Amherst H Wilder Foundation

AMHERST H. WILDER FOUNDATION: IMPROVING ACCESS TO AND QUALITY OF CCBHC SERVICES TO LOW-INCOME, UNDERSERVED CULTURAL AND ETHNIC COMMUNITIES VIA DIRECT SERVICES AND PRACTICE TRANSFORMATION IN MINNESOTA - THROUGH A FY24-27 CCBHC IA GRANT, WILDER WILL IMPROVE ACCESS, AFFORDABILITY, AND QUALITY OF MENTAL HEALTH AND SUBSTANCE USE SERVICES TO RESIDENTS IN RAMSEY COUNTY, MN WHO ARE UNDERSERVED AND EXPERIENCING SUBSTANTIAL DISPARITIES RELATED TO MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICE ACCESS AND OUTCOMES – ESPECIALLY CULTURALLY AND LINGUISTICALLY SPECIFIC CARE. WILDER’S PROJECT WILL PRIORITIZE RESIDENTS WHO ARE BELOW 200% OF THE FEDERAL POVERTY LINE, SPEAK A PRIMARY LANGUAGE OTHER THAN ENGLISH, AND/OR ARE FROM CULTURAL AND ETHNIC MINORITY COMMUNITIES, WITH SPECIFIC EFFORTS TO DEEPEN ENGAGEMENT WITH BLACK/AFRICAN AMERICAN, EAST AFRICAN, AFGHAN, AND SOUTHEAST ASIAN COMMUNITIES. THE PROJECT WILL REACH 2,000 CLIENTS ANNUALLY AND 3,500 CLIENTS TOTAL. THIS PROJECT ADDRESSES FINANCIAL, CULTURAL, AND LANGUAGE BARRIERS AND OVERALL ACCESSIBILITY TO BE RESPONSIVE TO CLIENTS’ NEEDS, INCLUDING HIGH-ACUITY CO-OCCURRING MENTAL HEALTH AND SUBSTANCE USE NEEDS, COMORBID PHYSICAL HEALTH CONDITIONS, AND COINCIDING SOCIAL DETERMINANTS OF HEALTH (E.G. HOUSING, TRANSPORTATION, IMMIGRATION BENEFITS, CIVIL LEGAL SERVICES, GOVERNMENT BENEFITS, AND FOOD ACCESS CONCERNS). OUR PROJECT PROPOSES THE FOLLOWING SERVICES TO IMPROVE OUR CCBHCS IMPACT IN OUR COMMUNITY: - EXPAND ACCESSIBILITY AND AFFORDABILITY OF CORE CCBHC SERVICES BY GROWING OUR PROVIDER BASE, DIVERSIFYING PROVIDER TYPES, AND OFFERING UNCOMPENSATED CARE COVERAGE FOR CLIENTS - REFINE POPULATION HEALTH STRATEGIES AND CARE MANAGEMENT PATHWAYS BY IMPROVING OUR PATIENT HEALTH REGISTRY, ANALYZING TRENDS, AND SUPPORTING CLINICIANS IN DATA-DRIVEN CLINICAL DECISION-MAKING - REDESIGN CARE COORDINATION PROCESSES AND IMPLEMENTATION BY ENGAGING COMMUNITY TO INFORM MEANINGFUL, WHOLE-FAMILY, MULTILINGUAL/MULTICULTURAL CARE COORDINATION NEEDS AND SHAPING OUR ASSESSMENTS, COMMUNICATIONS, REFERRALS, AND FOLLOW-UPS ON THIS BASIS. - DEEPEN INTEGRATION AND DEVELOPMENT OF OUR WORKFORCE, TO REFLECT THESE NEWLY-IMPROVED STRATEGIES FOR CARE AND TO INCREASE OUR ABILITY TO TRAIN AND TEAM COLLABORATIVELY/INTERPROFESSIONALLY THROUGH THESE ACTIVITIES, WE WILL ACCOMPLISH THE FOLLOWING GOALS AND MEASURABLE OBJECTIVES: 1. INCREASE CAPACITY AND AFFORDABILITY OF CULTURALLY-RESPONSIVE BEHAVIORAL HEALTH SERVICES FOR CLIENTS IN RAMSEY COUNTY TO REDUCE CURRENT DISPARITIES IN ACCESS AMONG OUR FOCUS POPULATION. A. BY END OF Y2, WILDER WILL INCREASE CLINICAL STAFF CAPACITY FROM 120 TO 134 FTES AND AT LEAST 50% OF NEW STAFF WILL BE REPRESENTATIVE OF OUR FOCUS POPULATION. B. BY END OF Y2, WILDER WILL HAVE EIGHT FTE CERTIFIED PEER SPECIALISTS/CULTURAL BROKERS (WE CURRENTLY HAVE FOUR FTE) AND 75% WILL REPRESENT OUR FOCUS POPULATION. C. BY END OF Y4, WILDER WILL INCREASE CAPACITY FROM 48,824 TO 54,683 CCBHC ENCOUNTERS ANNUALLY (12% INCREASE) WITH 75% SERVING OUR FOCUS POPULATION. D. BY END OF Y4, WILDER WILL SUPPORT UNCOMPENSATED CARE COSTS OF >3,500 CCBHC ENCOUNTERS FOR ~500 INDIVIDUALS WITH 75% FROM OUR FOCUS POPULATION. 2. INCREASE AND IMPROVE CARE MANAGEMENT AND CARE COORDINATION PRACTICES TO REDUCE OUTCOME DISPARITIES AMONG HIGH-COMPLEXITY/ACUITY BEHAVIORAL HEALTH CLIENTS IN OUR FOCUS POPULATION. A. BY END OF Y1, 90% OF CLIENTS WILL HAVE CURRENT CMS SOCIAL DETERMINANT OF HEALTH SCREENS AND FOLLOW-UP PLANS IN PLACE FOR CLIENT-PRIORITIZED SOCIAL NEEDS. B. BY END OF Y2, 65% OF DIRECT SERVICE STAFF WILL USE DATA FROM A REFINED POPULATION HEALTH MANAGEMENT AND CARE MANAGEMENT STRATEGY TO INFORM THEIR CLIENT CARE, DOCUMENTED IN EHR AND MEASURED BY MANAGEMENT CASE AUDITS. C. BY END OF Y3, 75% OF DIRECT SERVICE STAFF WILL USE NEW CARE COORDINATION PATHWAYS IN CLIENT CARE, DOCUMENTED IN EHR AND MEASURED BY MANAGEMENT CASE AUDITS. D. BY END OF Y3, 75% OF CLIENTS WILL SELF-REPORT THAT THEIR WHOLE-FAMILY CARE IS BEING SUCCESSFULLY COORDINATED. E. BY END OF Y4, 75% OF CLIENTS WILL MAINTAIN OR IMPROVE FUNCTIONING AS COMPARED TO THEIR PREVIOUS MEASUREMENT.

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

HOMELESS ASSISTANCE

HOMELESS ASSISTANCE

HOMELESS ASSISTANCE

HOMELESS ASSISTANCE

HOMELESS ASSISTANCE

PURPOSE: THE CONTINUUM OF CARE (COC) PROGRAM IS DESIGNED TO PROMOTE COMMUNITY-WIDE COMMITMENT TO THE GOAL OF ENDING HOMELESSNESS; PROVIDE FUNDING FOR EFFORTS BY NONPROFIT PROVIDERS, STATES, AND LOCAL GOVERNMENTS TO QUICKLY HOUSE HOMELESS INDIVIDUALS AND FAMILIES WHILE MINIMIZING THE TRAUMA AND DISLOCATION CAUSED TO HOMELESS INDIVIDUALS, FAMILIES, AND COMMUNITIES BY HOMELESSNESS; PROMOTE ACCESS TO AND EFFECTIVE UTILIZATION OF MAINSTREAM PROGRAMS BY HOMELESS INDIVIDUALS AND FAMILIES; AND OPTIMIZE SELF-SUFFICIENCY AMONG INDIVIDUALS AND FAMILIES EXPERIENCING HOMELESSNESS. THE MOST RECENT COC AWARD ANNOUNCEMENT LISTING AWARDS BY STATE AND COC IS ACCESSIBLE AT HTTPS://WWW.HUD.GOV/PROGRAM_OFFICES/COMM_PLANNING/COC/AWARDS. SELECT THE LINK UNDER THE FUNDING AND AWARD INFORMATION SECTION FOR THE APPROPRIATE FISCAL YEAR.; ACTIVITIES TO BE PERFORMED: CONTINUUM OF CARE PROGRAM FUNDS MAY BE USED TO PAY FOR THE ELIGIBLE COSTS USED TO ESTABLISH AND OPERATE PROJECTS UNDER FIVE PROGRAM COMPONENTS: (1) PERMANENT HOUSING, WHICH INCLUDES PERMANENT SUPPORTIVE HOUSING FOR PERSONS WITH DISABILITIES, AND RAPID REHOUSING; (2) TRANSITIONAL HOUSING; (3) SUPPORTIVE SERVICES ONLY; (4) HOMELESS MANAGEMENT INFORMATION SYSTEMS (HMIS), AND (5) IN SOME CASES, HOMELESSNESS PREVENTION. THIRTEEN TYPES OF ASSISTANCE MAY BE PROVIDED THROUGH THE CONTINUUM OF CARE (COC) PROGRAM: (1) COC PLANNING ACTIVITIES/COSTS FOR DESIGNING AND CARRYING OUT A COLLABORATIVE PROCESS FOR THE DEVELOPMENT OF AN APPLICATION TO HUD; (2) UNITED FUNDING AGENCY (UFA) COSTS FOR FISCAL CONTROL AND ACCOUNTING NECESSARY TO ASSURE THE PROPER DISBURSAL OF, AND ACCOUNTING FOR, FEDERAL FUNDS AWARDED TO SUBRECIPIENTS UNDER THE CONTINUUM OF CARE PROGRAM, (3) ACQUISITION OF REAL PROPERTY (INCLUDING STRUCTURES) FOR USE IN THE PROVISION OF HOUSING OR SUPPORTIVE SERVICES; (4) REHABILITATION OF STRUCTURES TO PROVIDE HOUSING OR SUPPORTIVE SERVICES; (5) NEW CONSTRUCTION, INCLUDING THE BUILDING OF A NEW STRUCTURE OR BUILDING AN ADDITION TO AN EXISTING STRUCTURE FOR USE AS SUPPORTIVE HOUSING; (6) LEASING OF A STRUCTURE OR STRUCTURES, OR PORTIONS THEREOF, TO PROVIDE HOUSING OR SUPPORTIVE SERVICES; (7) RENTAL ASSISTANCE, WHICH MAY BE SHORT-TERM, MEDIUM-TERM, OR LONG-TERM, AS WELL AS TENANT-BASED, PROJECT-BASED, OR SPONSOR-BASED, FOR TRANSITIONAL OR PERMANENT HOUSING; (8) SUPPORTIVE SERVICES TO ASSIST PROGRAM PARTICIPANTS OBTAIN AND MAINTAIN HOUSING; (9) OPERATING COSTS OF SUPPORTIVE HOUSING; (10) COSTS OF IMPLEMENTING AND OPERATING HMIS; (11) PROJECT ADMINISTRATIVE COSTS; (12) RELOCATION COSTS; AND (13) INDIRECT COSTS IN ACCORDANCE WITH 2 CFR PARTS 200, AS APPLICABLE. IN ADDITION TO USING GRANT FUNDS FOR THE ELIGIBLE COSTS DESCRIBED ABOVE, RECIPIENTS AND SUBRECIPIENTS IN CONTINUUMS OF CARE DESIGNATED AS HIGH PERFORMING COMMUNITIES MAY ALSO USE GRANT FUNDS TO PROVIDE HOUSING RELOCATION AND STABILIZATION SERVICES AND SHORT- AND/OR MEDIUM-TERM RENTAL ASSISTANCE TO INDIVIDUALS AND FAMILIES AT RISK OF HOMELESSNESS AS SET FORTH IN 24 CFR 576.103 AND 24 CFR 576.104, IF NECESSARY TO PREVENT THE INDIVIDUAL OR FAMILY FROM BECOMING HOMELESS. LIMITATION ON USE OF FUNDS: NO ASSISTANCE PROVIDED UNDER PROGRAM (OR ANY STATE OR LOCAL GOVERNMENT FUNDS USED TO SUPPLEMENT THIS ASSISTANCE) MAY BE USED TO REPLACE STATE OR LOCAL FUNDS PREVIOUSLY USED, OR DESIGNATED FOR USE, TO ASSIST HOMELESS PERSONS OR PERSONS AT-RISK OF HOMELESSNESS.; EXPECTED OUTCOMES: DECREASE IN THE NUMBER INDIVIDUALS AND FAMILIES EXPERIENCING HOMELESSNESS, MORE SPECIFICALLY USING PERFORMANCE INDICATORS SUCH AS THE LENGTH OF TIME HOMELESS, RETURNS TO HOMELESSNESS OVER TIME, AND EXITS TO PERMANENT HOUSING. COC PERFORMANCE PROFILE REPORTS CAN BE FOUND AT HTTPS://WWW.HUDEXCHANGE.INFO/PROGRAMS/COC/COC-PERFORMANCE-PROFILE-REPORTS/.; INTENDED BENEFICIARIES: INDIVIDUALS AND FAMILIES EXPERIENCING HOMELESSNESS.; SUBRECIPIENT ACTIVITIES: THE SUBRECIPIENT ACTIVITIES ARE UNKNOWN AT THE TIME OF AWARD.

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

HOMELESS ASSISTANCE

PROMISE NEIGHBORHOODS

CONTINUUM OF CARE PROGRAM

EVALUATION OF THE RADIUS PROGRAM, WHICH IS A COMMUNITY-BASED GIRLS'' DELINQUENCY PROGRAM THAT SERVES GIRLS IN THE TWIN CITIES, MINNESOTA.

HOMELESS ASSISTANCE

CONTINUUM OF CARE PROGRAM

HOMELESS ASSISTANCE

TWIN CITIES MOBILE MARKET EXPANSION

HOMELESS ASSISTANCE

SUPPORTIVE HOUSING PROGRAM

HOMELESS ASSISTANCE

CONTINUUM OF CARE PROGRAM

SUPPLEMENTAL SERVICES FOR RECENTLY ARRIVED REFUGEES

CONTINUUM OF CARE PROGRAM

PURPOSE: THE CONTINUUM OF CARE (COC) PROGRAM IS DESIGNED TO PROMOTE COMMUNITY-WIDE COMMITMENT TO THE GOAL OF ENDING HOMELESSNESS; PROVIDE FUNDING FOR EFFORTS BY NONPROFIT PROVIDERS, STATES, AND LOCAL GOVERNMENTS TO QUICKLY HOUSE HOMELESS INDIVIDUALS AND FAMILIES WHILE MINIMIZING THE TRAUMA AND DISLOCATION CAUSED TO HOMELESS INDIVIDUALS, FAMILIES, AND COMMUNITIES BY HOMELESSNESS; PROMOTE ACCESS TO AND EFFECTIVE UTILIZATION OF MAINSTREAM PROGRAMS BY HOMELESS INDIVIDUALS AND FAMILIES; AND OPTIMIZE SELF-SUFFICIENCY AMONG INDIVIDUALS AND FAMILIES EXPERIENCING HOMELESSNESS. THE MOST RECENT COC AWARD ANNOUNCEMENT LISTING AWARDS BY STATE AND COC IS ACCESSIBLE AT HTTPS://WWW.HUD.GOV/PROGRAM_OFFICES/COMM_PLANNING/COC/AWARDS. SELECT THE LINK UNDER THE FUNDING AND AWARD INFORMATION SECTION FOR THE APPROPRIATE FISCAL YEAR.; ACTIVITIES TO BE PERFORMED: CONTINUUM OF CARE PROGRAM FUNDS MAY BE USED TO PAY FOR THE ELIGIBLE COSTS USED TO ESTABLISH AND OPERATE PROJECTS UNDER FIVE PROGRAM COMPONENTS: (1) PERMANENT HOUSING, WHICH INCLUDES PERMANENT SUPPORTIVE HOUSING FOR PERSONS WITH DISABILITIES, AND RAPID REHOUSING; (2) TRANSITIONAL HOUSING; (3) SUPPORTIVE SERVICES ONLY; (4) HOMELESS MANAGEMENT INFORMATION SYSTEMS (HMIS), AND (5) IN SOME CASES, HOMELESSNESS PREVENTION. THIRTEEN TYPES OF ASSISTANCE MAY BE PROVIDED THROUGH THE CONTINUUM OF CARE (COC) PROGRAM: (1) COC PLANNING ACTIVITIES/COSTS FOR DESIGNING AND CARRYING OUT A COLLABORATIVE PROCESS FOR THE DEVELOPMENT OF AN APPLICATION TO HUD; (2) UNITED FUNDING AGENCY (UFA) COSTS FOR FISCAL CONTROL AND ACCOUNTING NECESSARY TO ASSURE THE PROPER DISBURSAL OF, AND ACCOUNTING FOR, FEDERAL FUNDS AWARDED TO SUBRECIPIENTS UNDER THE CONTINUUM OF CARE PROGRAM, (3) ACQUISITION OF REAL PROPERTY (INCLUDING STRUCTURES) FOR USE IN THE PROVISION OF HOUSING OR SUPPORTIVE SERVICES; (4) REHABILITATION OF STRUCTURES TO PROVIDE HOUSING OR SUPPORTIVE SERVICES; (5) NEW CONSTRUCTION, INCLUDING THE BUILDING OF A NEW STRUCTURE OR BUILDING AN ADDITION TO AN EXISTING STRUCTURE FOR USE AS SUPPORTIVE HOUSING; (6) LEASING OF A STRUCTURE OR STRUCTURES, OR PORTIONS THEREOF, TO PROVIDE HOUSING OR SUPPORTIVE SERVICES; (7) RENTAL ASSISTANCE, WHICH MAY BE SHORT-TERM, MEDIUM-TERM, OR LONG-TERM, AS WELL AS TENANT-BASED, PROJECT-BASED, OR SPONSOR-BASED, FOR TRANSITIONAL OR PERMANENT HOUSING; (8) SUPPORTIVE SERVICES TO ASSIST PROGRAM PARTICIPANTS OBTAIN AND MAINTAIN HOUSING; (9) OPERATING COSTS OF SUPPORTIVE HOUSING; (10) COSTS OF IMPLEMENTING AND OPERATING HMIS; (11) PROJECT ADMINISTRATIVE COSTS; (12) RELOCATION COSTS; AND (13) INDIRECT COSTS IN ACCORDANCE WITH 2 CFR PARTS 200, AS APPLICABLE. IN ADDITION TO USING GRANT FUNDS FOR THE ELIGIBLE COSTS DESCRIBED ABOVE, RECIPIENTS AND SUBRECIPIENTS IN CONTINUUMS OF CARE DESIGNATED AS HIGH PERFORMING COMMUNITIES MAY ALSO USE GRANT FUNDS TO PROVIDE HOUSING RELOCATION AND STABILIZATION SERVICES AND SHORT- AND/OR MEDIUM-TERM RENTAL ASSISTANCE TO INDIVIDUALS AND FAMILIES AT RISK OF HOMELESSNESS AS SET FORTH IN 24 CFR 576.103 AND 24 CFR 576.104, IF NECESSARY TO PREVENT THE INDIVIDUAL OR FAMILY FROM BECOMING HOMELESS. LIMITATION ON USE OF FUNDS: NO ASSISTANCE PROVIDED UNDER PROGRAM (OR ANY STATE OR LOCAL GOVERNMENT FUNDS USED TO SUPPLEMENT THIS ASSISTANCE) MAY BE USED TO REPLACE STATE OR LOCAL FUNDS PREVIOUSLY USED, OR DESIGNATED FOR USE, TO ASSIST HOMELESS PERSONS OR PERSONS AT-RISK OF HOMELESSNESS.; EXPECTED OUTCOMES: DECREASE IN THE NUMBER INDIVIDUALS AND FAMILIES EXPERIENCING HOMELESSNESS, MORE SPECIFICALLY USING PERFORMANCE INDICATORS SUCH AS THE LENGTH OF TIME HOMELESS, RETURNS TO HOMELESSNESS OVER TIME, AND EXITS TO PERMANENT HOUSING. COC PERFORMANCE PROFILE REPORTS CAN BE FOUND AT HTTPS://WWW.HUDEXCHANGE.INFO/PROGRAMS/COC/COC-PERFORMANCE-PROFILE-REPORTS/.; INTENDED BENEFICIARIES: INDIVIDUALS AND FAMILIES EXPERIENCING HOMELESSNESS.; SUBRECIPIENT ACTIVITIES: THE SUBRECIPIENT ACTIVITIES ARE UNKNOWN AT THE TIME OF AWARD.

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

HOMELESS ASSISTANCE

CONTINUUM OF CARE PROGRAM

SUPPORTIVE HOUSING NEW

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

CONTINUUM OF CARE PROGRAM

SUPPORTIVE HOUSING NEW

SUPPORTIVE HOUSING NEW

CONTINUUM OF CARE PROGRAM