Abbe center ccbhc project - in linn county, IA, abbe center ccbhc project will implement strategies to engage individuals who are "at-risk" for readmission to the behavioral health inpatient.…

Abbe center ccbhc project - in linn county, IA, abbe center ccbhc project will implement strategies to engage individuals who are "at-risk" for readmission to the behavioral health inpatient. "at-risk" is determined by a hospital admission within the last year instead of utilizing more cost-effective community-based services due to lack of engagement, timely access to services and/or understanding how to navigate the service system. Current populations served are children and adults with mental illness, serious mental illness, serious emotional disturbance, substance use disorders and CO-occurring disorders. In 2021, abbe center served 8,351 individuals in these categories, estimating 5% "at-risk." abbe center ccbhc will serve 350 unduplicated individuals determined to be "at-risk" each year, for an unduplicated four-year total of 800 individuals served. Nature of the problem: high incidence of people being readmitted to the hospital due to lack of engagement, timely access to services and/or understanding how to navigate the service system. Goal 1: decrease inpatient behavioral health readmission rate for ccbhc clients by 25% by providing timely access to services, enhancing engagement and care coordination to individuals identified as "at-risk." objective a: engage "at-risk" individuals and coordinate behavioral health services. - by january 2023, 60% of individuals "at-risk" will receive outreach/care coordination. - by april 2023, conduct a literature review and environmental scan for research informed practices related to transitions of care. - based on literature review, use implementation science to evaluate at least one transition of care research informed best practice by september 2026. - by september 2023, the outreach team will facilitate connecting 75% of their eligible clients to a community based or integrated health home program for longer term support. Objective b: provide timely access to prescriber and community-based services. - by september 2024, abbe center will expand an established urgent care track to include 24 hours per week availability for urgent timeslots in the clinic and through the access center. - by september 2025, 50% of clients referred by outreach will be enrolled in community-based service within 15 days from referral. Nature of the problem: individuals have more risk factors than are being identified. Goal 2: increase comprehensive screening activities to ensure individuals receive the resources needed to maintain their health and well-being. Objective a: increase health screenings to provide more integrated care. - by september 2024, increase primary care screening and monitoring by 50% - by september 2025, increase primary care services onsite by 25% - by september 2024, increase screening and referrals for substance use disorder by 50% - by september 2025, increase substance use disorder services onsite by 25%