Wellstone FY2022 ccbhc-PDI - samhsa ccbhc-PDI funding will fill gaps in madison county adult services as we prepare for agency-wide ccbhc status in the future

The ccbhc-PDI project aims to serve 1700 unduplicated economically disadvantaged adults in madison county, alabama. Approximately 75% of wellstone's adult outpatient clients in the madison county program currently are at or below the federal poverty level. Historically, economically disadvantaged communities have experienced increased health disparity and these disparities have only intensified since the start of the covid pandemic. Project funds will be used to: expand mobile crisis teams to 24/7 coverage, provide primary care to adult outpatient consumers, develop healthcare data infrastructure for future agency-wide ccbhc certification, implement measurement-based care, expand peer services with a living room model, initiate intensive community based mental healthcare for members of the armed forces and veterans, and conduct a community needs assessment with the goal of informing planning for the ccbhc project. Objectives of the project include: 1) the mobile crisis team will respond to a minimum of 1200 calls by by 9/29/26. 2) in the first year, 500 outpatient primary care screenings will be provided to include: BMI screening and follow-up, blood pressure monitoring, tobacco screening and cessation intervention, unhealthy alcohol use, diabetes screening and care, cardiovascular health screening, medication adherence, and/or HIV/viral hepatitis screening. 3) reduction of tobacco use in program participants by 5% from entry to care to 1 year reassessment. 4) increasing medication compliance in primary care participants by 25% over baseline. 4) implementing a ccbhc continuous quality improvement plan for clinical services and management by 5/29/23. 5) report on all required clinic-level ccbhc quality measures by 9/29/23. 6) develop health information systems to facilitate care coordination through CCD, and HIE information sharing. 7) provide walk-in support to 400 people through a peer support living room 8) a veteran's care coordinator will provide outreach and serve 50 active duty or veteran consumers by 9/29/23. While many of the required elements for ccbhc certification are already met at wellstone, the ccbhc-PDI grant will support wellstone's near-term plan to meet all ccbhc certification criteria on the way to our long-term goal of continuously improving behavioral healthcare for individuals across the lifespan.