Abbe Center For Community Mental Health Inc

ABBE CENTER CCBHC PROJECT - IN LINN COUNTY, IA, ABBE CENTER CCBHC PROJECT WILL IMPLEMENT STRATEGIES TO ENGAGE INDIVIDUALS WHO ARE "AT-RISK" FOR READMISSION TO THE BEHAVIORAL HEALTH INPATIENT. "AT-RISK" IS DETERMINED BY A HOSPITAL ADMISSION WITHIN THE LAST YEAR INSTEAD OF UTILIZING MORE COST-EFFECTIVE COMMUNITY-BASED SERVICES DUE TO LACK OF ENGAGEMENT, TIMELY ACCESS TO SERVICES AND/OR UNDERSTANDING HOW TO NAVIGATE THE SERVICE SYSTEM. CURRENT POPULATIONS SERVED ARE CHILDREN AND ADULTS WITH MENTAL ILLNESS, SERIOUS MENTAL ILLNESS, SERIOUS EMOTIONAL DISTURBANCE, SUBSTANCE USE DISORDERS AND CO-OCCURRING DISORDERS. IN 2021, ABBE CENTER SERVED 8,351 INDIVIDUALS IN THESE CATEGORIES, ESTIMATING 5% "AT-RISK." ABBE CENTER CCBHC WILL SERVE 350 UNDUPLICATED INDIVIDUALS DETERMINED TO BE "AT-RISK" EACH YEAR, FOR AN UNDUPLICATED FOUR-YEAR TOTAL OF 800 INDIVIDUALS SERVED. NATURE OF THE PROBLEM: HIGH INCIDENCE OF PEOPLE BEING READMITTED TO THE HOSPITAL DUE TO LACK OF ENGAGEMENT, TIMELY ACCESS TO SERVICES AND/OR UNDERSTANDING HOW TO NAVIGATE THE SERVICE SYSTEM. GOAL 1: DECREASE INPATIENT BEHAVIORAL HEALTH READMISSION RATE FOR CCBHC CLIENTS BY 25% BY PROVIDING TIMELY ACCESS TO SERVICES, ENHANCING ENGAGEMENT AND CARE COORDINATION TO INDIVIDUALS IDENTIFIED AS "AT-RISK." OBJECTIVE A: ENGAGE "AT-RISK" INDIVIDUALS AND COORDINATE BEHAVIORAL HEALTH SERVICES. - BY JANUARY 2023, 60% OF INDIVIDUALS "AT-RISK" WILL RECEIVE OUTREACH/CARE COORDINATION. - BY APRIL 2023, CONDUCT A LITERATURE REVIEW AND ENVIRONMENTAL SCAN FOR RESEARCH INFORMED PRACTICES RELATED TO TRANSITIONS OF CARE. - BASED ON LITERATURE REVIEW, USE IMPLEMENTATION SCIENCE TO EVALUATE AT LEAST ONE TRANSITION OF CARE RESEARCH INFORMED BEST PRACTICE BY SEPTEMBER 2026. - BY SEPTEMBER 2023, THE OUTREACH TEAM WILL FACILITATE CONNECTING 75% OF THEIR ELIGIBLE CLIENTS TO A COMMUNITY BASED OR INTEGRATED HEALTH HOME PROGRAM FOR LONGER TERM SUPPORT. OBJECTIVE B: PROVIDE TIMELY ACCESS TO PRESCRIBER AND COMMUNITY-BASED SERVICES. - BY SEPTEMBER 2024, ABBE CENTER WILL EXPAND AN ESTABLISHED URGENT CARE TRACK TO INCLUDE 24 HOURS PER WEEK AVAILABILITY FOR URGENT TIMESLOTS IN THE CLINIC AND THROUGH THE ACCESS CENTER. - BY SEPTEMBER 2025, 50% OF CLIENTS REFERRED BY OUTREACH WILL BE ENROLLED IN COMMUNITY-BASED SERVICE WITHIN 15 DAYS FROM REFERRAL. NATURE OF THE PROBLEM: INDIVIDUALS HAVE MORE RISK FACTORS THAN ARE BEING IDENTIFIED. GOAL 2: INCREASE COMPREHENSIVE SCREENING ACTIVITIES TO ENSURE INDIVIDUALS RECEIVE THE RESOURCES NEEDED TO MAINTAIN THEIR HEALTH AND WELL-BEING. OBJECTIVE A: INCREASE HEALTH SCREENINGS TO PROVIDE MORE INTEGRATED CARE. - BY SEPTEMBER 2024, INCREASE PRIMARY CARE SCREENING AND MONITORING BY 50% - BY SEPTEMBER 2025, INCREASE PRIMARY CARE SERVICES ONSITE BY 25% - BY SEPTEMBER 2024, INCREASE SCREENING AND REFERRALS FOR SUBSTANCE USE DISORDER BY 50% - BY SEPTEMBER 2025, INCREASE SUBSTANCE USE DISORDER SERVICES ONSITE BY 25%

ABBE CENTER CCBHC PROJECT

ABBE CENTER CCBHC PROJECT.