River Region Human Services, Inc

Transformative Care Coordination (TCC) Project - River Region Human Services [RRHS] of Jacksonville, Florida Will Establish a Patient-centered Ccbhc Behavioral Health Home [the Transformative Care Coordination Project] for Enrolled Clients, Providing Integrated Primary Care and Evidence-based Behavioral Health Treatments, Stage-specific Interventions, Care Coordination, Psychosocial Skill-building and Wellness Activities, Case Management and Peer Supports, and Intensive Transitional Care. the Majority of Existing RRHS Clients in Treatment for Cod, Sud, and Oud Do Not Have an Identified Primary Care Provider and Lack Access to Integrated Treatment for the High Incidence of Chronic Disease and Co-occurring Psychiatric Illness They Experience. This Project Is Designed to Remedy This Significant Service Gap and to Improve Access to Care and Health Outcomes for an Under-served, High Risk Population of Adults and Children. Services Will Be Targeted to Populations of Focus Living in Jacksonville’s Urban Core, With a Total Population of 110,841 Persons, 76% of Whom Are African American. Twenty-seven Percent Have No Identified Primary Care Provider, 37% Live in Poverty, Over 45% Have Been Told They Have High Blood Pressure, 18% Have Been Told They Have Diabetes, 13% Report Binge Drinking, and 21% Have Delayed or Gone Without Healthcare Because of Associated Costs. Strategies to Be Used Include: 1) Implementation of an Integrated Care Clinic Staffed by Primary Providers, Health Educators, and Engagement Specialists, With Embedded Services Provided to Clinic Clients by BH Treatment Staff; 2) Universal Screening for and Assessment/diagnosis of Depression, Anxiety, Smi, Problematic Substance Use, and Traumatic Stress, and Assessment of Clients’ Readiness to Change; 3) Implementation of Care Coordination, Using Disease Registries for Chronic Health Conditions Such as Metabolic Disorder, Diabetes, Copd, and Hypertension; 4) Stage-specific Ebps to Address Co-occurring Substance Abuse and MH Disorders, Delivered at a Site Adjacent to the Transformative Care Coordination Clinic, and at Community Locations; 5) Implementation of an Intensive Transition Service, Using the Critical Time Intervention Model, for Clients Exiting Jail-based Sud Treatment and After Psychiatric Hospitalizations and Overdoses, With Outreach Case Managers Teaming With Treatment Staff to Assist Clients in Transition to Reduce Risks of Reoffending and Repeated Hospitalizations. Project Objectives Include Enrollment of 75% Existing RRHS Sud Treatment Clients in the Transformative Care Coordination Clinic as a Medical Home, Clinically Significant Reductions in Hypertension and Child/youth Traumatic Stress, Clinically Significant Improvement in Psychosocial Functioning and Social Connectedness, No 30-DAY Past Substance Use After 6 Months of Outpatient Treatment, No 30-DAY Past Arrests After 6 Months of Transition Services, and Reduction in Repeat Psychiatric Hospitalizations. a Total of 825 Unduplicated Clients Will Be Served Over 2 Years, With 300 Adults and 50 Children/youth Served in Year 1, and 400 Adults and 75 Children/youth Served in Year 2. the Triwest Group, an Experienced National Project Evaluation Firm, Will Conduct the Performance Assessment, Provide Consultation Regarding Achieving Ccbhc Certification, and Assess the Fidelity of Collaborative Care.