H79SM086890

Abbe Center CCBHC Project - In Linn County, IA, the Abbe Center CCBHC Project will implement strategies to engage individuals who are "at-risk" for readmission to the behavioral health inpatient. "At-risk" is determined by a hospital admission within the last year instead of utilizing more cost-effective community-based services due to lack of engagement, timely access to services, and/or understanding how to navigate the service system.

Current populations served are children and adults with mental illness, serious mental illness, serious emotional disturbance, substance use disorders, and co-occurring disorders. In 2021, Abbe Center served 8,351 individuals in these categories, estimating 5% "at-risk." Abbe Center CCBHC will serve 350 unduplicated individuals determined to be "at-risk" each year, for an unduplicated four-year total of 800 individuals served.

Nature of the problem: High incidence of people being readmitted to the hospital due to lack of engagement, timely access to services, and/or understanding how to navigate the service system.

Goal 1: Decrease inpatient behavioral health readmission rate for CCBHC clients by 25% by providing timely access to services, enhancing engagement and care coordination to individuals identified as "at-risk."

Objective A: Engage "at-risk" individuals and coordinate behavioral health services.
- By January 2023, 60% of individuals "at-risk" will receive outreach/care coordination.
- By April 2023, conduct a literature review and environmental scan for research-informed practices related to transitions of care.
- Based on literature review, use implementation science to evaluate at least one transition of care research-informed best practice by September 2026.
- By September 2023, the outreach team will facilitate connecting 75% of their eligible clients to a community-based or integrated health home program for longer-term support.

Objective B: Provide timely access to prescriber and community-based services.
- By September 2024, Abbe Center will expand an established urgent care track to include 24 hours per week availability for urgent timeslots in the clinic and through the access center.
- By September 2025, 50% of clients referred by outreach will be enrolled in community-based service within 15 days from referral.

Nature of the problem: Individuals have more risk factors than are being identified.

Goal 2: Increase comprehensive screening activities to ensure individuals receive the resources needed to maintain their health and well-being.

Objective A: Increase health screenings to provide more integrated care.
- By September 2024, increase primary care screening and monitoring by 50%.
- By September 2025, increase primary care services onsite by 25%.
- By September 2024, increase screening and referrals for substance use disorder by 50%.
- By September 2025, increase substance use disorder services onsite by 25%.

Abbe Center For Community Mental Health

THE PURPOSE OF THIS PROGRAM IS TO INCREASE ACCESS TO AND IMPROVE THE QUALITY OF COMMUNITY MENTAL AND SUBSTANCE USE DISORDER TREATMENT SERVICES THROUGH THE EXPANSION OF CCBHCS. CCBHCS PROVIDE PERSON- AND FAMILY-CENTERED INTEGRATED SERVICES.

93.696 - Certified Community Behavioral Health Clinic Expansion Grants

Division of Grants Management [HHS - SAMHSA]

Cedar Rapids, Iowa 524053811 United States

Single Zip Code

Certified Community Behavioral Health Clinic (CCBHC)– Improvement and Advancement Grants (SM-22-012)

Amendment Since initial award the total obligations have increased 300% from $1,000,000 to $3,999,952.