Cima ccbhc - eastern area of puerto rico - as a ccbhc-PDI grant awardee, hospital menonita cima (cima) will provide ccbhc services to the municipalities of juncos, LAS piedras, yabucoa, humacao,…

Cima ccbhc - eastern area of puerto rico - as a ccbhc-PDI grant awardee, hospital menonita cima (cima) will provide ccbhc services to the municipalities of juncos, LAS piedras, yabucoa, humacao, naguabo, ceiba, and culebra in southeastern puerto rico. Cima will serve all individuals across the lifespan in need of behavioral health (BH) care, with a particular focus on addressing BH disparities for individuals over 65 years old with BH disorders and youth with substance use disorders (SUD). Cima's project goals are to: 1. Increase capacity to provide mental health treatment to older individuals (age 65 and above); 2. Improve and expand mental health and trauma-related evidence-based screenings and practices; 3. Increase access to evidence-based SUD services; and 4. Increase access to wrap-around services to address clients' physical health and social needs. We will address these goals by: (1) incorporating clinical pathways for elderly population-related diagnoses and for depression, ptsd, and anxiety, implemented with at least 80% fidelity on the fidelity scale; (2) screening at least 75% of ccbhc clients for suicide using the columbia suicide severity rating scale (c-ssrs) annually; (3) screening at least 75% of ccbhc clients BH disorders annually using standardized and validated instruments (e.g., PHQ-9, GAD-7, crafft, audit, c-ssrs, ftnd, cast, TSQ, S2BI, cage); (4) increasing referrals to our first episode psychosis (FEP) program by 15% over baseline; (5) reducing assertive community treatment (act) participants' emergency department (ED) use by 50%; (6) increasing the number of clients who initiated medication-assisted treatment (mat) and the SUD youth program by 25% from baseline over the grant period; (7) increasing the number of clients who receive vocational counseling by 15% from baseline; and (8) increasing the number of clients receiving primary care screening by 20% from baseline. We will collaborate with the mental health and anti-addiction services administration (mhaasa), the government entity responsible for mental health and SUD in puerto rico, to provide 988 crisis hotline and mobile crisis services. We will also establish a referral agreement with neomed, a local fqhc providing primary and HIV care, and estancia serena, a residential detoxification center that provides mat for individuals with SUD. We will partner with the university of puerto rico - medical sciences campus (RCM) to adapt our evidence-based practices to ensure they are culturally and linguistically appropriate for our population and provide training in measurement-based care to our staff. Finally, we will partner with plan DE salud menonita (PSM), an operating division of mennonite general hospital, INC. (mghpr) and a health insurance plan that provides coverage for 200,000+ commercial and medicaid beneficiaries in puerto rico, to identify individuals with serious mental illness (SMI), serious emotional disturbance (SED), SUD, and CO-occurring disorders (COD) to refer them to our ccbhc and gather beneficiary data to identify high-utilizing patients for TCM engagement. The project will serve 400 unduplicated individuals in the first two years of the project and 600 individuals in the last two years of the project, for a total 2,000 individuals over the course of the project.