Lcsc ccbhc-IA - project lcsc ccbhc-IA will offer the full array of ccbhc services to 800 unduplicated individuals (200 annually), primarily from lakewood, NJ (population 138,070), who are facing…

Lcsc ccbhc-IA - project lcsc ccbhc-IA will offer the full array of ccbhc services to 800 unduplicated individuals (200 annually), primarily from lakewood, NJ (population 138,070), who are facing serious mental illness, substance use disorders, opioid use disorders and CO-occurring disorders, and youth with serious emotional disturbance. This population is primarily orthodox jewish with 15.4% experiencing 14+ days of mental distress, the 3RD highest rate in NJ. This group experiences health disparities due to stigma, low socioeconomic status (25.1% of lakewood residents live at or below poverty (54.91% below 200% poverty), significantly higher than the regional proportion of 11.4% (23.8% below 200% poverty)) and cultural and language barriers. Strategies designed to reduce disparities in healthcare access and heightened challenges to accessing care are as follows: 1) improve mobile crisis services thereby reducing avoidable hospitalization and ED use; 2) maintain open access scheduling, as well as extended evening and weekend hours; 3) fully implement, improve and integrate standalone SUD services using EBP's; 4) hire a grant funded medical director and nurse care manager to oversee primary care screening and monitoring; 5) provide robust, quality targeted care management (TCM) services; 6) maintain highly successful community-based services and peer supports; 7) implement ccbhc specific training, supervision and/or coaching to staff; 8) increase use of evidence-based screening instruments to enable measurement-based care; 9) improve care transitions and care coordination, by securely sharing health information with our provider network; 10) maintain an outreach coordinator to develop, update and/or maintain care coordination agreements; 11) maintain 7-member ccbhc community/consumer advisory board; 12) implement a data-driven continuous quality improvement (CQI) plan; 13) maintain sliding fee scale so all services are available regardless of ability to pay, and 14) refine HIT to collect, track and report data and quality measures. Our (4) ccbhc project specific goals are as follows; 1) expand access to culturally competent, well-coordinated, integrated services by increasing availability and capacity of lcsc's ccbhc; 2) implement evidence-based screening, assessments, and treatment, TCM, community-based care and better use of data; 3) increase access to integrated care and use real-time data to drive decision-making; and 4) ensure financial sustainability and operational efficiency of our ccbhc. Examples of our measurable objectives tied to these project goals include implementation of open access same day scheduling, expanding collaborations to 20 community based organizations, universal standardized screening/assessment for all ccbhc patients, expansion of peer services, delivery of community-based supports including PSR, supported employment, and peer supports to 50 of the highest needs individuals annually; identification of 100% of clients at-risk of relapse and intervene early; develop EHR-based alerts for screening and follow up across 100% of ccbhc enrollees; and diversification of revenue streams by seeking grants, implementing fee-for-services options, and engaging in partnerships with new payers.