12-FY 2025-2026 Lycoming and Clinton County Human Services Plan Final Complete.pdf

FY 2025-2026 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 2025-2026 Human Services Plan as a joint project.

County Human Services funds incorporated into this FY 2025-2026 Human Services Plan include:

• Mental Health Community Based-Funded Services

• Behavioral Health Services Initiative (BHSI)

• Intellectual Disabilities Community Based-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

• Leslie McNemar, CAI Senior Fiscal Consultant, Clinton County Children & Youth Services

• Ron Frick, Lycoming County United Way

• Elizabeth Whitty, Clinton County Planning Department, Community Development & Housing

Coordinator

• Jim Hicklin, Director, 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

• Lauralee Dingler, Mental Health Specialist, Lycoming-Clinton Mental Health Services

• Deanna Kimble, Quality Manager, Lycoming-Clinton HealthChoices

• Vanessa Shellman, Clinical Oversight, Lycoming-Clinton HealthChoices

1. Please 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 NAMI, the Lycoming County Human Services Task Force, Behavioral Health Services Provider group (comprised of Adult Services Providers, Children Services Providers, and Private Practitioner providers), Community Care BH-MCO (Behavioral Health Managed Care Organization), the Lycoming County Health Improvement Coalition (LCHIC), the Clinton County Collaborative Board, KeystoneCares, Lycoming County Early Learning Team, Advocates for a Drug Free Tomorrow, Suicide Prevention Committee, Crisis Intervention Team (CIT) Steering Committee, Re-Entry Coalition, 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, CYF (Children, Youth and Families), JPO (Juvenile Probation Office), APO (Adult Probation Office), CJAB (Criminal Justice Advisory Board), Office of the Aging, Community HealthChoices, school personnel, members of law enforcement, the criminal justice system, medical personnel, local hospital systems, Physical HealthChoices, homeless shelters and service recipients of cross system services.

2. Please 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 BH 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 Reentry 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 2025. A Public Hearing was held on August 6, 2025, at which the Plan was reviewed, and attendees were provided the opportunity to provide comment.

3. List the consumer groups and other advisory boards that were involved 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.

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 work closely with the local hospitals (UPMC and Geisinger) and law enforcement in both counties to continue the ‘warm hand-off’ process for individuals who have experienced an overdose or other SUD-related emergency. Also, the SCA has partnered with the State of Pennsylvania in administering the Centers for Excellence in the bi-county area, as well as participated in the SAMHSA grant to expand Medication-Assisted Treatment in the region, including in the Lycoming County Prison.

Clinton County has a very active community-based Advocates for a Drug Free Tomorrow planning group that meets monthly to discuss concerns and implement new ideas.

Each county has also recognized the increase in mental health needs among special populations, such as the criminal justice involved population and children and adolescents. The bi-county is committed to the Crisis Intervention Team (CIT) training for law enforcement and other criminal justice stakeholders as well as crisis intervention providers. Two CIT training sessions were held during the past fiscal year, in fall 2024 and spring 2025, with another training scheduled for fall 2025. There is great interest in the training and both week-long classes were full. There is a waiting list for future classes. The CIT Steering Committee meets regularly and organized a de-escalation train-the-trainer session in the spring of 2025 that increased the pool of de-escalation trainers in the bi-county and across the region.

Additionally, the bi-county MH/ID office was able to secure grant funds to help law enforcement agencies offset overtime costs to send officers to the CIT training sessions.

Two local providers, including the Lycoming-Clinton MH/ID Program, continue to provide Mental Health First Aid trainings and to expand MH First Aid for Teens to additional school districts in the bi-county. Funds were provided by each county to cover the costs of the training manuals for participants. The bi-county MH/ID Program focused on the expansion of community training by hiring a full-time trainer. In addition, the SCA continues to administer the LETI grant for Clinton County. The Law Enforcement Treatment Initiative (LETI) in Clinton County started in October 2022 and continues to receive active referrals. The goal of the LETI program is to offer individuals with behavioral health needs the opportunity to engage in treatment versus entering the criminal justice system. Referrals by the district attorney’s office have resulted in individuals being completely diverted from the criminal justice system, and referrals received from police departments have the same intention. Referrals from the adult probation office promote strengthening connections in the community with certified recovery specialists (CRS) and aim to decrease the rate of recidivism. The grant has supported several training opportunities for professionals working in the criminal justice field, such as the National Treatment Court Conference, Crisis Intervention Team (CIT) training, and CRS training. Each county also identified teams to participate in the Behavioral Health Summit sponsored by AOPC.

Community-based mental health staff work within both county prisons. Clinton County has entered into a contract agreement with a mental health provider to supply mental health services directly in the Clinton County Prison. That program works directly with the bi-county forensic case manager and the local service providers to coordinate reentry efforts to reduce recidivism. The Lycoming-Clinton MH/ID Program expanded the mental health services it provides to the Lycoming County Prison. It now provides a full-time, master’s level, forensic psychological associate, and a full-time bachelor’s level boundary spanner case manager in the Lycoming County Prison, while also providing funding support for part-time psychiatric services. This expansion of services was the result of work done by a special sub-committee of the Lycoming CJAB identifying the specific mental health needs of the Lycoming County Prison and working with the Lycoming County Commissioners to increase local funding to address these needs. The Commissioners from each county signed Stepping Up Initiative resolutions, formally making a commitment to keep the mentally ill out of jail. The establishment of a cross-system database for mental health, substance-use disorder, and each county prison, was completed via a grant from PCCD; this database provides monthly aggregate data.

Collaborative efforts continue between the nine school districts in the bi-county area and the Lycoming-Clinton MH/ID Program. Mental Health case managers are assigned to work out of each school district, serve as members of the Student Assistance Program (SAP) team, and act as an initial referral source for students at risk for a Serious Emotional Disturbance (SED). The BH HealthChoices Program continues to emphasize services in the school districts including the creation of a new partial program run by the Intermediate Unit that focuses on dual-diagnosed students and a school-based IBHS Pilot that will focus on the three districts with highest utilization. A school-based, intensive outpatient program continues to operate in Clinton County due to the limited availability of partial hospitalization services for children and youth within the county.

The need for safe, affordable, permanent housing continues to be a major issue in both counties.

Cross-system collaborations to address housing needs for residents in each county are underway with an emphasis on collaborating with landlords to meet the needs locally. The bi-county MH/ID Program has developed a joint Housing Services Unit with Lycoming Children & Youth Services that will focus on helping keep individuals and families in community housing. Activities of the unit include working with landlords, teaching independent living skills, etc. The Lycoming-Clinton MH/ID Program and the Single County Authority (SCA), West Branch Drug and Alcohol Abuse Commission, provide the Community- Based Case Management initiative under Behavioral Health Choices, focusing on the Health-Related Social Needs (HRSN) and most specifically focusing on permanent housing needs.

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

The bi-county MH/ID Program operated the Blended Case Management Service for over 35 years. As the service grew and developed over the years it was increasingly difficult for the County Program to operate a Medicaid billable service alongside other base-funded services. The decision was made to end the County Program’s BCM service and transition the service to Provider Agencies who do not have to operate under the state civil service employment regulations. While this decision was a difficult one, the transition process went very well. Two new provider agencies opened BCM services within the bi-county, bringing the total number of BCM providers operating in the bi-county to three.

Despite initial trepidation, every service recipient was successfully transitioned to a new Provider, and many of the County Program staff also transitioned to the new Providers which provided continuity for the service and the service recipients have increased provider choice for the future.

A new housing support initiative was developed between the bi-county MH/ID Program and Lycoming Children & Youth Services. The new Housing Supports Unit combines the CBCM funding, County PHARE Grant Funds and CYS Needs-Based Plan funds to support individuals and families with obtaining and maintaining housing in the community. This program grew from recognition that both MH/ID and CYS were routinely providing housing-related support services to consumers including temporary housing in local hotel/motels, rental assistance, life skills training, etc. on a separate, case-by-case basis. The new Housing Support Unit includes a supervisor and case managers that will focus on the housing-related needs of individuals and families involved with the bi-county MH/ID system and/or the child welfare system. Future discussions with Clinton County’s CYS office to join this innovative approach are planned for the coming fiscal year.

Recruitment and retention of qualified staff remained a significant issue across the spectrum of services in the bi-county area. Lycoming-Clinton HealthChoices reinvestment funds were used to assist providers with meeting the challenges of finding and keeping staff in all positions. A shortage of psychological and psychiatric services continues across the local mental health system.

Part II - PUBLIC HEARING NOTICE

The joint Public Hearing for all services provided by Lycoming and Clinton Counties for the FY 2025-26 Human Services Plan was conducted on August 6, 2025, pursuant to the Sunshine Act, 65 Pa.C. S 701-716.

During the Public Hearing, it was noted that it is required that a Public Hearing be held prior to submission of the FY 2025-2026 Human Services Plan. A summary sheet of the Human Services Categories and respective allocation amounts was available, and the entire plan was reviewed. The total of the six (6) line items reflected in the FY 2025-26 Human Services Plan is $9,103,059 for FY 24-25.

STATE/FEDERAL FUNDS FY 2024-2025

Allocation

Mental Health Community Based Services $6,432,981

Behavioral Health Services Initiative (MH) $208,687

Intellectual Disabilities Community Based Services $1,270,392 Behavioral Health Services Initiative – (Substance Abuse) $586,579

Act 152 $215,235 Human Services Development Fund - Lycoming County $114,423

Human Services Development Fund – Clinton County $50,000

Homeless Assistance Program – Lycoming County $194,505

Homeless Assistance Program – Clinton County $30,257

TOTAL $9,103,059

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 Program works collaboratively with community stakeholders to assist individuals with mental illness to achieve their vocational goals. Community Services Group offers an accredited vocational and psychiatric rehabilitation program called the Commerce Park Clubhouse. Participants in the Clubhouse can develop marketable skills in the areas of food service and clerical, in a supported, simulated work setting that transitions to supported and independent employment. Additionally, programming at the Clubhouse includes a social component to assist with social skills development. These services are complemented by a separate, base-funded Independent Living Program (IL) that focuses on life skills development including use of public transportation, basic banking skills, and developing routines and a structured schedule so they can achieve their employment goals.

Skills of Central Pennsylvania also provides employment-related services as a part of their mobile and site-based psych services. These base-funded services assist with finding and maintaining meaningful, gainful employment in their communities. These services include career assessments, job shadowing, and 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.

Reentry committees remain active in each county with participants coming from stakeholders across the human service spectrum including the bi-county MH/ID office, BH HealthChoices, SCA, OVR, Career Link, behavioral health provider agencies, local colleges and representatives from the criminal justice and health care systems. The committees collaborate to help improve success for individuals returning to the community following incarceration. Job fairs and employer education opportunities have been developed by these committees, including Certified Recovery Specialists, providing information about the advantages of hiring individuals with special needs. The Office of Vocational Rehabilitation (OVR) regularly provides vocational support and assessments for individuals with mental health and substance use issues. 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, and job search websites like Indeed, Monster and Williamsport Help Wanted. A “Felon Friendly List” of employers is also posted and maintained at the resource centers. Rise Up Bakery, a faith-based program, works with individuals returning to the community from incarceration as well as with those living with a disability, teaching baking skills in a commercial kitchen. Graduates of the program receive ongoing support to obtain and maintain employment. The bi-county MH/ID Program participates in OVR’s Citizen’s Advisory Council (CAC). The CAC’s role is to provide feedback on OVR’s services, initiatives, and programmatic changes, and offer suggestions to assist OVR to meet community needs.

HOUSING:

Lycoming and Clinton counties have been focused on housing needs for the mental health community for many years. The key components to our ongoing success have always been made possible through collaboration with our community partners. These crucial relationships are developed and maintained by our Mental Health Program Specialist and Housing Specialist throughout the bi-county area. Self Determination Housing of PA Inglis communicates availability of 811 housing lists. The Public Housing Authorities (PHA) communicate availability of Public Housing and Section 8 lists and new project construction, while also sharing concerns and identifying additional assistance needs of their active lessees receiving mental health services.

The Clinton County PHA Executive Director and Lycoming-Clinton MH/ID Program’s Housing Specialist are both members of the Regional Housing Advisory Board (RHAB) for the Northern Tier Continuum of Care (CoC), which provides them with up-to-date Federal, State, and County housing options and funding sources.

The Lycoming-Clinton Joinder Board created the Joinder Housing Unit combining resources from Lycoming County CYS, MH/ID base funding and a PA Housing Affordability and Rehabilitation Enhancement Fund (PHARE) grant from Lycoming County. This program began with the hiring of a housing supervisor and will maintain 2 housing specialist caseworkers (one housing specialist is the CBCM) and 2 housing support caseworkers overseen by the Mental Health Program Specialist. This unit will focus on assisting individuals/families with maintaining their present housing by focusing on their independent living skills, budgeting, landlord/tenant relationship, and sustainability. The goal of this program is to decrease the need for emergency housing due to evictions or affordability of their current placement.

The Lycoming-Clinton MH/ID Program continues to provide the Community-Based Case Management (CBCM) service for individuals with a mental health diagnosis via a contract with the BH-MCO, Community Care

Behavioral Health. CBCM provides assessment and support for individuals receiving mental health services in the areas of housing and other Health-Related Social Needs. The ongoing goal is to collaborate with the local Community-Based Organizations (CBOs) to address the Health-Related Social Needs and to prevent or divert individuals from a higher level of care. Since beginning in July 2021, the CBCM housing specialist has worked with a total of 381 households. This fiscal year, the CBCM housing specialist referred approximately 84 households to resources to assist with all Health-Related Social Needs and funded 7 households to obtain/maintain permanent housing. Since 2023, the CBCM housing specialist provided outreach to other case management and human service agencies in the community, offering resources to strengthen their abilities to address the Health-Related Social Needs of individuals with whom they work.

Due to the success rate of the Master Leasing Program, some PHARE funding was again allocated to Lycoming County for hard-to-place individuals with co-morbidities. Lycoming County earmarked a portion of the PHARE monies for the human service contingent to STEP Inc. for a Supported Housing Program in which Lycoming- Clinton MH/ID Program is a referral partner. In fiscal year 24/25, the Lycoming-Clinton Mental Health Program continued to partner with the contracted crisis intervention provider, Center for Community Resources (CCR), which recently opened the site for their 4-bed Interim Housing Program. This program will provide temporary shelter for individuals experiencing a mental health crisis and act as a diversion from hospital emergency departments and county jails.

From January 2025 through March 2025, First Church in Williamsport provided an emergency warming center, including a meal and cot for guests (homeless individuals), and an opportunity to meet weekly at the center with local human service agencies. First United Methodist Church anticipates repeating this service in 2026.

The Lycoming-Clinton Joinder Housing Unit Supervisor maintains an up-to-date list of housing options in the bi-county and makes it available to mental health service recipients and service providers. The ongoing housing shortage in the bi-county area continues to directly impact mental health service recipients looking for affordable housing opportunities. As a result, the Joinder Housing Unit continues its focus on expanding contacts for an up-to-date list to include online apartment search options and other non-traditional options.

These contact options allowed the Joinder Housing Unit to continue to identify local housing options during the ongoing housing crisis. The Joinder Housing Unit continues to develop working relationships with new landlords and make connections for affordable housing for service recipients.

The Lycoming-Clinton Joinder Housing Unit continues to provide funding for mental health service recipients who are experiencing an emergency need for rent, utilities, or furnishings. This is provided 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.

There are multiple collaborative housing option teams in Lycoming and Clinton Counties. A seven county Northern Tier Regional Housing Advisory Board (RHAB) meets bi-monthly, maintaining compliance with the regional Continuum of Care and HUD. There is a monthly Homeless Management Information System (HMIS) meeting that reviews the By Name List (BNL) of homeless individuals and families in the bi-county area.

Lycoming County conducts a TASK force of approximately 180 not-for-profit/non-profit agencies that meet monthly for information and collaborative purposes updating their social services. In Clinton County there is a

Clinton County Housing Coalition (a 501(c)(3) organization) that continues to meet monthly and focuses on the housing and homeless issues of Clinton County.

Housing and housing support services in the bi-county area include:

• American Rescue Workers (ARW) Fresh Start Men’s Work Rehabilitation Program, 39 beds

• ARW Emergency Transient program for men, 6 beds

• ARW Saving Grace Emergency Shelter for families, men, and women, 24 beds

• 14 CRR beds (bi-county)

• Independent Living Support services (bi-county)

• Mobile Psychiatric Rehabilitation Services (bi-county)

• Homeless Assistance Program (HAP) monies (bi-county)

• Emergency Food and Shelter Program monies (EFSP)

• Two Safe Homeless Shelters for Domestic Violence Victims (bi-county)

• Family Promise of Lycoming County is a Transitional Housing Program providing services for up to 4 homeless families in Lycoming County.

• Journey House is a Transitional Housing Program for domestic violence that serves 4 families in Lycoming

County.

• Habitat for Humanity provides Permanent Housing for low-income families.

• Liberty House is a HUD funded Supportive Housing Program that can serve up to 31 women and children in

Lycoming County.

• Clinton County has an 811 PRA Permanent Supportive Housing Initiative with Meadows Edge Apartments.

• The Life Center, Clinton County’s homeless shelter, serves up to 14 women, couples, or families.

• The Merit House, Clinton County’s men’s homeless shelter can house 4 men.

• Certified Peer Support Specialists and Certified Recovery Specialists.

• Oxford House for women in recovery, 12 beds.

• First Church winter warming center open January – March, approximately 25 beds

• STEP Master Leasing Program

• STEP Supportive Housing Program

• Center for Community Resources/CCR Interim Housing Program (4 beds)

Part IV - HUMAN SERVICES NARRATIVE

This section of the Plan includes a description of how Lycoming and Clinton Counties intend to use the funds to provide services to their residents in the least restrictive setting appropriate to their needs. Information is provided on how funds will be expended within the categorical allocations provided by the Department of Human Services. Services that are provided by Lycoming and Clinton County only are separated in each of the categorical program narratives.

MENTAL HEALTH SERVICES

a) Program Highlights

Please highlight the achievements and other programmatic improvements that have enhanced the behavioral health service system in FY 24-25.

Behavioral Health Workforce Development Funding:

Lycoming-Clinton Behavioral Health Choices (LCHC) and their MCO, Community Care Behavioral Health, have con�nued to work together to develop addi�onal long-term workforce stabiliza�on strategies to rebuild and reinforce our local behavioral health system. In 2024, LCHC was approved for reinvestment spending in the amount of nearly $900,000 to provide funding to support local provider staff recruitment and reten�on ini�a�ves; 18 behavioral health providers from a variety of levels of care have been allocated $50,000 funding each. Par�cipa�ng providers have submited biannual progress/outcome reports which indicate posi�ve outcomes to date. Posi�ve outcomes include the hiring of new staff that resulted in a 35% decrease in open staff posi�ons across the provider network, and a decrease in client average wait �me for an appointment from 13 days to 12 days. Furthermore, a total of 43 provider staff were given licensing support (exams, applica�ons, renewals, and supervision) during the first six months of the plan and 41 of these staff members were retained, allowing these providers to expand the availability of appointments and permit faster access to services.

Community Based Organizations (CBOs) and Community Based Care Management (CBCM):

Community-Based Organizations (CBOs) are nonprofit organizations that work at a local level to improve life for residents and normally focus on building equity across society in many areas, including but not limited to access to social services. Community Based Care Management (CBCM) providers are nonprofit organizations that work to improve behavioral health outcomes and utilize partnerships with Community-Based Organizations (CBOs) and providers that encourage the use of preventative services, mitigate Health-Related Social Needs (HRSN) barriers, and reduce healthcare disparities. LCHC (Lycoming Clinton Behavioral HealthChoices) has incorporated five CBOs and two CBCM agencies into their service array. Two of the CBOs and both the CBCM providers’ focus was around housing; two of the CBOs had a focus on food insecurity.

During 2024, 531 individuals were referred to CBOs, with 94% receiving assistance with concerns regarding Housing Instability and Homelessness. Other significant areas of need indicated by referrals to CBOs and CBCM agencies included help paying for utilities, food insecurity, and financial strain.

Coordinated Specialty Care First Episode Psychosis Program:

Lycoming-Clinton Joinder was awarded a CMHSBG (Community Mental Health Services Block Grant) First Episode Psychosis (FEP) program grant in 2022-2023 and has recently been notified of a fourth year of funding. The partnering provider, Community Services Group (CSG), has served ten clients to date. Key to the success of the program has been FEP Team outreach and educational presentations regarding FEP and the new program with system partners, behavioral health providers, physical health MA (Medical Assistance) providers, MHIP facilities, CYS, and local colleges' counseling staff. Individuals and their families/support people are regularly encouraged to take an active role in the program. FEP family therapy sessions are endorsed as a valuable part of the therapeutic process, and the FEP team assists individuals and their families with resolving any barriers to engagement. A Certified Peer Specialist, a self-identified individual with lived experience as a behavioral health consumer, is an integral component of the FEP Team and participates in all team meetings and trainings.

b) Strengths and Needs by Populations:

Please identify the strengths and needs of the county/joinder service system specific to each of the following target populations served by the behavioral health system. When completing this assessment, consider any health disparities impacting each population. Additional information regarding health disparities is available at https://www.samhsa.gov/resource/tta/national-network-eliminate-disparities-behavioral-health-nned.

1. Older Adults (ages 60 and above)

STRENGTHS:

Lycoming-Clinton MH/ID remains a Trauma Informed Program. Trauma informed principals used by our case managers in performance of their duties assures that the older population we serve receive support in a safe, non-threatening manner. Community HealthChoices/Long Term Services and Supports (CHC/LTSS) in the bi-county continues to foster an increase in coordination of PH/BH care and support for older adults in our community. Case management, Mobile Psychiatric Rehabilitation, and Peer Support providers are successfully engaging older adults in services in their own homes, personal care homes/nursing homes, and in the community. Older adults are also supported in their own homes through Community Services Group’s Independent Living Program. As mentioned earlier, Lycoming-Clinton MH/ID maintains a contract with Community Services Group to provide Independent Living services to assist consumers, including older adults, with strengthening skills such as housekeeping, budgeting, meal prep and shopping. This service has been particularly helpful to our older population who wish to age in place rather than leave their homes and move into some form of congregate care.

Because older adults often have comorbid or chronic health conditions and typically seek help for concerning symptoms first from primary care physicians (PCPs), there has been ongoing outreach and education between behavioral health and physical health providers to strengthen collaboration and communication regarding medications and treatment. This outreach will continue over the coming year.

In May of 2025, Lycoming-Clinton MH/ID phased out our Targeted Case Management Program and welcomed two new providers of Blended Case Management services into our catchment, bringing the number of providers of Blended Case Management to three. With three providers to choose from, consumers have an opportunity to choose a provider who best meets their needs. Additionally, as the Targeted Case Management Program was phased out, we are 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 which may be impacting the individuals we serve.

NEEDS:

Many older adults are not familiar with the behavioral health system or how to access behavioral health resources in our counties; lack of transportation, physical disabilities, and a perceived stigma regarding addressing mental health needs are also common barriers to participation in treatment. Older adults in our counties have higher rates of readmission to inpatient treatment, a concerning rate of unidentified substance use disorders, poorer outcomes following inpatient hospitalization, and fewer natural supports to encourage long-term recovery. Although 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. Formalized community support could fill this gap in services for older adults. 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 and 59)

STRENGTHS:

Adults living with serious and persistent mental illness in the bi-county area continue to benefit from a continuum of outpatient community-based services. In addition to state mandated services, the bi-county service array includes special services like Mobile and Site-based Psychiatric Rehabilitation, Peer Support, Clubhouse, Community Residential Rehabilitation (CRR) homes, Independent Living Services (ILS), Community Employment and Social Rehabilitation.

In January 2025, the bi-county MH/ID Program made the decision to end its in-house Blended Case Management Services and transitioned the service to Provider Agency partners. As a result of this decision, 2 additional BCM providers were recruited (Center for Community Resources and Hope Enterprises) to the bi-county increasing the total providers of BCM to 3 (Service Access Management being the third). The MH/ID program worked with the 3 providers to make the transition of services smooth and seamless for recipients and the process was completed by May 2025.

The BH HealthChoices MCO, Community Care Behavioral Health, continued to provide a Pre/Postnatal Care Manager who offered outreach, coordination, and support to pregnant women and new moms experiencing mental health concerns. The bi-county BH HealthChoices continued to provide a Transportation Fund to assist adults and families to attend behavioral health appointments, physical health appointments, community support groups, and to travel to and from inpatient facilities for treatment. This fund assisted about 70 individuals throughout the year and continues to improve access and engagement to services. HealthChoices also developed an incentive program with unused admin funding that provided gift cards to service recipients for meeting attendance goals, completing paperwork, medication compliance, etc. This was a one-time incentive plan in 2024 that was very successful.

There is ongoing collaboration with the Criminal Justice System to divert or reduce the length of incarceration for individuals with serious mental illness. The bi-county MH/ID office provides forensic-focused administrative case managers who work with each county’s specialty courts, a boundary spanner who assists individuals transitioning from incarceration to the community and a psychological associate who works with incarcerated individuals with SMI.

The bi-county MH Crisis Program was able to add additional staff in Clinton County to cut-down on response times. They also opened a 4-bed Interim Housing Program within the Crisis Program office in Williamsport.

The Housing program provides a short-term living arrangement for individuals experiencing a MH Crisis with additional housing issues. The program has been at capacity with a waitlist since it opened in early 2025.

Needs:

The bi-county continues to struggle without a continuum of intensive, coordinated, community-based residential supports for adults with serious mental illness (SMI) that can reduce the number of adults who cycle in and out of state hospitalization, inpatient treatment, and the criminal justice system. Individuals with SMI living in the bi-county typically experience comorbid physical health conditions, housing instability, and multiple care coordination needs; their social support networks are small, and their relationships are commonly conflictual and unstable. Formalized transitional support could provide a safety net to SMI adults through information, linkage to resources, and assistance as part of discharge planning during transition back into their communities, and for engagement in treatment.

3. Transitional Age Youth (ages 18 through 26)

Lycoming-Clinton works 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 that collaborate closely with school districts and school based behavioral health services to meet students' Mental Health and Health-Related Social Needs. Lycoming-Clinton youth are also routinely connected and supported in working with OVR and STEP’s Youth Enrichment for Success (YES) program to assist with education and employment. A Coordinated Specialty Care First Episode Psychosis program, now in its third 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 transitional-age youth 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)- Counties are encouraged to include services like Student Assistance Program (SAP), respite services, and Child and Adolescent Service System Program (CASSP) coordinator services and supports, System of Care (SOC) as well as the development of community alternatives and diversion efforts to residential treatment facility placements.

Lycoming and Clinton counties have a small range of community-based services and programs in place and planned for implementation during 2025-2026 that support children and families and provide treatment modalities which can decrease utilization of Psychiatric Residential Treatment Facility (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, developing 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 schools, and additional therapists were assigned to school-based outpatient services to increase access for students. School based Intensive Outpatient Program (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 prevention of admission to 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 the 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’s 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’s service system, education on system processes, and targeted goals for addressed topics. In coordination with Behavioral HealthChoices, CASSP formed and coordinated a Psychiatric Residential Treatment Facility (PRTF) Work Group that aims to reduce out of home admissions, review data surrounding members who have been admitted, and address length of stay when receiving treatment at a PRTF for children with complex needs.

NEEDS:

Although many school-based services are already in place, local school districts are reporting a need for more IBHS services within the schools to assist with an increasing complexity of needs recognized among their students. In planning for the 2025-2026 school year, LCHC will be implementing a pilot School Based IBHS program to further increase access and utilization of IBHS.

Please identify the strengths and needs of the county/joinder service system (including any health disparities) specific to each of the following special or underserved populations. If the county does not currently serve a particular population, please indicate and note any plans for developing services for that population.

SPECIAL/UNDERSERVED POPULATIONS:

5. Individuals Transitioning out of State Hospitals:

Lycoming-Clinton MH/ID continues to identify coordination of services and Community Support Planning (CSP) with the State Hospital as a strength. This includes the CSP process, liaison meetings, clinical team meetings, participation in commitment hearings at the State Hospital, and meeting with the consumers to identify their goals and desires for community living. A variety of options are available to clients including CRRs, Personal Care Boarding Homes, and independent living with supports, which have been beneficial to individuals in both counties. Lycoming-Clinton MH/ID currently has five (5) beds procured at the Atlas/Coal Township Enhanced Personal Care Homes in Northumberland County. There is a CHIPP funded placement at Pahrtners for an individual who is both deaf and diagnosed with SMI. The provider for the proposed Residential Treatment Facility for Adults (RTF-A) continues to search for an approved location in the Bi-county area. This RTF will assist in meeting the diversion and step-down needs of this population.

Bi-county residents could benefit from the addition of a Long-Term Structured Residence (LTSR) as part of the array of residential options. Consumers within the State Hospital environment are on locked wards with a completely structured day. A small step to a structured environment upon discharge to the community could prove to be quite beneficial in easing this transition for many individuals. The LTSR can also provide a safety factor with a locked door preventing independent travel into community settings which a consumer may not be able to navigate safely or independently at the time of discharge. It would also allow individuals to be closer to family and local community supports. There are also individuals that have behavioral issues, arson histories, and are registered Megan’s Law offenders for whom finding housing options in the community is always difficult. 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 Hospital, as well as for diversion from the State Hospital system. Several individuals continue to be identified with the intention that once a location is established that an RTF-A will become a reality. Added civil beds are needed at Danville State Hospital to accommodate individuals found non-restorable to competency at Torrence 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. Individuals who could benefit from Intellectual Disabilities (ID) services are often placed on waitlists for services.