Solutions and opportunities for uplifting lives (soul) program - memorial healthcare system proposes to expand and improve the behavioral health care continuum in the south florida geographic…

Solutions and opportunities for uplifting lives (soul) program - memorial healthcare system proposes to expand and improve the behavioral health care continuum in the south florida geographic catchment area by becoming a certified community behavioral health clinic. (ccbhc) with the implementation of the solutions and opportunities for uplifting lives (soul) program. This initiative will allow memorial to implement and hardwire care coordination efforts as a pivotal feature within the ccbhc. Memorial proposes to serve 1,650 unduplicated consumers over the course of 4 years. The populations of focus comprise children, adolescents and adults in broward county, florida (a non-medicaid expansion state) with mental health disorders, who are uninsured or from under-resourced communities and vulnerable to health disparities. Their conditions impair routine functioning in everyday activities and can include serious mental illness, serious emotional disturbance, those susceptible to suicide risk, overdose and individuals with CO-occurring mental and substance use disorders. The participants reflect the demographic diversity of the service area and include consumers with special needs, veterans, those identifying as lgbtq+ and/or those at risk for suicide and overdose, vulnerability to homelessness and socioeconomic disparities that hinder access to health resources. A prevailing population characteristic is that they cannot afford services and/or CO-pays and are uninsured or underinsured. Care coordination is the lynchpin of the ccbhc model and is currently the weakest link in the catchment area's continuum of care. Whether services are provided directly by staff or through collaboration with service providers through designated collaborating organizations (DCO) agreements, communication and coordination to navigate the consumer between providers is essential to address the consumer's needs, preferences and barriers. Since the fragmented mental health system presents challenges for consumers as they transition from one care setting to another, memorial will hire and train a team of six (6) care coordinators to work with both adults and children/adolescents to ensure consumer-friendly warm handoffs to and from DCO partner agencies for clinical care and to address the consumer's social determinants of health (sdoh). To support the care coordination team's efforts to use measurement-based care (MBC) into program implementation to drive clinical decision making memorial will also enhance the organization's infrastructure. Enhancements to the electronic health record system will build capacity to collect, record, monitor, track, analyze and report on key data points resulting from evidence-based practices and interventions employed in the treatment of consumers. An advisory council will also provide input to help consumers access care and reduce disparities while complying with hipaa guidelines and improving the soul program services to be consumer-centered and outcome-based mental health care. The goals and objectives are to establish and meet all requirements to become a ccbhc by month 12 by increasing the quality of behavioral health services and increasing care coordination for consumers in broward county. An evaluator will analyze clinic-level quality measures on services received and data on retention in program services including care coordination, mental health services, substance use treatment, primary care and support services to monitor individual progress towards positive health outcomes including mental health functioning, stability (e.g., no overdose), suicidal thoughts or actions, and other successes (e.g., improvements in employment, housing status, decreases in criminal justice involvement, physical health indicators, increases in social support). Data towards training and enrollment goals will be analyzed monthly to address infrastructure, prevention and promotion (IPP) and national outcome measures (noms) goals with spec