE PERSON WHERE AND WHEN THEY NEED THEM. CRISIS HOTLINE CALLS ARE TRIAGED AND RESPONDED TO BY TRAINED STAFF (PEER, PSYCH REHAB, OR CLINICIAN) AND ASSESSED FOR SEVERITY, RISK, AND NEEDS. IF A MOBILE CRISIS RESPONSE IS WARRANTED, WE WILL DISPATCH A TWO-PERSON MOBILE CRISIS TEAM COMPRISED OF A LICENSED CLINICIAN AND CERTIFIED PEER SPECIALIST. BASED ON EACH PERSONS SOCIAL CONTEXT, WE WILL BUILD ON STRENGTHS CONGRUENT WITH CULTURE, RACE, AGE, SEXUAL ORIENTATION, AND HEALTH NEEDS THROUGHOUT THE CRISIS. PERSON-CENTERED AND TRAUMA-INFORMED CARE, RECOVERY, AND BEHAVIORAL HEALTH EQUITY ARE CORE VALUES OF THE PROGRAM. CLINICAL SUPERVISORS AND PSYCHIATRIST/NURSE PRACTITIONERS IN PSYCHIATRY WILL ALWAYS BE AVAILABLE FOR TELEHEALTH CONSULTATION AND ARE PART OF THE TEAM. ONCE THE SITUATION IS ASSESSED AND STABILIZED, A SAFETY PLAN IS IN PLACE; THE TEAM ENSURES CONTINUOUS CARE WITH THE CLIENTS PROVIDER THROUGH A WARM HANDOFF BY THE CARE MANAGER (CM), WHO WILL ALSO ADDRESS SERVICE GAPS. SUPPOSE THE INDIVIDUAL DOES NOT HAVE AN IDENTIFIED PROVIDER OR TREATMENT SYSTEM. IN THAT CASE, THE CM ENSURES RAPID WARM HANDOFF TO ACHIEVE, OR ANOTHER APPROPRIATE SERVICE PROVIDER OF THE CLIENTS CHOICE, FOR AN EXPEDITED INTAKE TO BEGIN SERVICES WITHOUT BARRIERS. TO ENSURE THEY RECEIVE AND ARE ENGAGED IN SERVICES, FOLLOW-UPS WITH THE CLIENT AND RECEIVING PROVIDERS WILL BE MADE WITHIN 3-5 DAYS. PEERS REMAIN ENGAGED WITH THE CLIENT UNTIL PARTICIPATING IN THE NEW TREATMENT. IF AN IMMINENT RISK TO ONESELF OR OTHERS IS IDENTIFIED, THE TEAM WILL ENGAGE EMS AND/OR LAW ENFORCEMENT AND PROCEED ACCORDINGLY. IN THE UNUSUAL SITUATIONS WHERE ED OR HOSPITALIZATION IS NECESSARY, WE WILL SUPPORT FAMILIES, SET EXPECTATIONS, AND FACILITATE ACCESS TO AVAILABLE INPATIENT BEDS. ACHIEVE WILL WORK CLOSELY WITH EMS AND LAW ENFORCEMENT AND PROVIDE CROSS-SYSTEM TRAINING FOR EMERGENCY RESPONDERS AND PARTNERS ON RECOGNIZING MH SYMPTOMS AND HOW (AND WHEN) TO REFER OR CONNECT PEOPLE TO MOBILE CRISIS TEAMS. TO ENSURE MEANINGFUL INVOLVEMENT IN THE DESIGN, MONITORING, AND EVALUATION OF PROGRAM SERVICES AND PROVIDE MEANINGFUL INPUT TO OUR BOARD, ACHIEVE WILL CONVENE STAKEHOLDER MEETINGS AND DISCUSSION GROUPS WITH THE COMMUNITY (CONSUMERS, FAMILY MEMBERS, COMMUNITY LEADERS, AND ADVOCATES). WE WILL INCREASE OUR OFFERINGS OF CULTURALLY RESPONSIVE AND SUSTAINABLE BH AND SUD SERVICES AND EXPAND ACCESS TO MORE THAN 1,079 UNIQUE INDIVIDUALS ACROSS THE LIFESPAN, INCLUDING A FIVE PERCENT INCREASE EACH GRANT YEAR. IN ALIGNMENT WITH COMMUNITY NEEDS, OUR GOALS AND MEASURABLE OBJECTIVES INCLUDE FULLY IMPLEMENTING THE 24/7 CRISIS RESPONSE TEAM BY THE FOURTH MONTH OF THE PROJECT, ADVANCING THE TEAMS SKILLSETS USING EBPS, IMPROVING COMMUNITY HEALTH OUTCOMES, LOWERING ED AND PSYCHIATRIC HOSPITALIZATION, ENHANCING DATA INTEROPERABILITY AND DATA UTILIZATION, AND STRENGTHENING C

ACHIEVE CCBHC INTEGRATED SERVICES EXPANSION