Integrated behavioral health: no wrong door to care - pacific clinics (PC), a newly merged organization of uplift family services and pacific clinics, seeks to enhance its ccbhc by increasing…

Integrated behavioral health: no wrong door to care - pacific clinics (PC), a newly merged organization of uplift family services and pacific clinics, seeks to enhance its ccbhc by increasing community access to high-quality mental health and substance use disorders (SUD) treatment and improving integration with primary care services for the purpose of increasing access to and improving the quality of community mental health and substance use disorder treatment by integrating services with physical health. PC staff provide comprehensive, integrated behavioral health services with primary care patients in a federally qualified health center (fqhc): school health clinics (SHC) of santa clara county, a designated collaborating organization (DCO). The target population is under-represented low-income families and immigrants in santa clara county, with a focus on county residents who are hispanic/latinx and non-english speakers. Services will continue to be delivered in an integrated manner across five clinics in SAN jose, california, to allow for more comprehensive assessment and treatment of physical, mental health, and substance use disorders in a manner that is less likely to be stigmatizing, more consistent with the target community's help-seeking behaviors, and relatively seamless in care. Our focus will be on ensuring that patients hard-to-reach populations within the fqhc are given access to the comprehensive services provided through the ccbhc. We expect to serve 862 new, unduplicated clients over the grant period. Our goals are: goal 1. Improve access to and integration of behavioral health services within primary care. 1A. Increase universal screening. By end of year 4, 60% of consumers with at least 2 SHC primary care visits/year will be screened using validated mental health and substance use tools (e.g., ASQ, PHQ-9, taps). 1B. Enhance primary care physicians (PCP) and medical assistant (MA) knowledge and skills to refer consumers with behavioral health needs. By the end of year 4, pcps will refer 50% of SHC consumers with behavioral health screening criteria to ccbhc services. 1C. Provide continuity of integrated care and increase patient engagement in BH services. By the end of year 4, 50% of patients who meet screening criteria are referred to the ccbhc will have a follow-up appointment scheduled with the referring PCP within 8 weeks. Goal 2. Expand access to SU services. 2A. Increase access to medication-assisted treatment (mat). By the end of year 4, 33% of SHC consumers with an alcohol- or opioid-use disorder diagnosis will receive mat; 2B. Increase access to substance use counseling and recovery supports. By end of year 4, 50% of SHC consumers screening with risky substance use will be referred to ccbhc substance use counseling and/or recovery supports. Goal 3. Improve quality of care and consumer outcomes. 3A. Assist consumers in reaching their individualized goals. By end of year 4, 50% of ccbhc-enrolled consumers will have met their treatment goals at discharge. 3B. Use measurement-based care to improve consumers' behavioral health. By end of year 4, 50% of ccbhc-enrolled consumers will significantly improve from pre-to post-treatment on at least one treatment target using a standardized, validated measure (e.g., PHQ-9). 3C. Improve consumers' functioning. By end of year 4, 60% of ccbhc-enrolled consumers will report improved daily functioning (ability to deal effectively with problems, school/work, and other people) from pre-to post-treatment on the national outcome measures (noms). 3D. Improve consumer's independence. By the end of year 4, 80% of ccbhc-enrolled consumers will be retained in the community (no nights spent homeless, hospitalized, in residential treatment, or in a correctional facility) at post-treatment on the noms. 3E. Improve consumer satisfaction. By the end of year 4, 80% of ccbhc-enrolled consumers will report high satisfaction with services on the noms.