Collaborations Between Health Systems and Community-Based Organizations to Address Behavioral Health

Collaborations Between Health Systems and Community- Based Organizations to Address Behavioral Health

ASTHO conducted a nationwide environmental scan, looking at how healthcare delivery systems are partnering with community-based organizations (CBOs) on behavioral health issues. By completing this research, ASTHO plans to be able to analyze and encourage public health leaders to engage in partnerships with healthcare systems and their community partners. ASTHO produced a chart of state- by-state results, which led to this summary of early findings.

Early Findings

Role of public health: Slightly over half of the behavioral health collaborations involving healthcare delivery system and community-based organizations identified did not specifically mention public health involvement. A recurring role of state public health agencies is often as a funder or as a convener (e.g., leading waiver implementation and design, membership in advisory groups, and participation in strategic planning sessions). Local public health agencies are more often formally identified as partners and can provide data and information on local community health needs and priorities.

Activities: Common priorities across the scan of collaborations included activities that focused on:

1. Addressing the social determinants of health for individuals with behavioral health needs (32 partnerships identified): These addressed housing stability (10), employment support (4), interpersonal violence (3), transportation (2), food security and nutrition (2), jail diversion programming (1), educational attainment (1), and medication management assistance (1). 17 partnerships focused on managing healthcare provider referrals to CBOs for social services.

2. Community and public outreach (26 partnerships identified): These partnerships focused on reducing stigma and educating community members on Mental Health First Aid (18), offering family support and counseling (4), and building crisis stabilization centers (2).

3. Integrating and co-locating behavioral health and primary care services (20 partnerships identified).

4. Expanding access to community-based behavioral health treatment (16 partnerships identified): This category included partnerships that expanded the use of peer support works and community health workers (6) and supported the development of out-patient care clinics (4).

5. System-level and policy changes (12 partnerships identified): Partnerships focused on data- sharing between sectors (5); securing 1115 waivers to expand access to care and/or incentivize collaborations with CBOs (3); expanding the Medicaid SUD benefit package to meet ASAM criteria (2); and expanding coverage for residential services (1).

6. Care coordination for high healthcare utilizers (11 partnerships identified).

7. Expanding licensed and non-licensed healthcare provider training and education (5 partnerships identified) and training CBO social service providers to recognize mental health needs (2 partnerships identified).

Specific populations and behavioral health concerns: Many of these partnerships focused on addressing health-related needs among populations at risk for post-partum depression or substance use disorder, youth, high-emergency department utilizers, and low-income populations. The top ranked listing of specific populations is as follows: 1. Low-income population (19 partnerships identified). 2. Family units with general behavioral health needs (13 partnerships identified). 3. Emergency department high utilizers (11 partnerships identified). 4. Students (11 school-based partnerships identified). 5. Individuals with co-occurring chronic disease and mental health issues (7 partnerships identified). 6. Youth at-risk for suicide (7 partnerships identified).

Other specific populations identified include: older adults, individuals with severe mental illness, LGBTQ youth, veterans, justice-involved individuals and ex-offenders, individuals experiencing homelessness, refugees, and new mothers (with a focus on post-partum depression or substance use disorder).

Methodology

States were separated into each HRSA region and searched individually. To identify state examples, a list of search terms was developed, in addition to a list of resources containing compiled lists of examples. The search terms and additional resources used can be found below. Each identified example was broken down by the categories shown below (state, partners, issue area, depth of partnership, level of public health engagement, and source). This search was limited to publicly available information and may not include all relevant examples of behavioral health collaborations in each state.

Search terms included the following: Partnership(s), Collaboration(s), Engagement(s), Coalition(s), Council(s), Program(s), Mental health, Behavioral health, Hospital, Community-based organization (CBO), and Healthcare delivery system.

Criteria for inclusion: • Must involve a health system/hospital partnering with community-based organizations. Public health involvement is not a criterion. • Must address behavioral health (e.g., improving access to care, reducing stigma, public education, payment reform).

Existing resources: • American Hospital Association – Behavioral Health Community Collaborations • ASTHO Have You Shared Stories • ASTHO Opioid/Addictions Database • CMS list of Section 1115 Demonstrations • Kaiser Family Foundation Waiver List • Practical Playbook Find a Partnership Tool • State health agency websites; health plan and hospital system websites

Collaborations Between Health Systems and Community-Based Organizations to Address Behavioral Health

ASTHO conducted a nationwide environmental scan, looking at how healthcare delivery systems are partnering with community-based organizations (CBOs) on behavioral health issues.

State Partners Issue Area Depth of Partnership: Statewide or Beginning/ Level of Public Source 1 Sharing information regional ending dates of Health 2 Coordinating/ aligning services partnership partnership (if Engagement 3 Collaborating (shared staff or resources) available) 4 Integrating (connected programming, strategic planning, funding) Alabama WellStone, 2-1-1 Connects, WellStone is a statewide 1. Sharing information. Statewide. No dates Not involved. WellStone Resources Crisis Services of North behavioral healthcare provider provided. Alabama, Huntsville that partners with a wide range of Hospital, North Alabama organizations and agencies to Mental Health Coalition, share information and arrange Alabama Department of access to care. Mental Health, city government, and others. Alaska Fairbanks Memorial The Golden Heart Project is a 1,2. Shared information and Regional. No dates Not involved. Fairbanks Memorial Hospital, CBOs, public safety collaboration of Fairbanks collaboration of resources. provided but Hospital - Golden and corrections, Memorial Hospital and community initiated prior to Heart Project government, health care, partners to address chronic January 2013. business, and behavioral alcoholism to individuals in the health treatment. community. Alaska Juneau Alliance for Mental The Juneau Primary and 1, 2, 3. Colocation and sharing Regional. Launched Not involved. SAMHSA grants Health, Front Street Behavioral Health Care Integration information and resources. October 2015. (Award number Community Health Center Project aims to improve the health SM062217-01 and - (FQHC). outcomes for adults with SMI and 02) co-occurring SUD with a history of trauma; will integrate primary care in a behavioral health setting. Arizona Dignity Health/St. Joseph’s Under the CMS-funded 1, 2. Dignity Health is in the Regional. 2017-2022. Not involved. AHC webpage Hospital and Medical Accountable Health Communities alignment track that analyzes Center, local community model, Dignity Health will serve as gaps in services and aligns List of bridge service providers. a bridge organization (BO) that efforts across the broader organizations links Medicaid beneficiaries with community. community service providers to address health-related social 1

needs. The BO identifies and partners with clinical delivery sites, including behavioral health providers and hospitals. Arizona Mercy Maricopa Integrated Mercy Maricopa made strategic 1, 2. Solicited community input Regional Projects Not involved. Supportive Service Care (managed care plan), network and staffing decisions to and engagement, deliberately (Maricopa initiated April Expansion for state/county/city health expand housing and employment incorporated itself into the County). 2014. Individuals with SMI officials, community support services for individuals network of local organizations (Aug. 2017) stakeholders. with serious mental illness (SMI). working with individuals with SMI. Aetna press release Arkansas Not available. Not available. Not available. Not available. Not available. Not available. Did not find partnerships that meet these qualifications (e.g., partnerships between health systems; partnerships with CBOs around general transitional care, state initiatives, etc.) California Marian Medical Center, Partnership aims to improve 1. Collaborating to identify at- Regional. No dates MCAH is part of the Dignity Health Dignity Health Foundation, screening and treatment of risk mothers and create referrals provided. California Foundation Santa Barbara County postpartum depression through a for those with postpartum Department of Division of Adult Mental toolkit and web-based resource depression. Public Health. Health Services, Santa directory. Barbara County Maternal, Child, Adolescent Health Department (MCAH), County Education Office Child Development Health Linkages Program. California California Department of Piloting coordinated care 1, 2, 3, 4. Based on a Statewide. December 2015- Public health Whole Person Care Health Care Services, lead (medical, socioeconomic, collaborative leadership December 2020. driving force Pilots Snapshot (July entity (health or hospital behavioral health needs) for structure, sharing data across behind the 1115 2016) authority, public hospital, or Medicaid beneficiaries who have partnering entities, and waiver (Medi-Cal tribal health program), been identified as high utilizers. coordinating services across 2020) and is

public health, managed care sectors (including creating new implementing local health plan, mental health infrastructure and processes for pilots in several agency, public housing collaboration as needed). counties. authority, and at least two other community partners (including COBs, community clinics, and physician groups). California Imperial County Public The Accountable Communities for 1, 2, 3, 4. Aims to create shared Statewide. July 2016- Local public health California Health Department, Merced Health Initiative supports six local vision and goals, define a present. agencies are Accountable County Department of communities through grant backbone facilitator, and create grantees. Communities for Public Health, Be There San funding to create a prevention- an infrastructure for data- and Health Initiative Diego, Santa Clara County oriented health system. Dignity finance-sharing between (CACHI) Public Health Department, Health and Santa Clara are agencies and providers. Sonoma County Department focusing on trauma and violence, State Health Care of Health Services, Dignity and Merced is focusing on Innovation Plan Health/St. Joseph’s Medical cardiovascular disease, diabetes, Center. and associated depression. California Asian Americans for AACI worked with the Linkage Lab 1, 2. Developed a contract Regional. Initiated in Not involved. Linkage Lab case Community Involvement to contract with healthcare payers between AACI and different 2013. studies (AACI), Santa Clara Family and providers to deliver payers to deliver behavioral Health Plan, Santa Clara integrated primary care and health services (partnership County Valley Health Plan, behavioral health for patients with spearheaded by CBO). Physicians Medical Group of mild to moderate mental health San Jose. diagnoses at FQHCs. California Cottage Health, multiple Community Partnership Grants 1,2,3,4. Shared information, Regional. Grant program Not involved. Cottage Health: CBOs. are given to various organizations. priorities, and funding. added Community As part of the initiative-level behavioral Partnership Grants approach, grantees partner with health focus one or more community with the 2017- organizations for their program or 2018 cycle. Runs service. Grantees also receive through the evaluation support through present. workshops, peer-learning, and one-on-one technical assistance, all of which is intended to foster collaboration and alignment of goals and outcomes. 3

Colorado Banner Health (Hospital The North Colorado Health 1,2,3,4. Sharing information and Regional. No dates Local public health North Colorado operations), Banner North Alliance aims to build healthcare aligning activities; engage in provided but involved. Health Alliance Colorado Medical, enter neighborhoods that integrate strategic and collaborative runs through partner organizations Paramedic Services, physical, dental, behavioral projects. the present. Centennial Mental Health health, and social needs. Center, Colorado Access, Kaiser Permanente, North Range Behavioral Health, Northeast Behavioral Health Partnership, Sunrise Community Health (FQHC), Summitstone Health Partners, Weld County Department of Public Health and Environment, Weld County Department of Human Services, Northern Colorado Medical Society, United Way of Weld County, University of Northern Colorado. Colorado Grand County Rural Health The Northwest Colorado 1,2,3,4. Sharing information and Regional (Routt Roadmap spans Not involved. Northwest Colorado Network, Middle Park Community Health Partnership aligning activities; engaging in and Moffat 2012-2016. Health Medical Center, Mind aims to develop a regional joint strategic planning. counties). Springs Heath, Northwest network of care that includes oral Colorado Dental Coalition, and behavioral health, health Northwest Colorado Health, promotion, disease prevention, Pioneers Medical Center, and acute care. Routt County Department of Human Services, Steamboat Medical Group, Steamboat Springs Family Medicine, The Memorial Hospital, Yampa Valley Medical Associates and Yampa Valley Medical Center.

Colorado Montrose Memorial Montrose Memorial Hospital 1,2,3. Shared information and Regional No dates Not involved. Creating Effective Hospital, Montrose County helped organize two school-based aligned activities, funding, and (Montrose). provided but Hospital-Community School District, Center for health centers which offer mental staffing. initiated prior to Partnerships to Build Mental Health. healthcare for children onsite at 2016. a Culture of Health schools, overseen by hospital clinical practitioners. Connecticut Connecticut Children’s Connecticut Children’s Medical 1,2,3,4. The model includes Statewide. Initiated in Yes, the AHA: Case Studies: Medical Center, CBOs not Center’s Children’s Center for Care shared information, and a 2016. Connecticut Connecticut identified. Coordination (CCC) expanded in strong focus on care Department of Children’s Medical 2016 to focus on children with coordination with shared Public Health Center – Connecticut behavioral health concerns at risk resources and funding. funded the Children’s Center for because of poverty or other social statewide Care Coordination determinants of health. The CCC replication of this links families to community model with Help Me Grow resources, with a focus on technical National Center emergency department discharge. assistance from the The model has been replicated CCC. nationally through the Help Me Grow® National Center. Connecticut Hartford HealthCare, CBOs The Hartford HealthCare 1,2. Shares information and Regional No dates Not involved. Hartford HealthCare not identified. Behavioral Health Network coordinates services with (Hartford). provided. Behavioral Health connects children adolescents, community partners. Network and adults to community behavioral health services. The Network includes several initiatives with community partners including the Depression Initiative, Seven Challenges, and Stop the Stigma. Connecticut Middlesex Hospital, CBOs Middlesex Hospital is the 1,2,3. The program shares Regional Care teams Not involved. 211: Community Care not identified. convener of a Community Care information, coordinates (Middlesex developed in Team’s and Related Team (CCT), which launched a services, and shares staff. County). 2010; pilot Care Coordination for program to use Intensive Care program with Connecticut’s Managers, Peer Specialists and care managers Vulnerable CCTs to reduce ED visits related to began 2014. Populations behavioral health. The CCTs meet regularly to provide case management establishing a 5

relationship and providing direct or indirect care and referrals. Connecticut Connecticut Mental Health The Connecticut Mental Health 1,2,3,4. Shares information, Statewide. No dates The Connecticut Connecticut Mental Center, Connecticut Center collaborates with the coordinates and aligns services, provided. Department of Health Center Department of Mental Department of Mental Health & collaborates resources, and has Mental Health & Health & Addiction Services, Addiction Services and Yale. shared funding from the CMHC Addiction Services Yale University Department Foundation. is involved in of Psychiatry. collaboration. Delaware Christina Care Health Substance Use Disorder: 1,2. Hospital makes referrals to Regional. No dates Not involved. Project Engage System, Project Engage Collaborates with hospital staff to CBOs. provided. (does not list specific CBOs). connect patients with community- based substance use disorder treatment programs and other resources. Delaware Christiana Care Health The Perinatal Case Management 1,2. Hospital refers patients to Regional. Launched Funding for the Brandywine Systems, St. Francis Service program: A perinatal program. October 2017. program is Counseling & Hospital, Beebe Medical outreach program for opioid- provided by the Community Services Center, Brandywine addicted mothers. Delaware Division Counseling & Community of Substance Abuse Services. and Mental Health. Florida United Global Outreach Participants in the Transformation 1,2. Partners share information Regional 2009-present. Not involved. Florida Hospital (nonprofit), Florida Hospital Effort have grown from UGO and and align services. (Bithlo). Partners with the Orlando, Aspire Health Bithlo residents to a network of Bithlo Services, Bithlo residents, 100 organizations, including Transformation community health centers, Orlando’s Florida Hospital, which Effort and a network of 100 agreed to become an anchor organizations. partner in the effort in 2011. Project addresses the social determinants of health (e.g., building healthy, green housing and bus service routes; installing public water and sewer systems; supporting victims of domestic violence) and providing healthcare and behavioral health services.

Florida Baptist Health, Brooks The Jacksonville Hospital 1,2,3. Coordinate and align Regional 2016-present. Not involved. Jacksonville Hospital Rehabilitation, Mayo Clinic, Collaborative consists of five activities, staffing, funding for a (Jacksonville). Collaborative St. Vincent’s HealthCare, UF health systems in NE Florida who new program. Health Jacksonville, formed to conduct joint community members, community health needs National Council for assessments. The collaborative Behavioral Health. identified mental health as a top priority and began a Mental Health First Aid training program for members of the public. Florida Florida Hospital Orlando, With partners, the Florida Hospital 1,2,3. Coordinate and align Regional Implementation Local public health Florida Hospital Orlando Health, Aspire Orlando completed a tri-county funding and activities, share (Orange County plan runs 2014- is involved. Community Health Health Partners (formerly community health needs information. and Orlando). 2016. Plan Lakeside Behavioral Health assessment, identifying mental Center), the Orange County health as the second top priority. Department of Health, and The hospitals, with local public the Health Council of East health funding, will aim to Central Florida. increase access to care and decrease ED utilization through an Outlook Clinic. They will also provide financial support to the Mental Health Association of Central Florida and partner with FQHCs to support enhanced behavioral health services in East Orlando. Florida Halifax Health, Florida Halifax Health and its public health 1,2. Coordinate and align Regional Implementation County public Halifax Health Department of Health in and community partners activities, share information. (Volusia and plan runs 2017- health involved. Community Health Volusia County and Flagler completed a CHNA that includes Flagler 2020. Priorities report County, Florida Hospital East behavioral health priorities. The counties). Region, One Voice for hospital partners will increase bed Volusia, an Flagler Cares capacity, will submit two grant (local nonprofit proposals to coordinate care with collaborative organizations). local behavioral health partners, and implement four Dementia education events for the public.

Georgia New Horizons Behavioral New Horizons Behavioral Health is 1. Sharing information. Statewide. No dates Not involved. New Horizons Health, SAMHSA, Georgia a public nonprofit organization of provided. Behavioral Health Association of Community community-based behavioral Partners Service Boards, Georgia health care, offering a full range of Department of Behavioral mental health services, addictive Health, East Alabama diseases treatment and Mental Health Center, developmental disabilities NAMI, West Central Georgia programs, and it partners with a Regional hospital, Georgia wide range of federal and regional Peer Support Specialist organizations/agencies. Program, Georgia Parent Support Network, Georgia Mental Health Consumer Network, The Family Center of Columbus, United Way of the Chattahoochee Valley, others. Georgia The North Georgia The North Georgia Partnership for 1,2. Shares information and Regional. No dates Not involved. The North Georgia Partnership for Behavioral Behavioral Health is regionally aligns services. provided. Partnership for Health, Advantage, Avita focused system of care for Behavioral Health Community Partners, individuals with mental health, Cobb/Douglas Community SUD, developmental disability, or Services Boards, Highland co-occurring disorder. The Rivers Health, Lookout nonprofit partnership partners Mountain Community with behavioral health providers. Services, and View Point Health. Georgia Emory Brain Health Center, The Emory Healthcare Veterans 1,2. Share information and align Regional September Not involved. Emory Healthcare Warrior Care Network Program is a free comprehensive services. (Atlanta). 2015-present. Veterans Program (national), and community care and treatment program for Community partners providing wellness post-9/11 veterans service-related Connections Case and family support. conditions. Study Georgia Tanner Medical Center, local Tanner Medical Center developed 1,2,3,4. Tanner Medical is the Regional Initiated in Not involved. AHA Behavioral juvenile judges, state the Tanner Intensive Program for leading organization, but (Carrollton). 2003. Health Challenges in Department of Children and Behavioral Change, a partial partners work jointly on the General Hospital Family Services, Department hospitalization program with securing funding, sharing of Juvenile Services, school intensive outpatient treatment for resources, and sharing system, local publicly adolescent sex offenders. State information. 8

funded medical agencies partners and assist with transportation providers. case management. Central challenges are around adequate reimbursement and securing patient transportation. Hawaii United Healthcare Services, Under the CMS-funded 1, 2. United Healthcare Services Regional. 2017-2022. Not involved. AHC webpage local community service Accountable Health Communities is in the alignment track that providers. model, United Healthcare Services analyzes gaps in services and List of bridge serve as a bridge organization (BO) aligns efforts across the broader organizations that links Medicaid beneficiaries community. with community service providers to address health-related social needs. The BO identifies and partners with clinical delivery sites, including behavioral health providers and hospitals. Idaho Memorial Behavioral Health, Memorial Behavioral Health is the 1,2,3. Shared information, Regional No dates Yes, Sangamon Children’s MOSAIC Sangamon County Public lead agency representing the coordinated and aligned (Sangamon provided. County Public Project Health, multiple CBOs. community-wide collaboration services, and shared resources. County). Health Department that includes an integrated mosaic is a member of the of services, networks, and collaboration. informal organizations. Community partners provide an integrated mental health system of care that ensures children have access to high-quality services with a focus on early identification and intervention. Illinois Illinois Department of Expands Medicaid SUD benefit 1,2. Requires shared Statewide. July 2018-June Illinois Department 1115 Waiver: Illinois Healthcare and Family package to meet American Society information and coordination 2023. of Healthcare and Behavioral Health Services, hospital and CBOs of Addiction Medicine (ASAM) between hospital and CBOs. Family Services Transformation not specified. Criteria and expanding Residential submitted waiver. and Inpatient Treatment for Individuals with Substance Use Disorder.

Illinois Chicago-Cook Task Force on The Task Force convened to 1. Sharing information: Experts Regional Initiated around Led by the Cook Chicago-Cook Task Heroin, Cook County develop recommendations on from health systems and CBOs (Chicago and 2015. County health Force on Heroin Hospitals, University of community engagement, provided information and Cook County). department with Chicago Urban Health Lab, educating healthcare guidance to inform the task participation by the Chicago Recovery Alliance, professionals, data collection, force recommendations and Illinois Department Chicago Police Department, treatment, trafficking and report. of Health and Chicago Fire Department overdose reversal. Illinois Department and multiple CBOs. of Human Services. Illinois Sinai Health System Integrating behavioral health into 2. Unclear on partnerships with Regional Projects Not involved. Hospital-Community partnering with the community and primary care. CBOs (vs. general community, (Chicago). initiated in 2000 Partnerships to Build community on behavioral public education). through at least a Culture of Health: A health initiatives (exact Under the Rainbow Program: 2016. Compendium of Case CBOs unclear), provides child and adolescent Studies outpatient behavioral health services and has provided educational materials to parents and teachers.

Adult Behavioral Health Program: Engages faith-based networks and community organizations to increase access to care and education. Illinois University of Illinois (UI) The Better Health Through 1,2,3,4. Shared resources, data, Regional No dates Chicago University of Illinois Health Hospital & Clinics, Housing partnership provides staff (including nurses and social (Chicago). provided. Department of Health: Better Health Center for Housing & housing for individuals who are workers) and funding provided Public Health, Through Housing Health, Chicago Department chronically homeless with by the hospital. Chicago of Public Health, Chicago intensive case management Department of Department of Family and services, including mental health Family and Support Support Services. services. Services involved in partnership. Indiana The Jason Foundation, The Jason Foundation addresses 1,2,3,4. The Jason Foundation Statewide. No dates Not involved. The Jason Aurora Chicago Lakeshore youth suicide through educational and partner network providers provided. Foundation Network Hospital, Timberline Knolls. and awareness programs for operate affiliate offices. Providers of Affiliate adolescents, educators and Offices parents.

Indiana Indiana University Health (UI IU Health partners with 1.Publicly available information Statewide. Initiated in Not involved. Indiana University Health), CBOs not listed. community organizations focused indicates shared information 2015; runs Health: In the on improving the health of those with CBOs. through 2018. Community who suffer from behavioral health and substance abuse disorders. Iowa CHI Health Mercy Council The Transitions Program helps 1,2. Staff meet weekly to share Regional Fall 2014- Not involved. Council Bluffs Bluffs, Council Bluffs students ease back into traditional information and discuss student (Council Bluffs). present (runs Hospital, Schools Community School District. classroom settings after being progress. length of each Partner to Improve treated for mental health-related school year). Mental Health issues. Iowa Appanoose County Mental The Appanoose County Mental 1,2,4. Shared information, Regional Initiated in Not involved, the How a small town Health Coalition: Centerville Health Coalition, after conducting coordinated strategy and shared (Appanoose 2014. county provides found better ways to Community Betterment, a needs assessment, learned the funding from the county. County). funding. treat those with Central Point Services, county did not have adequate mental illness Mercy Medical Center- access to psychiatrists and had no Centerville and the on-call therapists. They now Appanoose County Sheriff's provide on-call therapists Department. available to the court, jail and emergency room. Kansas Neosho Memorial Regional The Neosho Memorial Medical 1, 2. Shared information and Regional. No dates Not involved. Creating Effective Medical Center, South East Center partners with South East coordination of services. provided. Hospital-Community Kansas Mental Health Kansas Mental Health Center to Partnerships to Build Center. coordinate care and provide a Culture of Health transitional care services for people with mental illnesses and expanded services to its home health organization. The medical center observed a reduction in inappropriate emergency room visits and hospital admissions from because of this partnership. Kentucky Eastern State Hospital Peer Through this partnership, NAMI 1,2, 3. Shared information, Regional. No dates Not involved. NAMI: Eastern State Program, NAMI Lexington. offers group support services, coordination of services, and provided. Hospital Peer peer support services, and a share facilities and resources. Program council to assist families and loved one at the Eastern Shore Hospital during visitation.

Kentucky Mountain Comprehensive MCCC partners are receiving a 1,2,3. Shared information, Regional (Pike September Local public health SAMHSA grant Care Center (MCCC), Big SMAHSA grant to coordinate and colocation, and coordination of County). 2015- involved. awards (Award Sandy Healthcare, Pike integrate services through the co- services. September number SM062225- County Health Department, location of primary and specialty 2019. 01) and Pikeville Medical care services in MCCC’s Center. community-based behavioral health center. Kentucky University of Kentucky Under the CMS-funded 1, 2. University of Kentucky is in Regional. 2017-2022. Not involved. AHC webpage Research Foundation, state Accountable Health Communities the alignment track, so the Medicaid, CMS, community model, University of Kentucky will bridge organization will use service providers. serve as a bridge organization (BO) funds to direct beneficiaries to List of bridge that links Medicaid beneficiaries existing community resources, organizations with community service providers as well as analyze gaps in to address health-related social services and aligns efforts across needs. The BO identifies and the broader community. partners with clinical delivery sites, including behavioral health providers and hospitals. Kentucky Four Rivers Behavioral Four Rivers Behavioral Health in 1,2,3. Shared information, Regional No dates Not involved. Four Rivers Health, Baptist Health cooperation with Baptist Health coordination of services, and (McCracken provided. Behavioral Health Paducah, McCracken County Paducah provides shared staff and facilities. County and Specialized Children’s Schools, Paducah City on-site counseling to students and Paducah City). Services Schools, other county school staff at local schools. The goal is to systems. reduce absenteeism by each school clinic having a certified behavioral health counselor on- site for behavioral health issues such as stress, anxiety, depression, and substance abuse counseling. Louisiana Louisiana Behavioral Health The partnership is an umbrella 1, 2, 3, 4. Administrative Statewide. Community Spearheaded by Louisiana Behavioral Partnership: Magellan behavioral health managed care integration, service delivery forums began the LA Department Health Partnership Health Services, Louisiana program, that started as a redesign, resource-sharing. December 2011. of Health; Community and Department of Health, coordinated system of care for Implemented in however, Magellan Provider Forum community organizations children and was then broadened March 2012. serves as the and individual community to include adult mental health Statewide Louisiana Behavioral members. services and addiction services. Management Health Partnership Organization. overview slides

Maine St. Mary’s Health System, In Lewiston-Auburn, Maine, St. 1,2,3. Shared information, Regional No dates Not involved. AHA: Hospital- Central Maine Medical Mary’s Health System partners aligned programming, aligned (Androscoggin provided, but Community Center, Healthy with several CBOs through it’s strategies, and connections to County). partnership Partnerships to Build Androscoggin, B Street “Culture of Health” program to resources. founded prior to a Culture of Health: A Health Center. improve identified unmet need, 2016. Compendium of Case with a focus on behavioral health. Studies (Aug. 2017) Central Maine Medical Center, a hospital, works closely with St. Mary’s on Tri-County Mental Health Services and other behavioral health initiatives. Healthy Androscoggin, a community coalition, helps identify needs and find partners to address needs including related to youth substance use and alcohol use. B Street Health center links patients to mental health providers and other wraparound services. Maine MaineHealth, CBOs (not MaineHealth Behavioral Health 1,2. The program shares Statewide. 2010-present. Not involved. MaineHealth: identified). Integration Program: Provides information and coordinates Behavioral Health training and materials to primary and links individuals to Integration Program care offices throughout the community-based behavioral MaineHealth system, including health services. Maine Behavioral Healthcare. The integrated care team links patients to specialty behavioral health services in the community. Maine Acadia Hospital, National This collaborative identifies 1,2,3. Shared information, Regional 2015-present. Not involved. AHA: Acadia Hospital Alliance of Mental Illness inmates at risk for suicide, and coordinated strategic alignment, (Penobscot - Penobscot County (NAMI) Maine, Penobscot trains law enforcement to and programming. County). Jail Diversion Sheriff’s Office. intercept people with mental Program illness and send them to partner agencies and emergency departments. Partnerships also include the judicial branch, probation officers, state mental 13

health leaders and peers in recovery. Maryland LifeBridge Health, Sinai Perinatal mental health: The Sinai 1,2. Hospital-based and -led Regional Initiated in the Not involved. AHA: Hospital- Hospital, and the Baltimore Hospital Perinatal Depression initiative. Communities inform (Baltimore). 1990s. Ongoing Community Perinatal Mental Health Outreach Program is designed to CHNAs and identified behavioral at least through Partnerships to Build Professional Study Group. help women understand emotions health as a priority area. 2016. a Culture of Health: A that accompany pregnancy and Compendium of Case the post-partum period and Studies (Aug. 2017) promotes educational opportunities for maternal mental health practitioners. Maryland Bon Secours Hospital and Mental health support groups for 2,3. Hospital coordinates/aligns Regional Initiated in Not involved. Maryland Hospital National Alliance for the families: Bon Secours Hospital services and provides space that (Baltimore). 2016. Association: Mentally Ill (NAMI) facilitates a partnership with is used for NAMI family support Behavioral Health Metropolitan Baltimore. NAMI Metropolitan Baltimore, groups. Task Force who provides family support Environmental Scan groups for relatives of mentally ill (Jan. 2017) patients. Maryland The Partnership for a Peer Recovery Support Services: 1,2,3,4. Carroll Hospital and Regional (Carroll Initiated in Formal partnership Maryland Hospital Healthier Carroll County, Provides support for people Carroll County Health County). 2016. between hospital Association: Carroll Community College. recovering from SUD and/or Department have a formal non- and county health Behavioral Health mental illness. profit partnership (The department. Task Force Partnership for a Healthier Environmental Scan Operation Save a Life: Free Carroll County). (Jan. 2017) training to teach how to administer naloxone. The Partnership for a Healthier Carroll Mental Health First Aid: Free County (Apr. 2018) training to teach community members to identify symptoms of Mental Health First a mental illness or crisis and Aid connect them to appropriate resources. Hospital and health department responsibilities can be found here.

Maryland Health Systems: Bon SBIRT (Screening, Brief 1,2,3,4. Maryland SBIRT is a Statewide. Initial SBIRT Maryland SBIRT Secours Hospital, Mercy Intervention, Referral to statewide initiative sites Department of Medical Centers, Johns Treatment). administered and funded by the implemented Health and Complete list of Hopkins, MedStar, Maryland Department of Health 2010-2012. Behavioral Health partners University of Maryland Behavioral Health Ongoing to Administration Medical Center, Center for Administration. Hospitals and present. leads the initiative Children, Planned health centers provide referrals and provides Parenthood of Maryland, to CBOs. funding for School-Based Health initiative. Centers. Maryland Maryland Department of Expands Medicaid SUD benefit 1,2. Requires shared Statewide. January 2017- Maryland Maryland 1115 Health, hospital and CBOs package to meet American Society information and coordination December 2021. Department of Waiver: Assistance in not specified. of Addiction Medicine (ASAM) between hospital and CBOs. Health submitted Community Criteria. waiver. Integration Services (ACIS) pilot program

1115 Substance Use Disorder Demonstrations Maryland Druid Heights Community Healing Together: Preventing 1,2,3,4. Has a formal Regional BUILD Round 1 Local/city health Healing Together: Development Corporation, Youth Violence in Upton/Druid collaborative relationship (Baltimore City). grant awardees department Preventing Youth R. Adams Cowley Shock Heights: Addresses trauma and including integration of announced July involved. Violence in Trauma Center at the stress through case management, resources. 2017. Upton/Druid Heights University of Maryland preventive policing strategies, Medical Center, alternative discipline in Baltimore City Health community schools and trauma- Department. informed care in community schools. Massachusetts Riverside Community Riverside Community Partners, as 1,2,3,4. Shared information, Statewide. June 2018-June Involved through CMS: 1115 Waiver Partners (Brookline Center, one of MassHealth’s new aligns strategies and coordinates 2022. MassHealth, who MassHealth The Dimock Center, Behavioral Health Community care, and has shared funding selected Riverside Edinburg Center, Lynn Partners, is partnering with ACOs from being selected as one of Community Community Health Center, to provide specialty services and MassHealth’s behavioral health Partners as North Suffolk Mental Health care coordination. partners. partner. Association, and Upham’s Corner Health Center) and hospitals in Greater Boston, MetroWest, the North 15

Shore, and South-Central Massachusetts. Massachusetts AdCare Hospital, Alternative Central Community Health 1,2,3. Has a formal collaborative Regional No dates Not involved. Central Community Unlimited, Inc., The Bridge Partnership provides coordinated relationship including (Central provided. Health Partnership of Central Massachusetts, Behavioral Health and Long-term integration of resources. Massachusetts). LUK, Inc., Venture Services and Supports (LTSS) Community Service, Inc. Community Partner services. Massachusetts UMass Memorial, multiple UMass Memorial Community 1,2,3. Shared information, and Regional. No dates Not involved. UMass Memorial CBOs. Healthlink Behavioral Health and aligned care coordination with provided. Community Addiction Urgent Care department referral system to CBOs. Healthlink is an innovative approach to providing access to treatment for individuals experiencing a mental health crisis and/or addiction crisis. While the urgent care provides emergency services for behavioral health and addiction, the department provides referrals to other community behavioral health resources. Massachusetts Massachusetts General Revere Cares is a coalition 1,3,4. The coalition involves Regional 1997-present. The Massachusetts Massachusetts Hospital, multiple CBOs developed by Massachusetts shared information, shared staff (Revere). Department of General Hospital (schools, police, non- General Hospital. and integrated funding provided Public Health Revere Cares profits). by Massachusetts General provides grant Hospital and state and federal funding to the Revere Cares grants. coalition. Community Partners Michigan University of Michigan, Michigan Mental Health 1,2,3,4. Public-private Statewide. Initiated in Yes, the Michigan Michigan Mental Michigan Department of Integration Partnership (MIP): partnerships with provider 2005. Current Department of Health Integration Health Human Services Implements and evaluates organizations and community funding round Health Human Partnership (MDHHS), CBOs not programs to address behavioral organizations include sharing began Services (MDHHS) identified. health. information, aligning resources, September is leading the and funding. 2017. effort. Michigan Strong Beginnings (Healthy Strong Beginnings employs 1,2,3. Strong Beginnings shares Regional (Kent No dates Michigan Strong Beginnings: Start program), Kent County community health workers (CHW) information among partners and County). provided. Department of Strengthening Health Department, to meet with parents in the home shares and coordinates care. Health Human Families for a Heathy Spectrum Health, Michigan to offer social support, education Services (MDHHS) Start and encouragement, and is not directly

State University and behavioral health services involved, but the multiple CBOs. throughout their pregnancies and local health the first two years of their babies’ department is lives. The CHWs work with nurses involved (Kent and social workers and connect County Health families to needed resources. Department). Michigan University of Michigan Packard Health Center offers 1,2,3,4. Shared information, Regional No dates. Local Health Packard Health in School of Nursing, Packard integrated primary care and coordinated resources, and (Washtenaw Department - Partnership with the Health Center, Washtenaw behavioral health, with support shared staff. County). Washtenaw County University of Community Health from the University of Michigan Health Department Michigan School of Organization. School of Nursing. involved via Nursing Washtenaw Community Health Organization. Michigan Beaumont Health, Harry S. The School Wellness Program 1,2,3,4. Shared information, Regional. Initiated in Not involved. Beaumont Health - Truman High School. includes registered nurses and coordinated resources, and November School Wellness social workers who provide shared staff. 2011. Program at Harry S. mental health crisis counseling Truman High School and prevention education to adolescents. Michigan Michigan Department of The Capital Area Health Alliance 1,2. Shared information and Regional Initiated in Yes, the Michigan The Capital Area Health & Human Services, mental health partnership council shared goals of improving access (Clinton, Eaton, 2015; current Department of Health Alliance Barry Eaton District Health (MHPC) aims to increase the to behavioral health services. and Ingham strategic plan Health & Human mental health Department, Community number of individuals that access counties). runs 2017-2020. Services is a partnership council Mental Health Authority, behavioral health services member, along Ingham County Health (including mental health and with several local Department, Lansing substance use disorder services). health Community College, MSU departments: Barry School of Social Work, NAMI Eaton District Lansing, Peckham, Sparrow Health Department Health System, and other and Ingham County CBOs. Health Department. Michigan Henry Ford Health System Improve long-term health 1, 2, 3. Range of partnership Regional 2016-present. Involved in some Meeting the Health and Ruth Ellis Center (a outcomes of LGBTQ youth, using activities and shared planning, (Detroit). contracting. and Social Service Medicaid-contracted mental shared staff and space, multi- funding, and staffing. Program leaders Needs of High-Risk LGBTQ Youth in

health and social services source funding, and collaborative believe that more Detroit: The Ruth provider). planning and evaluation. consistent Ellis Health & contracts with the Wellness Michigan Center (2017) Department of Health and Human Services and public health entities will be important for the program’s sustainability. Michigan Mercy Health System The coalition works to reduce 1,2. Shared information and Regional No dates Not involved. Drug Free Muskegon (Muskegon), HealthWest substance use by sharing and coordination of services. (Muskegon provided. One County (Community mental health utilized joint data sources to County). initiative began services), local police effectively improve substance use as early as 2010. departments, schools, in the county. multiple CBOs. Minnesota The National Council, the Integrating tobacco cessation 1,2,3,4. Multisector work groups Statewide. Initiated in Yes, participated in ASTHO State Success National Behavioral Health services with mental health and and committees were October 2015. strategy sessions Story: National Network, Smoking Cessation substance abuse services. developed to form a state action that developed Council for Leadership Center, Multisector committees pledged plan; the Policy and Health multisector Behavioral Health Substance Abuse Mental to expand cessation training for Systems Change Committee workgroups and Promotes Tobacco Health Services mental health professionals. included health department committees. Cessation to Mental Administration (SAMHSA). Minnesota held a strategy session representatives, CBOs, and Health and Substance to develop an action plan and treatment facilities. Abuse Populations create subsequent committees to advance these policy changes. Minnesota HealthEast, Karen The Karen Chemical Dependency 1,2. Shared information and Regional (Karen No dates Not involved. Karen Chemical Organization, other CBOs Collaborative provides culturally coordination of services. community). provided. Dependency (schools, churches, etc.). and linguistically specific Collaborative treatment for refugees from Burma using drugs and alcohol. The program is informed by bi- monthly meetings including community leaders, healthcare providers, religious and spiritual leaders, interpreters, social workers, mental health specialists, 18

local law enforcement, evaluation specialists, and community health workers. Minnesota Hennepin County Health Hennepin Health, an Accountable 1,2,3,4. 1. Shares information, Regional 2012-present. Yes, the local Hennepin Health: A Department, Hennepin Care Organization, includes a coordinates services, (Hennepin health department Care Delivery County Medical Center, Coordinated Care Center, which collaborated on shared staff and County). – Hennepin County Paradigm for New Metropolitan Health Plan, operates out of the Hennepin integrated funding, strategic Health Medicaid NorthPoint Health and County Medical Center has an planning, and programming. Department, is one Beneficiaries Wellness Center, Multiple ambulatory intensive care unit, of the main four CBOs. providing primary care and partners. behavioral health services through multidisciplinary teams. Mississippi Mississippi State Hospital, Mississippi State Hospital, with its 1,2. Share information, Regional (Hinds August 2018- Not involved. Mississippi State Mississippi Association of partners, launched a pilot coordinate services and and Madison present. Hospital press Community Mental Health program to implement jail-based activities. counties). release Centers, Mississippi services in Hinds and Madison Department of Mental counties to reduce wait times for Health. inpatient behavioral health services. Mississippi UProot consists of over 90 Uproot is a collaborative effort to 1,2. Share information, align Statewide. 2014-present. State Public Health UProot priorities partner organizations assess and improve the health of activities. was the initial (including Mississippi Mississippians. These convener. UProot partners Hospital Association, Rush organizations were convened by Health Systems, Mississippi the Mississippi State Department Department of Mental of Health beginning in 2014 to Health and the State complete various components of Department of Health, and the State Health Assessment (SHA) CBOs. and the State Health Improvement Plan (SHIP). Priorities include increasing educational attainment to improve health and mental health, as well as building a culture of health. Missouri Missouri Department of The Community Mental Health 1,2,3,4. The program provides Statewide. November Not involved. Community Mental Mental Health, hospitals, Liaison program, part of the shared information, alignment 2013-present. Health Liaisons Community Mental Health Strengthening Mental Health of services, collaboration of staff Initiative, is led by the Missouri and shared funding provided by

Centers, law enforcement, Department of Mental Health. the Department of Mental courts, and CBOs. Through the program, 31 Health. Community Mental Health Liaisons work across the state to assist law enforcement and courts. Missouri Hospital and community The Bridges to Care and Recovery 1,2,3. The program includes Regional (St. 2013-present. Not involved. Behavioral Health behavioral health program was created in 2013 to shared information, aligned Louis). Network of Greater leadership, advocacy increase awareness and access to services, and shared volunteer St. Louis: Bridges to groups, and faith leaders. the behavioral healthcare system program participants. Care and Recovery in St. Louis. The program works closely with faith-based volunteers to act as community liaisons on the ground to build bridges to hospital and community resources. Program volunteers reported increased ability to assist those in crisis, educate and connect to resources, and reduce stigma. Montana Montana Healthcare Montana Healthcare Foundation is 1,2,3. Integrated and aligned Regional July 2018-2020. Local public health Funding opportunity Foundation, Bozeman providing grants that will bring services, planning, and (Southwest involved in announcement Health, Bozeman Health together a cohort of innovative information sharing. Montana). identifying Foundation, Community health care providers who will behavioral health Bozeman Health Health Partners, and implement integrated behavioral integration as a Foundation award Gallatin County Health health models and in so doing, community announcement Department. help to promote the more priority; unclear on effective use of existing resources scope of role in and the stronger alignment of new program. community partners. This initiative funds non-profit hospitals and clinics that provide primary care and are interested in incorporating behavioral health services. Nebraska Fillmore County Hospital, The Collaboration Committee, 1,2,3,4. The program involves Regional October 2015- Not involved. Bryan Health: Case Fillmore Central Public including the hospital and schools, shared information, coordinates (Fillmore present. Study – Hospital and Schools. integrate behavioral health into services, shared staff and County). school district 20

the school setting. School staff resources, and integrating partner for implemented a therapy referral funding from the Nebraska emotional health. process for at-risk students, Department of Education. connecting students with mental health professionals either at school or in the hospital, depending on needs. Nebraska University of Nebraska The University of Nebraska 1,3. Shared information, and Regional No dates Not involved. University of Medical Center College of Medical Center College of Nursing shared staff from the School of (Council Bluffs). provided. Nebraska Medical Nursing, All Care Health partners with the All Care Health Nursing students. Center Community Center. Center to provide physical and Partnerships mental health care. Nebraska CHI Health, Nebraska The Greater Omaha Healthcare 1,4. Shared information and Regional January 2018- Not involved. Omaha area health Medicine, Charles Drew Industry Partnership came integrated strategies. (Omaha). present. care organizations Health Center and together to find ways to ensure form partnership to OneWorld Community more access points to behavioral solve problems. Health Centers, Heartland health and better integrate Workforce Solutions, behavioral health into primary Omaha Public Schools, the care and improve the healthcare Greater Omaha Chamber of workforce. Commerce and Metropolitan Community College. Nevada Not available. Not available. Not available. Not available. Not available. Not available. Did not find partnerships between hospitals and CBOs. New Hampshire Hospital and healthcare The Building Capacity for 1,2,3,4. Regional IDNs share Statewide. May 2016- New Hampshire CMS: 1115 Waiver systems in each of the 7 Transformation waiver integrates information, coordinate and December 2020. Department of Building Capacity for regional Integrated Delivery physical and behavioral health and align services, collaborate staff Health and Human Transformation Networks. increases care coordination and resources, and have Services is leading CBOs vary by network. through 7 regional Integrated integrated strategic planning the effort. New Hampshire Delivery Networks (IDNs), a and funding. Department of coalition of providers, which Health and Human foster collaboration between Services: Building behavioral health providers and Capacity for community service providers. IDNs Transformation

each develop project plans with community input and receive incentive payments for performance on projects to increase integration across providers and community social service agencies. New Hampshire Cheshire Medical Center Behavioral Health Partner 1,2,3,4. The network shares Regional. March 2018- State involvement Cheshire Medical Dartmouth-Hitchcock, Network: The network aims to information, aligns strategies, 2021. not explicitly Center: Dartmouth- Monadnock Family Services, bridge gaps in communication makes cross-referrals among identified, Hitchcock: Phoenix House Keene between behavioral health partners, and has shared HRSA however, state Partnerships to Center, Monadnock Voices providers and agencies to create a grant funding. may be involved in reduce prescription for Prevention, and Keene model of cross-referrals among some capacity drug abuse Serenity Center. partners. The network was given HRSA grant established with funding from a funding. HRSA Office or Rural Health Policy three-year grant. New Hampshire Elliot Health System, Elliot Health System and Serenity 1,2,3,4. The organizations share Regional. Initiated in Not involved. Elliot Health System: Serenity Place. Place, with foundation funding, information, align strategies, August 2017. Elliot Hospital launched a SUD Medication make cross-referrals and have Receives Grant Assisted Treatment (MAT) and shared funding. Funding from the SUD ED project. The hospital Foundation for provides care coordination and Healthy Communities facilitates transitions to Serenity for Substance Use Place, a community-based Disorder and behavioral health treatment Medication Assisted agency offering inpatient and Treatment Projects outpatient substance use disorder treatment services. New Hampshire Frisbie Memorial Hospital, Frisbie Memorial Hospital and 1,2,3. The organizations share Regional. 2017-present. Not involved. Frisbie Memorial Rochester Community Rochester Community Counseling information, aligned strategies Hospital: Partnership Counseling. partner to increase access to and coordinate care. brings mental health mental health services through services to Rochester referrals, and care coordination. Transportation services will be available to eligible patients through Frisbie’s Patient Care-A- Van program. 22

New Jersey 49 hospitals participating in New Jersey’s DSRIP hospitals are 1, 2, 3, 4. Moving towards Statewide. 2012-2017. New Jersey DSRIP webpage DSRIP. 4 have a focus on focusing on improving care integrated primary, acute, Department of behavioral health (Bergen management for chronic behavioral health, and long- Health is leading CHCS blog on themes Regional Medical Center, conditions, including SUD. The term services and supports and this effort. from DSRIP states Kimball Medical Center, nine hospitals focusing on SUD involvement with community Monmouth Medical Center, are: 1) using electronic self- organizations as part of DSRIP hospitals St. Claire’s Hospital), and 5 assessment decision-support integrated health homes. have a focus on SUD (Capital tools, 2) creating integrated health Health Regional Medical homes for those with SMI, and 3) Center, Inspira Medical enforcing hospital-wide screening Center – Elmer and for SUD. Woodbury, South Jersey Health System, Trinitas Regional Medical Center). New Jersey Cooper University Health The South Jersey Behavioral 1, 2. Sharing information with Regional. 2013-present. The innovation Year 1 Final Care, Inspira Health Health Innovation Collaborative is CBOs and seeking input, collaborative was Collaborative Report Network, Kennedy Health, an initiative of five health systems contributing data across health formed in response Lourdes Health System, who joined aim to improve the systems, aligning efforts to to a 2013 tri- New Jersey Hospital Virtua, New Jersey Hospital quality, accessibility, capacity, and increase local capacity of county health Association website Association, Camden coordination of behavioral health behavioral health service assessment Coalition. services, including by assessing providers. collaborative Project fact sheet claims data and key stakeholder (made up of interviews with community-based hospitals, health providers and families to identify systems, and gaps in service. health departments in Burlington, Camden, and Gloucester counties). New Jersey United Way of Salem County The Live Healthy Salem County 1, 2. Centers on sharing Regional (Salem 2015-present. Local health The Live Healthy (lead), Salem County DHHS, Coalition members developed a resources and developing a County). department is a Salem County Southern Jersey Family Blueprint for Action to address community-wide behavioral contributing Coalition Medical Center, mental and behavioral health, health plan. partner. communities, Salem City SUD, and chronic disease and Blueprint for Action High School, Salem County obesity as priority areas for the Meals on Wheels, food local community. Goals include bank, Inspira Health developing a resource and 23

Network, Memorial Hospital recognition guide and sharing of Salem County, others. existing resources through community coalitions, as well as developing an educational campaign to reduce stigma and creating an online network service provider and referral system. New Jersey Jefferson University Jefferson University Hospitals 1, 2. Sharing information and Regional 2013-2015. Local and state Jefferson University Hospitals and community community health priorities coordinating efforts with CBOs; (Philadelphia). departments of CHNA partners (Pennsylvania include decreasing alcohol and however, specific roles are not health are listed as Department of Health, substance use (will explore identified and no effort to partners, but no Philadelphia Department of Alcohol Screening and Brief change partners’ activities or detail on scope of Public Health, Philly Rising, Intervention at its hospitals, share staff. role. Refugee Behavioral Health creating a city-wide database to Collaborative, Smokefree monitor ED patients who Philly, City health centers, frequently ask for narcotics, and more). support CBOs in reducing community violence through reducing gateway drug use among youths). New Jersey Hackensack University, Under the CMS-funded 1, 2. Hackensack is in the Regional. 2017-2022. Not involved. AHC webpage Camden Coalition of Accountable Health Communities assistance track, so the bridge Healthcare Providers, local model, Hackensack University and organization will use funds to List of bridge community service the Camden Coalition of direct beneficiaries to existing organizations providers. Healthcare Providers will each community resources. Camden serve as a bridge organization (BO) Coalition is in the alignment that links Medicaid beneficiaries track that analyzes gaps in with community service providers services and aligns efforts across to address health-related social the broader community. needs. The BO identifies and partners with clinical delivery sites, including behavioral health providers and hospitals. New Mexico Albuquerque Healthcare for The Supportive Housing Coalition 1, 2, 3, 4. This is a formal Regional No dates Not involved. Supportive Housing the Homeless, Albuquerque of New Mexico aims to reduce coalition with (Albuquerque). provided. Coalition of New Heading Home, NM homelessness and increase the member/supporting Mexico Solutions, Open Skies quality of life for people with organizations, a board of Healthcare, St. Martin’s directors, and staff. Funding partners 24

HopeWorks, Therapeutic behavioral health issues in New Living Services, UNM Mexico by creating Psychiatric Center, Local affordable, supportive housing in housing services, partnership with local developers, banks, communities and member foundations. agencies. New Mexico New Mexico Department of The State Innovation Model 1, 2, 3. Stakeholder group meets Statewide. 2013-December NM Department of NM State Health Health, Human Services Initiative for “A Healthier New regularly and represents 2018. Waiver Health is leading System Innovation Department, primary care Mexico” uses CMS funding to healthcare, academic, renewal in the effort. Plan (2016) providers, CBOs (not listed). integrate and coordinate governmental, consumer, and progress. behavioral health, public health, tribal communities. A CMMI letter on the and primary care to promote a “leadership team” of healthcare State Health System person-centered system and leaders and key stakeholders Innovation Plan engage with CBOs. Also aligns with will also lead efforts to maintain (2016) an 1115 Medicaid waiver effective and sustain the design. through December 2018. Centennial Care 1115 Waiver New Mexico New Mexico Medicaid Under the CMS-funded 1, 2. NM is in the assistance Regional. 2017-2022. This model aligns AHC webpage agency, Presbyterian Accountable Health Communities track, so the bridge organization with the NM Healthcare Services, local model, Presbyterian Healthcare will use funds to direct Department of List of bridge community service Services will serve as a bridge beneficiaries to existing Health’s health organizations providers. organization (BO) that links community resources (vs. the system Medicaid beneficiaries with alignment track that analyzes transformation community service providers to gaps in services and aligns work, although address health-related social efforts across the broader public health is not needs. The BO identifies and community). leading this model. partners with clinical delivery sites, including behavioral health providers and hospitals. New York New York State Department New York is pursuing a DSRIP 1, 2, 3, 4. This partnership Statewide. 2014-2019. The Department of OneCity Health of Health, OneCity Health program (known as OneCity includes several sub-projects Health is leading Performing Provider Performing Provider system Health or NYC Health + Hospitals) and hundreds of aligned CBOs the DSRIP program System partnership members (hundreds of to create a patient- and family- and health system partners and (umbrella agency CBOs, behavioral health centered integrated delivery was built on shared Community with both public Performing Provider providers, diagnostics and system that also addresses the Needs Assessments. health and System Network Lists treatment centers, long- social determinants of health and Medicaid). (DOH) term home health providers, engages with CBOs. The health centers, health Department of Health was Projects archive 25

comes, skilled nursing awarded five years of funding, and facilities, social service DSRIP is being implemented by 25 OneCity Health agencies, and community Performing Provider Systems, Overview (DOH) physicians). which each implements 7-11 projects that build integrated Challenges of delivery systems. Effective CBO Engagement discussion paper

CHCS blog on themes from DSRIP states New York 15 CBOs (Arab American The Connections to Care 1, 2. CBOs receive grant funds to Regional (New Initiated fall Local NYC RAND Evaluation of Association of New York, Partnership is a mayor-supported provide training for staff and York City). 2015. Department of Connections to Care Center for Employment three-year grant (2016-2019) that measure outcomes. health and Mental Opportunities, Red Hook, gives grants to 14 CBOs to train Hygiene is working Mayor press release Safe Horizon, Sheltering community-based social service with the NYC Arms Children and Family providers to recognize and begin Center for Services, Voces Latinas, to address clients’ mental health Economic more) and 15 mental health needs. Opportunity and providers (Mount Sinai Mayor’s Office to Adolescent Health Center, select grantees. NYU Lutheran Family Health Centers, University Settlement, Brookdale Hospital Center, others). New York The Weill Cornell Institute of The Weill Cornell Institute was the 1, 2, 3, 4. The WMH-Coalition Regional (New 2014-present. New York State Weill Cornell Geriatric Psychiatry, New founding partner of the have identified mental health York City). Office of Mental Medicine webpage York City Department for Westchester County Mental needs in the community starting Health (under on Working with the Aging, Department of Health Coalition (WMH-Coalition), in 2004 and have examined DOH) has funded Community Partners Community Mental Health, which includes over 30 agencies projects to integrate health, the coalition’s NAMI, Family Services of offering services or advocacy for mental health, and social work. Westchester (social service improved mental health among services for seniors. agency), St. Vincent Catholic older adults. Medical Center Westchester, WestMed, Burke Rehabilitation Hospital, and other community agencies. 26

New York Claxton-Hepburn Medical The River Community Wellness 1, 2, 3. Limited information on Regional. Initiated in Not involved. Connecting with Center, Fort Drum Program promotes mental health the logistics and roles within the 2013. Communities awards Behavioral Health and prevents substance abuse by: partnership. 2016 (page 22) Department, Upstate 1) providing an intensive Medical Center, Credo outpatient program that services 211 contact Community Clinic. active-duty military service information members suffering from post- traumatic stress, 2) supporting an outpatient behavioral health clinic for adults in the community, and 3) supporting a child and adolescent clinic in upstate New York. New York Bronx Partners for Healthy Nine-month high-intensity care 1, 2, 3. Nine-month pilot, Regional. 2017-2018. Not involved. SBH Health Blog Post: Communities, SBH Health coordination program targeting sharing and aligning staff and Expose CBOs to VBP System, Montefiore Medical high-utilizing patients with SMI resources; however, not a Arrangements Center (Bronx campus), who are precariously housed with permanent, integrated system. Visiting Nurse Service of care coordination services of non- New York, SCO Family of clinical professionals. Services, Riverdale Mental Health Association, four CBOs (not listed). New York Alliance for Positive Health, The AHI Health Home 1, 2. Requires shared Statewide. No dates Not involved. AHI Health Home Capital District Psychiatric Management Program is a information and coordination provided. Care Management Center, UVMHN Champlain partnership of primary care between service providers. Valley Health Network, providers, hospitals, behavioral Patient-Centered Northstar Behavioral Health health, and CBOs that connects Primary Care Services, Community community and social supports for Collaborative Maternity Services, Essex high-risk Medicaid beneficiaries webpage County Mental Health with HIV/AIDS, serious mental Services, Families First in illness, or two or more chronic CHCS issue brief Essex, Glen Falls Hospital, conditions in the North Country and more. and Adirondack Region. New York St. Joseph’s Hospital and Under the CMS-funded 1, 2. St. Joseph’s is in the Regional. 2017-2022. Not involved. AHC webpage Health Center, The New Accountable Health Communities assistance track, so the bridge York and Presbyterian model, St. Joseph’s and the New organization will use funds to List of bridge Hospital, local community York Presbyterian Hospital will direct beneficiaries to existing organizations service providers. each serve as a bridge community resources. The New 27

organization (BO) that links York Presbyterian Hospital is in Medicaid beneficiaries with the alignment track that community service providers to analyzes gaps in services and address health-related social aligns efforts across the broader needs. The BO identifies and community. partners with clinical delivery sites, including behavioral health providers and hospitals. New York St. Joseph’s Hospital, The Comprehensive Homeless 1,2,3,4. The program includes Regional No dates The local health Comprehensive Onondaga County Access to Nontraditional Clinical shared information, coordinates (Onondaga provided. department, Access to Department of Mental Experiences (CHANCE) program resources and staff, and shared County). Onondaga County Nontraditional Health, the Syracuse Rescue facilitates a connection between funding. Department of Clinical Experiences Mission, and the Salvation mental health services and the Mental Health, is a (CHANCE) Program Army. homeless individuals using partner. shelters. North Carolina Daymark Recovery Services, The Mobile Medication Program 1,3. Sharing information and Regional. Initiated April Not involved. News Observer: Rural NC Hospital Association. runs in two counties to visit resources. 2015. Programs Help behavioral health patients in their Spread Mental homes to teach them to manage Health Care medication. Hospitals partner with community programs to improve healthcare North Carolina 17 hospitals in western NC, WNC Healthy Impact is a 1,2. Sharing information and Regional 2011-present. Local public heath - Hospital Community local public health agencies, partnership among hospitals, coordinating services. (Asheville). 100 percent of Partnerships Case other community partners public health agencies, and public health Study Compendium (not listed). regional partners in the western agencies and part of the state that aims to work hospitals in WNC Health Network together to assess health needs western North and build collaborative plans. Carolina are Behavioral and mental health are collaborators. priorities. North Carolina Community Health Partners, Community Health Partners is a 1,2. Sharing information and Regional Initiated in July Local public health Community Health Local health departments, community-based Medicaid coordinating services. (Gaston and 1998. is involved. Partners hospitals, and CBOs (not managed care entity in Gaston, Lincoln listed). NC. It collaborates with local Counties).

health departments, hospitals, and community organizations to delivery care management, transitional care, and behavioral health integration. North Dakota Mercy Medical Center, Mercy Medical Center created a 1. Sharing information. Regional No dates Not involved. North Dakota North Dakota Addiction coalition to represent addiction (Fargo). provided. Addiction Treatment Treatment Providers treatment needs of the region to Providers Coalition Coalition (consisting of state legislators and payers, public and private spurring passage of legislation to AHA Practical Help organizations - unlisted). cover residential services. for Hospital Leaders North Dakota FirstLink (referral source FirstLink offers a Suicide Follow-up 1. Sharing information. Statewide. Initiated 2016. North Dakota RuralHealthInfo – that lists community Program in which individuals who Department of Rural Hospital resources and support expressed suicidal ideation receive Health is a Innovations groups), North Dakota State additional support and learn collaborator. Hospital, North Dakota about community resources. This Department of Health, St. program is offered in clinics and Alexus, Cavalier County hospitals across the states. Memorial Hospital, Southwestern and Upper Missouri District health units, Elgin Community Clinic, and other medical centers. Ohio Cleveland Clinic Hospital, By partnering with community 1,2,3. Shares information, Regional Initiated 2016. Not involved. Children’s Hospital CareSource, Community mental health agencies and coordinates and aligns services, (Cleveland). Association: mental health agencies and CareSource (a Medicaid MCO), and collaborates to share staff Achieving Population organizations. Cleveland Clinic integrates mental and resources. Health Through health care to primary care Mental Health offices, coordinates care and Integration streamlines referrals, and allows case management as necessary. Ohio State leads: Ohio Hospital Parity@10: A three-year campaign 1,2. Sharing information and Statewide. April 2018-2021. Not involved. Ohio Hospital Association, Ohio Council of to establish effective models to coordinating services. Association Partners Behavioral Health and enforce the Mental Health Parity with Stakeholders to Family Service Providers. and Addiction Act in 10 states, Address Behavioral including Ohio. Health Parity

National members: National Center on Addiction and Ohio Hospital Substance Abuse, Association members Partnership for Drug-Free Kids, Public Health Management Corporation. Ohio Cincinnati Children’s The MindPeace partnership 1,2. The mental health network Regional No dates Not involved. MindPeace Cincinnati Hospital, Hamilton County increases student access to mental established by MindPeace (Cincinnati). provided. Mental Health and Recovery health support, with a focus on shares information and Services Board, Community families that experience barriers coordinates services. Learning Center Institute, to access. MindPeace, school systems. Oklahoma INTEGRIS Health, Oklahoma INTEGRIS Health is partnering to 2, 3. OCCHD and INTEGRIS have Regional Initiated in Local public health INTEGRIS press City-County Health train community members to a coalition/workgroup that (Oklahoma 2016. leads a Mental release Department (OCCHD), not- recognize signs of mental illness worked together in training City). Health Coalition for-profit agencies. using a Mental Health First Aid community members. that includes OCCHD press release Curriculum. INTEGRIS Health and is a major partner. Oklahoma St. John Health System, Based on a CHNA, St. John aims to 1. Will share educational Regional (Tulsa). Fiscal years Not involved. St. John Health Mental Health Association improve capacity for humanized materials and information with 2017-2019. System of Oklahoma and other behavioral health crisis and acute community partners. implementation community partners, care through increased access to strategy (see page Oklahoma Department of health professionals throughout 55) Mental Health and Tulsa. (Will work with the mental Substance Abuse Services. health association to develop a community-level response program, as well as develop training resources for interested community organizations around suicide prevention). Oregon Project Access NOW, Kaiser In Project Access NOW C3 1,2,3,4. The collaboration Regional. Initiated in Not available – CHCS Case Study: Permanente, Providence Community Assistance Program, involves shared information, 2008. local public health Project Access Health and Services, six hospital systems and two coordination of care, shared often partners on NOW’s C3 FamilyCare, and Health coordinated care organizations staff and resources, and CCO activities and Community Share (CCOs). connect individuals in Portland, funding. management, but Assistance Program OR, to social services to ensure

safe discharge from emergency unclear on role in and inpatient settings. this project. Oregon Oregon Health & Science OHSU partners with several local 1,2,3,4. The collaboration Statewide. Not dates Not involved. Unity Center for University, Adventist Health, health systems and community involves shared information, provided. Behavioral Health Kaiser Permanente, Legacy partners to operate the Unity coordination of care, shared Receives National Health, CBOs not named. Center for Behavioral Health, staff and resources, and Honor which provides a coordinated funding. continuum of care for individuals Unity Center Partners experiencing a mental health crisis. Oregon Kaiser Permanente, multiple The Housing for Health behavioral 2,4. Alignment of services and Regional 2017-2020. Not involved. Housing for Health CBOs (not listed). health funding initiative provides strategy to address housing, and (Multnomah 2017-2020 funding and support to seven shared funding provided by County, Marion Behavioral Health CBOs including homeless shelters Kaiser Permanente. County, Lane Funding Initiative and other organizations to assist County). individuals with behavioral health disorders find affordable housing. Oregon Milwaukie High School, Milwaukie High School staff work 1,2,3,4. Shared information, Regional (North Initiated in Not involved. Building Sustainable University of Oregon Health with University of Oregon Health coordination of services, shared Clackamas 2015. Health and Education Sciences, Volunteers of Sciences' social work interns, an staff from MHU, OHSU and County). Partnerships: Stories America, other CBOs. alcohol and drug abuse counselor Volunteers of America, and From Local from Volunteers of America, a shared funding from the police Communities food pantry in partnership with department. the local food bank, and a dental hygienist office is in the school on a weekly basis. The District Attorney and Police Department support an on-site truancy program. Results of the program include: improved attendance and achievement in reading, writing, and math, and increased family engagement. Pennsylvania Hospital and Health System Addressing opioid addiction 1,2,3. Shared information, Regional. No dates Not involved. South Central PA Association of Pennsylvania, through: coalition building, coordinating/aligning services provided; Opioid Awareness Penn Medicine, PennState community education, provider and coordination of resources. ongoing. Coalition Health, Diakon Family Life education, changing organization

Services, Elements practices and building individual Behavioral Health, knowledge. Geisinger, Keystone Pharmacy Purchasing alliance, County of Lancaster, Lancaster Medical Society, Lancaster Health Center, Lancaster Pharmacists Association, Partnership for Better Health, Pennsylvania Recovery Organizations Alliance, OSS Health, Quality Innovation Network, Retreat Adduction Treatment Centers, Summit Health, TW Ponessa Associated, UPMC Pinnacle, WellSpan Health, The York County Medical Society. Rhode Island The Hospital Association of The Campaign to Change Direction 1,2. Shared information and Statewide. May 2018- State public health Rhode Island Change Rhode Island (HARI), Rhode is a national public health initiative aligned strategic priorities. present. is a partner. Direction on Mental Island Department of Health that aims to change the culture of Health (RIDOH) and Department of mental health so that all in need Behavioral Healthcare, receive the care they deserve. The Developmental Disabilities initiative is championed by and Hospitals, CBOs (not Landmark Medical Center, a HARI listed). member hospital. The initiative includes a steering committee and community events. Rhode Island Care New England, The Care New England and The 1,2,3,4. The formal affiliation Regional December 2014- Not involved. Care New England: Providence Center. Providence Center formed a included shared information, (Providence). present. Care New England formal affiliation to address intensive care coordination, and and The Providence behavioral health from a whole share strategic planning and Center Approve person perspective in the clinical funding between organizations. Formal Affiliation and community setting. South Carolina Public and private agencies, The multisector Behavioral Health 1. Share information. Statewide. 2017-present. Not available. Behavioral Health organizations, and Coalition aims to improve Coalition 32

healthcare providers (not behavioral healthcare and achieve listed). mental health and wellbeing across the entire state. South Carolina Medicaid designated The Healthy Outcomes Plan (HOP) 1. Share information. Statewide. 2009-present. Public health is not Hospitals and hospitals, South Carolina is a model for individual hospitals involved; Medicaid Partners Hit Department of Health and to share ideas and best practices is leading. Milestone in Healthy Human Services, the Duke for improving care coordination Outcomes Plan Endowment, hospital for at-risk populations, including partners (including FQHCs, those with high healthcare mental health centers). utilization. South Carolina AccessHealth, partners (can AccessHealth is a statewide effort 1,2,3. Shared information, Statewide. No dates Local public health Access Health include hospitals, free that supports community-based coordinates and shares provided. is involved. initiative clinics, certified rural health networks of care, including resources and activities. clinics, community health connections to behavioral centers, physicians, healthcare. medication providers, behavioral health providers and local health departments – not specified). South Carolina South Carolina Department Through a $1 million 1,2,3. Unclear on specific roles, Regional 2018. Not involved. DMH grant programs of Mental Health (SCDMH- appropriation, SCDMH will work but share information and (Charleston). funder), Charleston with partners to develop crisis coordinating resources and community, Charleston- stabilization centers in activities. Dorchester Community communities. Discussions are Mental Health Center, law ongoing in other communities to enforcement local hospitals. expand this work. South Dakota Rapid City Hospital, Rapid City Hospital’s Community 1. Sharing information. Regional (Rapid Fiscal years Not involved. Rapid City Regional community partners. Health Implementation Plan City). 2017-2019. Hospital Community focuses on strategies to reduce Health stigma around mental health Implementation Plan issues and to refer individuals to community resources (e.g., create a community mental health asset map, partner with 2-1-1 helpline to create comprehensive list of resources).

South Dakota Sanford Health System, Sanford Health is partnering to 2. Aligning activities. Regional. 2016-2019. Not involved. Sanford Health DARE program, Alcoholics provide AA programs and Community Health Anonymous (AA). meetings in the community and Needs Assessments the DARE program in schools to reduce alcohol and drug use (based on community health needs assessment). Tennessee Mental health Cooperative, The Mental Health Cooperative is 1,2. Sharing information and Regional Fiscal years Local public health Mental Health Davidson County Jails, receiving Pre-Arrest Diversion aligning priorities and activities. (Davidson 2017-2018. is a partner. Cooperative in Metro-Nashville Infrastructure state grant funds to County). Davidson County. Government, Metro- create a behavioral health jail Nashville Health diversion program for those Department, Metro- struggling with behavioral health Nashville Police needs. Department, Davidson County Sheriff, Metro- Nashville General Hospital. Texas Bexar County Health Partners in the collaborative 1. Share information. Regional (Bexar No dates Led by the Bexar County Health Collaborative: UT Health support several projects, including County). provided. local/county public Collaborative Science Center, University the Youth Mental Health Advisory health agency. Health Center, Methodist Council, which meets monthly to Georgia Health Policy Healthcare, local public share resources and work on Center profile health, Baptist Health community mental health needs. System, San Antonio Clubhouse, The YMCA, Our Lady of the Lake University, Community First Health Plans. Texas Cook Children’s Health Care The Wellness Alliance for Total 1, 2, 3, 4. This is a formal Regional Initiated in Local public health Robert Wood System, Wellness Alliance Children’s Health (WATCH) of coalition with members, (Denton 2014. is a member of the Johnson Foundation for Total Children’s Health Denton County is a collaboration officers, and bylaws. County). coalition, but state Report of Denton County, medical of both public and private public health is not clinics, local public health, organizations working to increase involved. WATCH of Denton counseling centers, local awareness of and access to County school district, community children’s mental health services organizations, United Way. (through educational campaigns Coalition members among the public and providers). Strategic plan 34

Texas Texas Medicaid, UT Health Under the CMS-funded 1, 2, 3. Texas has grantees in Regional. 2017-2022. Not involved. AHC webpage. Sciences Center, Parkland Accountable Health Communities both the assistance track (where Center for Clinical model, three bridge organizations BO shares information, directs List of bridge Innovation, CHRISTUS (BO) will link Medicaid beneficiaries to community organizations Health Santa Rose. beneficiaries with community resources) and the alignment service providers to address track (where BO aligns broader health-related social needs. The community services). BO identifies and partners with clinical delivery sites, including behavioral health providers and hospitals. Texas Central Health, City of Central Health System partners 2. Central Health appoints three Regional (Travis No dates Not involved. Central Health Austin, Community Care with Integral Care, which is the board members to Integral County). provided. community partners Collaborative, Downtown local mental health authority. Care’s Board of Trustees. Austin Alliance, Funders Integral Care provides community- Integral Care (SAMHSA, HUD, St. David’s based prevention, assessment, Foundation), school and intervention for individuals in districts, police Travis County living with mental departments, housing health, SUD, or intellectual and authorities, Texas Council of development disabilities by Community Centers, providing crisis response, CommUnityCare. integrated care, residential treatment, and housing services. Texas Texas Health and Human Texas’ 1115(a) waiver (Healthcare 1, 2, 3. Regional healthcare Statewide. December 2011- Department of 1115 evaluation Services, community mental Transformation and Quality partnerships are multisectoral September State Health report health centers, regional Improvement) expanded Medicaid and have an anchoring entity 2016. Services regional healthcare partnerships managed care to statewide (lead healthcare provider public health Role of community (community medical coverage, shifted reimbursement typically). Members share in directors facilitate mental health associations, local to hospitals for uncompensated strategic planning, information- the regional centers in Texas government, academic care, and created a DSRIP sharing, recommending new healthcare Medicaid 1115 health centers, Department inventive pool for building community partners for partnerships, Demonstration of State Health Services, healthcare infrastructure and inclusion, etc. though a separate Waiver hospitals). collaborations, including with agency (TX HHS) is community mental health centers. the waiver lead. Waiver Overview and Background Resources; Regional Healthcare Partnerships 35

Texas Integral Care (local authority Integral Care provides integrated 1,2. Works with the community Regional. No dates Not available. Kaiser Health News: for mental health). care in Austin, Texas, who and partners to share provided. Texas Clinics Busting received coordinated mental and information and resources. Silos of Mental and physical healthcare services. Physical Health

Integral care Utah Intermountain Healthcare, Intermountain and partners 1,2,3. Shared priority setting, Regional 2013-present. State public health Intermountain Utah Department of Health, conducted a joint community information sharing, and (Sanpete, involved in the Healthcare: Idaho Department of Health health needs assessment, which activities. Sevier, Utah community health Improving and Welfare, local health identified opioid abuse and Valley, the needs assessments. Community Health departments, other depression as high priorities. Central Region, healthcare organizations, Worked with community partners and Dixie) but Behavioral Health and community partners (unspecified) to provide continuing to Network (schools, local mental health behavioral health visits to expand through authorities, community uninsured individuals (Behavioral 2019. health centers, and CBOs). Health Network) and fund and implement 42 new suicide prevention programs in schools. Utah Sanpete Valley Hospital Sanpete Valley Hospital launched 1,2,3,4. Share information, Regional 2014-present. Not involved. Community (critical access hospital), the Sanpete Behavioral resources, staffing, funding. (Sanpete Partnerships for church groups, school Community Health Network, County). Improving Behavioral districts, the Central Utah which offer grief support, resource Health Counseling Center, groups for parents, mental health behavioral therapists, First Aid classes, and periodic community leaders, and screenings, and many services are hospital staff offered at low or no cost to patients who qualify. Funded through a grant from Intermountain Healthcare. Vermont Vermont Agency of Human Expands coverage of behavioral 1,2,3,4. Share information, Statewide. July 2018- Not involved; CMS: 1115 Waiver - Services, hospital and CBOs health services including coordinate and align services, December 2021. however, the Vermont Global not specified community-based services. The collaborate staff and resources, Vermont Agency of Commitment to waiver allows improved care and have integrated strategic Human Services Health coordination and transitions from planning and funding. leads the initiative. residential and inpatient facilities to link with community-based services.

Vermont OneCare Vermont (ACO), OneCare Vermont partners with 1,2,3,4. Share information, Regional November Not involved. Cathedral Square: Howard Center, Supports Howard Center, a behavioral coordinate and align services, (Burlington). 2017-December Partnership with and Services at Home health organization, to deliver collaborate staff and resources, 2018. Howard Center Adds (SASH) at Cathedral Square behavioral health services at and have integrated strategic Mental Health Cathedral Square, an affordable planning and funding provided Clinician at Two Sash housing community. Mental by OneCare Vermont. Sites health clinicians will provide individual and group therapeutic OneCare Vermont support as well as participation in care-coordination and treatment OneCare Vermont planning. List of Hospitals

Howard Center Vermont University of Vermont The University of Vermont 1,2,3. Shared information, highly Regional. No dates Not involved. Advisory Board: You Medical Center, Community Medical Center partners with aligned coordination and provided. can partner to Health Centers of housing organizations, community alignment of services and transform housing Burlington, Champlain health centers and other CBOs. resources, and have integrated and health care for Housing Trust The hospital identifies ED patients strategic planning. the homeless. This at risk (often with behavioral AMC has – and saved health conditions), referring them $1.7M to outreach workers at community health centers and Champlain Community Health Housing Trust to coordinate Centers of Burlington affordable community housing. Champlain Housing Trust Virginia Valley Health System, The Northern Shenandoah Valley 1, 2. The groups share Regional May 2014- Not involved. Northern Winchester Medical Center, Substance Abuse Coalition has information and have a joint (Winchester present. Shenandoah Valley Winchester Police convened to implement an strategic and operations plan region). Substance Abuse Department, Northern educational campaign, installing Coalition Shenandoah Valley Drug Take Back Boxes, and Substance Abuse Coalition, improving access to a peer American Hospital and community members recovery network and transitional Association care. presentation Washington Harborview Medical Center The Gun Violence Initiative 1,2,3. The initiative shares Regional. Initiated 2014. Not involved. Community identifies hospital patients treated information, aligns services, and Connections: for gunshot wounds, making shares staffing of social workers. Harborview Medical referrals to social workers who Center 37

address high-risk behaviors. Following discharge, a case manager is assigned to patients to use evidence-based strategies with victims and their families, analyze the role of guns in victims’ lives, address mental health needs, develop strategies for conflict resolution and connect them to community resources. Washington University of Washington The intent of the program is to 1,2,3. The program shares Statewide. Initiated 2015. Not involved. Washington state Department of Psychiatry expand mental health services information, aligns services, and ranks No. 47 for and Behavioral Science, across Washington state by shares staffing of psychiatry mental health care, primary care clinics, school training psychiatrists to partner residents in a fellowship but UW has a plan to and community health with primary care doctors and program in integrated care. improve things centers, rural hospitals, and others in the community, like correctional facilities correctional facilities, and in the health care industry, like community health centers. Washington CHI Franciscan Health, The Prevent-Avert-Respond (PAR) 1,3,4. Shared information, Regional (Pierce Initiated 2015. Not involved. CHI Franciscan Health Catholic Health Initiatives, Mental Health Initiative is a shared staff of community County). Receives Funding for CBOs. community-based program to mental health director, and New Behavioral prevent mental health crises and integrated funding. Health Initiative respond to community members in mental distress. Funded by the Catholic Health Initiatives, the program will create a new position of a full-time community mental health director to lead the initiative. Washington Providence St. Peter The Providence Community Care 1,2,3. The program includes Regional. No dates Not involved. Providence Health & Hospital. Center provides a single point of shares information, aligned provided. Services Washington: access for a range of services to services, and shared staffing A new approach to street-dependent individuals. between CBOs who co-locate behavioral health CBOs co-locate their services and their services at the center. care offer long-term primary and behavioral health care, shelter options, resources to help clients 38

find food, clothing, jobs, and long- Providence term housing. In addition, the Community Care center offers functional services, Center including bathrooms, showers and laundry facilities. Wisconsin The Jason Foundation, The Jason Foundation addresses 1,2,3,4. The Jason Foundation Statewide. No dates Not involved. The Jason Willowcreek Behavioral youth suicide through educational and partner network providers provided. Foundation Network Health. and awareness programs for operate affiliate offices. Providers of Affiliate adolescents, educators and Offices parents. Wisconsin Children’s Hospital of Project Ujima is a multidisciplinary 1,2,3. Shares information, Regional 1996-present. Not involved. Case Studies Wisconsin, Project Ujima. collaboration addressing youth coordinates services, makes (Milwaukee). Children's Hospital of and adult violence in Milwaukee referrals to resources. Wisconsin - Project using individual, family and Ujima community intervention and prevention strategies. Camp Ujima is a summer day camp for violence-exposed youth. Wisconsin Southwestern Wisconsin Healthier Wisconsin Partnership 1,2,3,4. The program requires Regional (Iowa, 2016-2024. Local health Healthier Wisconsin Community Action Program, Program: community-based shared information, aligned Grant, Green department in Partnership Program Advancing a Healthier behavioral health program. The services, collaboration of Lafayette, and participating Wisconsin Endowment at Advancing a Healthier Wisconsin resources and integrated Richland counties are the Medical College of Endowment at the Medical planning through a shared Counties). involved in the Wisconsin, University of College of Wisconsin funds the implementation plan. program. Wisconsin Population Health program to focus on community- Institute. behavioral health. Initial funding supports developing In Iowa, Grant, Green implementation plans with a goal Lafayette and Richland of statewide improvement in counties: all seven regional behavioral and physical health. hospitals, five health departments, and other CBOs. Wyoming Ivinson Memorial Hospital, Ivinson Memorial Hospital created 1. Sharing information. Regional. No dates Not involved. AHA Case Studies: community members. a Suicide Prevention Community provided. Ivinson Memorial Forum, where mental health Hospital professionals and representatives

from local schools and community agencies share information with community members. Wyoming Cheyenne Regional Medical Cheyenne Regional Medical 1, 2. Sharing information and Regional. No dates Wyoming #OnTheMap – Center Behavioral Health Center works closely with coordinating activities/services. provided. Department of Behavioral Health Service, Medicare, Wyoming community partners to pilot a B- Health role is as a Services Department of Health, Well program in two PCMH in convener (connects Wyoming Behavioral Cheyenne and to implement a the partners to Institute, Wyoming State suicide prevention program. funding Hospital, law enforcement, opportunities). Community Action of Laramie County, the Comea Shelter, individual therapy clinics, vocational rehabilitation organizations, Peak Wellness Center.