Ccbhc I & a grant - as a ccbhc-IA grant awardee, horizon health services (HHS) will expand and enhance our ccbhc services to serve all individuals across the lifespan in need of behavioral…

Ccbhc I & a grant - as a ccbhc-IA grant awardee, horizon health services (HHS) will expand and enhance our ccbhc services to serve all individuals across the lifespan in need of behavioral healthcare in the east side of buffalo city (east buffalo), erie county, new york (NY), with a particular focus on addressing BH disparities for black individuals with criminal justice (CJ) involvement and/or transitioning from inpatient, emergency department (ED), or residential treatment. HHS' project goals are to: (1) improve targeted case management (TCM) for those who are non-health home (HH) eligible or refuse to participate in HH; (2) increase the capacity of the clinic to meet the medical and medication needs of our patients; and (3) reduce the rate of never events (overdose/suicide attempt/patient death). We will address these goals by strategically and proactively outreaching and engaging patients, especially those coming from a higher level of care or the CJ system. Specifically, we will: (1) hire 1 FTE targeted case manager; (2) offer TCM to 90% of eligible patients; (3) provide targeted outreach to 90% patients coming from a higher level of care; and (4) screen 90% of new patients for health-related social needs (HRSN). We expect that 50% of eligible patients will receive TCM in each year of the grant period. To improve patient access to medication and medical monitoring, we will hire 1 FTE nurse, 1 FTE population health specialist, and 1.3 FTE psychiatric nurse practitioner (PNP) to provide medication consultation/education to 75% of patients prescribed BH RX and primary care screening and monitoring, including referral to ongoing primary care, to 75% of patients who are not consistently connected to primary care. Through improved monitoring and TCM, HHS aims to reduce the rate of never events by 20% as well as improve hedis rates for follow-up after hospitalization for mental illness (FUH), high-intensity care for SUD (FUI), ED visit for mental illness (FUM), and ED visit for alcohol and other drug abuse or dependence (FUA) rates by 25% over the grant period. We will collaborate with two fqhcs, evergreen health and community health center of buffalo (CHCB), to provide primary care services to HHS patients in need of further treatment for medical conditions, including ongoing monitoring of health needs and HIV and HEP screenings and care. We will also partner with the crisis services of erie county (CSE) to offer the full range of 24/7 crisis services; restoration society to provide psychosocial rehabilitation (PSR) and other peer-supported services; horizon village's terrace house to provide SUD crisis stabilization; and endeavor health services to provide clubhouses and personalized recovery oriented services (PROS) to HHS patients. The project will serve 300 unduplicated individuals in the first year of the project and 450 individuals for each year thereafter, for a total of 1,650 individuals over the course of the project.