Cccbhc-IA grant - barry county community mental health authority (BCCMHA) proposes to improve overall health and wellbeing of residents of barry county, michigan -- a rural county of 63,544 residents

The barry county catchment area has a dearth of both primary care physicians (PCPS) and behavioral health (BH) providers per population ratio. The ccbhc-IA project will allow BCCMHA to fill identified service gaps through expansion, increased outreach capacity, and intensification of care coordination with community partners to foster integrated care. Populations of focus for the project are all individuals across the lifespan in need of BH services within the catchment area. Subpopulations include individuals with comorbid medical conditions with special focus on those diagnosed with diabetes, those with a BMI of 30 or greater, and those with CO-occurring mental health and substance use disorders (SUD). BCCMHA recognizes veterans and lgbtqi+ persons as populations underserved in the catchment area and has identified these groups as additional subpopulations of focus. Over the four-year period BCCMHA aims to serve at minimum 495 unique individuals, averaging 120 new individuals per year. The goals of the ccbhc-IA project are to increase access and utilization of behavioral health (BH) services, identify and address substance misuse, and improve healthcare access and quality for all community residents. The project will achieve these goals by implementing the following strategies: 1) increase access to BH services for county residents through coordination with psychiatric inpatient facilities to ensure that a minimum of 60% of individuals receiving treatment have a follow-up visit with a BH provider within 7 days of discharge; coordination with the local emergency department (ED) to ensure that at minimum 40% of adults seen at the ED for with a principle BH diagnosis have a follow-up visit with a BH provider within 7 days; 2) increase outreach and penetration regarding available BH services through utilization of an outreach liaison to increase community contacts by 10% annually; utilization of a veterans navigator to increase the number of veterans, members of the armed forces, and military families by 5% each year; 3) demonstrate improved outcomes through adoption of measurement-based care strategies; 4) increase initiation and engagement of SUD treatment through coordination with local ED to ensure individuals seen with a principle SUD diagnosis have a follow-up with a BH provider within 7 days; improved screening and brief interventions and follow-up for positive screens; and 5) deliver integrated care for BH and physical health risks and needs through referrals and follow-up to community PCPS and through monitoring and management of diabetes leading to 60% of adults diagnosed with diabetes having an A1C below 9.0% in grant year 1. BCCMHA will collect, analyze, and disseminate data from the ccbhc project to inform sustainability efforts and continue programming after the lifetime of the award.