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Meta House’s Women In a Supportive Environment (WISE) program will serve women with substance use disorders (SUDs) and co-occurring disorders (CODs) and their children who are experiencing homelessness. The purpose of WISE is to develop a local infrastructure to support recovery housing and outpatient treatment for women with SUDs and CODs and their children who are experiencing homelessness. The proposed housing program will provide supportive services for women living in Meta House’s 26 units of supportive recovery housing (located on a single site), including integrated behavioral health and recovery-oriented services, coordination of housing and supportive services, and connecting women and families with Medicaid and other benefits. The program expects to serve 437 women and 171 of their children during the five years of the grant. The goals of WISE are closely aligned with the goals of the GBHI FOA: 1) create a Steering Committee to develop an infrastructure for coordination and service integration in the system of care; 2) conduct outreach and serve women and families with SUDs and CODs who are experiencing homelessness; 3) provide services to support recovery and housing stability; 4) help women maintain their recovery and improve their quality of life; 5) increase housing stability for women and their families through connecting women to permanent housing and improving self-sufficiency; and 6) connect families to health care and benefits. To achieve these goals, The WISE program will integrate the following evidence-based practices: 1) Recovery Housing for housing stability, maintaining reduced substance use, and improvements in self-sufficiency and quality of life; 2) Gender-Responsive Treatment for SUD and COD treatment; 3) Motivational Interviewing for treating SUDs and CODs; 4) Seeking Safety for treating SUDs and trauma; and 5) Case Management and Peer Support for housing stability, self-sufficiency, and connecting clients to community resources. Meta House has provided gender-responsive, trauma-informed, culturally-competent substance abuse and mental health treatment for over 50 years and supported housing for nearly 20 years. WISE will allow Meta House to provide SUD/COD treatment, case management, and recovery support services within a supported recovery housing program in a community that has steadily been reducing funding and support for recovery housing and for supported transitional housing, particularly for women and families who may be living doubled-up or are otherwise at imminent risk of being homeless. These services are badly needed by the women and families with SUDs/CODs who are experiencing homelessness in Milwaukee. The performance assessment for WISE will be conducted by an external evaluator with more than 20 years of experience evaluating SAMHSA grants. The performance assessment will use findings from intake and 12 month follow-up evaluation interviews, as well as qualitative and process data, to examine the extent to which WISE meets the goals listed above.

Skid Row Development Corporation (SRDC) in partnership with Volunteers of America of Los Angeles (VOALA) will connect homeless individuals in Los Angeles County, California with substance use and co-occurring substance use and mental disorders to permanent housing and behavioral health treatment integrated with primary health care, trauma-informed care, case management, and linkages to public benefits and recovery-oriented supportive services. The proposed infrastructure will be a critical resource to increase the number of program-enrolled individuals placed in permanent housing with the supports to ensure recovery from behavioral health issues and sustain long-term stability. Population: SRDC will prioritize services for chronically homeless/homeless individuals all of whom will have high rates of substance use and/or co-occurring substance use and mental disorders, health care needs and significant socioeconomic disparities due to their homelessness. The population in need includes a heterogeneous mix of races, genders, and ages. It is anticipated that the project will serve 48 participants in Year 1 and 64 participants annually in Years 2-5 for a total of 304 unduplicated participants over the five-year project period. Interventions: Using a holistic and comprehensive service system, SRDC will utilize the EBPs of Motivational Interviewing, Housing First and Critical Time Intervention as well as trauma-informed care to link individuals with permanent housing while also partnering with VOALA to provide onsite substance use and co-occurring treatment, and Kedren Health to access additional mental health services and primary health care. SRDC will likewise provide intensive case management and work with VOALA Benefits Specialists to connect participants with public and VA benefits through use of SOAR as well as wraparound and recovery-oriented supports to promote stability and improved outcomes. Goals & Objectives: The primary goal of the project is to support the expansion of local implementation of a community infrastructure that integrates permanent housing, behavioral health treatment and services for SUD and COD and other critical services for chronically homeless or homeless individuals in Los Angeles County. Expected outcomes by the end of the project period include: 1) Increase coordination with and expansion of the number of entities engaged in responding to homelessness in LA County by 20%; 2) Improve identified behavioral health outcomes of participants by 60%; 3) Reduce past 30-day tobacco use of participants engaged in cessation services by 35%; 4) Increase housing stability for participants by 60%; 5) Increase participation rates in peer and recovery-oriented services by 65%; 6) Increase benefits enrollment of participants by 70%; and 7) Maintain operational integrity of the program by completing 100% of required tasks on time and within SAMHSA requirements. Morehead State University will conduct an independent evaluation which will focus on achievement of targeted goals, objectives, and outcomes, and continuous quality improvement.

MISSION-West proposes to provide evidence based co-occurring mental and substance use disorders (COD) wraparound services to assist 165 chronically homeless individuals in Western Massachusetts, a region that has been hit with economic decline, limited behavioral health resources, and limited state funding for homeless services. Wraparound services will be provided by Behavioral Health Network, and in collaboration with the Western Massachusetts Regional Network to End Homelessness, which currently tracks and helps place chronically homeless individuals into permanent housing. The evidenced based wraparound service model to be used in this project is Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking (MISSION), which was developed to address the behavioral health and housing needs of chronically homeless individuals with a co-occurring mental health and substance abuse disorder. MISSION is delivered by case manager-peer support specialist teams, and systematically integrates Critical Time Intervention case management, Integrated Mental Health and Substance Abuse Treatment, Peer Support, Vocational Rehabilitation, and Trauma Informed Care. MISSION is listed in the Substance Abuse and Mental Health Service Administration-National Registry for Evidence Based Practices (SAMHSA-NREPP). In this proposed project, the University of Massachusetts Medical School is the Local Lead Agency and Evaluator and will work closely with the Behavioral Health Network, a Western Massachusetts clinical provider who has delivered MISSION in a prior SAMHSA Grant, along with the Western Massachusetts Regional Network, which is an established system of agencies and providers created through the Governor's Office to serve as a hub to identify, track and place chronically homeless individuals with the aim of reducing the incidence and prevalence of homelessness in the region. The two case manager-peer specialist clinical teams funded through this grant will deliver MISSION services to 165 individuals (30 in Years 1 and 5; 35 in Years 2-4) that will include rapid placement in permanent housing using a Housing First approach, along with one year of wraparound support. MISSION-West participants will also receive linkages to community-based, state, and federal mainstream benefit programs such as MassHealth (our state Medicaid program), Massachusetts Department of Mental Health, and Public Health services. We anticipate that the 165 chronically homeless individuals who receive MISSION-West services will have: 1. fewer days homeless; 2. fewer days of substance use; 3. improvement in mental health; and 4. fewer hospitalizations from baseline to follow-up. This project has been developed with significant input from local and state agencies, providers and consumers, the Massachusetts Interagency Council on Housing and Homelessness and is consistent with the Massachusetts' Plan to End Homelessness.

Project Name: Grants to Benefit Homeless Individuals of San Diego County Population to be Served: Volunteers of America Southwest (VOASW)’s project will target homeless individuals in the San Diego-Carlsbad MSA who have a substance use disorder (SUD) or a co-occurring disorder (COD). This population includes the chronically homeless, formerly incarcerated, mentally ill, and veterans. Last fiscal year, VOASW’s Renaissance Treatment Center’s client population was 53.6% white, 16.3% Black/African American, and 9.3% Hispanic/Latino. Eighty-six percent were men and 13.2% were women, and 5.6% were veterans. Strategies and Interventions: The project’s purpose is to enhance our infrastructure to better serve the population of focus by implementing the use of validated screening and assessment tools, evidence-based practices, and a new aftercare and follow-up program to ensure successful placement and retention in permanent housing. VOASW will also use GBHI funds to enroll clients in benefits programs, convene a steering committee of key partners to guide implementation and integrate processes into local systems, and hire an evaluation consultant to improve our ability to collect and use data to monitor and optimize treatment outcomes. Screening tools include Ferrans & Powers Quality of Life Index, SBIRT, SOCRATES, Trauma Assessment for Adults, and the Kessler 10. We will also implement evidence-based practices Seeking Safety and Motivational Interviewing. Project Goals and Measurable Objectives: The project’s goal is to improve treatment, recovery, and housing outcomes for the target population by achieving the following objectives: 1) Create a local steering committee composed of key stakeholders, 2) Improve and streamline the intake process using validated screening tools, 3) Enhance treatment and case management through the use of evidence-based practices, 4) Develop and implement an aftercare program to improve long-term outcomes for housing and recovery by offering support after program exit, and 5) Integrate process and outcome evaluation and continuous quality improvement processes. Number of People to be Served: 350 (50 during year 1 and 75 during years 2-5) Project Summary: Volunteers of America Southwest (VOASW) proposes to use Grants for the Benefit of Homeless Individuals (GBHI) funding to serve 350 homeless individuals with substance and alcohol use disorders, many of whom have co-occurring disorders and experienced trauma, through our Renaissance Treatment Center (RTC) residential substance abuse treatment program. In the target area, there is a shortage of high-quality, evidence-based treatment programs that help address underlying issues that contribute to homelessness. VOASW’s proposed GBHI project will respond to the problem of the lack of providers who are equipped to adequately serve San Diego’s large population of homeless people with SUDs, CODs, and trauma.

COLUMBUS HOUSE, INC. RECOVERY INTERVENTIONS SERVICE TEAM PROGRAM ABSTRACT Columbus House and its collaborative partners will create the Recovery Interventions Service Team (RIST) program to serve homeless persons with substance use disorders and co-occurring disorders in three urban areas in Connecticut. RIST will use the new Critical Time Intervention for Rapid Rehousing (CTI-RRH) model combined with peer recovery support specialists to move this population into permanent housing using behavioral and other supports. The target populations for RIST are homeless adults over the age of 25, young adults ages 18 to 24, and families exhibiting the characteristics of severe mental illness, SUDs, or CODs in Meriden, Middletown, and New Haven. This target population also include veterans and LGBTQ. RIST will engage homeless individuals who lack a fixed, regular, and adequate nighttime residence. Additionally, RIST will target individuals experiencing posttraumatic stress disorder (PTSD) and other dangerous or life-threatening conditions. The goals of RIST are to 1) enhance and expand services for the target population using CTIRRH, SSI/SSDI Outreach, Access, and Recovery (SOAR), employment, primary healthcare, behavioral healthcare, and housing, 2) increase the availability of these services to the target population by co-locating them in the three urban areas, and 3) increase access to behavioral healthcare by partnering with local clinical providers committed to serving this population and increase access to RRH using existing housing resources. RIST will conduct street outreach, take referrals from the state Coordinated Access Networks (CANs), and accept referrals from grassroots, community-based organizations to reach approximately 100 individuals annually or 500 over the five-year period. It will then enroll 80 homeless persons in RIST annually using CTI-RRH and several evidence-based practices (EBPs) that remove barriers and connect them with services. RIST will assess clients entering the program using the VI-SPDAT or TAY-VI-SPDAT to determine the level of behavioral intervention required. Each will be assigned to a certified peer recovery support specialist/case manager that formerly experienced homelessness and SUDs or CODs. These clients will remain in the program for six months. Per the CTI-RRH model, RIST clients will receive intensive services during the first four months of engagement. The intensity of these services will lessen in the last two months and shifted to the behavioral health and other providers. RIST will retain clients by involving them in their individual treatment plans and ongoing contact with their case managers. By the end of the five years, approximately 150 to 200 individuals and families will have permanent housing along with continued treatment per their behavioral health provider.

Summary: The overall goals of the Finding Home Project are to decrease homelessness in rural Mendocino County, California, and improve the health, well-being, and self-sufficiency of homeless people who have co-occurring disorders. Through treatment, integrated care management, wraparound support, housing, professional development, and infrastructure improvements, the project will strengthen community infrastructure for the homeless. Mendocino County has developed an effective Continuum of Care for the Homeless with 30 participating partners. With the Mendocino County Health and Human Services Agency as the applicant, the Finding Home Project builds upon these established partnerships to provide integrated mental health and substance use disorder treatment and care management in three homeless service hubs. The project will serve 60 clients each year, including transition-age youth. Over the five-year period, an unduplicated total of 165 clients will receive treatment and support. Finding Home components include: *Evidence-based practices; *Integrated assessment and treatment teams; *Universal enrollment in the Continuum of Care Coordinated Entry System; *Primary healthcare and wraparound services, including housing, coordinated through intensive care management; *Social Services support for eligibility determinations and benefit enrollment; *Professional development and cross-training in co-occurring disorders; and *Homeless Management Information System upgrade, to increase access to client data for care management. Anticipated outcomes include the following: *70% demonstrate decreased symptoms of mental illness and substance dependence *80% demonstrate adherence to harm reduction behaviors *40% achieve abstinence *75% rate of retention in services *20% gain employment *50% show decreased criminal justice involvement *50% decrease number of emergency room visits *20% secure permanent supportive housing *100% feel involved in project development and in their own care *80% report increased social connectedness

Pathways Home will serve Montgomery County’s chronically homeless individuals with substance abuse and/or co-occurring disorders whose service needs are not being met by creating a unique Housing First Integrated Behavioral Health Team designed to serve this population. Strategies include ensuring continuity of care and services to provide consistency of relationship and access to specialty behavioral health services to allow successful connection to permanent housing. These individuals are not being served by existing systems of care. The first group are individuals with co-occurring disorders who are not engaged in treatment, have limited insight into their illnesses, and who do not meet the County’s criteria for being served by a Medicaid funded ACT team due to a lack of hospitalizations OR they are on a lengthy waitlist to receive these services. The second group is individuals with chronic substance use/abuse challenges who are not actively engaged in addictions treatment. Of the chronically homeless individuals 75% are male and 25% are females. Of these, 4% reported being between the ages of 18-24, 60% reported being between ages 25-60, 10% reported being over 60 years of age and 26% had no response to the age question with 44% reporting justice system involvement. Pathways to Housing DC will employ the following Evidence Based Practices in the Pathways Home project: Pathways’ Housing First, Integrated Dual Disorder Treatment (IDDT), Peer Supports, and Comprehensive Case Management (CCM) in serving approximately 225 unique individuals over 5 years: Year One - 60; Year Two - 45; Year Three - 45; Year Four - 45; Year Five - 30. Goal 1: Fill a serious service gap in the community by creating the first Housing First-IBHT Team targeting chronically homeless Montgomery County residents with substance abuse and/or mental health disorders. Goal 2: Develop a comprehensive “By-Name List” of all chronically homeless individuals in the County. Goal 3: Play a key role in ending chronic homelessness in Montgomery County Goal 4: Help maintain an 85% housing success rate for those individuals supported by the Pathways Home team who have moved into permanent housing. Goal 5: Expand the Project to serve more specifically other special populations not being served well by existing resources. This includes adults who are justice involved, those leaving institutional settings (nursing homes, long term hospitalizations, and jail), and unaccompanied youth.

The Family Service of Greater New Orleans New Directions project will target the parishes of Orleans and Jefferson in Louisiana which continue to experience increasing homelessness. According to the data, the total homeless count in the area was 1,626. The majority of the homeless population is found in Orleans Parish (1,603 individuals) Of these, 909 individuals were sheltered either in emergency shelter (527) or transitional housing (382). Additionally, 717 people were unsheltered. The target population for the New Directions project is comprised of individuals experiencing homelessness as defined by the Homeless Emergency Assistance and Rapid Transition to Housing Act. Specifically, the individuals targeted by the New Directions project will be 875 individuals (adults/youth) experiencing homelessness that have substance use disorders (SUDs) or co-occurring mental and substance use disorders (CODs) and/or families who experience homelessness, with one or more family members that have an SUD or COD (100 participants in years 1 and 5, 225 participants in years 2-4). Based on existing FSGNO and homeless demographic data, the composition of the population served will be 23% white, 53% black/African American, 8% Latino/Hispanic, and 1% Asian and 15% other races. It is estimated that 59% will be female, 40% will be male, and 1% will be transgender. Eighty percent will be heterosexual and 20% will be of other sexual orientations. The strategies used include: outreach and engagement through an outreach worker and providing direct treatment for SUDs and CODs using evidence-based practices, case management, and therapeutic case managers that are competent in administering assessments such as the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure and the National Stressful Events Survey PTSD Short Scale. The project will also provide coordination of services such as enrollment in Medicaid, SNAP, links to employment and housing programs through services provided by the grantee and housing partners that utilize the HUD Coordinated Entry Process. The New Directions project will implement a high-quality cost effective model for providing behavioral health treatment to the target population that is linked to permanent housing and other services by providing at least three counseling sessions to 100% of participants, 525 (60%) enrollments in Medicaid and other health insurance programs, placement for 700 individuals in to housing, of which 350 will be permanent housing by the end of the project. The project goals include, expanding the identification of untreated homeless individuals with an SUD or COD and linking them to treatment and resources, providing coordinated services to support permanent housing, and delivering comprehensive services directly and indirectly that strengthen the housing and behavioral health infrastructure.

The purpose of the San Luis Obispo Homeless Recovery Hub (SLO Hub) is to develop integrated services, co-located at the Homeless Services Center, for chronically homeless individuals with co-occurring mental health and substance abuse disorders. SLO Hub will provide 130 individuals with integrated treatment and intensive case management for self-sufficiency, permanent housing, recovery supports, employment, and education. The Community Action Partnership of San Luis Obispo County (CAPSLO) will be the lead agency in a partnership with Transitions-Mental Health Association (TMHA), and in collaboration with seven additional community partners who will provide evidence-based co-occurring treatment, primary care, community support, and case management services on-site, and short-term residential recovery, tobacco cessation, additional mental health counseling, and permanent housing in the community. SLO Hub will support participants in their recovery as they improve their health and wellness, live a self-directed life, and strive to reach their full potential. Services will be culturally and linguistically appropriate, respectful of and responsive to the health beliefs, practices, and needs of the diverse client population. It will reduce disparities in treatment for the chronically homeless by providing available, on-site services at the Homeless Services Center while linking participants to permanent housing and other recovery supports essential to maintain sobriety. A 30-client ongoing caseload will be maintained throughout the project period, with new participants added as openings occur, for a total of 130 individuals over five years. Participants are estimated to be 65% male, 75% White, 18% Hispanic, 84% over age 24, 16% LGBTQ, and 17% veterans, in accordance with the local chronically homeless population. This population reports experiencing substantial substance abuse (68%) and mental health issues (59%). An independent evaluator will lead the local performance assessment. SLO Hub will create an integrated treatment system that has been previously unavailable in this community for the chronically homeless population. Project goals are to develop a co-located, multi-agency system of services that is fully integrated and to provide a wrap-around recovery program for participants to improve the quality of their lives through recovery support while providing opportunities for permanent housing. Project objectives include developing a Steering Committee with consumer representation that focuses on increased service integration on-site; conducting outreach to at least 100 potential clients annually; securing permanent housing for at least 95% of participants who remain in services; and linking at least 90% of participants to community volunteers and peer support. At least 85% of participants will participate in counseling services, 20% will enter short-term residential recovery programs as needed, and at least 70% will reduce substance use and experience improved mental health. As a result, participants will remain in recovery, while experiencing stability and self-sufficiency.

ABSTRACT Integrated housing, substance abuse/co-occurring treatment, and support services for homeless in the middle Tennessee by Buffalo Valley, Inc. Grants for the Benefit of Homeless Individuals (GBHI), TI-17-009 (2017-2022) This project will address a critical gap in access to integrated permanent housing, substance abuse/co-occurring/physical health treatment, and support services for homeless individuals and families with substance abuse or co-occurring disorder in a 24 county area in rural middle Tennessee. The project plans to serve 350 persons during the five-year duration of the project. The purpose of this project is to help reduce homelessness in our target area by providing behavioral health and other recovery-oriented services in coordination with integrated community systems that support long-term sustainability with permanent housing and support services for homeless individuals and families who experience SUDs or CODs and to enroll them in mainstream benefits programs. BVI will offer an evidence-based, integrated, and culturally sensitive model of services designed to provide a community system to sustain recovery and prevent them from becoming homeless again. Based on the “Prevalence and Characteristics of People Experiencing Homelessness in the United States, July 2011” report, 26.2% to 34.7% of all sheltered homeless persons, experienced severe mental illness or chronic substance use issues. Homelessness in rural America receives far less attention than urban homelessness. During 2016, BVI received over 1,500 requests for housing but could only serve close to 500 individuals due to lack of resources. SAMHSA underscores that only 10 percent of those needing treatment received services at a specialty facility in the past year (SAMHSA NSDUH, 2006). The goals of this project are: Goal 1: Provide integrated, comprehensive behavior health and other recovery-oriented services to 350 homeless individuals and families who experience SUDs or CODs; Goal 2: To support and enhance integrated community systems that provide permanent housing and supportive services for the target population; and Goal 3: To engage and connect homeless clients who experience SUDs/CODs with health insurance, Medicaid and other mainstream benefits programs.

Colorado Coalition for the Homeless proposes the CCH 2017 GBHI project to serve homeless people in metropolitan Denver who are experiencing substance use disorders or co-occurring substance use/mental health disorders. The population of focus will be primarily comprised of adults experiencing chronic homelessness, but will also include unaccompanied homeless adults (25 years old or older) and unaccompanied homeless youth (18 to 24 years old). The proposed project will expand and integrate treatment for substance use disorders and co-occurring mental health/substance use disorders with supportive housing and other critical recovery support services including peer services, preventative health services, patient navigation, and case management. Each project participant will be co-enrolled in supportive housing in collaboration with the local HUD driven Coordinated Entry System. GBHI project services will be accessed in conjunction with supportive housing services. Each GBHI participant will receive services from a multi-disciplinary team of clinicians, case managers and peers. The proposed project’s multi-disciplinary team will collaborate to achieve the following goals and measurable objectives. Goal 1) Expanded access to integrated housing and supportive services. Measurable objectives: 1a) enroll a total of 30 participants in Year 1; 1b) enroll an additional 40 participants in Year 2 for a total of 70 participants; 1c) enroll an additional 30 participants in Year 3 for a total of 100 participants; 1d) the number of participants will remain 100 in both Years 4 and 5; and 1e) a total of 150 participants will be served over the five-year life of the proposed project. Goal 2) Improved housing stability among participants. Measurable objectives: 2a) link 100% of participants to permanent housing; 2b) 70% of participants in their first year of project participation will remain stably housed or move to an alternate, affordable permanent housing destination; and 2c) 60% of participants in their second year of project participation will remain stably housed or move to an alternate, affordable permanent housing destination. Goal 3) Reduced substance use among participants. Measurable objectives: 3a) 30% of participants will reduce substance use from intake to six months of project participation; 3b) during project participation 40% of participants will engage in substance use disorder or behavioral health treatment for co-occurring disorders; and 3c) during project participation 50% of participants will engage in recovery-oriented peer support services. Goal 4) Increase benefits enrollment in Medicaid, Medicare, other health insurance, Supplemental Security Income, Social Security Disability Insurance and Supplemental Nutrition Assistance Program or other income. Measurable objectives: 4a) 75% of participants who have been enrolled in the project for at least six months will be receiving benefits or income; and 4b) 95% of participants who have been enrolled in the project for at least 12 months will have sustained receipt of benefits or income. page 1

WISH (Wellness Integrated Supportive Housing) will serve individuals experiencing homelessness in combination with severe substance use, behavioral health, and/or co-occurring disorders in Penobscot County, Maine. Peer support specialists and recovery coaches, using a Motivational Interviewing (MI)-Critical Time Intervention (CTI) service model, will provide systemic continuity of support via linkages to services, Housing First (HF) options, and recovery planning to the target population: homeless individuals, youth, and families with high vulnerability. This evidenced-based provision of services is correlated with improved health outcomes and housing stabilization. The WISH Steering Committee will be comprised of local and state public health agencies, substance use and behavioral health agencies, housing authorities, law enforcement departments, representatives from currently and formerly homeless persons in recovery, and homeless services providers. The population to be served includes subpopulations of veterans, persons exiting jails/prisons, persons fleeing domestic violence, and unaccompanied homeless youth with similar compromising conditions/high vulnerabilities. The applicant, Penobscot Community Health Care (PCHC) – a Federally Qualified Health Center based in Bangor, Maine – provides a range of highly integrated primary care, behavioral health, and dental care services to this population through their homeless shelter: Hope House Health & Living Center (Hope House). Penobscot County is a region of high poverty, low education, vast numbers of uninsured residents, and high rates of individuals with disabilities (when compared to national and state proportions). Our sparse population (estimated to be 152,692 in 2015, for a county that is larger than Rhode Island and Delaware) exhibits rates of poverty that are 26.7% greater than the national average. The 2016 homeless population in Penobscot County was 84.39% white, 6.23% Black or African American 0.45% Asian, 3.79% American Indian or Alaska Native, 4.78% multiple races, and 4.24% Hispanic or Latino. The veteran population in the county was 42.2% greater than the U. S. rate in 2015. A peer service model that depends on proactive outreach will be an important, missing complement to existing, in-reach services in Penobscot County. It has the potential to significantly improve the lives of homeless persons suffering from disabling conditions. The primary objectives of WISH are: 1) improved treatment utilization for severe substance use, behavioral health, and/or co-occurring disorders within homeless populations; 2) increased rates of health insurance within the target population 3) increased transitions to permanent housing; 4) reduced jail nights; and 5) reduced ED admissions. By combining an MI approach with a peer CTI model and the principles of HF, the complementary interventions will strengthen the probability of WISH achieving its desired outcomes. The project objectives align with SAMHSA’s expectations of increasing the number of program-enrolled individuals, and transitions to permanent housing that supports recovery-oriented treatment services around behavioral health. Performance measures to include: abstinence from use, housing status, employment status, criminal justice system involvement, access to services, retention in services, and social connectedness. PCHC/Hope House anticipates serving approximately 750 people throughout the lifetime of the project.

Streetwork, a program of Safe Horizon, proposes to expand our programming for homeless youth to by implementing Streetwork CARES (Connecting, Attaching, Respite, Empowerment, Safety) for Youth with Substance Use Disorders and Co-Occurring Disorders (“CARES”), which will include case management and evidence-based mental health treatment tailored to the needs of homeless young people with substance use disorders and co-occurring disorders. CARES will serve 102 youth in year one and 137 youth in each subsequent year, serving a total of 650 youth over the five-year grant period. Streetwork’s client population identifies as 43% Black; 40% Latino/a; 30% lesbian, gay, or bisexual; 55% male, 38% female, and seven percent transgender. Socioeconomically, all of Streetwork’s clients have very little income and live under the poverty level. This population, with whom Streetwork has been working since 1984, experiences high rates of mental illness, substance use disorders, and victimization. Streetwork serves a total of 1,100 unduplicated youth on an annual basis at our two drop-in centers. We conduct approximately 300 intakes of young people annually, all of whom will be screened for substance use disorders and co-occurring disorders. Given current intake data, we predict that approximately 48% (144 young people) will screen positive for substance use disorders and, of these, approximately 26% (78 young people) will screen positive for co-occurring disorders. Streetwork will partner with the Safe Horizon Counseling Center, a licensed outpatient mental health clinic that has been serving victims of crime and abuse since 1988. This partnership will expand access to evidence-based mental health treatment by bringing it on-site at the larger of Streetwork’s two drop-in centers. Clients will be engaged in Seeking Safety, an evidence-based model that has been found effective for both substance use and mental health. Additionally, Streetwork will provide intensive case management to this population to connect them to housing, benefits, healthcare, and other supportive services designed to move them toward safety and stability. Streetwork will continue to implement the ARC Framework (Attachment, Self-Regulation, Competency), an evidence-based practice, to engage homeless young people, a population that is known to be difficult to engage, in our continuum of services. ARC provides conceptual guidance and core principles of intervention for working with youth who have experienced multiple and/or prolonged traumas, which are very common among our clients.

St. Joseph Center’s People Recovering In Mutual Engagement (PRIME) implements a model of substance use treatment that is effective over a period of time as homeless individuals stabilize in permanent housing and engage in a process of recovery from homelessness, substance use, and mental illness. The project builds on St. Joseph Center’s IMHT and permanent supportive housing programs for high-need populations, intensifying focus on substance use disorders among clients with diagnosed mental illness. PRIME employs four evidence-based practices: Motivational Interviewing, Trauma-Informed Care, Critical Time Intervention, and Cognitive Behavioral Therapy. The project engages clients through street outreach, hospital referrals, and the Coordinated Entry Systems serving homeless individuals in West (SPA 5) and South (SPA 6) Los Angeles. The goal of PRIME is to integrate treatment of substance use disorders into a Housing First model of care that will motivate homeless individuals to engage in recovery so as to improve their housing stability, live a self-directed life, and develop a system of support that will sustain their recovery and help them avoid a relapse into homelessness. The objectives are: (1) over the five-year project period, 375 homeless adults with co-occurring substance use and mental illness will be enrolled in services and 75 individuals will be enrolled during the first project year, (2) over the 5-year project period, 300 homeless adults with co-occurring substance use and mental illness will become permanently housed and ten individuals will be housed during the first project year, (3) over the 5-year project period, 90% of program clients will remain in permanent housing for at least 6 months. Participants are supported by a network of community agencies including PRIME’s partnering organizations Los Angeles County Department of Health Services Housing for Health, Venice Family Clinic, Los Angeles County Department of Public Health (Substance Abuse Prevention and Control), Los Angeles County Department of Health Services (Medicaid), and, UCLA Integrated Substance Abuse Programs (ISAP). PRIME will be evaluated for implementation, reliability and validity of the performance management plan, process of implementation, and outcomes achieved with program clients.

Cook Inlet Tribal Council, Inc. (CITC), a mature, tribally-operated social services non-profit serving Anchorage, Alaska, proposes the Anchorage GBHI Collaboration to serve individuals of all genders in Anchorage who are experiencing homelessness, as well as substance use and co-occurring substance use and mental health disorders. Through a coordinated collaboration between key housing, behavioral health, and social services providers, the project will provide a host of wraparound social and cultural services including linkages to prioritized housing vouchers and comprehensive recovery treatment to individuals experiencing homelessness. Particular emphasis will be placed on serving disproportionately impacted Alaska Native and American Indian community members within this population. CITC proposes to serve 375 unduplicated individuals in total over five years through Anchorage GBHI Collaboration, including 238 individuals who will receive housing and/or recovery needs assessments and intensive case management; 200 of whom will also receive outpatient or intensive outpatient treatment. A minimum 150 individuals screened will receive housing vouchers, and 82 individuals per year (an estimated 35 unduplicated each year) residing in permanent supportive housing will have access to on-site pre-contemplation recovery groups and linkages to treatment and case management if desired. Through this service provision, Anchorage GBHI Collaboration will expand and coordinate supports at the system entry points most likely to address service gaps experienced by those living on the street, attempting to access emergency shelter, and/or experiencing repeated recidivism related to substance use and co-occurring disorders and homelessness. The project will more than double the number of complex-based permanent supportive housing rental units in Anchorage with access to on-site non-residential recovery service linkages. The enhancement and success of permanent supportive housing in Anchorage is vital for improved outcomes and self-determination in the lives of formerly homeless community members. It is also important in shifting our city toward more humane and lasting solutions to chronic homelessness.

Yakima Neighborhood Health Services (YNHS) proposes to further develop the local system for supporting homeless and near homeless youth, adults, and families experiencing SUD or COD by establishing a Community Resources Services Center (CRSC) to provide a one-stop, low barrier, coordinated entry point to the continuum of services available within the county, including permanent housing and integrated mental health/substance use treatment. YNHS is renovating an abandoned grocery store in which to locate the CRSC and 40 beds of transitional housing which will be completed in 2018. Meanwhile, the CRSC services will be provided from the location known as the Depot which currently houses the daytime warming center and the extreme winter weather shelter. Staff will also be located in our Sunnyside office to reach the homeless in the lower Yakima Valley. All homeless and near homeless youth, adults and families will be screened and assessed for the presence of SUDs or CODs. Those with SUDs or CODs will work with a case manager to develop appropriate treatment approaches and identify needs for other recovery support services. Referrals for additional services not provided directly by YNHS or its contractors will be made to the over forty homeless services providers participating in the Homeless Network of Yakima County. YNHS proposes to provide expanded services to 100 individuals and families annually (500 through the lifetime of the grant), including an estimated 44% Hispanic, 42% non-Hispanic white, 4% African American, 4% American Indian/Alaska Native, 4% mixed race, and 2% other. An estimated 9% will be below age 18, 1% will be comprised of families, and 0.5% will identify as Lesbian/Gay. YNHS will directly provide outreach and engagement services, all screening and assessments, case management and coordination, integrated behavioral health/substance abuse treatment, medical care including medication management, dental, vision, and transportation services. Housing referrals and placement will be made by YNHS’ housing support staff. 90-day or less inpatient mental health and detox treatment, and outpatient treatment for those needing intensive mental health care will be provided via contract by Comprehensive Healthcare. Substance use treatment services will be provided via a contract with Triumph Treatment. YNHS has a co-located medical and dental clinic serving the homeless at both agencies. YNHS has partnered with both agencies for many years. Supported employment training and placement will be provided via a contract with Entrust Community Services. Entrust will also provide Peer Mentors to assist in providing housing supportive services. A Steering Committee will be established to monitor that program goals are being met. Members will include representatives from the Washington State Department of Social and Health Services Behavioral Health Administration; a Medicaid representative; Yakima Health Department; Yakima Housing Authority; Triumph Treatment Services; an individual who has experienced homelessness and is in recovery; a Yakima County Homeless Network Continuum of Care representative; a Yakima Police Department representative; and the SAMHSA project Officer. Data will be collected from participants via face-to-face interview at intake, six months post intake, and at discharge and reported electronically utilizing SAMHSA’s SPARS system.

The City of Pasadena Public Health Department (PPHD) requests $1,995,605 to implement Operation Link, a five-year, community-based project that will engage, assess, serve, and house chronically homeless, high acuity adults and families in Pasadena, California (pop. 139,731). The PPHD will partner with Pasadena-based Union Station Homeless Services, who has served the homeless community for four decades and currently administers the San Gabriel Valley’s Coordinated Entry System. Operation Link will assess 610 homeless individuals over the five-year project, and provide intensive, wraparound services and linkages to permanent supportive housing to 280 of these individuals. The project is cost effective: A study in Los Angeles found that it costs, on average, $23,000 annually to provide public services to an individual who is living on the street. For the proposed Operation Link population that equates to $6.4M spent every year in emergency room services, time spent in jail, etc. The study found that providing permanent supportive housing reduced those costs by 57 percent, or approximately $3.65M in savings for Operation Link’s clients. The potential savings is a significant sustainability mechanism for the proposed project that will be explored by area stakeholders during the project period. Operation Link will be a critical component of the City’s broader effort to combat homelessness which includes ongoing and targeted data collection on the City’s homeless population, strategic planning and coordination, and efforts to increase the inventory of transitional and permanent housing. The broader effort – the Pasadena Continuum of Care (CoC) – is funded by the U.S. Department of Housing and Urban Development (HUD). The Pasadena CoC’s Health Care Committee has agreed to serve as the Steering Committee for Operation Link. While the number of homeless in Pasadena has been trending down in the last five years, the current prevalence of homelessness in Pasadena (measured in number per 100,000) is higher than state and national averages, and worse than other major California cities like Los Angeles and San Diego. The problem is fueled by Pasadena’s reputation for tolerance toward the homeless community and the concentration of the San Gabriel Valley’s services in Pasadena, which lead homeless people throughout Southern California to migrate to Pasadena. The City’s homeless population has disproportionate representation of: African-Americans, victims of domestic violence, and persons with a criminal history, physical disabilities, and behavioral health issues. The project is an expansion of a Health Resources and Services Administration (HRSA)-funded pilot project that served a similar but narrower population: homeless individuals with co-occurring disorders who were also HIV+. The project successfully housed 85 percent of clients. Several important lessons were learned during the pilot project and these are driving the need for the proposed project: 1) the high prevalence of co-occurring disorders among the chronically homeless, their extremely high acuity, and the lack of sufficient substance abuse and mental health services to address this population; and 2) the need to customize the outreach approach to: a) include trauma-informed approaches, b) implement outreach after-hours and on weekends, and c) target emerging and changing ‘hot spots’ where the City’s homeless congregate. The project will benefit from a number of assets and resources that will be leveraged, including: 1) the Pasadena CoC’s ongoing activities; 2) an existing Coordinated Entry System that is administered by project partner, Union Station Homeless Services; 3) the framework, project materials, and knowledge from the earlier pilot project; and 4) an estimated $1,627,325 in leveraged services and contributions from the PPHD and Union Station Homeless Services that are offered as a demonstration of the commitment to Operation Link.