Project Grant H79SM088962

EQUALOPS: TACKLING THE SOCIAL DIVIDE - RED ROCK BEHAVIORAL HEALTH SERVICES (RRBHS) WILL REPLICATE OUR SUCCESSFUL CCBHC MODEL IN NORMAN, OK, TO SERVE A CATCHMENT AREA (CA) OF CLEVELAND AND MCCLAIN COUNTIES, HRSA DESIGNATED SHORTAGE AREAS WITH SIGNIFICANT HEALTH AND BH DISPARITIES. WE WILL DEVELOP AND IMPLEMENT POPULATION HEALTH MANAGEMENT (PHM) SYSTEMS, INCORPORATE SOCIAL DETERMINANTS OF HEALTH INTO ASSESSMENT, STRENGTHEN HEALTH SCREENING AND MONITORING, AND EXPAND CLINICAL SERVICES. THE PROPOSED PROJECT, EQUALOPS: TACKLING THE SOCIAL DIVIDE, WILL SERVE 500 UNDUPLICATED INDIVIDUALS IN THE CA, (100 IN YEAR 1, 125 EACH IN YEARS 2 AND 3, 150 IN YEAR 4). SERVICE EXPANSION IS VITAL, AS THE OK DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES ESTIMATES THAT 89.2- 94.8% OF CA ADULTS WHO NEED BH SERVICES DO NOT RECEIVE THEM. RRBHS DELIVERED TRAUMA-INFORMED, COMMUNITY BASED AND CULTURALLY APPROPRIATE BH CARE AND SERVICES TO 15,806 INDIVIDUALS ACROSS CENTRAL OK IN 2022, MANY OF WHOM HAD SERIOUS MENTAL ILLNESS (SMI), SERIOUS EMOTIONAL DISTURBANCE (SED), SUBSTANCE USE DISORDERS(SUD), CO-OCCURRING DISORDER (COD) AND OTHER BH NEEDS. THE CA HAS 344,893 RESIDENTS, WITH 51% ASSIGNED FEMALE AT BIRTH AND 19.1-25.3% UNDER 18(CENSUS); 3.8% ARE LGBTQ (WILLIAMS INSTITUTE). ACROSS NORMAN (THE COUNTY SEAT OF CLEVELAND COUNTY AND THE THIRD LARGEST CITY IN OK), CLEVELAND AND MCCLAIN COUNTIES, BETWEEN 69.5-72.9% ARE WHITE, 1.3-5.7% ARE BLACK, .8-5.6% ARE ASIAN OR PACIFIC ISLANDER, 4.1-7.5% ARE NATIVE AMERICAN, 8.7-9.9% ARE LATINX AND 6.5-11.2% SPEAK A LANGUAGE OTHER THAN ENGLISH AT HOME(CENSUS). POVERTY RATES ARE 9.2-16.7%, WITH NEARLY 50% OF RRBHS CLIENTS IN POVERTY. MCCLAIN COUNTY IS HRSA-DESIGNATED RURAL. THE CA IS IN TORNADO ALLEY AND EXPERIENCES SIGNIFICANT COMMUNITY LEVEL TRAUMA FROM FREQUENT NATURAL DISASTERS. ALSO LOCATED IN THE CA IS THE UNIVERSITY OF OK (OU), WITH APPROXIMATELY 30,000 STUDENTS; COLLEGE AGED YOUNG ADULTS (18-24) HAVE UNIQUE BH CHALLENGES AND HIGH BH NEED. THE CA HAS HIGHER THAN NATIONAL RATES OF BEING UNINSURED (10.9-16.4%), NOT HAVING A PRIMARY CARE PROVIDER, ALCOHOL AND SUBSTANCE USE, SUICIDE, DIABETES, HEART DISEASE AND HYPERTENSION. THERE ARE TWO GOALS: GOAL 1 IS TO REDUCE BH ACCESS GAPS, AND EXPAND ACCESS TO AND AVAILABILITY OF HIGH QUALITY, TRAUMA INFORMED BH SERVICES AND SUPPORTS. OBJECTIVES AND ACTIVITIES INCLUDE: 1.1 REDUCE WAIT TIMES AND INCREASE CAPACITY VIA STAFF HIRING (CLINICIANS FOR VIRTUAL OUTPATIENT CARE, POPULAR IN OUR RURAL CA, PEERS) AND EXPANDED WEEKEND/EVENING HOURS; 1.2 INCREASE SERVICE AVAILABILITY FOR CHILDREN AND YOUTH VIA HIRING, OUTREACH AND INFRASTRUCTURE EXPANSION TO INCREASE ENROLLMENT; 1.3 INCREASE AVAILABILITY AND ACCESSIBILITY OF SERVICES FOR COLLEGE AGE YOUNG ADULTS (18-24) VIA STAFF HIRING, TRAINING, AND OUTREACH TO AND RELATIONSHIP BUILDING WITH THE OU. 1.4 ADD AN ADDITIONAL CRISIS RESPONSE TEAM VIA CLINICIAN HIRING. GOAL 2 IS TO DEVELOP AND IMPLEMENT POPULATION HEALTH MANAGEMENT (PHM) SYSTEMS TO BETTER TRACK AND ADDRESS HEALTH OUTCOMES AND SOCIAL DETERMINANTS OF HEALTH (SDOH), FUEL DATA-DRIVEN DISPARITY REDUCTION, IMPROVE HEALTH AND BH OUTCOMES AND FURTHER TAILOR SERVICES TO THE CA'S NEEDS. OBJECTIVES AND ACTIVITIES INCLUDE: 2.1 INSTITUTE STANDARDIZED TRACKING OF SDOH WITH A SDOH SCREENING TOOL USED AT ENTRY TO CARE AND TREATMENT REVIEW; THE TOOL WILL BE INTEGRATED INTO OUR EHR, WITH DASHBOARDS CREATED; 2.2 REVISE OUR RISK STRATIFICATION TOOL TO INCLUDE SDOH; 2.3 STAFF TRAINING IN SDOH, PHM; 2.4 DEVELOP, IMPLEMENT PHM SYSTEMS, ADDING MANAGEMENT LEVEL DIRECTOR OF PHM, SENIOR DATA ENGINEER, EHR IMPROVEMENTS TO BETTER IDENTIFY AND ADDRESS DATA DRIVEN HEALTH PRIORITIES (DISPARITIES, HEALTH CONDITIONS AND BEHAVIORS, OUTCOMES); 2.5 BUILD CAPACITY FOR TRACKING AND FACILITATING CLIENT ACCESS TO PRIMARY CARE BY ESTABLISHING RELATIONSHIPS WITH HEALTHCARE PROVIDES/AGENCIES AND IMPROVING REFERRALS, ASKING ABOUT ASKING ABOUT PRIMARY CARE ; 2.6 IMPROVE INTERNAL RATES OF HEALTH SCREENINGS VIA HIRING, TRAINING AND INFRASTRUCTURE BUILDING.