Behavioral health services north is seeking a ccbhc improvement and advancement grant to improve and build upon ccbhc expansion grant of 2020. - behavioral health services north (bhsn) is a non-profit…

Behavioral health services north is seeking a ccbhc improvement and advancement grant to improve and build upon ccbhc expansion grant of 2020. - behavioral health services north (bhsn) is a non-profit corporation and existing ccbhc expansion grantee in NY that will continue to serve all adults and children within clinton, franklin and essex counties, who experience MH and/or SUD issues. The ccbhc-IA award will allow the bhsn ccbhc to continue advancing its ccbhc services in whole-person integrated care, with a strengthened population health/equity foundation. The predominantly rural service area, which is within a region called "north country," is older, less diverse, and more male than NY as a whole, with a concentration of native americans in franklin county. Compared to NY state, clinton and franklin county have higher rates of those living below the federal poverty line(FPL); clients in our catchment are sicker, with a higher percentage diagnosed with 2 or more chronic medical conditions and higher rates of inpatient hospitalization. Disparities in the impact of MH/SUD in the region compared with NY and the US include higher rates of poor MH days, frequent mental distress, excessive drinking, driving deaths related to alcohol, drug overdoses and suicide mortality. All 3 counties have been designated as rural health professional shortage areas for primary care and MH providers. Our goals and objectives will be fulfilled through enhancements in our care coordination services with health information system improvements that enable risk stratification and a data-informed population health approach toward addressing disparities in utilization, service gaps and needs to target appropriate care. We plan to serve 3,400 unique clients in year 1, with an additional 200 over the next 3 years, totaling 4,000 by end of the grant period. Our goals and objectives are: *goal 1. Enhance care coordination services to target the right care at the right time for ccbhc clients -objective 1.1. Establish definitions of risk tiers within 12 months of grant award using a combination of clinical assessment tools, client demographics, utilization, sdoh screening results, symptom rating scales as per measurement-based care, outcomes and client needs. OBJ 1.2. Using completed EHR enhancements, apply tiering protocols to current and new ccbhc clients and establish a plan to focus on high risk and rising risk clients-within 18 months of grant award. *goal 2. Improve health outcomes -objective 2.1. Advance outcomes specified in year 2 risk bearing VBP contract with northwinds IPA measured by the following hedis measures: 2.1A. Increase the percentage of clients who have health screenings by 25 % 2.1B. Increase the percentage of clients with follow-up after hospitalization by 20 % 2.1C. Increase the percentage of client follow-up after crisis care by 25 % 2.1D. Reduce inpatient utilization by 5 % *goal 3. Enhance access to MH/SUD care -OBJ 3.1. Implement patient portal by 12 months of award that enables clients' meaningful involvement in their own care, including appointment scheduling, access to care plan, crisis support; self-assessments, and daily journaling. OBJ 3.2. Implement the 4M model of care for older adults by training staff and identifying eligible clients by end of year 2. OBJ 3.3. On an annual basis 90 % of ccbhc clients with a history of substance use will receive sbirt