FY 2026-2027 COUNTY HUMAN SERVICES PLAN

LYCOMING AND CLINTON COUNTIES

INTRODUCTION

The Department of Human Services has developed the content for counties to submit a consolidated County Human Services Plan. Lycoming and Clinton counties have agreed to the development of the FY 2026-2027 Human Services Plan as a joint project.

County Human Services funds incorporated into this FY 2026-2027 Human Services Plan include:

Mental Health Community Base-Funded Services Behavioral Health Services Initiative (BHSI) Intellectual Disabilities Community Base-Funded Services Act 152 of 1988 Drug and Alcohol Services Homeless Assistance Program Funding Human Services Development Funds

The following distribution chart identifies the oversight entity for each of the line-item allocations.

Lycoming-Clinton Joinder Board

West Branch Drug & Alcohol Abuse Commission (Lycoming and Clinton counties)

Lycoming County Clinton County

Mental Health Services

BHSI (Substance Abuse Services)

Homeless Assistance Human Services Development Fund

BHSI - MH Act 152 Homeless Assistance Intellectual Disability Services

Human Services Development Fund – Lycoming County

The West Branch Drug & Alcohol Abuse Commission, the Clinton Children & Youth Services and the Lycoming Children & Youth Services have also affirmed their agreement with the two-county planning process for this fiscal year.

PART I: COUNTY PLANNING PROCESS

Lycoming and Clinton counties created a planning team of Administrators, Directors, and other personnel from all program areas represented in the County Human Services Plan on a County or bi-county Joinder level. The list of Planning Team members is as follows:

Keith Wagner, MH/ID/HealthChoices Administrator, Lycoming-Clinton Joinder Board Lori Kriner, Fiscal Officer, Lycoming-Clinton MH/ID Program Matthew Salvatori, Administrator, Lycoming Children & Youth Services Shea Madden, Executive Director, West Branch Drug & Alcohol Abuse Commission Jennifer Reeder, Assistant Director, West Branch Drug & Alcohol Abuse Commission Autumn Bower, Director, Clinton County Children & Youth Services Brittney Camerer, Fiscal Operations Officer, Clinton County Children & Youth Services Carolyn Hawk, President/CEO, United Way of North Central PA Blayne Lamey, Community Impact Coordinator, United Way of North Central PA Elizabeth Whitty, Community Development & Housing Coordinator, Clinton County Planning Department Jim Hicklin, County MH Director, Lycoming-Clinton Mental Health Services Lauralee Dingler, Mental Health Specialist, Lycoming-Clinton Mental Health Services April Shimel, Assistant Administrator, Lycoming-Clinton Administrative Entity Jacqueline Miller, Director, Lycoming-Clinton HealthChoices Kelly Gordon, CASSP Coordinator, Lycoming-Clinton MH/ID Program Deanna Kimble, Quality Manager, Lycoming-Clinton HealthChoices Vanessa Shellman, Clinical Oversight, Lycoming-Clinton HealthChoices

1. Identify critical stakeholders’ groups, including individuals and their families, consumer groups, providers of human services, and partners from other systems.

Individuals receiving services and their families, as well as providers of services, consumer groups, partners from other systems and community members interested in participating in the Human Services Planning Process were provided with numerous opportunities to contribute to the development of the Annual Plan. Participants included members of the local National Alliance on Mental Illness (NAMI) of Central PA, Lycoming County Human Services Task Force, Behavioral Health Services Provider group (comprised of Adult and Children’s Services Providers and Private Practitioner providers), Community Care Behavioral Health Managed Care Organization (CCBH-MCO), Lycoming County Health Improvement Coalition (LCHIC), Clinton County Collaborative Board, Keystone Central School District Keystone Cares community engagement programs, Lycoming County Early Learning Team, Advocates for a Drug Free Tomorrow coalition, Suicide Prevention Committee, Crisis Intervention Team (CIT) Steering Committee, United Way of North Central PA, Lycoming County Reentry Coalition, Positive Behavioral Intervention Supports (PBIS) core team, Participant Advisory Committee (PAC), Executive Leadership Advisory Committee (ELAC), Consumers and Family Satisfaction Team (CFST) Advisory Committee, Children's Services Workgroup, HealthChoices Adult Member/Family Advisory Board, HealthChoices Parent/Child/Family Member Advisory Committee, Lycoming/Clinton Human Services Steering Committee, Peer Support Specialists, Certified Recovery Specialists, Children, Youth and Families (CYF), Juvenile Probation Office (JPO), Adult Probation Office (APO), Criminal Justice Advisory Board (CJAB), Area Agency on Aging (AAA), Community HealthChoices, school personnel, members of law enforcement, members of the criminal justice system, medical personnel, local hospital systems, Physical HealthChoices, homeless shelters and service recipients of cross system services.

2. Describe how these stakeholders were provided with an opportunity for participation in the planning process, including information on outreach and engagement efforts.

Members of the Human Services Planning Team participate in stakeholder meetings regularly. Input on the Plan was received, and the planning process discussed by Team members at the monthly or quarterly meetings of the Behavioral Health Adult Services Provider group, the Behavioral Health Children’s Services Provider group, the Behavioral Health Private Practice group, the bi-county Reinvestment Committee, the Behavioral Health Adult Services Advisory Committee’s parent/family Advisory sub-committee, the Adult Outcomes sub-committee, the Lycoming County Human Services Task Force, the Clinton County Collaborative Board, the Lycoming County Health Improvement Coalition, NAMI of North Central PA’s Board meetings and ongoing support group meetings, the Re-entry Coalition Committee and ongoing meetings with the nine school districts in the bi-county.

The Lycoming-Clinton Human Services Advisory Board members were also given the opportunity to offer input into the Plan’s development during their quarterly meetings in 2026. A Public Hearing was held on July 14, 2026, at which time the Plan was reviewed, and attendees were provided the opportunity to provide comments.

3. List the advisory boards that participated in the planning process.

The following boards were involved in the development of the Human Services Plan: the Lycoming-Clinton Human Services Advisory Board, the Lycoming-Clinton HealthChoices Reinvestment Committee, NAMI of North Central PA Board of Directors, the Peer Support Providers Group, the Lycoming County Health Improvement Coalition, the Lycoming County Human Services Task Force, the Clinton County Collaborative Board, the Adult and Children’s Behavioral Health Providers Groups, the Reentry Committee, and both the Lycoming and Clinton County Criminal Justice Advisory Boards.

4. Describe how the county intends to use funds to provide services to its residents in the least restrictive setting appropriate to their needs. The response must specifically address providing services in the least restrictive setting.

Both Lycoming and Clinton County continue to emphasize services for residents that are provided in the most natural and home like setting as is appropriate for the need. The Single County Authority (SCA) continues to use a combination of state and federal, Medicaid, opioid settlement, and criminal justice grant funds to expand Medication Assisted Treatment (MAT), warm handoff programs, and recovery supports across the bi-county area, including in the Lycoming County Prison. Community-based mental health staff continue work within both county prisons to coordinate reentry efforts to reduce recidivism. The Lycoming-Clinton MH/ID Program continues to fund Forensic case management staff, a full-time master’s level forensic psychological associate, a full-time bachelor’s level boundary spanner case manager, and part-time psychiatric services in the Lycoming County Prison.

Mental Health services for school aged children/youth continue to be provided collaboratively between the Lycoming-Clinton MH/ID Program and the nine school districts in the bi-county area. The Lycoming-Clinton MH/ID Program and the school districts will continue to jointly fund Mental Health case managers based out of each school district, who also serve as members of the Student Assistance Program (SAP) team and function as an initial referral source for students at risk for a Serious Emotional Disturbance (SED).

Appropriate, safe, and affordable housing within both Lycoming and Clinton counties continues to be a high priority need. The joint Housing Services Unit created collaboratively between the bi-county MH/ID Program and Lycoming Children & Youth Services combines Community-Based Care Management (CBCM) funding, Pennsylvania Housing Affordability and Rehabilitation Enhancement (PHARE) Grant Funds and CYS Needs-Based Plan funds to support individuals and families with obtaining and maintaining housing in the community.

The program continues to focus on helping individuals with Serious Mental Illness (SMI) and families with children find and maintain appropriate housing in local communities. Activities of the Housing Services Unit include working with landlords and teaching financial and independent living skills, etc. The Lycoming-Clinton MH/ID program also collaborates with Hope Enterprises, Inc., to provide Independent Living & Residential Support Services designed to support individuals with SMI residing in independent housing who require structured assistance to maintain stability, safety, and independence. These services replaced supports previously provided through Community Residential Rehabilitation Services (CRRS) homes and include individualized, person-centered residential and independent living supports; coordination between program staff and designated landlord(s);

behavioral health support focused on housing stability and community integration; and on-site and remote support services utilizing approved technology. An individualized, person-centered treatment plan is developed within the first 30 days of service and is reviewed within the first 60 days of service, with subsequent reviews every 6 months thereafter.

During the initial 30 days of program participation, Transitional Residential Support Services are provided to each participant in order to address the intensive, non-billable coordination and stabilization activities required as a result of relocation of individuals from the CRRs to independent living. These services include housing coordination, lease and utility set up and support, physical move planning, development of person-centered plans to increase stabilization and monitoring during relocation, and cross-system coordination. In an effort to promote independence, stability, and recovery in the least restrictive setting possible, Remote Support Technology services are also provided to participants based on individual needs. The provider maintains a comprehensive 24/7 on-call system to support individuals receiving Independent Living/Residential Support Services to include immediate access to relevant consumer information, crisis intervention protocols, and clear escalation and response procedures.

The MH/ID program also continues to collaborate with Center for Community Resources (CCR) to provide temporary housing for up to four (4) residents of Lycoming and Clinton counties at a time, eighteen years (18) or older, and experiencing a temporary housing crisis for up to thirty (30) days through the Interim Housing program. In certain circumstances and as agreed upon by both the program and the participant, stays can be extended beyond the thirty (30) days, and the program can be accessed by the same participant as many times as needed. Participation in other services provided by the MH/ID program and CCR are not required in order to participate in this program. However, a safety assessment is completed for each resident at the time of acceptance into the program to determine the need for medical/behavioral health evaluation or treatment and referrals completed as needed.

5. Describe any substantial programmatic and funding changes being made as a result of last year’s outcomes.

The Interim Housing program was initially grant-funded but will now be Base-funded going forward. As noted, late in the previous fiscal year the MH/ID program shifted Base funding from CRRs to the newly developed Supportive Living & Residential Support Services which will continue into the upcoming fiscal year. Due to a significant decrease in the number of residents of the bi-county who are deemed Medicaid eligible, the MH/ID program is creating a new staffing position that will focus on helping residents apply or reapply for Medicaid and Social Security benefits and support them throughout the application processes. We have applied to be a COMPASS Community Partner in order to facilitate this work and track progress.

PART II: PUBLIC HEARING NOTICE

The joint Public Hearing for all services provided by Lycoming and Clinton counties for the FY 2026-2027 Human Services Plan was conducted on July 14, 2026, pursuant to the Sunshine Act, 65 Pa.C. S 701-716.

Information was provided on the services proposed to be provided under the Plan. As Lycoming and Clinton counties are not participants in the Block Grant Program, there were no material changes made to prior methodology and practice regarding anticipated expenditures.

Additional stakeholder input was received through attendance at the various board and committee meetings described in Part I.

PART III: CROSS-COLLABORATION OF SERVICES

Employment:

Lycoming-Clinton MH/ID and our Blended Case Management providers support a number of individuals who are gainfully employed, but either do not need or choose not to participate in paid employment supports. To that end, paid employment support is generally underutilized in our catchment. This trend has remained consistent for many years. Regardless, employment services are introduced and offered at the time of intake and periodically throughout the individual’s involvement with Lycoming-Clinton MH/ID.

Lycoming-Clinton MH/ID works collaboratively with community stakeholders across human service programs to assist the consumers we serve achieve their vocational goals. Lycoming- Clinton MH/ID contracts with Community Services Group to provide an accredited vocational and psychiatric rehabilitation program in Williamsport called the Commerce Park Clubhouse.

Participants in the Clubhouse program have the opportunity to develop marketable skills in the areas of food service and clerical, in a supported simulated work setting. Additionally, programming at the Clubhouse includes a social component to assist with development of social skills and other employment-related “soft skills”, transitional, supported, and independent employment. This service is available to consumers in both Lycoming and Clinton County. This year, Community Services Group is working on a revitalization of the community employment component of their program. Community Services Group is in the process of planning a community event to kick off the new focus on community employment.

Lycoming-Clinton MH/ID continues to maintain a contract with Skills of Central Pennsylvania to provide employment services to consumers in the bi-county area, which assist with finding and maintaining meaningful, gainful employment in their communities. Services encompass career assessments, job shadowing, job readiness courses, assistance with the pre-employment phase such as resumé building, interviewing skills, job searching, job finding, job placement, direct training and retraining on the job by Skills’ Employment Training Specialists.

The MH/ID Program, HealthChoices and the SCA continue to participate in re-entry committees in each county. These committees include representatives from OVR, Career Link, behavioral health provider agencies, and local colleges. The committee collaborates to help improve success for individuals returning to the community following incarceration. Certified Recovery Specialists from West Branch Drug and Alcohol Abuse Commission (WBDAAC) provide a presentation for employers in Lycoming County which talks about the advantages of hiring someone with special needs. The SCA and Lycoming-Clinton MH/ID make regular referrals to the Office of Vocational Rehabilitation for vocational support and assessments. The SCA has collaborated with HealthChoices to establish a recovery resource center in both Lycoming and Clinton counties which offers computer access to web sites such as Career Link, local temp agencies, Indeed, Monster, and Williamsport Help Wanted online job search websites. A “Felon Friendly List” of employers is also posted and maintained at the resource centers. Lycoming- Clinton MH/ID is four years into a relationship with Rise Up Bakery, a faith-based program working with individuals returning to the community from jail, and individuals living with a disability to learn baking skills in a commercial kitchen. Graduates of the program receive ongoing support when they secure employment. The County MH Director continues to sit on the OVR Citizen’s Advisory Council (CAC). The CAC’s role is to provide feedback on OVR services, initiatives, and programmatic changes, and provide suggestions to OVR with regard to needs in the community.

As previously noted, Base-funds are leveraged to support the Joinder Housing Services Unit, CCR’s Interim Housing program and Hope Enterprises’ Independent Living/Residential Support Services program. While the primary focus of each of these programs is housing, participants are also assisted in achieving financial stability which may include support in obtaining employment-related services and/or employment.

Housing:

The housing needs of individuals with Mental Illness and other vulnerable populations within Lycoming and Clinton counties remain a priority focus of the County MH/ID program and its community partners and stakeholders. The Lycoming-Clinton MH/ID Program has a new Housing Supports Unit (in collaboration with Lycoming CYS) and the unit staff collaborate with community partners (public housing agencies, housing coalitions, etc.) and focus efforts on developing and maintaining relationships with landlords, shelters and others that are crucial for safe, affordable, and stable housing for those at risk of or experiencing homelessness. They work most closely with the Public Housing Authorities (PHA) in both counties.

The Joinder Housing Services Unit combines resources from Lycoming County CYS, MH/ID Base-funding and a PA Housing Affordability and Rehabilitation Enhancement Fund (PHARE) grant from Lycoming County to assist individuals with SMI and families with children in maintaining their present housing or obtaining new housing by focusing on independent living skills, parenting skills, budgeting, landlord/tenant relationships, and sustainability. The Housing Unit also addresses emergency needs for rent, utilities, or furnishings in the form of a 0% interest loan that ensures that housing is not lost in an emergency when no other resources are available in the community. The goal of this program is to decrease the need for emergency housing or out-of-home placements for children due to affordability issues of their current housing or evictions. The Joinder Housing Unit continues to develop working relationships with new landlords and make connections for affordable housing for service recipients. The Unit Supervisor maintains an up-to-date list of housing options in the bi-county and makes it available to service recipients and providers. The Joinder Housing Services Unit also continues to collaborate with CCBH-MCO to provide Community-Based Case Management (CBCM) services for individuals with a Mental Health diagnosis. Assessments and support are provided to individuals receiving Mental Health services in the areas of housing and other Health-Related Social Needs to prevent or divert individuals from needing higher levels of care.

The Lycoming-Clinton MH/ID Program continues to partner with Center for Community Resources (CCR) to operate a 4-bed Interim Housing Program. This program will continue to provide temporary shelter for individuals experiencing a mental health crisis and function as a diversion from hospital emergency departments and county jails.

During the winter months First Church in Williamsport continues to operate the Code Blue emergency warming center for individuals experiencing homelessness. Code Blue collaborated with other community service providers and provided space within the center to connect guests of the center with available services and supports. Code Blue is currently working to expand their program from a temporary to a year-round program. They are also working to obtain a larger facility outside of the current space within the Church that will allow them to serve even more individuals.

PART IV: HUMAN SERVICES NARRATIVE

MENTAL HEALTH SERVICES

a. Program Highlights:

Please highlight the achievements and other programmatic improvements that have enhanced the behavioral health service system in FY 25-26.

Behavioral Health Workforce Development Funding:

Lycoming-Clinton Behavioral Health Choices (LCHC) and CCBH-MCO have continued to collaborate on workforce stabilization strategies to rebuild and reinforce the local behavioral health system. The eighteen behavioral health providers that were allocated Reinvestment Funds for staff recruitment and retention initiatives submitted biannual progress/outcome reports for 2025 which continue to indicate positive outcomes. Positive outcomes include hiring of new staff that resulted in a 43% decrease in open staff positions across the provider network, and a decrease in the average client’s wait time for an appointment from 15 days to 13 days.

Furthermore, a total of sixty-seven provider staff were given licensing support (exams, applications, renewals, and supervision) and 64 (93%) of these staff members were retained, allowing these providers to fill positions requiring a license and to expand the availability of behavioral health outpatient appointments for all age ranges resulting in faster client access to services.

LCHC also developed a Workforce Development program which is a college loan forgiveness initiative to increase access to high quality mental health and substance use disorder services across Lycoming and Clinton counties to strengthen the local provider workforce. The program supports bachelor’s and master’s level students in human services related fields by offering meaningful loan forgiveness. In return, participants commit to two years of full-time employment with a participating behavioral health provider in Lycoming or Clinton County following graduation. By aligning students, providers, colleges, and local behavioral health leadership, the

Lycoming-Clinton Behavioral Health Workforce Development program helps build a sustainable, well-trained workforce that serves our community long term. Local providers will have access to motivated, prescreened candidates with a two-year employment commitment. The program includes a structured monthly cohort training that increases retention and ongoing coordination and administrative support. Provider responsibilities include employing accepted participants, providing supervision and role-appropriate training, maintaining communication with LCWI administrators, and supporting each participant’s two-year employment commitment. Students will receive tuition reimbursement up to $20,000 for bachelor’s level participants and up to $45,000 for master’s level participants. Direct connection to participating behavioral health providers, structured professional development through the two-year cohort model, and clear post-graduation employment pathways are also provided. Colleges/universities participate by identifying qualified students in human services related fields, encouraging eligible students to apply, providing faculty letters of recommendation, and coordinating communication with LCWI administrators as needed.

Community Based Organizations (CBOs) and Community Based Care Management

(CBCM):

Lycoming-Clinton Behavioral HealthChoices (LCHC) has within its service array five CBOs and two CBCM agencies. Two of the CBOs and both of the CBCM providers focused on housing needs and two CBOs focused on food insecurity. During 2025, 428 individuals were referred to CBOs, with 95% receiving information and assistance with concerns regarding Housing Instability and Homelessness. All (100%) of the individuals who obtained housing with this support continued to retain their housing beyond 90 days. Other significant areas of need indicated by referrals to CBOs and CBCM agencies included help with unemployment, financial strain, and transportation.

Supportive Living/Residential Support Services: Stabilizing Housing and Mental Health Lycoming-Clinton MH Program closed the Community Residential Rehabilitation Services (CRRs) for individuals with SMI operated by Community Services Group in February 2026.

There were six individuals residing in the CRR in Lycoming County and four individuals living in the CRR in Clinton County affected by these closures. In order to continue to support the individuals receiving those services and in order to divert from needing higher levels of care, the County MH program contracted with Hope Enterprises Inc. to create Supportive Living/Residential Support Services for those individuals affected by the CRR closures. The residents were given the option to participate in the Supportive Living Service and were provided support to secure other housing options if they were not interested in the new program.

Of the six Lycoming County CRR residents, four chose the Supportive Living Service, one secured Section 8 housing with help from CRR staff, and one secured an apartment with help from BCM and CRR staff. Of the four Clinton County residents, one secured shared living with help from BCM and CRR staff, one moved out of state with family, and one had been in an inpatient placement for some time prior to the transition and the team had previously determined that it was not in the individual’s best interest to return to the CRR upon discharge. The fourth individual left the CRR without notice and returned to his home county prior to the transition to Supportive Living. The Supportive Living Service home opened 2/17/26. Four individuals transitioned and three additional referrals were received filling the capacity of the service at seven by 3/31/26. One resident was subsequently discharged from the program in May due to hospitalization and eventual transition to a skilled nursing facility. Another resident was discharged 6/13/26 as they secured shared living with help from the Joinder Housing Unit Supervisor. One individual was accepted to the service on 6/30/26 upon discharge from an extended acute care facility. And another individual was accepted into the program in June as well from a stay at the CCR Interim Housing program with the assistance of a Joinder Assessment Unit casemanager. For individuals living with mental health challenges, the loss of stable housing can quickly lead to crisis, including hospitalization, homelessness, and repeated involvement with emergency systems. The Supportive Living Service is designed to prevent that cycle by helping individuals remain in their own homes or apartments while receiving the support they need to maintain both housing stability and mental wellness. Participants receive intensive case management through a Hope Enterprises, Inc., BCM, who works directly with them in the community to address their individual needs and promote long-term success. The program focuses on helping individuals achieve the goals identified in their mental health treatment plans through consistent, individualized support. BCMs assist with developing daily living and decision-making skills, maintaining connections to community resources, and addressing issues that may arise with neighbors or landlords through conflict resolution and problem-solving. In addition, the Lycoming/Clinton Joinder provides rental assistance, reducing financial stress and allowing participants to focus on recovery and maintaining stability.

Supportive Living addresses two of the greatest barriers to long-term success, housing insecurity, and the lack of consistent support. By tackling both challenges simultaneously, participants are more likely to maintain stable housing, remain engaged in treatment, and avoid crises that often result in hospitalization or other higher levels of care. Stable housing is a critical foundation for mental health recovery. Supportive Living ensures that individuals are not forced to choose between paying rent and managing their mental health. Instead, the program provides the structure, resources, and support necessary to promote recovery, independence, and lasting success within the community.

b. Strengths and Needs by Populations:

1. Older Adults (ages 60 and above)

Strengths:

Efforts outlined in previous years’ plans continue to be employed including engagement with older adults with mental illness on the provider level, increasing coordination of PH/BH care and support for older adults in our community, ongoing outreach and education between behavioral health and physical health providers to strengthen collaboration and communication regarding medications and treatment, and expanding our use of Administrative Case Management at the BSU level to do a more thorough assessment of those referred to the Joinder and development of a more comprehensive treatment plan to address Health-Related Social Needs. The Joinder Training Specialist also developed and provided Trauma-Informed Care for the Helping Professional, Question, Persuade, Refer (QPR), and MH and Older Adults trainings that were offered and presented to Joinder staff and community partners to promote awareness and education.

Needs:

Previously identified needs persisted within Lycoming and Clinton counties. There has also been an increase in suicide deaths in the older adult population within the bi-county area as well. Barriers such as the rurality of our counties, access to transportation, and stigma of mental health in this age group also persist. Unfortunately, while there are dedicated staff in local provider agencies who serve older adults, there currently are no specialized services or programs to specifically address the complex needs for this population. Geriatric Psychiatry continues to be a need in our area to support this population. As many of the consumers we serve live in rural areas, our program would benefit from training on how to engage rural populations, particularly those within this age group.

2. Adults (ages 18 to 59)

Strengths:

Lycoming-Clinton MH/ID continues to provide a wide array of mental health services to the residents of Lycoming and Clinton counties. Services include Mobile and Site-Based Psychiatric Rehabilitation, Individual and Group Psychotherapy, Medication Management, Intensive Outpatient Treatment, employment services, Social Rehabilitation (Clubhouse), Blended Case Management, and Administrative Case Management. Lycoming-Clinton MH/ID also maintains a contract with Roads to Freedom/Center for Independent Living to provide payee services to thirty adult individuals we serve. Lycoming-Clinton MH/ID pays for the service which provides our neediest individuals with a little extra spending money each month. Adults with mental illness also benefit from a continuum of housing supports, if needed, as explained further in the Housing Section of this Plan.

Needs:

Adults in Lycoming and Clinton counties face significant health disparities, primarily driven by rurality, economic instability, and Social Drivers of Health. Systemic barriers, including longer travel times to specialized care and broadband deficits, result in poorer chronic disease outcomes and delayed treatment for residents across the region. Both Lycoming and Clinton counties are federally designated as mental health Professional Shortage Areas. Mental health conditions and substance use disorders (SUD) are the top community health needs identified by local stakeholders. Clinton County, in particular, experiences increased health and social needs compared to Lycoming, consistent with its more rural geography. Residents face a higher physician-to-patient ratio than urban counterparts, exacerbated by travel distances to regional systems like UPMC and Geisinger. While telehealth is used to bridge the rural care gap, the region has lower rates of computer ownership and reliable internet subscriptions (approx. 76%) compared to state and national averages.

3. Transition age Youth (ages 18-26) - Counties are encouraged to include services and supports assisting this population with independent living/housing, employment, and post-secondary education/training.

Strengths:

Lycoming-Clinton MH/ID and LCHC work closely with Lycoming and Clinton County CYS Independent Living Programs to identify transition age youth who will be transitioning to the adult mental health system. Youth in our counties utilize the Independent Living Program, Clubhouse, Site-Based and Mobile Psychiatric Rehabilitation, and/or Clinton County Community Connections while in high school and beyond. The availability of Youth/Transitional Age Youth (TAY) Peer Support has expanded, and is being provided by two agencies, who collaborate closely with school districts and school based behavioral health services, to meet students' mental health and Health Related Social Needs. Youth in both counties are also routinely connected and supported in working with OVR and STEP’s YES program to assist with education and employment. A

Coordinated Specialty Care First Episode Psychosis program, now in its fourth year of operation, continues to experience increases in referrals of this population, and is providing community-based treatment to TAY and their families, including assistance with education and employment goals, housing, and independent living.

Needs:

Many TAY in Lycoming and Clinton counties are diagnosed with serious mental illness, serious emotional disturbances, and psychosis. However, specialized treatment and support remains a primary need for this population. The TAY population is the most difficult to engage in services, experiences numerous barriers such as transportation to services, and can be quite challenging to reintegrate into the community. This population could benefit by expansion and implementation of evidence based intensive, collaborative, and multidisciplinary services which not only focus on “hard” skill development but also focuses on addressing emotional and relational needs. TAY treatment models such as the Transition to Independence Process (TIP) model, would be perfectly positioned to serve youth and young adults (14-29 years old) with, or at risk of, serious mental illness who have extensive histories of multisystem involvement, out-of-home placements or homelessness, high prevalence of developmental trauma, involvement with the court system and/or incarceration, and co-occurring substance use/abuse problems. LCHC persists in exploring services and programs for this population but has not yet been successful in identifying a provider willing or able to expand to offer these services, due to ongoing staffing deficiencies. As the child autism population continues to grow older with only one agency for support available in our counties, LCHC is also exploring models and specialized programs for TAY with ASD.

4. Children (under age 18) - Please describe your county’s efforts to support children, youth, and families through home and community-based services. Please be specific in describing how you believe these efforts will decrease Psychiatric Residential Treatment Facility utilization.

Strengths:

Lycoming and Clinton counties have a small range of community-based services and programs in place that support children and families and provide treatment modalities which can decrease utilization of PRTFs. Routine collaboration and coordination occur between behavioral health providers, families, and supports through CYS Family Centered Services and the Family Group Decision Making, as a means for identifying family strengths, a family plan, and preventing out-of-home placements. Last school year, the Joinder successfully collaborated with local school districts to increase the number of School Outreach workers available in school buildings, and additional behavioral health therapists were assigned to school-based outpatient services to increase access for students. School based IOP is also available to students in Clinton County, and Community and School Based Behavioral Health (CSBBH)programs operate in the largest school districts in each county. Establishing behavioral health services within the local school districts’ buildings has significantly reduced barriers to accessing children’s services and has increased utilization/retention in services.

Moreover, it has allowed for easier, more meaningful engagement of families and support in treatment, and has prevented admission to higher, more restrictive levels of care.

The Child and Adolescent Service System Program (CASSP) Coordinator works tirelessly with county school districts, behavioral health providers, Juvenile Probation, Children and Youth Services, Home Health Aide / Home Nursing Providers, and BH- MCOs to strengthen collaboration with child-serving systems. CASSP facilitates meetings with families and providers which function to promote and support the least restrictive levels of care, recognize gaps in a child/adolescent continuum of care, offer discussion towards resources, and ensure follow-up care for youth leaving out-of-home placements or inpatient hospitals. CASSP works to identify programs, resources, and treatment options offered throughout the Commonwealth to assist in closing gaps/barriers and expanding children services in Lycoming and Clinton counties. To assist and address children/adolescents and families with complex needs and/or challenging system barriers, Lycoming-Clinton CASSP was a selected participant for the Commonwealth’s Pediatric Capacity Building Institute (CBI): Youth with Complex Needs, and the Mental Health Roundtable Work Group. Both groups offer solution-focused discussion towards treatment options/models available throughout the Commonwealth, strategies for bridging communication and coordination within the children service system, education on system processes, and targeted goals for addressed topics. In 2025, CASSP incorporated education for youth regarding how to come prepared, advocate, and set goals in their treatment team meetings to have their voices and opinions heard with respect to the treatment and services they want and need.

Needs:

Although many school-based services are already in place, local school districts are reporting a need for more IBHS services and family supports within the schools to assist with an increasing complexity of needs recognized among their students, and specifically students in grades K-2.

The closure of numerous PRTFs (including those which served special and challenging populations) that resulted from a variety of issues during the COVID pandemic, has intensified the problem of identifying facilities which exclusively serve and will accept for treatment, females, and programs that serve children with sexually acting out and/or perpetrating behavior. Additional PRTFs are needed, preferably in our region, to appropriately serve these populations. Moreover, as we acknowledge a growing trend in children being diagnosed with trauma, these PRTFs should be competent in treatment modalities that address second generational trauma impacts on the family and offer treatment approaches for those with lived traumatic experiences.

Special/underserved populations:

5. Individuals transitioning from state hospitals

Strengths:

Lycoming-Clinton MH/ID continues to identify coordination of services and Community Support Planning (CSP) with the State Hospital as a strength.

The county Mental Health program continues to utilize Community Services Group’s (CSG) Enhanced Personal Care Boarding Home and to assist in meeting the needs of this population. Although, the Mental Health program ended its contract with CSG for the CRR and Independent Living services, we entered into a contractual agreement with Hope Enterprises, Inc., to provide Supportive Living/Residential Support Services instead. Project Transition continues to search for an approved location for an adult RTF program as an additional step-down service from State Hospitals.

Needs:

There are currently no structured step-down residential services within the bi-county area. As identified in previous plans, residents being discharged from State Hospitals would greatly benefit from the addition of a Long-Term Structured Residence (LTSR) as part of the array of residential options. Aside from the benefits of the service itself, having a local LTSR within the bi-county area would assist with individuals being able to return to their local communities rather than having to consider moving to areas several hours from home. Additional funding to support alternative least restrictive treatment options such as the proposed Residential Treatment Facility for Adults (RTF-A) would also be of benefit for individuals with serious mental illness being discharged from State Hospitals, as well as for diversion from the State Hospital system. Additional civil beds are needed at Danville State Hospital to accommodate individuals found non-restorable to competency at Torrance State Hospital Regional Forensic Psychiatric Center in need of transfer to a state hospital. Service availability for individuals without Medicaid is an ongoing challenge which burdens base funding.

6. Individuals with co-occurring mental health/substance use disorder.

The Coordinated Specialty Care FEP program provider for individuals ages 16-35 in Lycoming and Clinton counties receives referrals from and collaborates closely with local substance use disorder providers, as approximately 35% of individuals in the targeted FEP population are also using substances to self-medicate or cope with symptoms. Because the FEP provider does not offer integrated co-occurring treatment, the provider established a formal collaboration with a local dually licensed outpatient clinic to deliver co-occurring outpatient therapy to FEP clients. This collaboration also includes medication education and support for clients interested in Medication Assisted Treatment. HealthChoices reinvestment funds have also been approved for the implementation of an adult trauma-informed MH IOP, that serves individuals with co-occurring substance use disorder. Presently, a dually licensed outpatient clinic provider is pursuing expansion of their peer support staff to meet the needs of individuals with co-occurring mental health and substance use disorders. During the 2025-2026 school year, this same dually licensed outpatient provider served several school districts as a school-based outpatient provider, allowing children and adolescents with co-occurring diagnoses to receive counseling within the school setting.

Needs:

Although two dually licensed outpatient clinics operate in the bi-county, no integrated treatment services exist. In addition, recruitment and retention of staff who are licensed and/or otherwise qualified continues to suppress agency expansion of co-occurring evidence-based practices and modalities. Assisting local providers in gaining staff and professional competency in delivering integrated treatment for mental health and substance use disorders would reduce the fragmentation of services for individuals with co-occurring disorders, foster a better quality of care, and support long-term recovery.

7. Criminal justice-involved individuals

The Criminal Justice Advisory Boards (CJAB) within Lycoming and Clinton counties continue to be highly active with each having its own Mental Health Sub-committee. A primary focus of the Sub-committee continues to be Crisis Intervention Team (CIT) training. In September 2025, two 4-hour CIT refresher courses were provided to previously trained CIT participants followed by a reception to acknowledge individuals who have implemented CIT principles into their daily service delivery. In the fall of 2025 and spring of 2026 additional CIT trainings were held with bi-county police, adult probation departments, emergency services personnel, Center for Community Resources (CCR) crisis services staff, and designated MH staff participating. Each class graduated twenty participants. The impact associated with the CIT Training Project continues to include both improved tracking of processes and systemic outcomes as well as individual consumer quality of life outcomes. Mental Health co-responders continue to support three law enforcement agencies across the bi-county area and continues to be a priority as this program has shown positive outcomes regarding diversion from higher levels of care and increase access to services within the community. The MH/ID program continues to seek and apply for grant funding as well as committing Base funds to continue to support this program. The Joinder Training Specialist also offered five Mental Health First Aid (MHFA) trainings throughout the year with fifteen participants from the Joinder and community partners participating in three of them.

The Regional Veterans Court including the following PA counties: Blair, Clinton, Centre, Mifflin, Huntingdon, Perry, Juniata, and Clearfield, continued to operate over the past year. The Regional Veterans Court model continues to grow and adjust its service delivery to best serve Veterans. Likewise, the Veteran’s Court in Lycoming County also continues to operate. The Lycoming County Veteran’s Court Veteran Mentoring Program continues to assist Veterans to regain control of their lives and successfully connect to and maintain treatment, leading to successful completion of the Lycoming County Veterans Court Program.

The Lycoming-Clinton MH Program continues to highly prioritize jail diversion through the Mental Health Services Forensic Unit. The unit has two full-time positions based in the Lycoming County Prison (LCP) and one Forensic Case Manager (FCM) that acts as a boundary spanner for inmates with SMI being released back into the community. One LCP-FCM continues to secure information for court ordered OHMSAS Outpatient competency evaluations and Torrance State Hospital competency restoration referrals, as necessary. The second LCP-FCM is a master’s degree level Psychological Specialist Associate (PSA) who completes MH assessments through referrals from LCP counselors as well as court ordered MH assessments from the Lycoming County Court.

The PSA also completes suicide observations and meets regularly with inmates who need a higher level of supervision that requires them to be isolated from other inmates as per LCP policy. The Forensic Unit continues to work with many of the mental health consumers involved with probation and parole in the bi-county area, Mental Health Courts, both county prisons, supervised bail programs, pre-release centers, as well as assists with the CIT steering committee. The Unit has achieved good outcomes through its excellent coordination of care for jail diversion, reentry, and individuals at each intercept point in the judicial system. Center for Community Resources (CCR) continues to provide mobile crisis services that complement the existing services for prison diversion for those with SMI, including the three co-responder positions.

Needs:

Lycoming-Clinton MH/ID continues to make the exploration of the development of service options for justice involved individuals a priority, specifically focusing on housing resources for forensically involved individuals and for individuals with SMI. PHARE projects in both counties continue to provide some additional resources. However, the Master Leasing Program in Lycoming County has continued to decrease its support for forensically involved consumers with SMI over the last several years, further complicating the housing need.

Other previously identified needs remain such as the availability of Forensic Peer Support specialists to assist individuals participating in the Treatment Courts in the bi-county area, the creation of a regional Stepping Up team involving other county stakeholders, and access to a local or regional evaluation and restoration of competency program for forensically involved individuals with SMI. Access to these types of service could significantly improve overall outcomes for this population.

8. Veterans

The most notable development in the area of supports for Veterans in our region is Hope Enterprises opening a Fairweather Lodge just outside the Borough of Muncy, in Lycoming County. The Veteran’s Fairweather Lodge is a voluntary community-based mental health recovery program designed to support veterans in building independent, meaningful lives. Veterans live together in a supportive home environment while working toward personal recovery goals at their own pace. Based on Dr. George Fairweather’s evidence-based model, the Lodge integrates safe housing, employment, peer support, and shared responsibility. Originally created to serve Veterans, the model continues to promote dignity, purpose, and lasting community connection.

Veterans living with mental illness in Lycoming and Clinton counties are supported with a variety of services.