Cvfc ccbhc-PDI - champlain valley family center (cvfc) ccbhc will target individuals in need of BH care in rural northeastern new york's high poverty counties of clinton, esses, and franklin with a…

Cvfc ccbhc-PDI - champlain valley family center (cvfc) ccbhc will target individuals in need of BH care in rural northeastern new york's high poverty counties of clinton, esses, and franklin with a focus on adults experiencing serious mental illness (SMI), children experiencing serious emotional disturbance (SED), those who have substance use disorders (SUD), and/or CO-occurring mental health/substance use disorders (COD), especially those discharged from the regional hospital following a psychiatric admission, justice-involved individuals, and individuals and families representing the military/veteran population. Our area includes four mental health hpsa designations, its average per capita income is $26,348 annually, 22.7% of the region's population is on medicaid, and 5.1% do not have health insurance. The average suicide rate is 13.6 per 100,000. In 2021 our area's opioid overdose rate had increased by 637% since 2015 and our local hospital has 200 adolescents and 40 adults boarded in the ER for more than a day at any given time; 50% were diagnosed with SUD yet only 42.2% received an outpatient follow up appointment within 7 days of release and only 11.1% of youth up to age 17 diagnosed with SUD received a follow up care appointment within 7 days. As well, 70% of this population requires mat that they do not receive. Our region's six adult correctional facilities, release APX. 138 individuals annually who have an SUD and 1,250 individuals are on probation or parole, yet we are seeing only a few of these high risk clients. Veterans comprise 8.4% of the population within our region, in contrast to a NYS average of 3.9%, however the two clinics meant to serve them are not presently able to provide timely access to clinical assessment and veterans and their families require information and support related to SUD and suicide prevention. The ccbhc model offers a vital framework and critical expansion funding for cvfc's integrated mental health and substance use treatment services for children and adults. Our goals include expanding access and timely initiation of community-based BH services, reducing overdose and suicide, providing transportation support to treatment from the hospital and upon release from jail integrating primary care to address CO-occurring chronic conditions, and establishing a process to monitor continuous quality improvement. To accomplish these goals, we will expand our peer and clinician capacity, hire a nurse practitioner capable of prescribing mat, implement dialectical behavioral therapy in our clinic and school-based services, CO-locate services in our local hospital and jail, partner with homeward bound a veteran peer organization to serve veterans, and establish DCO collaborations with primary care clinics and our regional mobile crisis provider. As a result, we will expand access to care for 50 new, unduplicated children and adolescents each year via school-based DBT training and 75 new unduplicated children and adolescents with SED and 200 adults with SMI/SUD/COD will engage in DBT to avoid overdose/suicide, 160 individuals with an opioid use disorder will receive mat, 300 clients will be provided with transportation to care and services, and we will provide pre-discharge assessments and warm handoffs from the hospital for 45 new adult and adolescent patients annually, conduct 75 BH screenings for justice involved individuals each year, and increase our BH care for veterans by 5% in Y1 and 5% each year thereafter. As well, 70 % of clients served at the ccbhc will be connected to a PCP in year 1. Additionally, we will integrate care to track and monitor client health, medication adherence, and areas for needed improvement in year 2 and each year thereafter. Ccbhc funding will allow cvfc to serve an additional 980 individuals over the grant period, including 180 in Y1, 225 in Y2, 265 in Y3, and 310 in Y4.