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PROJECT ABSTRACT SUMMARY Project Name: Western Lane Mobile Crisis Response (MCR) Western Lane Fire and EMS Authority’s Mobile Crisis Response Program (MCR) is the first rural 24/7/365 mobile mental health crisis response program in Lane County, serving 19,128 residents in rural and remote areas. The proposed SAMHSA grant project will increase MCR’s capacity by establishing rural best practices staffing, improving law enforcement diversion through jointly developed protocols for response without law enforcement and by MCR providing safe, voluntary transport, and improving protocols and outreach to address suicide mortality rates that are nearly three times higher than county average. MCR serves a 980-square mile remote area bound on the east by coastal mountain range and the west by the Pacific ocean. Census data shows the project population catchment area of 19,128 residents has a disproportionately high percentage of older adults, veterans, and children < 18 living in poverty. Communities in Western Lane are high need as indicated by known factors associated with rural health disparities and its impact on mental health, including remoteness, isolation, poverty, social support and stigma. Suicide death rates in MCR service area are nearly three times higher than county average which is higher than state average. Enhanced infrastructure is needed to address gaps. Project goals are to implement a new staffing model based on SAMHSA best practices for rural mobile crisis programs whereby staff are multi-role providing crisis response to 19,128 rural service area residents, conducting community outreach to frequent users, providing voluntary transport, and collaborating with out of area resources and subject matter experts to be the rural face of suicide prevention outreach to high need audiences in the service area -veterans, children, and older adults. Measurable objectives include achieving adequate staffing levels within year one and sustaining at 80% through the end of project period; creating joint protocols with law enforcement and first responder agencies for response without law enforcement accompaniment with year one, reducing law enforcement accompaniment by 50% within year one and 60% within city limits by year 3; on-boarding eight frequent users into the community outreach program in year one, serving approximately 12 discrete frequent users per year resulting in over 44 individuals over the 4 year project period; achieving 50% reduce in 911 calls and 25% reduction in law enforcement use in Year 1. Suicide outreach measurable objectives are to conduct 12 outreach activities to each targeted audience per month, reaching a 30%, 75%, 85% of school age children in years 1,2,3 respectively; 25%, 50%, 75% of area veterans in years 1,2,3 respectively; and, reaching 75%, 90%, 90% of older adults’ liaisons in years 2,3,4 respectively.

The Indiana Innovative Community Crisis Response Partnership will create a streamlined mobile crisis response that is culturally responsive and works for and with community members. This project will operate through the 988 system in the State of Indiana and pilot in three high-need counties: St. Joseph, Lake, and Sullivan. St. Joseph, Lake, and Sullivan Counties are all high need counties due to elevated poverty rates and minimal or absent mobile crisis response. These counties have different demographic indicators: Lake County being the most urban and largest with 498,558 individuals; St. Joseph County being mostly suburban and having a population of 79,806 individuals; and Sullivan County being mostly rural with a population of about 20,758 individuals. In Lake County, approximately 5.1% of the population are veterans and 9.6% have a disability. The racial and ethnic makeup of the county is mostly White (53.8%), followed by Black (24.4%), Hispanic (19.6%), two or more races (2%), and Asian (1.7%). Native American and Native Hawaiian residents make up less than 1% of the population. In St. Joseph County 4.9% of the population are veterans and 11.3% have a disability. The racial and ethnic makeup of the county is mostly White (71.8%), followed by Black (13.8%), Hispanic (9.1), two or more races (3.1), and Asian (2.7). Native American and Native Hawaiian residents make up less than 1% of the population. In Sullivan County, approximately 6.6% of the population are veterans and 12.3% have a disability. The racial and ethnic makeup of the county is mostly White (91.6%), followed by Black (4.9), Hispanic (1.8%), and two or more races (1.4). Asian, Native American, and Native Hawaiian residents make up less than 1% of the population (CDC, n.d.). All in all, these three counties represent diverse and high-need communities where need for mobile crisis services is imminent. Project goals include: 1) create and enhance mobile crisis teams using culturally and developmentally appropriate services, 2) Implement a streamlined system with dispatch functionality through 988 and post-crisis follow-up protocols, and 3) Prioritize the use of data and evidence-based practices and measurement. These goals will be measured through key performance indicators, and this data will allow for project evaluation to identify gaps in service, and community mapping of crisis-need. This project will pilot a streamlined 988 crisis response that will allow for investment into community mental health. With a streamlined system, from the initial crisis call to the follow-up protocols, fewer individuals will fall through the cracks, and more lives will be saved. This project will serve the entire constituencies of each county, a total population of about 599,122 people.

The City of Newark’s Community Crisis Response Partnerships aims to improve the City’s crisis response system by enhancing existing co-responder teams to effectively provide trauma-informed comprehensive community-based behavioral health crisis services to individuals experiencing mental health emergencies, including those who are homeless. The project is a collaborative effort of the City’s Office of Homeless Services (OHS), Office of Violence Prevention and Trauma Recovery (OVPTR), Newark Police Division (NPD), and Office of Public Safety, 988 Suicide and Crisis LifeLine Center and behavioral health care provider (Rutgers University Behavioral Health Care (R-UBHC)) and community-based organizations (Mental Health Association (MHA) and Bridges Outreach Inc (Bridges)). The project’s goals are to: 1. increase access to comprehensive community-based behavioral health crisis services across the City of Newark by enhancing the capacity of existing co-responder and mobile crisis response teams so that they are ready to respond within one hour of dispatch; 2. create a compassionate, caring, and culturally competent behavioral health crisis workforce equipped to safely diffuse mental health crises by increasing the racial/ethnic diversity of crisis responders as well as providing in-service evidence-based and cross-agency training opportunities; 3. enhance the responsiveness to homeless individuals experiencing mental health crises by increasing collaboration between Newark’s systems for crisis care and homeless services; and 4. create an integrated city-wide crisis response system across the care continuum by enhancing cross-agency collaboration through data sharing and formalized partnerships with community-based organizations, hospital emergency departments, crisis receiving, and stabilization programs as well as R-UBHC 988 Lifeline /crisis call center. The project’s objectives are: to hire three additional social workers to increase availability on co-responder teams at NPD precincts; recruit 100% racial and ethnic diverse crisis responders to deliver culturally and linguistically appropriate responsive crisis response services; provide evidence-based crisis intervention training to crisis co-responder social workers and NPD officers; provide group training and one-on-one coaching on self-care to OVPTR staff; incorporate homeless screening assessment tools and/or questions into the crisis hotline screenings; integrating a licensed clinical social worker into homeless outreach and engagement teams; provide monthly training to increase the knowledge of trauma-informed care and population-specific issues and challenges related to homelessness among OVPTR social workers, NPD officers, and Public Safety Telecommunications (PST)); educate OVPTR co-responder teams on homeless programs, resources, and services through annual and quarterly training co-led by community-based homeless service organizations; develop and implement protocols for partnering and coordinating project activities with OVPTR co-responder teams, NPD, Office of Public Safety, 911/PST, as well as the 988 and crisis hotline call center operated by R-UBHC; establish inter-departmental and external data sharing agreements; conduct a review of the crisis response and screening law to streamline local response and identify opportunities for early behavioral health intervention; develop and implement post-crisis follow-up protocols for all recipients of mobile crisis response services; create a visual crisis map of the local crisis systems; lead the development and implementation of collaborative community safety plans; and develop and launch a public and cross-agency communications campaign to increase awareness of the 988-call line. By 9/29/2026, the project anticipates screening at least 2,000 unduplicated individuals for behavioral health issues and training 1,113 professionals across the behavioral health crisis care system.

The West Virginia Bureau for Behavioral Health Cooperative Agreement for Innovative Community Response Partnerships Program will create mobile crisis response teams to serve adults, children and youth experiencing a behavioral health crisis in Kanawha County, WV. The dedicated support for the creation of these teams will propel the development of crisis services in WV allowing for greater coordination in the development of this program, alongside the rollout of 988, with local law enforcement resources and 911 Public Safety Answering Points. Progress made in the development of this program will be scalable and will influence and enhance the development of further teams across WV.

SAMSHA FY 2022 Cooperative Agreements for Innovative Community Crisis Response Partnerships Genesee Health System’s Abstract Summary This program will serve residents of Genesee County, Michigan with behavioral health care needs that experience acute crises and escalation of symptoms. Genesee County Michigan has a population of approximately 400,000 individuals. Residents of Genesee County have experienced varying levels of personal and environmental trauma from the Flint Water Crisis, an increase in community violence, and the lingering impact of the covid-19 pandemic. The intended goal of this project is to provide comprehensive mobile crisis care in Genesee County, increase jail and hospital diversion and improve access to mental health treatment, by ensuring adequate post-crisis care. The target population is those that are most under resourced in Genesee County, such as individuals who are uninsured or underinsured, veterans, and those that are most disconnected from midtown; which is also home to the county government, the majority of social service organizations, and the county hospital which is the region’s only Level 1 Trauma center. GHS has just launched a mental health co-response program in partnership with Genesee County Sheriff’s Dept. This program needs further development. One of the goals of this project would be to partner with the County 911 communications center to develop a mental health-specific dispatch code to flag mental health-related calls. Law enforcement will be utilized when a call comes through dispatch indicating there may be imminent safety risks. GHS has already began to work with 988 (miCal) to receive referrals for behavioral health crisis care. We aspire to use this avenue to further provide mobile crisis services. We anticipate these calls will come into GHS’s main phone line or directly to the urgent care itself. Staff will be trained to utilize a decision tree to indicate whether crisis calls warrant law enforcement co-response or simply a mobile crisis call. Goals include: Improved access to behavioral health services, improve the proper disposition of mental health calls, hospital/jail diversion, timely access to crisis services as well as enhancing Genesee County’s crisis continuum. GHS cannot independently accomplish the goals listed above. GHS currently works with mental health providers in the community through an existing provider network. Further, GHS has an existing Memorandum of Understanding with several local law enforcement agencies, as well as an established relationship with the Genesee County 911 Consortium. Given the geographic expanse of Genesee County, and the reported 5,000 mental health-related calls that come through the service center. There is a need to centralize the current crisis service offerings, as this fragmented approach, generally confuses community members and results in low service utilization and heavy dependence on law enforcement or the hospital emergency department.

Texoma Community Center (TCC) is the Local Mental Health Authority in North Central Texas bordering Oklahoma. TCC has forged collaborative relationship with the law enforcement agencies for the counties in this catchment area and propose to strengthen and expand that relationship and improve the full continuum of crisis care in this area. TCC’s Mobile Crisis Outreach Team (MCOT) has been operating since 2007 and has been involved with jail diversion activities since that year, but has also been expanding into cross-training, participated in the sequential intercept mapping, the 988 initiative and cross-site evaluations. TCC seeks to improve and expand those activities to reduce the burden on area law enforcement. TCC will use this grant to work with the City of Sherman to develop a co-responder program since Sherman showed to have the highest area of need, and to also work with other towns in this primarily rural area to work toward that same co-responder model for effective crisis response. TCC has the infrastructure to capture and report the essential data and has a proven history of highly successful metric compliance.

South Dakota's Rural Mobile Crisis Response project will demonstrate and evaluate innovative regional rural mobile crisis response approaches through dedicated staffing and coordinated supports for crisis care in partnership with three existing Community Mental Health Centers, providing infrastructure available to impact more than 115,000 South Dakotans residing in the three target geographic regions that presently have minimal to no mobile crisis response service availability. Each region will develop response and follow-up care protocols using a multi-tiered approach, relative to level of acuity of the individual in crisis, supported by existing crisis response resources and newly developed co-responder teams. South Dakota is uniquely positioned to capitalize on multiple strategic initiatives that, when working together, have the potential to significantly disrupt the current pathway for rural mobile crisis response services. By aligning ongoing workforce capacity building efforts around community health workers with recent telehealth capacity enhancements afforded to EMS services statewide, this project will complete the connection to appropriate regional response services delivered by local, qualified and trained behavioral health personnel. Dedicated staffing at the CMHC level will afford staff capacity and time to foster these partnerships. The project's goals center on demonstration of regional mobile crisis response and follow- up care, built on interagency partnerships across the continuum of care for dispatch, emergency response, crisis stabilization, referral to higher levels of care as needed, and follow-up services. Key staff will focus on the creation of evidence-based crisis response and follow-up protocols and define and implement crisis intervention training needs as needed to support implementation. Each region will have flexibility to define and solution opportunities that best meet the gaps in service across their catchment areas, with some opting to focus more on technological resources and others on creative workforce training and capacity building efforts. Each have the same vision: to develop and implement strategies for mobile crisis response services in rural/frontier areas that deliver the timeliest and most safe response for staff and individuals served alike. The program assessment is designed to collect information and monitor in a way that allows for continuous quality improvement at each stage of deployment, from which state and federal partners can learn from in what will hopefully be innovative, multidisciplinary, and collaborative response strategies that can be applied to other areas of the United States with similar geographic and service area challenges.

ABSTRACT Hennepin County 911 Alternative Mental Health Response Project (ALT) SAMHSA Community Crisis Response Partnerships Grant NOFO No. SM-22-016 Hennepin County Behavioral Health will implement a 911 Alternative Mental Health Response (ALT) pilot in Brooklyn Park, Minnesota. ALT teams consisting of a senior social worker and a community paramedic will respond to low-risk 911 behavioral health calls for service instead of BPPD officers, reducing disparities in justice system involvement for people with mental health disorders and connecting them to stabilizing mental health and social services. ALT teams will assess and respond to urgent behavioral health and medical needs at the scene and stabilize the person in the community or via voluntary transport to Hennepin County’s walk-in / drop-off behavioral health clinic. ALT will also work closely with BPPD’s existing embedded social workers to provide follow-up stabilization services. Over a 45-month implementation period, ALT teams will respond to 4,500 911 mental health calls, reducing the number of mental health calls currently responded to by BPPD officers by 95%, and perform an estimated 3,000 field assessments. The targeted benefits are a 30% increase in connections to stabilizing services for residents involved in 911 mental health calls and a 30% decrease in repeat 911 mental health calls. The lead applicant is Hennepin County’s Behavioral Health Division and the partnering applicant is the Brooklyn Park Police Department (BPPD). Additional partners include the Hennepin County Sheriff’s Office, which operates 911 dispatch, and North Memorial Health, a Level 1 Trauma Center that will provide the community paramedic. A Hennepin County 911 Mental Health Reform Task Force consisting of mental health and justice partners, youth and adults with lived experience of mental health disorders, and BIPOC residents invested in police reform will serve as the project advisory board. Brooklyn Park (population 86,478) is the fourth largest city in the Twin Cities, Minnesota metro area and part of Hennepin County (Minneapolis and its suburbs). It is significantly more racially diverse than the city of Minneapolis, with 60% of residents identifying as BIPOC (30% African American, 20% Asian, 5% Hispanic, and 5% as multi-racial or other identities). Twenty-four percent of residents are foreign-born and 9.2% percent have income below the federal poverty line (2020 US Census data). Brooklyn Park has the highest crime rate in Hennepin County, with 7,820 total crimes in 2020 (90 crimes per 1,000 residents vs. 59.7 for Minneapolis). Brooklyn Park also has over 300 group homes that serve people living with mental illness and/or additional disabilities in congregate care settings. Having police officers respond to 911 mental health calls is contributing to racial disparities in justice system involvement, increasing the potential for escalation, and failing to provide needed mental health, primary care, and stabilizing services. By dispatching ALT teams to 95% of 911 mental health calls in Brooklyn Park, the Hennepin County 911 Alternative Mental Health Response project will produce better outcomes for both public safety and residents with mental health disorders in Brooklyn Park.

In an effort to address the service gaps in the Crisis Continuum of Care, ICBHS proposes the establishment of the Mobile Triage Response Team (MTRT) program. The program will serve individuals experiencing psychiatric emergencies within Imperial County. The County of Imperial is located on the southern border of California and encompasses 4,175 square miles adjacent to the United States-Mexico International Border. The community is a primarily agriculture driven and is comprised of 17 population centers surrounded by 500,000+ acres of land dedicated to agricultural production. The awarding of the Community Crisis Response Partnerships grant would allow ICBHS to develop new mobile crisis response team that will address service gaps for individuals experiencing psychiatric emergencies within Imperial County, mitigate the unnecessary use of law enforcement, shorten response times within the community and further strengthen the continuum of care model. The MTRT program will bring increased service capacity by integrating an additional mental health professional staff that will provide crisis call de-escalation, respond to dispatch requests and provide continuum of care resources to individuals during post-crisis, follow-up. As part of discharge planning and post crisis follow up, the MTRT program will offer referrals to the ICBHS outpatient clinics, social services to secure health and safety net benefits, and provide client with supports to ensure there access barrier to services are mitigated. It is estimated this program will provide services to 150 individuals annually and 600 thought the lifetime of the project. The goals of MTRT include the following: Goal #1: Reduce the percentage of individuals requiring a 5150 application by emergency responders. Goal #2: Reduce the percentage of cancelled crisis response requests by community agencies. Goal #3: Increase community agency outreach, engagement, and education about behavioral health services. Goal #4: Decrease the number of clients transferred from the MHTU to an inpatient psychiatric hospital due to a psychiatric condition. Goal #5: Establish a behavioral health conscious approach to the joint response model and decrease the average response time for urgent condition requests.

535,000 individuals. Current services will be expanded to a second location and further strengthened by the addition of four clinical and behavioral health professionals. Call response rates and community resolved rates will be improved with capacity expansion. Residents in Montgomery County have a variety of compounding risk factors that place them at extreme danger for mental distress, mental illness, developing Substance Use Disorders (SUD), and experiencing unintentional drug overdoses. The Mayo Clinic identifies key risk factors that can increase risk of mental illness including stressors like financial issues stemming from lack of education or employment, chronic medical conditions, trauma including military combat or assault. According to the latest 2022 U.S. Census, Montgomery County has a poverty rate of 14.7% with that increasing to 29% in Dayton. This is exacerbated by a 9.5% high school dropout rate and a 12.6% unemployment rate for the county. Data USA reports that 7% of residents do not have health insurance and the county is home to over 38,800 veterans. Based on these statistics, risk factors for mental illness in the geographic catchment area are concerning for the Montgomery County Alcohol, Drug Addiction, & Mental Health Services (ADAMHS), elected officials, health care providers, and the community at large. Through expansion of services, the current 24/7 crisis care services will reduce call response times, increase the community resolved rate, decrease justice involvement, and train community members in crisis intervention. Fully staffed after March 2023, the response rate will remain or decrease from the current 20 minutes, significantly less than 1hour national goal; Increase the community resolved rate from the current 85% to 90% by year two; and implement updated referral policies in the first year. Within the first 90 days, an updated protocol for crisis care will be implemented. Evaluation services will be conducted by Wright State University who has been responsible for evaluating millions of dollars in grant funds.

The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) is seeking $750,000.00 in response to the FY22 Cooperative Agreements for Innovative Community Crisis Response Partnerships from the Substance Abuse and Mental Health Services Administration (SAMHSA). Following the SAMHSA someone to talk to, someone to respond, and somewhere to go model, ODMHSAS proposes to utilize project funds to support this overarching crisis infrastructure goal by addressing gaps in the state current mobile crisis team capacity within two of the most populous counties within the State of Oklahoma, Oklahoma County and Tulsa County. Mobile crisis response teams are a part of the Oklahoma Comprehensive Crisis Response (OCCR), which is a behavioral health crisis continuum of care, developed by the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS), serving individuals in the least restrictive means possible and prioritizing community-based diversion approaches to prevent the need for higher levels of care and to avoid unnecessary law enforcement and criminal justice involvement for people in behavioral health crisis. The ODMHSAS proposes the following project goals which complement the significant investments already made into building the capacity of Oklahoma to comprehensively address Oklahomans in crisis. ODMHSAS released RFPs to invest in a statewide network of 988 dedicated mobile crisis teams. These teams became operational statewide on July 5, 2022- in alignment with the 988 call center launch. Each region of the state has at least one team which operates 24/7 and meets the requirements of the RFP, which was developed to align with guidance provided by the SAMHSA Best Practice Toolkit. Additionally, ODMHSAS has invested in five additional flexible teams which can respond across regions to assist in surging or unanticipated demand. These flexible teams will begin operation in the late summer of 2022. The expansion of these mobile crisis team services within Oklahoma and Tulsa Counties are the focus of this project application. Goal 1: Increase the capacity of 988 dispatching mobile crisis teams in Oklahoma and Tulsa County. Goal 2: Provide ongoing technical assistance, training, and evaluation of mobile crisis teams. This project will support the investments already made including the purchase of a single, statewide 988 call center, two back up centers, expansion of technology, creation of emergency transportation, and expansion of community-based URCs and CCs.

Tropical Texas Behavioral Health (TTBH) is proposing to establish the TTBH-Edinburg Police Department (PD) Mental Health Unit (MHU) in Edinburg, Texas under the TTBH-Edinburg PD Community Crisis Response Program. The goals of this program are to increase the capacity of mobile crisis response teams while expanding access in high-need communities; increase collaboration to improve crisis stabilization in the community for adults, children, and youth; and improve equity in the continuity of care and post-crisis follow-up, including for those with suicidal ideation and/or a previous suicide attempt. This program will also benefit individuals in crisis, who come in contact with law enforcement, who may be appropriate for diversion from the justice system and into routine behavioral health care services. TTBH's target population are individuals residing in Edinburg, Texas in Hidalgo County. Our service area is designated High-Poverty Areas or Persistent-Poverty County. Based on the U.S. Census Bureau, Hidalgo county's poverty rate was 41.9% in 1990, 35.9% in 2000 and 23.9% in 2020. Edinburg has a poverty with a rate of 22.6%, an average rate almost twice of Texas at 13.4% and twice of the U.S. at 11.4%. The area is predominantly Hispanic population at 87.7%. Our population rate of individuals without medical insurance is 26.7%, higher than Texas at 20.8% and two and a half times higher than the U.S. at 10.2%. Challenges in our service area also includes identification as a Medically Underserved Area (MUD ID 1489644651) and a Health Professional Shortage Area (HPSA ID 7481397026) for Primary Care, Psychiatrist, Psychologists, Licensed Professional Counselors and Licensed Chemical Dependency Counselors by Health Resources and Services Administration (HRSA). The TTBH-Edinburg PD MHU will be a community-based, ride along-respond service model targeting the delivery of immediate screening, assessment, and brief intensive intervention services to adults and adolescents who may be experiencing a mental health crisis. Collaboratively, the team will identify the best approach to assist the individuals with the least restrictive methods. The MHU will engage in evidence-based techniques to promote effective strategies by law enforcement to identify and reduce the risk of harm to individuals with mental health crisis and to the public's safety. TTBH will provide triage services to individuals 24 hours per day 7 days per week, including holidays, for the purpose of gathering information to determine the need for further assessment and immediate treatment. Triage services will be provided by a Qualified Mental health Professional (QMHP), who has the capabilities to make appropriate clinical decisions to determine an appropriate course of action and to stabilize the situations as quickly as possible. The MHU intends to continue outreach efforts with community partners by forming a Mental Health Alliance to identify resources to appropriately serve the community. If awarded, this will be the first collaborative crisis responder team developed with the Edinburg P.D. TTBH proposes to serve 500 persons (as referred by police department: service calls) with an indication of behavioral health needs per year for a total of 2,000 persons for the four years of this grant. We anticipate that 60% of those service calls maybe suicide/crisis incidents requiring screening and from those incidents 90% will require assessment and treatment. This program will adapt the goals to increase the capacity of mobile crisis response in our community, increase collaboration to improve crisis stabilization of individuals in our community and to improve equity. Crises follow up services are provided to individuals who are not in imminent danger of harm to self or others but require additional assistance to avoid reoccurrence of the crisis event.

This project focuses on partnering with an Indian tribe to pilot implementation of Mobile Crisis Team (MCR) within a tribal community in Washington and document best practices to determine how the state can further support the expansion of tribal MCR teams. Additionally, this pilot will demonstrate the positive impacts and relief that Tribal MCR may have on the regional and statewide crisis system. As part of this project, the HCA identified the Tulalip Tribes (Tribes) as a partner to develop one 24/7 tribal MCR program.

Rockingham County Bridging the Gap Program Granite Pathways’ Safe Harbor Recovery Center (SHRC) provides peer recovery support Services (PRSS) primarily to residents of Rockingham County. The strength of this small RCO is amplified through close partnerships with a broad base of community-based resources that produce an increase in the level and quality of long-term recovery support. Solidifying collaborative relationships to provide fully integrated recovery supports is critical to achieve our goals to immediately assist individuals to achieve and sustain recovery, to achieve economic wellbeing, to impact the future course of substance misuse, and to mitigate the long-term effects on children of living with a parent with SUD. In NH, the biggest gap in service is encountered when individuals leave intensive treatment or correctional settings. While substance use disorder (SUD) is a chronic, relapsing disorder, “much of existing SUD care remains based in an acute care model that focuses on clinical stabilization and discharge, failing to address the longer-term needs of people in recovery. . .” 8 With a treatment dropout rate from intensive services and outpatient care varying from 30 to 60%, prescribed aftercare is not enough to keep people engaged. Varied, flexible Peer Recovery Support Services can play a key and integral role in bridging the gap between intensive treatment and working on recovery day to day. Our service array is intended to focus on developing recovery capital to build resilience and to address critical social determinant of health (SDOH) needs through assessment, wraparound support, and targeted care coordination. Expansion will also include evidence-based parenting education. Staff capacity will be increased to provide assessment of social determinant of health needs as an important enhancement to focused recovery support and targeted care coordination. Career planning and employment services will continue as a key component of the service array. Nonetheless, the need for a strong and formal network of community providers is greater than ever. If better articulated and structured, current inter-agency collaboration could come closer to achieving maximum impact. An effective resource network will increase the capacity of each entity to meet the needs of individuals with SUD and co-occurring mental health concerns. Using resources of this grant, we will convene a project Steering Committee to both oversee grant activities and to formalize collaborative community relationships. With a well-coordinated network, SHRC will be best positioned to help individuals achieve and maintain recovery. Our network capacity to offer a broader array of services at the necessary level of intensity to meet individual needs at every stage of recovery will be game-changing. We endorse harm reduction for those not ready to stop using substances. Through outreach and education, we initially try to simply reduce risks individuals face. Through relationships with community providers, we distribute Narcan, Harm Reduction Kits, and provide referrals for medical, mental health, SUD, sexual and domestic violence, housing, and food resources.

Phoenix House’s Brooklyn Community Recovery Center is proposing to implement an evidence-based program increase the prevalence and quality of long-term recovery support services for persons suffering from substance abuse disorders (SUD) and co-occurring substance use and mental disorders (COD) New York City by supporting the expansion, enhancement and delivery of recovery support services (RSS) as well as promotion of and education about recovery using art. BKCRC will serve a total of 450 unique individuals over the course of the performance period. A total of 100 individuals will be served in the first year; 150 in the second year; and, 200 in the third year. The proposed name of the project is Building Communities Of Recovery Through Peer Recovery Support Services And The Art Of Advocacy. The population of focus for the proposed project will be adults aged 18 years and older in recovery from SUD and COD within New York City, with a focus on Brooklyn The goal of the proposed program is to expand and enhance recovery support service capacity within New York City through the provision of peer recovery support services (PRSS) for persons with SUD and co-occurring COD and promote and provide education about recovery through art. The proposed project aims to implement and achieve activities that will support eight objectives required to achieve the project goal. The objective of the project are: (1) Objective 1: Provide PRSS to an additional 100 unique individuals in year one; 150 unique individuals in year two; and, 200 additional unique individuals in year 3; (2) Objective 2: Provide recovery support services (RSS) to an additional 100 unique individuals in year one; 150 unique individuals in year 2; and, 200 additional unique individuals in year 3; (3) Objective 3: Develop memorandum of understanding with regional and local harm reduction partners to provide harm reduction services to referred program participants by quarter one of the performance period; (4)Objective 4: Refer at least 20 individuals per year in need of harm reduction services to regional and local harm reduction partners; (5) Objective 5: Provide Opioid Naloxone Education and Distribution (OEND) to 25 program participants every year; (6) Objective 6: Host a yearly art festival in the fourth quarter of the performance period in collaboration with Friends of Recovery – New York and OnPoint NYC to educate the public about recovery and reduce discrimination and negative attitudes concerning people with addiction and in recovery, reaching at least 1,000 persons annually; (7) Objective 7: Develop a feature length documentary on recovery by quarter two of year 3 to educate the public about recovery and reduce discrimination and negative attitudes concerning people with addiction and in recovery, reaching at least 1,000 persons annually; and, (8) Objective 8: Provide access to peer recovery coach training for 20 individuals per year in efforts to increase the peer recovery specialist workforce in New York City.

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PROJECT ABSTRACT Project Title: Macon County Recovery Community Program The Community Health Improvement Center dba Crossing Healthcare (Crossing) is a 501(c)(3) Section 330 funded Community Health Center organization providing comprehensive primary and preventative medical services, nutrition services, outreach and enabling services, behavioral health services, substance use disorder (SUD) treatment including Medication Assisted Treatment, transitional housing, and recovery living, in Decatur, Macon County, in east central Illinois. Through this initiative, Crossing Healthcare and the Macon County Recovery Community (MCRC) seek to improve long-term recovery for persons with substance use disorder through purposeful supportive connections with peers in recovery, family and community education, and community-based collaborations. The population of focus includes individuals aged 18 and older with SUD and families of individuals with SUD. Demographics of the service area document increasing rates of heavy drinking and opioid use among adults of all ages, racial and ethnic groups, as well as pregnant women. Project goals include: Expand access to coordinated Peer Recovery Support Services for persons with SUD and their families to increase the likelihood of long-term sobriety. Increase the capacity of the catchment area to provide safe, healthy, family-like substance free living environments for persons in recovery. Increase family and community awareness of SUD and its long-term implications through the development of the Macon County Recovery Community. To achieve these goals, a formal peer recovery support program will be developed, with clients screened for unmet needs when entering the program and offered weekly recovery support services by trained peer recovery staff. The MCRC will work together to identify sources and services for addressing identified client needs. Monthly social events will be conducted with clients to promote meaningful connections and positive social interventions. The MCRC will also work to expand area-wide harm reduction efforts, provide SUD education to family members of persons with SUD, youth education at schools, and general community education. The project will also focus on expanding the availability of recovery housing in the community by partnering with two local landlords. Project partners in the MCRC including Crossing Healthcare, Baby TALK, the Empowerment Opportunity Center, Workforce Investment Solutions, and Project Read Plus. Together, the partners offer a menu of individualized, person-centered, and strength-based services for persons in recovery. Peer Recovery Support Services will be directly provided to 40 unique individuals in Year 1, 60 in Year 2, and 80 in Year 3, for a total of 180 persons. Moreover, over 200 persons annually will receive some type of SUD training and/or education services.

The Purpose of Recovery is applying to offer the Bridging the Gap to Recovery Program, a comprehensive array of recovery support services for vulnerable young people and adult men and women, family, friends and allies seeking support for substance use disorders in Orange County, California. Services will include evidenced and peer-based recovery support services, such as one-on-one recovery coaching, telephone recovery support, leadership/life skills training, harm reduction community collaboration and workshops, recovery support groups, family education, and sober social activities for 300 uninsured or underinsured high-risk individuals over a three-year period. These services will be offered to individuals transitioning from recovery residences, criminal justice settings, primary care settings, perinatal clinics, MARS/MAT, inpatient and outpatient treatment programs. This project also aims to increase access to family group support for 60 friends, family or allies of individuals with SUDs per year. The Purpose of Recovery (TPOR) is a nonprofit Recovery Community Organization (RCO) based in Anaheim and provides recovery support services for individuals and families facing challenges related to SUD and co-occurring mental health problems. As a grassroots, peer-led organization, TPOR’s staff and volunteers are composed of individuals with lived experience, including those in recovery, their family, friends and allies. Through this program, TPOR will mobilize resources within Orange County’s recovery community to increase the prevalence and quality of long-term recovery support from substance misuse and addiction by collaborating with regional and local harm reduction community partner efforts and providing educational programs to the community at large. Additionally, TPOR will host positive social activities, develop a Peer Leadership Council, and an annual Recovery Rally all designed to raise awareness and reduce stigma across the regions for an additional 1,000 people over a three-year period. Measurable goals include: enhancing recovery outcomes for individuals by 40%; improved SUD family communication by 40%; increasing positive association and referrals of peer recovery support services in the region by 40%.

Lighthouse Recovery Community Center (LRCC) is requesting funds to increase recovery capital and measure whether the changes engage and retain more peers in the recovery community thereby improving the infrastructure of long-term recovery support. LRCC will serve 50 adults annually at each location, 300 adults during the life of the project, affected by substance use over the life of the grant. The geographic catchment area is Manitowoc & Sheboygan County, Wisconsin and the population of focus are adults ages 18 and older who are affected by substance use and seeking to establish or maintain recovery. Goal 1: Reduce substance use and related health consequences by increasing the prevalence and quality of long-term recovery support from substance use. Objective 1a: LRCC will increase the delivery of unduplicated PRS services for 300 people by September 30, 2025 as measured by GPRA and monitored through the data dashboard. Objective 1b: LRCC will implement ongoing professional development for recovery coaches and/or certified peer support, educating a minimum of 19 peer providers each grant year, 57 total, by September 30, 2025 as measured by training logs and monitored through the data dashboard. Objective 1c: LRCC will increase the rate of PRS professionals retained in the recovery community from 30% to 45% by September 30, 2025 as measured by LRCC enrolled peer professionals and monitored through the data dashboard. Goal 2: LRCC will strengthen the connection between community agencies and the recovery community in an effort to destigmatize substance use disorders (SUD). Objective 2a: LRCC will establish a Recovery Resource Council that meets a minimum of eleven times per grant year to discuss service coordination across agencies, as measured by meeting minutes and monitored through a data dashboard. Objective 2b: LRCC will provide ten recovery education events to community businesses, service groups, or the general public by September 30, 2025. LRCC will track events through board meeting minutes recording event summary and monitor events hosted through a data dashboard.

McShin's Intensive Peer Recovery Supports (IPRS) will primarily serve persons with co-occurring conditions and a history of incarceration in their home communities upon release from RSW jail. This project will also focus on training the peer work force and provide on the job training opportunities for those who wish to become certified peers in Virginia. Finally, McShin will work with the certified harm reduction sites in the service area to assure access to peer supports and services.

The Phoenix will serve people by helping them overcome substance use disorder in Wichita, Kansas, providing recovery support services designed and implemented by peers in recovery; programs include fitness, wellness, and social events where staff and trained volunteer peer mentors will cultivate an environment designed to be fun, emotionally and physically safe, inclusive, and accessible. The only requirement for entry is 48 hours of continuous sobriety. All events are free to participants and open to individuals from all pathways of recovery. Some participants join The Phoenix’s programs after completing formal substance use disorder treatment, but others have never attended formal treatment programs. Some have participated in recovery groups such as 12-step programs and Recovery Dharma meetings. This project will primarily serve the Wichita metropolitan area, though some participants come from rural areas surrounding Wichita. Program activities include yoga, meditation, CrossFit, group fitness, arts, social events, and more. These events bring people together, but the core of Phoenix programs is the explicit focus on cultivating a psychologically safe environment where peers can gather in recovery to heal. This model was developed based on academic research around recovery capital. Phoenix programs encourage growth in five key areas of recovery capital that help individuals build the inner resources to stay sober and thrive in recovery. These five areas are connectedness, hope, identity, meaningful life, and empowerment. This first goal of the program — to increase the size and connectedness of the recovery community in Wichita through the provision of community-based activities to improve long-term recovery support — will be achieved by serving 1,300 individuals in year one; 1,950 in year two; 2,925 in year three; and a total of 6,175 participants in total during lifetime of the project. The second goal — to reduce the levels of stigma experienced by people with substance use disorder and those in recovery, as well as reducing stigma within the broader community, with the role of meaningful activity and social connection acting as a catalyst for positive change — will be achieved by hosting two or more large-scale events for families and supporters of people in recovery during each year of the grant award, for a total of at least six such events. Another objective in alignment with this goal is the formation of at least five new community partnerships with value-aligned organizations during the lifetime of the project. The third goal — to increase the number of volunteer peer mentors who will lead meaningful activities, improve connection amongst the people and places within the locale, and fuel the recovery movement in Wichita — will be achieved by recruiting, training, and activating 25 volunteer peer mentors in year one, 40 in year two, and 60 in year three, for a total of 125 new volunteer peer mentors during the lifetime of the project. This project will serve primarily serve adults in recovery from substance use disorder. The Phoenix provides an inclusive environment that welcomes people of all races, genders, and sexual orientations. Community standards prohibit any discriminatory language or behavior; all participants are informed of these standards at the beginning of every program event, and both staff and volunteer peer mentors help ensure adherence to the standards throughout. Phoenix events are free to anyone with 48 hours of sobriety, which helps reach people of all socioeconomic groups, ensuring that those living in poverty have access to high-quality recovery support programs. A secondary demographic that will be targeted is supporters and allies of people in recovery. This focus helps reduce stigma around recovery in the broader community.

Friends of Recovery of Delaware and Otsego Counties, Inc. (FOR-DO) will establish a Recovery Community Center (RCC) in Chenango County in a highly rural, under-resourced, and economically depressed area of New York State. The Recovery Center, to be known as "The Turning Point of Chenango County" will be centrally located in the county seat and serve at least 1500 unduplicated individuals over 3 years through providing evidence-based practices for recovery support services. The population to be served includes individuals 18 and up that reside in Chenango County, NY who are personally impacted by Substance Use Disorder(SUD) and/or addiction. The goal is: to significantly increase the availability of recovery support services that increase access, resources and retention in services for those impacted by SUD in Chenango County. Objective #1-operationalize a full-service Recovery Community Center in Chenango County offering a comprehensive spectrum of recovery support services within the first 4 months. Objective #2-to increase access to services and appointments with providers that address social determinants of recovery and wellness by 50%. Objective #3-to reach a total of 250, 500, and 750 unduplicated individuals in years 1,2, and 3 respectively. Objective #4-to decrease the number of people in recovery from SUDs from relapsing and maintain sobriety by 25%. Life skills education, recovery support services, peer support groups, social and recreational activities, and transportation will be offered weekdays, weekends, and nights. FOR-DO currently operates two recovery centers in counties neighboring Chenango County. The organization has ample experience and expertise in recovery services adapted to the rural region, solid experience in administering federal grants, and in-depth familiarity with the area and its referral partners.

The Coulee Council on Addictions, Inc. (dba Coulee Recovery Center) (further known as “CRC”) is requesting funding to expand the Recovery Support and Relapse Prevention programming by enhancing current programs based in La Crosse County, Wisconsin (WI.). With funding CRC would also have the opportunity to help five other counties in WI. and one county in Minnesota. Programming would increase Peer Support assistance in Recovery, Veterans programming and education and support for family members and friends of the individual seeking long-term recovery in predominantly rural counties. The programming would provide job opportunities for at least 15 additional Recovery Coaches/Peer Support Specialists, continuation of Veterans Program Coordinator and addition of a Recovery Support & Relapse Prevention Project Coordinator. Each of the counties included in this request are rural counties with decreased recovery support services. During the grant period, the Project Director would work to develop a Stakeholder-Peer Advisory Committee (SPAC) in each county that services are being provided. The purpose of the SPAC would be to function as a committee that meets quarterly to provide feedback, accountability for implementation and grant activities, sustainability and discuss more generally on topics related to peer support in all community settings in service delivery area. Over the last five years the amount of substance use disorder treatment services in La Crosse County, Wisconsin (“WI.”) and the surrounding counties has declined. Most specifically Mayo Clinic Health System in La Crosse, WI. eliminated their residential treatment services in the summer of 2019. This elimination reduced the amount of beds for residential treatment in La Crosse County by 50%. Waiting periods to see a clinical staff person can be up to eight weeks. Individuals who need in-patient or detox services must either go to other counties in Wisconsin, or even outside of Wisconsin. As many individuals benefit highly from detoxification or in-patient services, neither of these are offered in the La Crosse County area. When an individual departs the area to complete detox or in-patient treatment, they come back to the area to find a lack of ongoing services to aid in their recovery.

This project aims to embed diversity, equity and inclusive principles into the recovery-oriented system of care (ROSC), train and pay a stipend to a group of 10 Black, Indigenous, (and) People of Color (BIPOC) Recovery Coaches. The funding will enable the BIPOC Recovery Coaches to receive workforce development trainings that can help prepare them to take on a mentor role while also giving them skills to strengthen their recovery. The project has an overall goal to prepare BIPOC Recovery Coaches with skills that can help facilitate change with the members they work with; specifically, those in the black and brown communities. The diversity of the community we serve calls us to prioritize diversifying the recovery coach workforce. This goal will be completed by organizing topics that will be covered in the training, recruiting skilled trainers, and developing materials for the training. To ensure that this training/mentorship program has fulfilled the overall goal, evaluations will be conducted both during and after the program is complete.

FOCUS: Recovery and Wellness Community Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment (SAMHSA CSAT) Building Communities of Recovery (BCOR) Project Abstract The proposed project, Forging Forward in Recovery, will be led and implemented by FOCUS to expand and enhance peer recovery support services to individuals (18 years or older) in recovery from substance use or co-occurring substance use and mental disorders (COD), and their chosen families who live in rural areas that are considered transit deserts within Hancock County, Ohio. The project will also target outreach to subpopulations including individuals who are LGBTQ or non-binary, local college students, and veterans. Hancock County is a predominantly rural area with a population density of about 140 residents per square mile. Most residents are White, non-Hispanic/Latino (89%), about 6% are Hispanic/Latino, 2% are Black/African American. English is the most common language; 5% speak a language other than English at home. About 10% of Hancock County residents live below the federal poverty line. There are about 4,500 veterans (6%) who live the county (US Census Bureau, 2021). According to the latest local community health assessment, about 4% of residents identify as LGBTQ+ (Hancock Public Health, 2018). The goals of the proposed project are to: 1) enhance the organization’s capacity to implement and sustain evidence-based practices; 2) implement evidence-based practices that increase an individual’s recovery capital to decrease the possibility of relapse, re-admission to treatment, ED visits, arrest, overdose, or suicide; 3) increase awareness of and engagement in PRSS and RSS in rural/remote locations within the county; and 4) decrease stigma among local employers and educational institutions about people in recovery To accomplish these goals, the proposed project will expand training and workshop opportunities (e.g., Motivational Interviewing, Mental Health First Aid, self-care practices, CRAFT, WRAP, Battle Buddies, Recovery Guides, Narcan access) to a wide range of stakeholders including our Board of Directors, staff, volunteers, clients, their families and others in the community. The project will expand upon the skill-building activities such as the developing peer-led podcasts and peer-led photovoice projects. FOCUS will also enhance the linkages with existing resources to better coordinate RSS and other services (e.g., TANF, Medicaid, childcare, legal, employment, financial literacy, vocational services). This proposed project will reach at least 300 individuals per year (a total of at least 900) through the various programs, activities, outreach, and trainings however, only a portion of these individuals will be appropriate for the GPRA requirement of collecting client-level NOMs surveys. Therefore, we propose to target a minimum total of 175 unique individuals by the end of the project period.