Burke's certified community behavioral health clinic improvement and advancement grant - burke's FY 2023 certified community behavioral health clinic - improvement and advancement (ccbhc-IA) grant…

Burke's certified community behavioral health clinic improvement and advancement grant - burke's FY 2023 certified community behavioral health clinic - improvement and advancement (ccbhc-IA) grant program endeavors to improve, enhance, and expand capacity for our chronic care management (CCM) model within the east texas region. This project shall target adults with serious mental illness (SMI), children and youth with serious emotional disturbance (SED), and individuals with CO-occurring psychiatric diagnoses, substance use disorders (SUD), and/or physical health disorders in our twelve counties: angelina, houston, jasper, nacogdoches, newton, polk, sabine, SAN augustine, SAN jacinto, shelby, trinity, and tyler. The ccbhc-IA program shall serve 600 individuals each year, with a cumulative 2250 unduplicated individuals served over the project period. Through use of these funds, burke shall expand current service delivery capacity for integrated behavioral health and primary care, physical screening, care management, and population health monitoring by adding 0.5 FTE medical doctor, 3.0 FTE nurses, 5.0 FTE care managers, 1.0 FTE applications programmer, and 0.5 FTE population health coordinator. These staff shall reach the historically under-served target population, reduce social determinants of health (sdohs) related to economic instability and access to care, and build upon current care coordination projects. Project staff will focus on measurable objectives, implement provisions to improve population health indicators, such as high blood pressure, BMI, and unhealthy alcohol use, reduce access to physical care by 10% and trauma symptomology by 10% in the hispanic subpopulation of focus, implement netsmarttm caremanager software for risk stratification, and develop a needs assessment and sustainability plan. Burke shall formally partner with brown family health center, INC. As its designated collaborating organization (DCO) for this project, to provide primary care and infectious disease vaccination. The medical doctor and nurses shall work to conduct physical health and infectious disease screenings, chronic disease prevention, and referrals. The care managers shall coordinate consumers enrolled on the medical doctor's caseload to improve retention, maintenance, and daily functioning post-project. The applications programmer and population health coordinator shall work on caremanager implementation and execution, health information technology (HIT) interoperability, and endeavor to monitor health outcomes and inequity across the project timeline to address appropriate interventions when needed.