2022 ccbhc-PDI - summitstone health partners (SHP) will establish a ccbhc to expand quality-driven, data-informed, community-based health and primary care for individuals across the lifespan who…

2022 ccbhc-PDI - summitstone health partners (SHP) will establish a ccbhc to expand quality-driven, data-informed, community-based health and primary care for individuals across the lifespan who have or are at risk for a mental illness or substance abuse disorder or CO-occurring disorders in larimer county. To reduce health inequities, SHP will focus on people discharging from its crisis stabilization services; veterans/members of the armed forces; and bipoc communities. The project will address the most pressing needs of our community, which has experienced dramatic increases in serious mental illness, overdose deaths, and suicide in recent years. SHP's clinical division reports that up to 75% of clients who leave crisis services do not transition into ongoing treatment. To support clients' ongoing stabilization and recovery, SHP will expand its street medicine and addiction rapid transition team (SMARTT), which will reduce return utilizations of crisis services by providing community-based, flexible services that build therapeutic alliances and, crucially, center on providing clients with the right care at the right place at the right time. SHP will also provide additional supports for youth aged 12-18 experiencing mental health crises, including obtaining licensure for five-day crisis stabilization unit stays and the addition of a crisis transitions family peer specialist. In collaboration with the cheyenne VA health care system, SHP will provide outpatient/intensive outpatient SUD and medication-assisted treatment (mat) to veterans and members of the armed forces. Through formal DCO relationships and current programming, SHP will ensure that all clients receive expert primary care screening, referral, and evidence-based intervention as well of provision of recommended vaccinations within 12 months of award. Equitable and representative care, an existing agency priority, will be further advanced through ongoing opportunities for education and self-reflection at every level of the organization, including the board of directors, allowing SHP to keep apace of larimer county's quickly changing racial and ethnolinguistic landscape and adjust services as needed to guarantee that anyone can access care regardless of their background. Finally, SHP will expand its current capacity for continuous quality improvement as part of the agency's ongoing commitment to providing the highest quality and equitable care. Funds will be used to hire a program evaluation specialist; launch a continuous quality improvement committee and implement a performance measurement and management plan. Additionally, SHP will make investments in EHR updates; data connectors to support data sharing with dcos and other referral sources; and the integration of noms data and building automated reassessment alerts into the EHR. SHP will serve 150 individuals in year 1; 180 in year 2; 216 in year 3; and 259 in year 4 for a total of 805 individuals. Goal 1 is to raise SHP's standard of care by achieving 100% of the ccbhc standards for staffing, access, care coordination, scope of services, quality and other reporting, and governance and accreditation. Goal 2 is to build SHP's capacity to reduce health disparities by providing evidence-based, trauma-informed care to the population of focus through outreach, service expansion, and infrastructure investments. Goal 3 is to develop and sustain SHP's capacity for continuous quality improvement to increase efficiencies and reduce health disparities.