Western montana CCBHC improvement and advancement project - western montana mental health center (WMMHC), a certified community behavioral health clinic (CCBHC) "improving integration and advancing…

Western montana CCBHC improvement and advancement project - western montana mental health center (WMMHC), a certified community behavioral health clinic (CCBHC) "improving integration and advancing access project", will utilize grant funds to strengthen and expand the nine core CCBHC services to continue to provide comprehensive and coordinated behavioral healthcare to adults with serious mental illness, children and youth with serious emotional disturbance, and people with substance use disorders or CO-occurring disorders, most most of whom come from low income households. The geographic catchment area where services will be delivered includes missoula county (population 121,630), which is the site of WMMHC's existing cbhc clinic. WMMHC will expand primary care screening and monitoring, and services to the butte clinic in silver BOW county (population 35,180) during the grant period. WMMHC is identifying two service areas for improvement and advancement:(1) primary care screening and monitoring and care coordination for individuals with chronic diseases such as diabetes and hypertension and those with risk factors for health problems and death from illnesses such as heart disease or cancer (e.g. pre-diabetes, obesity, tobacco use), and (2) rapid access to mental health therapy for clients served by WMMHC. WMMHC is also identifying two subpopulations for which we plan to address behavioral health disparities: native americans and individuals identifying as hispanic or latino. At the end of year 1 of the expansion grant, data showed that 49% of WMMHC's adult male CCBHC enrollees had waist circumference measurements that put them at a greater risk for health problems and death from illnesses such as heart disease and cancer, and 65% of adult female enrollees had at-risk measurements. 45% of enrollees had high systolic blood pressure (>130 mmhg) and 64% of enrollees had high diastolic blood pressure (>85 MM HG). Native americans and hispanic/latinos experience higher rates of diabetes and obesity in missoula and silver BOW counties than white, non-hispanics. Self-reported rates of tobacco use were higher among CCBHC enrollees than the estimated rates among all adult montana residents statewide (60% of enrollees versus 30% statewide). Goal 1: improve and advance rapid access to mental health therapy for clients, while supporting productivity of clinicians. Objectives: (1) implement a continuous quality improvement plan for increasing rapid access to therapy for clients with acute needs. Develop plan by month 6 of grant. Implement by end of year 1. Set goals for years 2-4. (2) decrease clinician caseloads by 5% by identifying and discharging clients who have either (a) not been engaged in therapy for 90+ days or (B) no longer need therapy and may benefit from other supports. (3) increase rapid access to therapy for clients with acute needs, as evidenced by a 25% decrease in wait times. (4) develop a plan to train therapists in brief evidence-based interventions. Develop plan by end of year 1. Implement in year 2. Goal 2: improve provision of and advance access to self-management of chronic health conditions through enhanced primary care screening and monitoring, health and wellness services, and delivery of care coordination. Objectives: (1) for each quarter, 50% of individuals with chronic health conditions will complete referrals to specialty care and other community resources for supportive services as part of their care coordination plan, as documented by staff service logs and WMMHC's electronic health record. (2) 70% of clients reporting daily tobacco use will receive one or more tobacco cessation supports. (3) 40% of clients reporting daily tobacco use will reduce tobacco use after 2 months of active engagement in tobacco cessation program. (4) 50% of clients with chronic diseases an/or those with risk factors for health problems and death from illnesses such as heart disease or cancer will be engaged in an evidence-based we