Net centers CCBHC - net proposes to build on the CCBHC/icwc experience to implement CCBHC core services at a location which currently houses one of our six mat (medication assisted treatment)…

Net centers CCBHC - net proposes to build on the CCBHC/icwc experience to implement CCBHC core services at a location which currently houses one of our six mat (medication assisted treatment) outpatient addiction/recovery sites. This location was chosen to impact a demographic shift among those who died of unintentional overdoses in philadelphia in 2021. Located in the 19132-ZIP code, IT will be centrally located in our targeted catchment area encompassing north and eastern north philadelphia, particularly the ZIP codes 19132, 19121, 19133, and 19140. As a city of neighborhoods, this comprises strawberry mansion, brewerytown, glenwood (demographically more 90% african american) and fairhill (80% latino, largely of puerto rican descent). With a total population of over 160,000 individuals, this area has an unemployment rate as high as 26%, and 63% of the population lives at or below the poverty line. Through a variety of coordinated and integrated activities, net will address gaps in the continuum of resources that serve to link those with serious mental health, substance use disorder and high-risk medical conditions with enhanced integrated resources and treatment. Net will serve 1,550 participants (250 year one, 400 year two, and 450 years three and four). The certified community behavioral health clinic (CCBHC) PDI grant aligns with net centers mission and history. We have provided comprehensive, quality-driven, and cost-effective services throughout the greater philadelphia region for over 50 years. Net centers already has a significant presence in this community providing mat addictions/recovery services, a multilevel of care residential program, and withdrawal management services. Additionally, net is the sole provider of child welfare case management services for the region and has developed an integrated approach that supports child welfare involved families with expertise and resources from within our addiction treatment continuum. Using a population health management framework, we will focus on physical health conditions most prevalent in our geographic area such as diabetes, HIV, asthma, hypertension, and obesity, all of which directly correlate to the high rates of poverty and demographics in this area, as reported in philadelphia's 2020 health of the city report. We will also improve access to various non-treatment supports that impact health outcomes and/or the social determinants of health. While we will focus on all social determinants, a priority area is to facilitate better integration with the primary care provider; assuring follow up for patients with high-risk medical conditions; and increasing capacity to assess high risk medical conditions; we will expand support services for those in treatment, and their families, by developing and implementing the role of a community navigator (CN). They will enhance care coordination and strategic client engagement. Services will be delivered at the clinic and in home and community settings, including other collaborating agencies or service providers, as needed. Goals to be achieved include expanding our network of community partners; increasing awareness of health resources and harm reduction strategies; increasing the utilization of mat; reducing AMA discharges; increasing capacity to serve persons with complex medical conditions and expanding the continuum of care coordination options.