The Pima Prevention Partnership (PPP) Building Bridges program will strategically apply the proposed funding to enhance its existing Medicaid-supported outpatient treatment services with needed wrap around and intensive case management services using an integrated care model for 300 adolescents, 13 – 21 years old with co-occurring serious emotional and substance use disorders who are experiencing homelessness to improve their health and housing outcomes. Youth who have been diagnosed with a life-altering and potentially long-term chronic functional impairment (SED) are one of our most vulnerable citizen groups and have a high likelihood of poor life outcomes without meaningful, sustained support. Building Bridges will be used to systematically pilot individualized sets of wrap around services above what is possible with Medicaid funding alone to address this adolescent population’s complex needs and low treatment completion rates. Building Bridges is a program of Sin Puertas, PPP’s state-licensed Sin Puertas behavioral clinic focused on serving court-involved adolescents and their families since 1991. The program will enroll and serve 300 adolescents, 13-21 years old, over five years (60 per year) with a combination of intensive outpatient treatment services utilizing an evidence-based COD treatment model, Adolescent – Community Reinforcement Approach (A-CRA) and evidence-based trauma curricula, Structured Sensory Interventions for Children, Adolescents and Parents (SITCAP-ART) delivered by certified behavioral health technicians. Pathways Coaches will provide case management services, averaging 4 hours per month, following the Assertive Continuing Care model and an integrated care focus. The course of treatment will be six months with after-care group supports to be available indefinitely. PPP receives referrals from the Pima County Juvenile Court Center and from local health homes operated through the regional behavioral health authority, which manages the integrated care (primary and behavioral health) needs of Medicaid-insured adults and children. All referred youth have a substance use diagnosis and approximately 80% have a co-occurring serious emotional disturbance. On average participants report having experienced 14 traumatic events, with a range from zero to 40 incidents. The ethnic/racial composition of participants is 65% Latino/a, 5% African American, 5% American Indian, and 25% Caucasian; these percentages indicate an over-representation of Latinos and American Indians compared to Tucson’s general population. Building Bridges program completers will demonstrate a) increased safety and security by completing the program and by taking steps toward meeting basic needs and developing a community safety net; b) reductions in general life problems and substance use; and c) increased community re-engagement as evidence by school attendance and/or employment.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080726-01 PIMA PREVENTION PARTNERSHIP Tucson AZ SNYDER WILLIAM $500,000

The purpose of the Health Home Hope (H3) Project is to end the cycle of homelessness for households currently experiencing long term unsheltered homelessness in Tucson and Pima County through the expansion, integration, and coordination of local community behavioral health (BH), physical health and housing support systems. We will provide BH and other recovery-oriented services to those experiencing long-term unsheltered homelessness through (1) intensive street outreach, (2) navigation designed to rapidly connect individuals with substance use disorder and or co-occurring disorders to mainstream treatment and recovery services including Medication Assisted Treatment (MAT), and (3) coordinate housing and services that support sustained recovery and wellness within permanent housing. The population of focus is unsheltered homeless households in Pima County experiencing substance use disorders and chronic health conditions, including single adults, youth and families. Pima County accounted for 15 percent of Arizona’s population and 23 percent of the state’s homeless population in 2017. The proposed (H3) Project includes a part-time medical outreach team (Family Nurse Practitioner, Medical Assistant, and Care Coordinator) to deliver non-emergency medical treatment during outreach visits at Old Pueblo Community Services (OPCS); and a dedicated behavioral health (BH) team (Psychiatrist, BH Professional (Therapist), and BH Case Manager) for all individuals referred by the OPCS navigator and peer guides for SA or COD screening, treatment, and follow up BH and SA care. All participants will be screened using the Vulnerability Index – Service Prioritization Decision Assessment Tool (VI-SPDAT) tool, screened for depression using the PHQ 2/9 tools, Screening, Brief Intervention, and Referral to Treatment (SBIRT) screening tool, and will be provided linkages to housing, health insurance, and a myriad of other services identified through social determinants of health (SDOH) screenings. Our goal is to move 150 of the most vulnerable unsheltered homeless individuals into permanent supportive housing, while increasing their wellness, to include their ability to manage their addictions, mental health symptoms, and acute and chronic physical conditions. This team will initiate approximately 200 contacts with unsheltered homeless individuals each year (1,000 total), offering non-emergency medical assistance, screening for the presence of addiction and mental health concerns, SA/COD treatment and medication monitoring/ MAT, and immediate enrollment into mainstream benefits, such as Medicaid, TANF, and SNAP. Additionally, we will provide intensive navigation assistance to a minimum of 60 individuals per year, 300 during the project. A minimum of 75 patients per year will be seen for medical and MH services for a total of 375 over 5 years. As a result, at follow-up, we expect 45% of participants to experience a reduction in days using drugs or alcohol, 50% a reduction in criminal activity, 75% increase in social connectedness, 50% reduction in emergency room usage, and a 50% increase in income from all sources.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080732-01 EL RIO SANTA CRUZ NEIGHBORHOOD HLTH CTR TUCSON AZ SAMORANO ROGELIO $500,000

The goal of the Tulare County Treatment for Individuals Experiencing Homelessness (TIEH) program is to reduce homelessness and increase wellness and self-sufficiency among individuals in Tulare County who are homeless and are experiencing serious mental illness (SMI), serious emotional disturbance (SED), or a co-occurring substance use disorder (COD). The program will serve transitional aged youth (TAY) ages 16-25, adults 26-59 and older adults 60+. Each year, the program will provide outreach to 200 unduplicated individuals to screen for program eligibility. This will be completed by the Street Outreach Specialist who will spend a majority of their time in the field, seeking out homeless individuals and screening for eligible services. Additionally, outreach will be provided in partnership between the Mental Health Case Manager(MHCM) and local law enforcement where the MHCM will participate in ride-alongs with the local police department, seeking out homeless individuals who demonstrate a need for mental health and/or substance use services. The TIEH program seeks to enroll a minimum of 40 individuals into the program. Program participants will create a Consumer Wellness Plan based on treatment needs and wellness goals, receive integrated evidence based treatment for mental health or substance use disorder, and case management services. All participants will be linked to safety-net services (i.e. Medi-Cal, Supplemental Nutrition Assistance Program, cash aid, etc.) and screened through the Supplemental Security Income (SSI) Advocacy Unit under the SSI/SSDI Outreach Access and Recovery (SOAR) program to assist in self-sufficiency. In addition to mental health treatment, program participants will also receive services through Community Services Employment Training (CSET) in assisting with self-sufficiency and housing readiness. CSET’s case management team will provide supported employment services, budgeting education, assistance with basic needs, and housing placement assistance.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080662-01 MENTAL HEALTH BRANCH VISALIA CA CRUZ MICHELE $499,030

The Boulder County Pathways to Housing Stability (BCPHS)project targets adults experiencing chronic homelessness who have a mental health, substance use or co-occurring disorder, and who may have or are at risk of medical issues. The project is designed to quickly identify, enroll and transition participants into permanent supportive housing (PSH), and provide needed services to ensure that placed individuals can remain stably housed over the long term. The project, which is focused on the provision of services across Boulder County, Colorado, will enroll 345 participants and seek to place 280 in PSH over five years. BCPHS will be implemented in coordination with an existing effort known as Homeless Solutions for Boulder County(HSBC), a county-wide Housing First initiative focused on housing individuals experiencing chronic homelessness. The county is in a high state of readiness to implement BCPHS due to efforts by HSBC leadership to implement core elements of a county-wide homeless system including an intake and triage process, shelter and day services and a cross-agency management information system. While HSBC is supported by government and non-profit agency leaders, the county lacks sufficient navigation, behavioral health and medical resources to meet the needs of those eligible for PSH. As a result, housing vouchers and other housing opportunities are not effectively utilized as needed service support cannot accompany placements. The Project will be implemented through a highly experienced collaborative team: - The Project Director, Jennifer Biess has diverse experience managing homeless projects for the Urban Institute, and currently directs the HSBC initiative. She will be dedicated 25% to the project and supported by Dr. James Adams-Berger who has extensive experience overseeing SAMHSA projects and managing evaluation and reporting requirements. - The Primary treatment provider Mental Health Partners (MHP), manages housing vouchers for the State’s Division of Housing and brings over 55 years of experience providing evidence-based, trauma informed substance use disorder, mental health and co-occurring disorder treatment services to the County’s most vulnerable populations. MHP’s lead on the project, Barbara Guastella, is the Housing Team program manager and coordinates clinical services at MHP for homeless populations. - OMNI Institute (OMNI), the project evaluator, is Denver-based evaluation firm with extensive experience evaluating SAMHSA projects, homeless and treatment-related service efforts, and conducts the state’s annual Point-in-Time survey. Dr. Katie Page, the project evaluator, has extensive experience evaluating homeless and treatment projects. - The HSBC Executive Board will also play a key role in supporting the project. This board is comprised of key county leaders who have a direct role in funding and supporting the homeless services system in Boulder County. Members include, public housing directors; directors of the Departments of Housing and Human Services, Public Health and Community Services; municipal leaders from the two largest cities, Boulder and Longmont; and the director of the HUD continuum of which Boulder is a member. Support from the HSBC means that the BCPHS project will be well-managed, that there will be access to additional resources needed by the project, and that BCPHS can be sustained well after the funding period. Also, participation of the continuum director ensures use of the coordinated entry process known as OneHome. The project is also fully supported by the State's Division of Housing and a large number of community based services providers. Finally, the project is cost effective as the County is donating the time of two staff to manage the project - Jennifer Biess, the current director of the HSBC project, and Dr. Adams-Berger. This means that the vast majority of resources will be used to support the provision of needed treatment services.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080793-01 COUNTY OF BOULDER BOULDER CO BIESS JENNIFER $490,740

SMA Behavioral Health Services, Inc. proposes Volusia County Pathways to Wellness and Housing (PATHWAYS). Over a 5 year period Pathways will serve 190 adult chronically homeless individuals who have a serious mental illness and may also have a co-occurring substance use disorder residing in Volusia County Florida. Evidence-based practices to be employed are Permanent Supported Housing (PSH) and Assertive Community Treatment (ACT). Pathways will receive referrals from and be supported by local mental health advocacy and homeless service providers including NAMI, Volusia/Flagler Coalition for the Homeless, First Step Shelter, Halifax Urban Ministries and The Neighborhood Center of West Volusia. Goals are: 1) Develop an effective infrastructure that provides evidence based primary and behavioral healthcare to the population of focus combined with recovery support services that cumulatively assure good physical and emotional wellbeing, safe and stable housing, purposeful daily activities and access to community relationships and social networks, and 2) Reduce chronic homelessness among the population of focus. Measurable objectives include: • Implement with fidelity Permanent Supportive Housing and an Assertive Community Treatment team, concurrent with evidence based treatment and recovery support approaches including Motivational Interviewing, Cognitive Behavioral Therapy, Medication Management and Wellness Recovery Action Plan. Staff will be trained and supervised to ensure fidelity compliance rates of 90% or more. • Collect NOMs data on 100% of program participants at enrollment, 80% of participants every 180 days post enrollment and 80% at discharge. • 90% of enrolled participants placed in rapid rehousing or permanent supported housing within 30 days of enrollment. 95% of enrolled participants placed in rapid rehousing or permanent supportive housing within 60 days of enrollment. • 85% of enrolled participants shall not experience homelessness for a period of one year following enrollment, 80% of enrolled participants shall not experience homelessness for a period of 2 years following enrollment. 75% of enrolled participants shall not experience homelessness for a period of 3 years following enrollment. SMA will employ Permanent Supportive Housing (PSH) and Assertive Community Treatment ACT) as its primary evidence based practices. Core elements of PSH include 1) helping people obtain housing quickly; 2) providing services following housing placement; 3) basing services on individual’s desires and needs, and 4) not requiring service engagement to retain housing. Treatment and recovery support services to augment housing will be provided through an ACT team consisting of peers, social workers, nurses, psychiatric registered nurse practitioner, and access to vocational, addictions and mental health counselors. ACT services will include primary care, psychiatric and substance use treatment, medication, and recovery support services.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080675-01 SMA BEHAVIORAL HEALTH SERVICES, INC. DAYTONA BEACH FL SHARBONO NICOLE $500,000

The Triple H (Housing-Help-Hope) program serves uninsured homeless adults that have a serious mental illness or a co-occurring disorder (COD). The catchment area for Triple H is the City of Atlanta, DeKalb and Fulton counties, all located in the state of Georgia. Triple H will provide permanent supportive housing (PSH), intensive mental health services, outpatient treatment, short-term substance use disorder residential treatment, case management, peer support, linkage to mainstream benefits and an array of other services. The result - access to healthcare and sustainable housing regardless of insurance or income status. The US Department of Housing and Urban Development's (HUD) 2017 Annual Homeless Assessment Report to Congress states that 10,174 individuals were homeless on a single night in January 2017 in Georgia. Of those individuals throughout the state of Georgia, 43% (4,325) were found in the catchment area. Given the makeup of the homeless population in the greater Atlanta area, the majority of our clients are likely to be chronically homeless, African American and male. Further, approximately 60% of clients do not have health insurance, dramatically reducing access to behavioral health services and establishing a cycle of homeless recidivism. Over the life of the grant, Triple H expects to provide supportive services to a minimum of 200 unduplicated homeless adults (40 annually). The number of clients was determined by 1) the need in the catchment area, 2) the amount of grant and in-kind resources, and 3) the availability of permanent, affordable housing. Based on our housing and behavioral health experience, the annual cost per client (12,500) is reasonable considering the housing, support and services they will receive. The overall goal of the program is to increase the personal and economic self-sufficiency of homeless individuals by strengthening their connections to treatment, housing and community. Using an independent evaluator, we will measure three specific goals: 1) increase access to treatment and housing and improve housing stability for a minimum of 200 high-risk homeless individuals, 2) improve clients' behavioral health status by providing comprehensive treatment and relapse prevention services to a minimum of 200 clients, and 3) increase clients' self-sufficiency by providing case management and ancillary services focused on employment, benefits and connection to community support.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080640-01 CARINGWORKS, INC DECATUR GA WALKER SCOTT $499,530

The U.S. territory of Guam is requesting funding to support Project LINC which stands for Linking Individuals in Nurturing Communities. The population of focus will include children and adolescents ages 5-18 years old that are experiencing homelessness and who have a Serious Emotional Disturbance (SED) or Co-Occurring Disorder (COD) which is defined as an individual with both a psychiatric diagnosis and substance use disorder. Guam Behavioral Health and Wellness Center (GBHWC) has been the single state agency for both mental health and substance abuse on the island for over 30 years. Over the past 15 years, the child/adolescent services division (I Famagu’on-ta) has led the System of Care for children’s mental health in Guam and in the Micronesian region. The three most frequently reported SEDs experienced by I Famagu’on-ta youth are Major Depressive Disorders, Conduct Disorders, and Hyperactivity/Attention Deficit Disorders. Suicide also continues to plague the island as the sixth leading cause of death with 50 individuals, or about 1 person a week who died by suicide – 22% of them between the ages of 10-19 in 2016. Although we are isolated, our strategic location has played a role in the movement of alcohol and illicit drugs into the island. Twenty-five percent of public high school students report currently drinking alcohol and 30% report that they currently use marijuana. Additionally, Guam’s Drug & Alcohol division reports that the inhaling of butane, gasoline, and other chemicals are on the rise amongst youth. Guam’s latest homeless data show that in 2016, 112 individuals resided in shelters, but there were 973 homeless individuals – almost half of them children – whose nighttime residence was a public or private place not designed or ordinarily used as a regular sleeping accommodation for human beings such as in a car, park, abandoned building, bus station, or within the jungles of Guam. Although I Famagu’on-ta has made a lot of headway through the years, there is still a lot of needs to address. Project LINC proposes to serve at least 25 youth and their families in the first year, and no less than 50 youth annually thereafter, to ultimately serve over 225 youth for the length of the project period.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080693-01 GUAM BEHAVIORAL HEALTH AND WELLNESS CENTER TAMUNING GU UNPINGCO ANNIE $1,000,000

Abstract Idaho’s Treatment for Individuals Experiencing Homelessness project will implement transformative changes in the behavioral health service delivery to individuals who are diagnosed with a serious mental illness (SMI) and/or a Co-Occurring Disorder (COD); have been institutionalized in a state or community hospital setting and discharged within the past year; and are currently experiencing or are at risk of homelessness. Idaho will 1) Provide navigation services to identified individuals at the time of project entry; 2) Provide an array of behavioral health services in the community upon release from hospitalization; 3) Provide s a step down from hospitalization that will provide a supportive living environment; and 4) Ensure connection to long term stable housing. Idaho’s goals and objectives are to: 1) Reduce state and community hospitalization readmissions for individuals with an SMI and/or COD who experience unstable housing. Idaho will deliver mental health and/or substance use disorder services to 28 individuals during year 1 and 37 individuals each year for years 2-5 for a total of 177. Idaho will provide navigator services to at least 80% of eligible participants within 2 business days of entry into the project. At least 60% of project participants will avoid readmission to psychiatric hospital settings within twelve (12) months of entry into the project. 2) Increase project participant access and retention of safe, suitable and affordable housing. SOAR Case Management services will be provided to at least 80% of eligible project participants within six (6) months of entry into the project. Navigator will connect 80% of eligible participants with their local HUD Coordinated Entry within six (6) months of entry into the project. At least 80% of project participants without insurance will apply for Medicaid and other eligible benefits within 3 months of admission to the project. 3) Promote recovery, resilience and independence in the community of choice. At least 45% of project participants will report continued involvement with local supportive services and resources after six (6) months of admission to the project. At least 70% of participants will report no arrests in the past thirty (30) days after six (6) months of entry into the project. 4) Develop a collaborative, approach to providing services and supports. A Steering Committee will be established within 4 months of project award. The Steering Committee will be composed of consumers and other stakeholders, and will meet quarterly to review project outcomes, consult, and review evaluation results. In years 3-5, the Steering Committee will be expected to actively assist with efforts to identify collaborating partnerships and funding to ensure project sustainability after the grant period ends.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080814-01 IDAHO STATE DEPT OF HEALTH AND WELFARE BOISE ID ANDUEZA ROSIE $1,000,000

In this Treatment for Individuals Experiencing Homelessness (TIEH) project, Nicasa, a behavioral health services organization offering mental health and substance abuse treatment as well as family supportive services will partner with PADS (Providing Advocacy Dignity and Shelter) Lake County to expand each agency’s ability to serve the homeless population coping with a serious mental illness (SMI) or co-occurring disorder of an SMI and substance abuse. At any given time in Lake County, there are 500 homeless individuals on the streets or in shelters. Lake County is characterized by areas of great wealth and pockets of abject poverty. African Americans make up 7.5% of the general population of the county, but are 59% of the 1,538 homeless individuals that PADS served in FY 17. The Lake County Coalition for the Homeless documents that 27.5% of these people are already diagnosed with an SMI and a significant percentage has a COD with substance abuse. The overarching goals of this TIEH project are to expand Nicasa’s and PADS’ ability to integrate behavioral health treatment and recovery support services for individuals and families with SMI or COD who are experiencing homelessness We seek to increase the capacity to provide accessible, effective, comprehensive, coordinated, integrated and evidence-based treatment services, peer support, and other recovery support services and linkages to sustainable permanent housing. Linking the two agencies more closely will allow us to reach an extremely vulnerable population that might otherwise “fall through the cracks.” Nicasa, in collaboration with PADS, will serve 40 adults in the first year of the grant and 60 adults each in years two through five with a total of 280 adults served over the five year grant period. Evidenced based programs that will be utilized in this TIEH project include numerous screening tools, Housing First, Motivational Interviewing, Integrated Treatment of Co-Occurring Disorders, and Cognitive Behavioral Therapy. Nicasa is licensed to provide both mental health and substance abuse therapies. PADS, the largest provider of services to the homeless in Lake County operates a Day Resource Center, a seasonal Emergency Shelter program, a Family Shelter, a small Housing First program and a Supportive House program. The TIEH project will be formally evaluated by Dr. Richard Sherman of the Sherman Consulting Group, LLC (SCG, LLC). Anticipated outcomes include statistically significant improvement in participants’ mental health status, personal and social functioning, abstinence from substance use, reduced criminal justice involvement, improved employment and housing status, access and retention in services, and social connectedness. Nicasa, PADS, and SCG, LLC, have significant and long-standing experience in achieving long-term success on federally-funded projects. We anticipate no barriers to opening these expanded services in the fourth month of the grant period.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080664-01 NORTHERN ILLINOIS COUNCIL ON ALCOHOLISM AND SUBSTANCE ABUSE ROUND LAKE IL PAVLOVIC NADA $500,000

The purpose of this project will be to reduce homelessness and negative outcomes related to individuals in recovery from SMI, SED, or COD in the Greater St. Louis/Southwestern Illinois area. The goal of the project will be to provide evidence-based interventions that reduce risk, improve health, and engage the POF in meaningful steps toward recovery. The Project’s name will be called the Wellness Outreach Network or WON. WON will be able to serve 50 individuals each year of the project or a total of 250 individuals over the course of the 5 year project. The population of focus (POF) for this project will center on homeless individuals, youth and families experiencing serious mental illness (SMI), serious emotional disturbance (SED), or co-occurring disorders (COD). In the state of Illinois the term COD is defined as: Co-occurring-Co-existing mental health and substance use disorders or developmental disabilities. Individuals eligible to receive services under this Part must have a diagnosis of mental illness. WON will be a team-based, community approach to engage the POF as they navigate from place to place such as residences, hospitals, courts, jails, and/or involvement with law enforcement. This will be achieved by utilizing an integrated approach to treat every need that may be contributing to the individual’s present situation. This method will consist of addressing the following needs/services areas: 1. Housing; 2. Primary Care; 3. Wellness Education; 4. Employment Services; 5. COD Therapy; 6. Peer Support/Outreach and 7. Support for Justice involved individuals. If you will, picture the POF in the middle of a circle surrounded by the 7 potential services listed. By taking this integrated approach the POF will have at their disposal what is needed to resolve their SMI, SED, or COD. Additionally, multiple opportunities to engage in services will be provided. WON will utilize several evidence based models for this project. They include the following: 1. The Screening Brief Intervention and Referral to Treatment (SBIRT), 2. Motivational Interviewing (MI), 3. Housing First, 4. Permanent Supportive Housing (PSH), 5. Collaborative Care, 6. Individual Placement and Support (IPS), 7. Whole Health Action Movement (WHAM) 8. Integrated Dual Diagnosis Treatment (IDDT), 9. Seeking Safety, 10. Community Reinforcement Approach (CRA) and 11. Risk–Need–Responsivity (RNR). Project WON members will be trained/re-trained and supervised as needed on each of the EBPs listed. WON will be evaluated by TriWest, a contracted evaluator who has experience evaluating SAMSHA projects. Chestnut Health Systems will also form an Advisory Board. The Advisory Board will be formed of key community stake holders to guide and/or improve the process of WON. It will include but not be limited to organizations who have signed letters for commitment for the project along with representatives from County Probations, law enforcement, domestic violence advocates, staff from shelters, other agencies serving the POF. Additionally, members of the POF will also be recruited to serve on the Board to share their lived experience of homelessness, housing instability, and barriers they encountered while trying to enter suitable sustainable housing and/or treatment for their SMI, SED, or COD. Chestnut Health Systems is requesting 2,453,152.81 from SAMSHA for the 5 year project.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080751-01 CHESTNUT HEALTH SYSTEMS, INC. BLOOMINGTON IL MELVIN EMMA $499,518

Casa Esperanza Inc.’s proposed “CasaCare: An integrated dual disorder treatment model for Latinos experiencing homelessness” program will aim to reduce relapse and increase housing stability among Latinos living with co-occurring substance abuse and mental health disorders (CODs) and experiencing homelessness by expanding access to integrated substance use and mental health disorder treatment and related recovery support services, including housing support, psychiatry, and primary care. Over 5 years, CasaCare will serve 560 individuals. CasaCares’ goals are: 1) Improve access to integrated mental health and substance use treatment and primary care for Latinos with co-occurring disorders experiencing homelessness; 2) Provide intensive case management to support clients being fully engaged in the development, implementation and completion of goals in their Person-Centered Care Plan (PCCP); 3) Provide recovery support services to engage clients and help them increase knowledge of community resources; increase client capacity for self-management; and identify and reduce risky behavior to maintain recovery; and 4) Build housing stability for homeless Latin@s with CODs by providing housing search, placement, and retention services, integrated with COD treatment and recovery supports. CasaCare will use Integrated Dual Disorder Treatment (IDDT), an evidence based framework with demonstrated efficacy for individuals with co-occurring disorders and is suitable for long term use. The IDDT model recognizes treatment must address multiple co-occurring disorders, including chronic health problems. Thus, the model includes pharmacological treatment and health promotion. IDDT also aligns with housing stabilization work. Core components of the IDDT model include Multidisciplinary Team (MDT);Assertive Community Treatment; Motivational Interviewing (MI); Cognitive Behavioral Therapy (CBT); Illness Management and Recovery (IMR); Intensive Case Management (ICM); Supported Employment/Education (SE/E); and Self Help/Peer Support. Virtually 100% of the people we serve have a co-occurring disorder and an extensive trauma history, 90% have chronic medical conditions, and nearly 100% have experience homelessness, making IDDT the ideal intervention for our population. However, while some IDDT studies have included Latino participants, IDDT experts acknowledge that more work is needed to evaluate its effectiveness for Latino clients. To advance these efforts, CasaCare will draw on our comprehensive understanding of this population and other EBPs that are strongly aligned with IDDT’s core components and principles to build a culturally-competent IDDT model. Modifications will include Cultural Modifications grounded in Relational Cultural Theory and modifications to help clients develop Vocational Interest, Literacy and Basic Skills.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080754-01 CASA ESPERANZA, INC. ROXBURY MA CANUTO MELISA $500,000

Volunteers of America Chesapeake, Inc. (VOAC) proposes to enhance existing services for chronically homeless individuals with serious mental illness (SMI) or co-occurring disorders (COD). VOAC will implement a low-barrier, progressive engagement approach to ensure behavioral health, housing, and income stability needs are met. VOAC will enroll homeless individuals in its COMPASS program from the northern Virginia counties of Arlington, Fairfax, and Loudoun (including the City of Alexandria). With an initial emphasis on housing stabilization, VOAC will rapidly re-house participants using Housing Locators with established landlord relationships. Coinciding with efforts to stabilize housing, VOAC will enhance existing services by implementing a “Treatment on Wheels” program component to reach homeless clients who do not engage in behavioral health services on their own and who are most likely to recidivate back into homelessness. Utilizing a mobile unit, VOAC can bring clinicians to shelters, apartments, homeless service centers, and more to eliminate transportation and motivation barriers, gain client trust, and ultimately improve client stabilization. VOAC will assess COMPASS participants for other service needs, including enrollment in health insurance, Medicaid, and other benefits (SSI/SSDI, TANF, SNAP, and more). VOAC hopes to maintain a higher-level continuity of care for this often disengaged population to truly impact their stability, recovery, and well-being. At last count, there were 1520 homeless individuals in the geographic catchment area, 274 (18%) of whom were defined as chronically homeless. Chronically homeless individuals in this area tend to be African American veteran men over age 55. Among the homeless population in this area, 274 (18%) had a severe mental illness and 243 (16%) were chronic substance abusers. VOAC intends to serve 60 unduplicated clients per year (300 in the five-year grant period). VOAC has established the following three goals for its COMPASS program: 1. Improve the mental/behavioral stability of homeless individuals with SMI/COD. 2. Increase housing stability for homeless individuals with SMI/COD. 3. Reduce homeless recidivism rates among homeless individuals with SMI/COD by engaging them in support services to develop self-sufficiency skills. VOAC expects that 62% of program participants will be stably housed within 90 days (50% of whom will remain stably housed for at least nine months), 75% will experience a decrease in mental health symptoms and improved social functioning, 65% will enroll in public health benefits, and 60% will have a stable income (among other stability-focused outcomes) by program exit.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080760-01 VOLUNTEERS OF AMERICA CHESAPEAKE, INC. LANHAM MD MCQUEENEY GWEN $500,000

Project Summary: The Mobile Integrated Behavioral Health Team (MIBHT) project provides outreach and recovery supports to adults experiencing homelessness diagnosed with a serious mental illness and/or co-occurring substance use disorder in Kalamazoo County, MI. The team will use Peer Supports and evidence based practices to provide outreach in the community, engage individuals in treatment and link them with housing opportunities and benefits. Target Population: Kalamazoo County adults experiencing homelessness are the population of focus. A significant percentage of them have a mental illness and/or co-occurring substance use disorder, are racially diverse (49% African American/Black compared to 12% of the county population), have experienced significant trauma, and are geographically transient (55% previously lived outside of the county). Two subpopulations have been identified for this project including individuals with military experience and African American/Black individuals. Strategies/Interventions: Services will be culturally sensitive and trauma informed. Evidence based practices used will include Screening, Brief Intervention, Referral and Treatment (SBIRT), Motivational Interviewing, and Peer Support services. MIBHT partners with Ministry with Community, a daytime shelter, drop-in center for the homeless, for outreach and engagement strategies. A total unduplicated count of 270 individuals will be enrolled in the project over 5 years; Year 1 = 30, Year 2 = 60, Year 3 = 60, Year 4 = 60, and Year 5 = 60. Goals/Objectives: Goal 1: Increase access to culturally competent, integrated behavioral health treatment services for individuals experiencing homelessness. Objective 1: Conduct outreach throughout Kalamazoo County to 500 individuals. Objective 2: Provide evidence based, integrated mental health/substance use disorder treatment for 270 enrolled individuals. Objective 3: Provide Peer Support services to 270 enrolled individuals. Goal 2: Improve housing status by coordinating services that support permanent sustainable housing. Objective 1: Link and coordinate housing referrals through the Kalamazoo County Coordinated Entry System (CES) for 270 enrolled individuals. Objective 2: Assist 135 enrolled individuals with application for benefits. Objective 3: Assist 100 enrolled individuals to transition from homelessness to permanent housing options. Goal 3: Increase the coordination of and access to available community services for the population of focus. Objective 1: Link and coordinate access to primary care for 100 enrolled individuals. Objective 2: Coordinate outreach services to military service members with the Veteran Navigator staff and other Veteran’s services to all enrolled homeless military service members. Objective 3: Annually, MIBHT staff will enroll an increasing percentage of African American individuals who are homeless into the project.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080669-01 KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES KALAMAZOO MI MEINTS BETH $500,000

Detroit Rescue Mission Ministries (DRMM) and All Well-Being Services (AWBS)will partner to provide clinical, recovery and temporary shelter services to adults who have SMI or COD and who are homelessness. This collaboration will create an integrated care environment through a Modified Therapeutic Community (MTC), access to and stabilization in permanent housing and engagement in treatment and services. The name of the new program is GATHER. Population of Focus (POF): The POF for GATHER (Gaining Access to Treatment and Housing for Empowerment and Recovery) are men and women, including women with children, who have a Serious Mental Illness (SMI) or a Co-Occurring Disorder (Serious Mental Illness and Substance Use Disorder) and who are homeless. They have also experienced multiple variations of trauma, both as adults and children. The geographic catchment is Wayne County, Michigan. Project Goal: By strengthening capacity and leveraging the resources of DRMM and AWBS over a five-year period, this program will produce better mental and primary health and housing outcomes. The project will serve 120 people a year and 400 people over five years who are homeless and experiencing SMI or COD in Wayne County, Michigan. Strategies: Strategies for the proposed project include: Modified Therapeutic Community (MTC); temporary housing; permanent housing; Trauma Recovery and Empowerment Model (TREM) as well as M-TREM; Seeking Safety; Outpatient and Intensive Outpatient Services; Motivational Interviewing; Cognitive Behavioral Therapy; Dialectical Behavioral Therapy; Whole Health Action Management; Assertive Community Treatment Team; Peer Support. Outcome Objectives: Outcome objectives include: 85% of POF’s immediate housing need and basic health needs are met via emergency housing and meals; 50% of MTC group participants will develop at least three goals they would like to discuss at future groups to achieve personal mental health, SUD or housing goals; 38% of participants will succeed in moving to a permanent housing placement; 32% of participants securing permanent housing will maintain housing for six months or longer; 25% of participants securing permanent housing will maintain housing for 12 months or more; 23% of participants moving to independent permanent housing will have housing voucher assistance or locate housing in which housing cost is limited to less than 35% of monthly income; 40% of participants with SUD will improve in measures of SUD well-being; 40% of participants will improve on measures of health well-being; 25% of participants will secure community-based education, job placement or work experience, and/or social networks.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080771-01 DETROIT RESCUE MISSION MINISTRIES DETROIT MI MOORE AURINE $500,000

The ""3-2-1"" Project will strengthen St. Louis' service system for people who are homeless. The project will initiate 3 major activities (outreach homeless people; provide an array of evidence-based practices; and establish a Center of Excellence to improve service practices) for 2 subgroups (homeless adults with SMI or COD; youths with SED and their families) for 1 mission: to end homelessness and improve health and recovery. The project will achieve four goals: Goal 1: Improve access and utilization of behavioral health, support, and housing services and resources for people who are homeless with SMI or COD. Objectives specify targets for the numbers of persons to be outreached and engaged, screened and linked. Goal 2: Increase the availability, array, and provision of integrated behavioral health, recovery support, and housing services for the population of focus. Specific objectives indicate the number of persons to be served by EBPs, including ACT, IDDT, CRA, Trauma Therapies and Housing First Navigators. Goal 3: Improve client functioning and outcomes in key areas of need. The specific objectives specify outcome targets for improvement in the areas of mental health, substance abuse, trauma symptoms, benefits received and housing. Goal 4: Increase the infrastructure capacity of the service system to more effectively serve and house people who are homeless, especially those with SMI or COD and homeless youths and families. Specific objectives include establishing a Center of Excellence for serving homeless people and conducting a series of training and TA activities to improve the knowledge and skills of area providers (and to ultimately improve services to homeless people) and to conduct needs assessment and planning to improve permanent housing options. We plan to reach and enroll 428 unduplicated homeless individuals (380 homeless adults with SMI or COD, and 48 unduplicated youths/families with SED) in the project over the five-year period. The annual numbers of persons enrolled will be 80 homeless adults with SMI or COD (except for year 1, which will be 60 adults because of startup) and 10 SED homeless youths/families with SED (except for year 1, when there will be 8 because of startup).

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080698-01 PLACES FOR PEOPLE, INC. ST. LOUIS MO BLANCO JULIA $497,356

Project Name: Region IV Supportive Housing Collaborative Project Summary: The project will provide comprehensive, community-based integrated medical and mental health treatment, recovery support services and linkages to sustainable permanent housing for individuals with SMI, SUD, and/or COD who experience homelessness. Population to be Served: Persons experiencing chronic homelessness and other vulnerable homeless populations who have a co-occurring disorder (COD) including SMI and/or SUD. Strategies/Interventions: Outreach and engagement using a Coordinated Entry System; direct behavioral health, substance abuse, and medical services; targeted case management; enrolling homeless in benefit programs; provision of wrap-around and recovery support services. Project Goals and Objectives: Goal 1: Increase client access to services and coverage through outreach, engagement and enrollment. • Assess, screen, and if appropriate provide application assistance to 90% of program participants for enrollment into Medicaid, SSI, SSDI, Housing and other programs. • Facilitate at least two outreach activities per month to connect potential clients to services. Goal 2: Implement an evidenced-based Permanent Supportive Housing program using a Housing First approach. • Use Coordinated Entry System for referrals among community providers. • Provide comprehensive evidenced-based onsite services at LaGrave on First. • Provide quarterly training to project staff and Region IV Collaborative on methods and techniques for addressing mental health, substance use, and COD issues among the homeless. • Conduct quarterly and annual program evaluation activities and report findings to Region IV Collaborative. • Secure coverage for case management and other support services through Medicaid, expanded state funding, etc. Goal 3: Provide integrated mental health and substance use interventions for the homeless. • Provide screening, brief intervention and referral to treatment (SBIRT) services at 75% of Valley Community Health Center (VCHC) new patient exams (age 12 and older). • Provide comprehensive, integrated mental health and substance use interventions, including trauma informed services, to 80% homeless persons enrolled in program. • Provide case management and/or care coordination services to 85% of homeless persons enrolled in program. • Provide recovery support services to 80% of homeless persons enrolled in program. Number of people to be served annually and through the life of the project: Year 1 = 550; Year 2 = 300; Year 3 = 275; Year 4 = 260; Year 5 = 250; Total for project = 1,635.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080689-01 GRAND FORKS HOUSING AUTHORITY GRAND FORKS ND ARMBRUST KATIE $500,000

Treatment for Persons Experiencing Homelessness: Park Center will serve persons (ages 18 and over) experiencing chronic homelessness who have mental illness and co-occurring disorders (CODs) of mental illness and substance use in the metropolitan Nashville, Tennessee (Davidson County) area as its priority population. Utilizing outreach and engagement strategies, Park Center will serve 150 people per year to reduce barriers and increase access to basic medical and psychiatric care through a unique partnership with Vanderbilt University Medical Center; outpatient treatment and recovery services; affordable housing; disability benefits; and employment services. According to the Strategic Plan to End Chronic Homelessness in Nashville, the significant gaps in services for persons experiencing chronic homelessness in the Nashville area include: lack of affordable housing; lack of health insurance; lack of access to health and behavioral healthcare; a lengthy disability determination process; and a fragmented system of care. Park Center is a licensed, CARF accredited (Commission on the Accreditation of Rehabilitation Facilities) nonprofit organization with a proven track record of providing wraparound services for persons experiencing chronic homelessness who have mental illness and co-occurring disorders (CODs) of mental illness and substance use. Through this project, Park Center will provide outreach, psychiatric and basic medical care to 50 persons per year on the streets through the Street Psychiatry partnership with Vanderbilt University Medical Center; refer 20 persons to Park Center's Intensive Outpatient (IOP) or Outpatient (OP) treatment programs per year; move 40 persons experiencing chronic homelessness into permanent housing per year; utilizing a peer specialist, ensure that 32 out of 40 (80%) retain housing; Park Center's SOAR Coordinators will apply 40 people for disability benefits (social security income, SSI/social security disability income, SSDI) per year; ensure that 38 out of 40 (95%) of people who applied for SOAR benefits will receive an approval; and refer 20 people per year to Park Center's Supported Employment program.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080688-01 PARK CENTER, INC. NASHVILLE TN BLUM ASHLEY $500,000

An integrated, collaborative, and multidisciplinary team from The University of Texas at Austin Dell Medical School (DMS), CommUnityCare Health Centers (CUC), and Austin Travis County Integral Care (IC) will implement a project titled, “A Community-Based Integrative Dual Disorder Treatment Intervention for Individuals Experiencing Homelessness in Austin, Texas.” We will focus on serving clients who are adults experiencing chronic homelessness with a chronic medical condition and a co-occurring disorder (COD) of serious mental illness (SMI) and substance use disorder (SUD). Our collaborative team will leverage and augment the expertise and existing resources of DMS, CUC, and IC, and fill critical service gaps for individuals experiencing homelessness in Austin, TX. We will use the evidence-based practices of integrated dual disorder treatment (IDDT), trauma informed care, individual placement and support, and housing first, to design and implement an intervention called the Integrated Community Recovery Treatment team (I-CRT). The I-CRT intervention will utilize existing assertive outreach teams, and fits into the broader continuum of care provided by CUC, IC, and community partners for individuals experiencing homelessness in Austin, TX. The I-CRT team is mobile and community-based, providing comprehensive and integrated primary care, mental health care, substance abuse treatment, intensive case management, enrollment in social programs, provision of recovery support services, and placement in sustainable permanent housing. The I-CRT intervention aims to improve mental health, decrease substance use, increase access to primary care services, increase enrollment in social programs, and increase placement and maintenance in sustainable permanent housing. We will proactively address racial behavioral health disparities in the design, implementation, and evaluation phases of our intervention. We will conduct a robust process and outcome evaluation, and an efficient and practical performance measurement and quality improvement process.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080714-01 UNIVERSITY OF TEXAS, AUSTIN AUSTIN TX MERCER TIMOTHY $475,505

The goal of King County F-SHARP is to improve housing and clinical stability for homeless families with SMI, SED, or COD by providing Critical Time Intervention (CTI) services including outreach, integrated mental health and substance abuse treatment, support to enroll in health insurance and other public benefits (e.g., Medicaid, SSDI, SNAP, VA, etc.), and recovery-oriented supports coupled with units of Housing First Rapid Re-Housing (RRH) as identified by King County’s Coordinated Entry for All (CEA) system. Objectives will include the degree to which: • CEA referrals result in F-SHARP engagement and service enrollment • Interventions have been implemented to fidelity • Participants are enrolled in Medicaid or other health insurance, and, using SOAR, are enrolled in SSI/SSDI and other benefit programs • Participants obtain and retain housing • Adult participants reduce mental illness and substance use symptoms • Children in homeless families are connected to needed services F-SHARP expects to serve 40 unique family households per year for each of the 5 years of the project for a total of 200 families. With an average of 1.5 adults per household, this would equate to 60 adults served per year and 300 adults served throughout the life of the grant, plus approximately 500 children who would also benefit from family services.

Award Number Grantee Organization Name Grantee City Grantee Statesort descending Project Director Last Name Project Director First Name Award Amount
SM080623-01 SEATTLE-KING COUNTY PUBLIC HEALTH DEPT SEATTLE WA KNASTER WASSE JESSICA $499,930