Project Grant H79SM087045

PROJECT ENGAGE - BRIDGES HEALTHCARE'S PROJECT ENGAGE WILL EXTEND THE REACH OF CCBHC SERVICES TO BRIDGES' NEW SERVICE LOCATIONS IN WEST HAVEN AND STRATFORD, CONNECTICUT, AND IMPLEMENT TWO NEW STRATEGIES - A WELLNESS-ON-WHEELS MOBILE VEHICLE PROGRAM AND A DEDICATED COMMUNITY OUTREACH SPECIALIST - IN ORDER TO MAKE BOTH PRIMARY CARE SCREENINGS AND MENTAL HEALTH/SUBSTANCE USE SERVICES MORE ACCESSIBLE TO LOW-ACCESS AND UNDERSERVED POPULATIONS IN THOSE AREAS. POPULATIONS SERVED/CLINICAL CHARACTERISTICS. THE PROGRAM'S FOCUS IS ON THE RESIDENTS OF WEST HAVEN AND STRATFORD (POPULATION 107,000), AND IN PARTICULAR ON HEALTH DISPARITIES EXHIBITED BY THEIR HISPANIC, BLACK, AND LOW INCOME POPULATIONS (OVER 28,000, 22,000, AND 10,000, RESPECTIVELY). EACH OF THESE POPULATIONS EXHIBIT LOW ACCESS TO CARE FOR ONE REASON OR ANOTHER, AND CONSEQUENTLY ARE AT HIGH RISK FOR POOR HEALTH OUTCOMES. IN THE CASE OF THE HISPANIC POPULATION, AT LEAST FOUR BARRIERS TO CARE RESULT IN INADEQUATE MEDICAL CARE AND CREATE ADVERSE HEALTH OUTCOMES - A HIGH UNINSURED RATE, FINANCIAL INSECURITY, A LANGUAGE BARRIER, AND, IN MANY CASES, CONCERNS ASSOCIATED WITH NON-CITIZENSHIP STATUS. RESULTING HEALTH DISCREPANCIES INCLUDE HIGH RATES OF HIV FOR ALL THE TARGET POPULATIONS, AS WELL AS HIGH RATES OF HYPERTENSION, OBESITY, DIABETES, AND DEPRESSION. IN THE LAST THREE YEARS, THE DRUG MORTALITY RATE AMONG NON-HISPANIC BLACK RESIDENTS MORE THAN DOUBLED AND NOW IS HIGHEST AMONG ANY DEMOGRAPHIC GROUP. AMONG HISPANIC RESIDENTS, THE RATE INCREASED BY 40%. FINANCIAL INSECURITY IS A FACTOR FOR ALL. COST IS THE REASON FOR NOT GETTING NEEDED MENTAL HEALTH CARE CITED BY NEARLY HALF OF THOSE WITH SERIOUS MENTAL ILLNESS. PROPOSED STRATEGIES AND INTERVENTIONS. THE PURPOSE OF THE WOW MOBILE VEHICLE PROGRAM IS TO PROVIDE ACCESS TO CARE TO CLIENTS AT LOCATIONS CONVENIENT TO THEM. TARGET NEIGHBORHOODS MIGHT INCLUDE GROUPS WHO ARE WITHOUT INSURANCE, HOMELESS, NON-ENGLISH-SPEAKING, OR, FOR OTHER REASONS, NOT COMFORTABLE IN A TRADITIONAL OFFICE SETTING. SERVICES WILL BE PROVIDED REGARDLESS OF AN INDIVIDUAL'S CITIZENSHIP OR ABILITY TO PAY. IN YEAR 1, THE VEHICLE WILL CONDUCT A VARIETY OF HEALTH SCREENINGS, MONITOR KEY HEALTH INDICATORS, AND IDENTIFY CHRONIC DISEASES AND COMORBID CONDITIONS; OFFER CLIENT EDUCATION, COUNSELING, AND SUPPORT AS NEEDED; AND PROVIDE A WARM HAND-OFF TO EITHER CASE MANAGEMENT OR TREATMENT AS NEEDED. STARTING IN YEAR 2, WE WILL PROVIDE SUBSTANCE USE/MENTAL HEALTH SCREENING AND HARM REDUCTION SERVICES (E.G., SYRINGE EXCHANGE). THE COMMUNITY ENGAGEMENT SPECIALIST (CES) WILL PROACTIVELY IDENTIFY AND ENGAGE UNDERSERVED OR DIFFICULT-TO-ENGAGE CLIENTS, BY ESTABLISHING INFORMAL AND FORMAL COLLABORATIONS AND PARTNERSHIPS IN THE COMMUNITIES WE SERVE, OUTREACH IN INFORMAL SETTINGS LIKE CHURCHES, COMMUNITY CENTERS, OR IN OTHER COMMUNITY SETTINGS, AND HELPING CLIENTS FIND RESOURCES AND SERVICES TO SUPPORT AND ENHANCE THEIR RECOVERY PROCESS. GOALS/OBJECTIVES. GOAL I: TO ENHANCE AND IMPROVE ACCESS TO BEHAVIORAL AND PHYSICAL HEALTH SERVICES THROUGH THE WELLNESS-ON-WHEELS (WOW) PROGRAM AND ACTIVE COMMUNITY ENGAGEMENT EFFORTS. OBJECTIVES 1-3: THE WOW PROGRAM SERVES 100 CLIENTS PER YEAR, 50% RECEIVING REFERRALS TO PRIMARY OR SPECIALTY CARE, 23% HISPANIC AND 19% BLACK. OBJECTIVE 4: STARTING IN YEAR 2, ADD MENTAL HEALTH/ADDICTION SCREENINGS FOR 90% OF THOSE SERVED. OBJECTIVE 5 AND 6: THE COMMUNITY ENGAGEMENT SPECIALIST PARTICIPATES IN 40 EVENTS AND MEETS WITH 50 CLIENTS PER YEAR. GOAL II: TO INCREASE THE NUMBER OF CLIENTS SERVED AT OUR WEST HAVEN AND STRATFORD LOCATIONS. OBJECTIVES 1-2: STRATFORD AND WEST HAVEN LOCATIONS SERVE 100 CLIENTS IN YEAR ONE AND 125 IN SUBSEQUENT YEARS, 23% HISPANIC AND 19% BLACK. UNDUPLICATED CLIENTS SERVED. WE PROJECT THAT THE PROJECT WILL SERVE 250 UNDUPLICATED INDIVIDUALS IN THE FIRST YEAR AND 275 FOR SUBSEQUENT YEARS. THE TOTAL NUMBER OF UNDUPLICATED CLIENTS DURING THE PROJECT PERIOD IS 1075.