The family center's ccbhc program - the family center of brooklyn, NY ccbhc service improvement project will serve all populations of focus, improving behavioral and health outcomes through enhanced…

The family center's ccbhc program - the family center of brooklyn, NY ccbhc service improvement project will serve all populations of focus, improving behavioral and health outcomes through enhanced trauma-informed screening and behavioral health treatment, expanding care coordination for vulnerable ccbhc clients WIT multiple chronic health conditions and risks, and implementing targeted case management, engagement, and follow-up services using the critical time intervention model to ensure continuity of care after in-patient MH and SUD treatment episodes and overdoses. Demographic characteristics of the high-risk central brooklyn populations served will be: over 90% will be members of underrepresented minority groups, 76% african american, nearly 13% hispanic, less than 10% non-hispanic white. Twenty percent of residents are foreign born, mostly from the caribbean or central america, with 90% being english proficient from trinidad, jamaica, and guyana. The median age is 32.8 (slightly younger than NYC overall). Nearly 58% of the population 18 years and older is female. The clinical profile will be: 40% of adults above the 80TH percentile of disability on the whodas, 20% above the moderately severe level for depression, 15% severely anxious, 6% homeless, and 55% unemployed and not seeking work. The majority of TFC-ccbhc consumers have primary diagnoses of SUD/COD; 13% of adults have "substantial" or "severe" drug abuse and indicate hazardous or harmful alcohol use; 23% of children/youth screen into the medium to high-risk range for substance abuse. High rates of pre-diabetes, diabetes, HIV, and other CO-morbidities mirror community rates. Goals and measurable objectives include: goal 1: reduce the impact of trauma, including covid-related trauma, on the behavioral health of those enrolled in the ccbhc and their families. Objectives: screen 100% of the ccbhc enrolled population for the impact of trauma on behavioral health (BH) and well-being; initiate a mindfulness intervention for consumers with positive trauma screens to enhance coping skills for anxiety, depression, emotional distress, using DBT mindfulness groups mindfulness-based cognitive therapy (mbct); implement routine telehealth peer/case manager check-INS for 100% trauma-impacted consumers/those in significant distress; conduct BH needs assessment of catchment area. Goal 2: improve health and treatment outcomes via enhanced health screening, emphasis on medical outcomes in treatment planning, wellness education/support, and coordination with primary/specialty medical care. Objective: by project month [PM] 5, 85% of consumers determined to have or be high-risk for metabolic disease, HBP, HIV and other CO-morbidities will receive monthly medical monitoring/support; 75% will show health marker improvements after 6 months and show significant BH treatment gains compared to those with no improvement. Goal 3: provide new team-based intensive transitional care during high-risk care transitions, including post-release from in-patient psychiatric or residential SUD treatment, using the critical time intervention model. Objectives: by PM 5,initiate intensive transitional care; 70% of consumers enrolled in intensive transitional care will remain engaged in care for at least 3-months following each transition, as measured by service data; for SED and SMI clients receiving team-based transitional care following discharge from in-patient settings, reduce the 30-day psychiatric hospital readmission rate to 15% below area baseline; by PM 3, implement enhanced pre-release collaborative discharge planning for 100% ccbhc adults and youth completing residential SUD treatment. A total of 800 adults and 300 children/youth will be served, with 200 adults and 75 children/youth served each of the 4 project years.