Grants Dashboard

Community Rehabilitation Center (CRC) plans to partner with The Sulzbacher Center, and the Jacksonville Housing Authority or the implementation of Project Safe Horizon will focus on 1) engaging and connecting the population of focus to behavioral health treatment, case management, and recovery support services; 2) assisting with identifying sustainable permanent housing by collaborating with homeless services organizations; and 3) providing case management that includes care coordination/service delivery planning and other strategies to support stability across services and housing transitions. The proposed unduplicated numbers to be served: 30 year 1, and 80/year years 2 thru 5, for a total of 350 participants who are experience serious mental illness (SMI), serious emotional disturbances (SED), or cooccurring disorders (COD) who are experiencing or at imminent risk of homelessness. Project Safe Horizon will expand existing services compendium by increasing the number of locations providing supportive housing and increasing the number of persons and families receiving services. The project will also enhance current services by incorporating evidence-based practices and tools for delivering counseling, behavioral therapies, psychosocial services, and recovery support services including using a shared decision-making approach. EBP’s include Assertive Community Treatment, Seeking Safety, and Cognitive Behavioral Therapy. The expected outcomes of the program will be 1) Strengthened organizational capacity to increase number of persons in mental health or co-occurring disorders treatment and permanent housing; 2) increased number of clinic patients receiving housing and treatment services leading to reduction of mental health problems, substance use, and homelessness among participants; and 3) a comprehensive evaluation of processes and outcomes as measured by successful collection of GPRA, and service dosage data supporting an increased involvement in treatment and supportive housing services. Safe Horizons will accomplish its goals by implementing the following required activities: Outreach and engagement activities, SMI/SED/COD treatment, evidence-based harm reduction practices; SOAR Case Management; Recovery support services; availability of permanent housing; and establishing The Jacksonville Homeless Steering Committee.

Outside In Outpatient Counseling is a program serving homeless youth and young adults in Portland, Oregon who are experiencing serious mental illness (SMI), serious emotional disturbance (SED), or co-occurring disorder (COD). Specialized outreach and care designed to expand access and retention in services for individuals identifying as Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, or Intersex (LGBTQI) is also available. Anticipated treatment outcomes include improved housing stability, reduced substance use and mental health symptoms, and improved functioning in everyday life. Outreach and placements into public housing will be coordinated through the Multnomah County Homeless Youth Continuum (HYC), the HUD-coordinated entry system for transition age youth. Additional grant strategies include (1) an expanded trauma-informed, culturally appropriate infrastructure that includes skilled providers with lived experience, (2) integrated behavioral health treatment and other recovery supports, (3) assistance enrolling into resources for health insurance, Medicaid, and mainstream benefits, including SSI/SSDI, TANF, SNAP, and SOAR, (4) increased access to culturally specific healthcare services, including gender affirming care, and (5) continuity of care for transition age youth moving from transitional living programs to independent housing. Evidence-based treatments include Acceptance Commitment Therapy (ACT), Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI). PSU's Regional Research Institute will track and assess project implementation, sharing outcomes and lessons with Outside In and its program partners for planning purposes. The program is designed to serve 40-60 youth and young adults per year for a total of 280 served over the course of the five-year grant. The anticipated project period is September 30,2023 through September 29, 2028.

Abstract Project Name: Vegas Stronger - TIEH Vegas Stronger, a nonprofit serving the Las Vegas Valley, will provide comprehensive, integrated, and evidence-based treatment to youth, Spanish speaking individuals, and people experiencing homelessness or at imminent risk of being homeless with serious mental illness, serious emotional disturbance, and co-occurring disorders. This will be achieved by hiring staff to provide evidence-based, trauma-informed, and culturally appropriate treatment programs. This includes two counselors (including one youth counselor), a case manager, a bilingual outreach specialist and a bilingual support specialist. Help Hope Home’s 2022 Point-In-Time results showed 5,645 people were experiencing homelessness in Southern Nevada. The report further disclosed that 516 were individuals in families with children and 314 were unaccompanied youth and young adults. The survey revealed that 74% of the homeless population self-reported a disabling condition, and of those, 36% cited substance abuse and 33% cited mental health. There are three zip codes in the service area with a significant demand for services. Vegas Stronger is located in zip code 89101 and focuses on this zip code as well as the two adjacent zip codes, 89106 and 89030. This area contains a 57% Hispanic population and 49.85% Spanish-speaking households. Goals of the program are: GOAL #1 - Provide outreach efforts to increase access to evidence-based treatment and recovery support services. GOAL #2 Increase capacity for treatment and recovery support services by expanding evidence-based, trauma-informed, and culturally appropriate treatment for SMI, SED, and COD. GOAL #3 Increase access to coordinated services that are culturally and linguistically sensitive through community-based programs to promote health equity. Specific strategies include: • Conduct consistent and supportive street and community outreach. • Establish two new intensive outpatient (IOP) groups, one for adults and one for youth with complimentary activities such as peer support services. • Provide case management services including, providing care coordination, and assisting clients with enrollment in Medicaid, health insurance, and other mainstream benefits. • Provide telehealth services. • Implement telehealth services. • 116 clients assisted with permanent housing (20 year 1, 24 years 2-5). • 580 individuals receive case management services (100 year 1, 120 years 2-5) • 580 individuals screened for health insurance, Medicaid, and/or other benefit programs and enrolled if necessary and eligible. (100 year 1, 120 years 2-5) • New Spanish Vegas Stronger website (vegasmasfuerte.org) within eight (8) months. • 870 brochures printed in Spanish handed out to Spanish-speaking individuals (150 year 2, 180 years 2-5). All written materials to be translated to Spanish within six (6) months. • Signs in Spanish to be purchased and installed within three (3) months. The population of focus are youth, Spanish-speaking individuals, and people experiencing homelessness or at imminent risk of being homeless. One hundred (100) clients will be served in the first year. One hundred and twenty (120) will be served in subsequent years for a total of five hundred and eighty unduplicated (580) individuals. By the end of the five-year period, access to treatment for individuals with SMI/SED/COD will be dramatically increased.

The Bridge's Treatment for Individuals Experiencing Homelessness (TIEH) Program is designed to serve marginalized youth and adults living in Manhattan, the Bronx, and Brooklyn who are experiencing homelessness, coupled with mental health and/or substance use disorders, or co-occurring disorders. The specific populations to be served include youth and adults, including people of color (POC), low to no-income individuals, people experiencing homelessness (PEH), and people with complete mental health (MH), serious emotional disturbances (SED), substance use disorders (SUD), and co-occurring disorders (COD). The project's overall purpose is to assist these individuals by helping them enroll in mainstream benefits, appropriate treatment, and recovery programs so they will succeed in sustainable permanent housing accessed through a coordinated approach by The Bridge. Project goals include 1) improving access and decreasing barriers to integrated behavioral health (BH) care among high-need individuals through a comprehensive range of outreach, screening, assessment, treatment, care coordination, and recovery supports; 2) improving efforts to engage and connect clients to enrollment resources for health insurance, Medicaid, and mainstream assistance; and 3) improving access and decreasing barriers to housing and services that support sustainable permanent housing amount high-need individuals through a coordinated approach. Project objectives include 1) increasing response time to less than 3 hours for 85% of those in need of BH care by developing and implementing a 24/7 crisis intervention, risk assessment, and treatment response system for high-need individuals. 1.2) increase utilization of BH services by strengthening social supports amount 85% of high-need individuals by utilizing peer support. 2.1) increase response time to less than seven days to enroll 85% of clients in mainstream assistance programs by collaborating with such programs and developing relationships that allow for faster enrollment for clients. 2.1) increase utilization of mainstream assistance programs and The Bridge programs for BH, SUD, and housing services by 50%. 3.1) Increase advocacy for PEH seeking sustainable permanent housing by coordinating with housing authorities and 20 other landlords on how to best interact with residents with MH conditions or co-occurring conditions. 3.2) increase utilization of a landlord list that PEH can contact to locate sustainable permanent housing. 4.1) review and improve diversity, equity, and inclusion policies and practices to address the disparities in MH outcomes. 4.2) hire a Training Specialist to build the capacity of a least 100 employees to deliver culturally responsive, evidence-based care to 150 individuals each year. The number of people to be served annually is approximately 150 for a total of 712 through the full five-year grant period. Interventions that will be used during this project include Motivational Interviewing, peer support, cognitive behavioral therapy, dialectical behavioral therapy, medication-assisted treatment typically used for SUD, supported employment, and Integrated Dual Disorder treatment. These interventions are designed to assist PEH with MH/ SED and/or SUD who want treatment and seek housing.

The proposed Healing to Recovery project demonstrates an innovative collaboration between two established entities: Behavioral Health Network of Greater St. Louis and Haven Recovery House, with the overarching intent of establishing recuperative care models in recovery housing settings for homeless and at risk of homelessness young adults and men, women, and all genders and orientations ages 18-65, located within the St. Louis Metropolitan Statistical Area. The POF will primarily emanate from the City of St. Louis, population 296,958, which is a unique independent governance within 65 square miles, and the adjacent northern sector of St. Louis County, comprised of 26 highly diverse separate municipalities, population 322,003, occupants of which are historically and persistently marginalized, with poverty rates ranging as high as 46%. Significantly high incidences and hotspots saturated by gang activity, violent crime, poverty, and disinvestment in both the City of St. Louis and northern St. Louis County are well documented, ranking among the highest in the United States, with both areas located in the footprint of a Federal Promise Zone. According to Continuum of Care (CoC) data, the 2022 HUD Point in Time census of homelessness in St. Louis increased by 34% in the 5 years from 2018, and by 60% during 2023. Healing to Recovery will focus on the following strategies and interventions serving 30 persons in year 1, 60 in year 2, 60 in year 3, 60 in year 4 and 30 in year 5 for a total of 240: outreach and engagement, with a focus on marginalized populations; screening, mental health and substance use disorders services, case management including enrollment in mainstream benefits and linkage to stable housing, recovery support services, and referral / follow-up; the development of a steering committee; collaboration with the 988 system; and stakeholder mapping. Project goals and objectives are as follows: Goal 1: Increase the number of medically fragile, SUD/COD, homeless individuals with an emphasis on African Americans served, engaged, and retained in services throughout the project. Objective 1.1: Up to 240 clients will be provided comprehensive recuperative care services in a recovery housing setting, mental health and co-occurring disorder services over the 5-year project. Objective 1.2: 100% of clients in the program will be connected to BH or SUD treatment. Objective 1.3: 100% of clients in the program will receive recovery support services and meet with a peer support specialist. Objective 1.4: 60% of clients enrolled in the project will be retained in treatment or recovery services for 6 months. Objective 1.5: 100% of clients needing interpretation / translation will have access to appropriate services throughout the project. Goal 2: Improve behavioral and health outcomes for 70% of clients enrolled in the project. Objective 2.1: 70% of clients enrolled in the project will report a reduction in SUD/COD symptoms over 6 mos. Objective 2.2: 70% of clients in SUD/COD treatment services will experience a reduction in drug and alcohol use / misuse over 6 months. Objective 2.3: 100% of clients who are not covered will be offered assistance with enrolling eligible participants or their families including health coverage, food stamps and social security programs, as applicable, throughout the 5-year project. Objective 2.4: 70% of clients will improve social connections at 6-month follow up. Objective 2.5: 50% of clients will be in sustainable, permanent housing by the end of the project.

Meridian Behavioral Healthcare, Inc., working in partnership with Alachua and Putnam Counties and other key community partners will implement a Treatment for Individuals Experiencing Homelessness (TIEH) Partnership Program to strengthen and expand a comprehensive and collaborative service system of integrated, and evidenced-based outreach, treatment, recovery, housing supportive services for primarily adults, with Serious Mental Illness (SMI), Serious Emotional Disturbance (SED), and Co-Occurring Disorders (COD) experiencing homelessness, targeting the African American homeless population. Meridian TIEH Partnership program will utilize a mobile unit to provide outreach, screening, assessment and treatment services on-site in neighborhoods where many encampment sites are located, and cultural and linguistic disparities are evident. The collaborative service system will operate as a strategic co-responder team to enhance opportunities for outreach to identify and actively engage individuals experiencing homelessness; living on the streets, living in encampment sites and other areas to assist them to access mental health and substance use treatment, healthcare, recovery services, housing, mainstream benefits, employment, other services, resources and benefits that many in this vulnerable population may not be able to easily access, navigate or afford without assistance. The program will also focus on strengthening and addressing the social and family support systems, poverty and socioeconomic needs and community connectedness beneficial for the persons served. The goals and objectives related to for programs treatment and services are as follows: GOAL1: Decrease Health Disparities/Improve Mental Health Outcomes: Objective 1A:100% of individuals enrolled in TIEH will complete the Health/Wellness Section of the enrollment assessment and assist to connect to integrated physical and behavioral healthcare treatment/ services as needed; evaluated annually. Objective 1B: 80% of TIEH enrolled participants, who are enrolled in MH Treatment or Services will be actively participating in treatment or services, evaluated annually. GOAL2: Reduce Homelessness: Objective 2A: Conduct strategic outreach engagement services to connect individuals experiencing homelessness to housing and other services. Objective 2B: By end of the grant, 60% of individuals enrolled in the program will be placed in permanent housing and/or provided housing support services related to permanent housing securing placement. GOAL3: Increase Income-/Non-Cash Benefits: Objective 3A: 25% of Individuals enrolled in program will increase income benefits through employment, SNAP, Social Security or Disability, evaluated annually. GOAL 4: Decrease Criminal Justice/Juvenile Involvement amongst Participants Objective 4A: 50% of individuals enrolled in program will have no criminal justice involvement, evaluated annually. GOAL 5: Improve Social Connectedness and Community Involvement: Objective 5A: 50% of enrolled participants will improve social consecutiveness, community and/or family involvement, evaluated annually. GOAL 6: Expand/Strengthen Community Partnerships: Objective 6A: At least one (1) presentation quarterly to existing and/or new community partners regarding TIEH services or attend a community health awareness event/conference hosted by community agencies. Meridian TIEH Partnership Program anticipates providing services to 250 unduplicated persons per year and 1,250 throughout the life of the project.

The selected population focus for the A-RMI Program (Aniz Rehousing for the Mentally Ill) is disadvantaged African-Americans age zero and over in Atlanta, GA. Aniz serves over 2,700 members annually, primarily in metro Atlanta. It additionally conducts street outreach and reaches 2,200 individuals through brief contact SBIRTS, providing HIV testing to over a 1,000 annually. The A-RMI project will serve members of the Atlanta population who are experiencing unstable housing. Aniz is the only wraparound Harm Reduction service provider in Georgia which eliminates the precondition of sobriety for stable housing. Aniz wraparound services provide case management, holistic harm reduction services, mental health counseling and emotional support and therapy, and trauma-informed care. Participants have access to health care through the Aniz, Inc. on-site 340B clinic as well as referrals to primary care, linkage to government benefits such as Medicaid, SNAP, and local government resources. Aniz operates on a holistic harm reduction approach through trauma-informed care. Aniz works to link individuals to health care and support services so that the cycle trauma is broken. Aniz utilizes several Evidence-based Practices (EBPs) targeted specifically to the member’s needs, risk analysis, and trauma. For the purposes of the A-RMI program, the processes are already in place. For SUD COD UHIs, there are three levels based on assessment: low, moderate, and high risk. For SUD SED and SMI, they are classified as minimally, moderately, or severely impaired. For low risk/moderately impaired, the therapeutic strategy is to provide feedback, mental and emotional wellness counseling, education, reinforce Holistic harm reduction and offer positive reinforcement and support and referral to a counselor. For moderate risk/impairment, the therapeutic strategy is to provide brief interventions, mental and emotional wellness counseling including feedback, advice, assessment of readiness to change, assistance in changing. For high risk/severe impairment, the therapeutic strategy is to provide brief intervention and referral to specialty treatment. The goal of a referral is to assure that the individual contacts a specialist for treatment, as the screening indicates that their substance issues may be too severe to be managed with only brief intervention/require additional assessments to determine the severity of the problem. Severely emotionally disturbed and mentally ill are linked to medical care for treatment and medication. Aniz wraparound services provide case management, holistic harm reduction services, mental health counseling and emotional support and therapy, and trauma-informed care. Participants have access to health care through the Aniz, Inc. on-site 340B clinic as well as referrals to primary care, linkage to government benefits such as Medicaid, SNAP, and local government resources.

The Seneca TIEH Initiative provides comprehensive, coordinated, evidenced-based services for individuals/children/youth/families with a serious mental illness/serious emotional disturbance, or co-occurring disorder who are or are at imminent risk of experiencing homelessness. The focus population is rural & suffers poor mental health, social health determinants, substance use & homelessness. The project will serve 544 people (75-Y1, 94-Y2, 108-Y3, 124-Y4, 143-Y5). Project goals (interventions/strategies) are to (1) Engage and connect the focus population to behavioral health treatment, case management, and recovery support services via (A) Hiring a Project Director, Evaluator, Youth/Adult Crisis Specialists, Case Managers, Peer Recovery Support Specialists (PRSS), Therapist & Training Coordinator to expand focus population services; (B) Conducting community outreach in areas where unhoused individuals congregate to offer services; (C) Providing annual training to community partners to increase partner ability to identify and serve clients with SMI/SED/COD; (D) Working with referral partners to obtain program referrals; (E) Partnering with area schools to identify and obtain program referrals for families at risk of or experiencing homelessness; (F) Working with the state crisis line to obtain program referrals; (G) Identifying culturally competent referral pathways for disparity group members & (H) Referring and following-up on referrals for individuals who are deemed ineligible for TIEH services. (2) Assist with identifying sustainable permanent housing for the focus population by (A) Working with area housing providers to identify safe permanent housing for clients; (B) Linking 100% of clients to housing resources & (C) Conducting a landscape analysis to determine all available resources for the unhoused. (3) Provide case management that includes care coordination & service delivery planning that supports stability across services and housing transitions for the focus population via (A) Purchasing an initiative vehicle to be used to provide outreach, services & telehealth for clients; (B) Creating a person-centered service delivery plan with each client; (C) Providing case management services to clients; (D) Providing PRSS services to clients & (E) Ensuring clients receive infectious disease screening & education. (4) Improve focus population mental health, social & substance use outcomes via (A) Serving 544 clients; (B) Empowering clients to have statistically significant improvement in stable housing outcomes at 6-month follow-up; (C) Empowering clients to have statistically significant improvement in NOMs mental health outcomes at 6-month follow-up; (D) Empowering clients to exhibit a statistically significant decrease in substance misuse at 6-month follow-up; (E) Empowering clients to exhibit a statistically significant improvement in NOMs social outcomes at 6-month follow-up; (F) Empowering clients to remain in treatment for at least 6-months throughout the life of the grant; (G) Monitoring disparity group outcomes to ensure equal access/service/outcomes/retention; (H) Completing a social determinant of health survey to identify needs based on disparity group status & (I) Implementing the national CLAS Standards. (5) Sustain TIEH services for the focus population post-grant funding via (A) Initiating a Steering Committee which will oversee the program & (B) Creating a program sustainability plan to be updated annually.

The overarching goal of the UTHealth Homeless Outpatient Mental Health Expansion Services (UTHealth HOMES) Program is to promote long-term mental health recovery, reduce substance use, and ensure access to all needed services, benefits, supports, and permanent housing for people experiencing homelessness (PEH) with SMI or COD (SMI/COD). To accomplish this goal, UTHealth HOMES will enroll and deliver services for 500 unduplicated PEH with SMI/COD (80 PY1; 105 PYs2-5) through the following program activities tailored to individual patient needs and preferences through a shared decision making (SDM) process: (1) assertive outreach; (2) screening and referral; (3) trauma-informed, culturally responsive, person-centered, evidence-based, behavioral health treatment using Motivational Interviewing (MI), cognitive behavioral therapy (CBT), and Seeking Safety; (4) case management delivered by community health workers to address social determinants of health (SDoH) and link participants to all needed benefits, resources and primary care; (5) peer support; and (6) coordinated access assessments and coordination of housing and services that support sustainable permanent housing in collaboration and consultation with medical care providers. Additionally, UTHealth HOMES will train 410 service providers on the Behavioral Health Guide for Implementing the National CLAS Standards improve behavioral health outcomes and achieve equity within the CoC. The program is housed within the University of Texas Health Science Center at Houston (UTHealth) Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences at McGovern Medical School. Community partners include: UTHealth Harris County Psychiatric Center, UTHealth Houston Emergency Opioid Engagement System (HEROES) program; Bread of Life, Inc., Temenos CDC, Avenue 360 FQHC, The Harris Center for Mental Health and IDD (LMHA), Open Door Mission, Sharpen Recovery Housing, and The Coalition for Homeless of Houston/Harris County (HUD CoC). The goals of the program are to: Goal 1: Increase the availability of outpatient behavioral health (BH) treatment for PEH with SMI/COD by screening, assessing and delivering appropriate BH services through the UTHealth HOMES program; Goal 2: Decrease mental health symptom severity and the incidence and level of substance use and promote recovery for PEH with SMI/COD by providing comprehensive evidence-based BH treatment; Goal 3: Improve the physical health status of PEH with SMI/COD through primary care linkage/coordination; Goal 4: Address SDoH through linkages and case management to meet all benefit/resources needs; Goal 5: Provide CLAS training to advance health equity and improve service quality within the CoC. Measurable objectives include the number of participants enrolled in BH treatment per year, significantly decreased mental health symptoms, substance use, and psychiatric hospitalizations, improved mental health recovery and medication adherence, percentages of participants assisted with applying for and accessing all needed benefits and resources and linked with permanent housing, and the number of service providers trained, knowledge gained and skills used. All participants will be offered BH treatment, case management, and assessed for and linked with permanent housing using harm reduction principles and practices.

The University of Arkansas for Medical Sciences (UAMS) (applicant) and Our House Shelter, Inc. (OH) (sub-recipient) will collaboratively co-lead a project for adult parents (or custodial caregivers; PCC) in Pulaski County, Arkansas (AR), who have a serious mental illness (SMI), serious emotional disturbance (SED) or co-occurring SMI and substance use disorder (COD; together referred to as MI/COD) who are experiencing homelessness or at imminent risk of homelessness (EHIH) with at least one child 0-18 yrs. (PCCF-MI/COD). Our community-based participatory project is entitled “Home Together: Reducing family homelessness through integrated mental health treatment, recovery, and supportive community services”. Home Together’s overarching goal is to increase access to and delivery of coordinated, comprehensive behavioral health treatment and recovery support services and increase sustainable, permanent housing among PCCF-MI/COD by providing Home Together enrolled client families with strengths-based peer-supported case management and trauma-informed family-focused care coordination. Home Together staff will enroll 90 eligible families annually (68 families in year 1) into the project and coordinate direct evidence-based services in a trauma-informed continuum of care to an average of 3 persons per family for a total of 428 unduplicated families and an unduplicated count of 1,284 individuals served over the 5-year project. Based on our successful first iteration of the Home Together project funded by 2018 SAMHSA TIEH funding (SM080742) a large proportion of families served are expected to be members of underserved populations who are overrepresented in AR’s homeless population. Among clients served in our project from 2019-2022, 84% self-identified as Black and 3% as Hispanic. Many of these individuals lived in overpoliced, racially-segregated communities of concentrated poverty that lack access to quality, culturally and linguistically appropriate healthcare and social resources, which exacerbates both chronic and acute health conditions and racial health disparities across the life course experienced by these populations. Furthermore, regardless of race or ethnicity, people with MI/COD face disproportionately high rates of poverty, housing and employment discrimination, and criminalization. In 2018, UAMS and OH partnered to address these long-standing needs and service gaps and (despite barriers/delays caused by COVID-19 pandemic) enrolled 302 unduplicated primary clients and provided direct services to them and their 682 children in our first 4 project years, with 85% reassessment rate and 79% housing success rate at 6-month follow-up. In the current Home Together application, eligibility has been expanded to include fathers and other custodial caregivers as well as families with children up to 18yrs. The proposed Home Together project will: 1) Implement multiple outreach and engagement strategies to identify and connect with individuals and families EHIH and MI/COD; 2) Screen all identified referrals EHIH for MI/COD and project eligibility and accordingly, refer all individuals EHIH screened positive for MI/COD to appropriate services with follow-up or project enrollment; 3) Ensure timely delivery of integrated mental health and substance use services; 4) Provide strengths-based peer-supported case management and trauma-informed family-focused care coordination for PCCF-MI/COD, and 5) Implement culturally and linguistically appropriate practices to increase access to and engagement in mental health, recovery, and supportive community services among underserved populations in PC.

Samaritan Daytop Village proposes Project STAR (Screening, Treatment, Assessment, and Recovery), which will offer behavioral health services to 420 single adult homeless women who experience serious mental illness (SMI) and/or substance use disorders (SUD) in Queens, NY. Project participants will be connected to community-based treatment and recovery supports and engage in mental health supports and case management at the shelter where they reside. Project STAR addresses the unmet needs of homeless women with SMI/SUD who are placed in a general population homeless shelter, rather than a specialized shelter that would address their need for connections to behavioral healthcare and recovery supports, which in turn are a prerequisite for transitioning into sustainable permanent housing. Samaritan Daytop Village (SDV) will serve women who are residents of two general population shelters, which are operated by SDV in a low-income, underserved neighborhood in Queens, NY. The shelter population represents marginalized populations of color: 74% of shelter residents identify as Black, 17% as Hispanic/Latina, 5% as White/Non-Hispanic, 4% as other. The average age of shelter residents is 45 years old, and less than 2% identify as transgender. In Year 1, SDV will serve 60 clients, and 90 in each of Years 2-5, for a total of 420 participants. Funding will enable SDV to enhance shelter services through 1 FTE Project Director (a licensed clinician who will spend half their time on direct service delivery), 1 FTE licensed BH Specialist, 2 FTE credentialed Peer Specialists, and 0.5 FTE Licensed Creative Arts Therapist. Project staff will conduct continuous outreach and engagement of women who have a diagnosis of SMI/SUD or show signs and symptoms of significant behavioral health issues. Enrolled participants will be assessed to determine treatment needs, preferences, strengths and resources, which will form the basis for the development of a collaborative service plan. The primary objective of Project STAR is to securely connect homeless women with SMI/SUD to trauma-informed, culturally competent, client-centered, evidence-based, and integrated mental health and SUD services through community-based providers. Based on each woman’s Service Plan, the project team will provide active referrals to ensure that clients have access to integrated and comprehensive care for mental health and SUD, including psychiatric evaluations, psychopharmacological and addiction medications as well as outpatient mental health and SUD treatment. Referrals may be made to SDV’s own licensed clinics, residential programs, recovery centers, and care coordination programs as well as those operated by SDV’s network of partners. Project STAR staff will further offer individual and group mental health and recovery support services to promote emotion regulation, wellness management, and trauma coping. Case management will address barriers to care and promote transition to community housing. Over the course of the project, 294 women will be connected to behavioral health care, and 250 women will have participated in psycho-education, skills-building, and other interventions for trauma coping, recovery, and wellness management as well as in peer recovery support services. As a result, 50-70% of women will report improved medication adherence, reduced depression, anxiety, aggression, and/or PTSD symptom severity, and 60% will have improved SUD status and overall functioning. A minimum of 40% of participants will maintain their connection to behavioral healthcare post-discharge and show improved housing status.

Team Management 2000 Inc. (TM2K) a minority run Certified Behavioral Healthcare Clinic (CCBHC) located both Northern NJ (23yrs) and (4yrs) in Atlanta Georgia delivering ambulatory outpatient services for this vulnerable population. TM2K seeks to implement the ""Circle of Life"" Homeless Recovery Initiative (HRI) project to further reduce homelessness among those suffering with addiction and mental illness in the Metro Atlanta Area (Atlanta, Fulton and DeKalb Counties) using innovative mobile outreach, Evidenced Based Practices with treatment and comprehensive case management to further interrupt the cycle of mental illness addiction and homelessness. Circle of Life proposes to serve 45-50 homeless consumers annually and 225 individuals who have co-occurring substance and mental health disorders in total over the five year grant. We anticipate these individuals will be ages 16-65 and 40 per will be female and 50 per male and 10 percent Transgender, and of those 15 percent will be families. Demographic show 70 per are heterosexual and 30 percent will identify as LGBTQ, MSM or YMSM. The majority of the them will be HIV positive with other co-morbidity's and uninsured living below the federal poverty standard. The project will provide medical mobile Outreach and Engagement strategies to connect the homeless population to outpatient services. We anticipate reaching 30-50 consumers per month and 360 per year and 1800 over the 5 year gran period. All consumers admitted will receive substance abuse and mental heath treatment, a individual treatment and housing plan and MAT or opiate addiction. They will all receive a Comprehensive Case Management plan with coordination of care, housing placement and benefits to support economic stability and sustainability. The outcomes will show 60 per having a better quality of life, 60 per reporting a decrease in psychological episodes, 75 per remaining in treatment for at least 6 months, 50 per will have transitional housing and 25 per will have permanent housing, 75 per will be insured and have access to primary medical and 75 per will be clean and sober from alcohol and drugs. This project will build upon the success of our NJ TIEH where we delivered excellent measure's and outcomes and rank as a high performing SAMHSA grantee

The CCSI Homeless Partnership Program is a community collaboration that brings together key organizations with the intent of improving access to, and retention in, services to support persons with Serious Mental Illness (SMI) or Co-Occurring Disorders (SMI/Substance Use Disorders) who are homeless or at imminent risk of homelessness to be successful in recovery and in maintain stable housing. The project goals are to: • Increase the capacity of the behavioral health and homeless systems to identify and engage persons with SMI and/or COD who are homeless and not engaged in service • Identify sustainable permanent housing options for individuals enrolled in the Project • Provide evidence-based, integrated mental health and substance use interventions for COD treatment and case management services for enrolled individuals • Provide linkages to recovery support services The geographic area to be served is Monroe County, New York. The Project brings together organizations who provide services within and/or oversee the Mental Health, Substance Use Disorder, Medicaid, Homeless, and Housing systems in the community, along with community-based and peer-run recovery support services. It puts in place an infrastructure to support the integration of services from the various service delivery systems in providing integrated care, recovery support, and housing for the population of focus (adults 18+ with SMI or COD who are experiencing homelessness or at imminent risk of homelessness). This will be accomplished through establishing processes for easy access and incorporating a focus on evidence-based approaches throughout outreach, engagement, care management, treatment, and housing. Primary interventions to be used include Critical Time Intervention, Peer Support/Recovery Coaches, Housing First, and Integrated Treatment for COD. These interventions will be supported with training and coaching of Project staff and community partner agencies in areas such as Motivational Interviewing, Health Equity, Trauma-Informed care, Housing First, and the CTI approach. The project is designed to set procedures and practices in place that can easily be expanded over the duration of the grant to support growth in the use of evidence-based strategies for engagement, care management, and treatment to meet the needs of the population of focus and foster stability in permanent housing. The Project will serve 75 individuals per year (45 in Year 1), for a total of 345 persons over the five-year duration of the grant. It is expected that the population to be served will mirror that of the homeless and/or behavioral health population in Monroe County, with a significant proportion of this population being non-white.

This proposal from the Center for Excellence in Community Mental Health (CECMH) at the University of North Carolina at Chapel Hill is in response to funding opportunity SM-23-006 (Treatment for Individuals Experiencing Homelessness) and seeks funding to combine supportive housing services and comprehensive wrap-around evidence-based supports to address the housing, health, and behavioral health needs of homeless persons with SMI in North Carolina. Our project, called HomeLink, will connect participants to: (1) stable and affordable housing; (2) enhanced psychosocial rehabilitation targeting independent living skills necessary to maintain stable housing; and (3) enrollment resources for health insurance, Medicaid, and mainstream benefits (e.g., Supplemental Security Income)/Social Security Disability Insurance, Temporary Assistance for Needy Families, Supplemental Nutrition Assistance Program, etc.). We will accomplish these aims by creating a HomeLink team comprised of a team lead, a housing specialist, a peer-support specialist, and coordinated independent living skills specialists (occupational therapy). The team will combine a variety of evidence-based practices (e.g., occupational therapy, Housing First, motivational interviewing, illness management and recovery, etc.) to provide direct services and coordinate comprehensive case management with local mental health service providers to serve individuals who are chronically homeless or at risk of becoming homeless. We anticipate serving 100 persons annually and 500 persons over the entire project. We have letters of commitment from local mental health service providers and community stakeholders to engage (1) individuals who are chronically homeless; (2) individuals in assisted living facilities who are at risk of becoming homeless; (3) individuals transitioning from institutionalized settings; and (4) individuals receiving assertive community treatment or outpatient services who are at risk of homelessness. HomeLink will collaborate with local housing agencies and our local managed care organizations - Alliance Health - to access housing and housing vouchers. Currently, routine community mental health services fail to provide skilled assessment and interventions targeting the independent living skills of adults with SMI who are homeless or at risk of homelessness. The CECMH recognizes that housing and comprehensive health and behavioral health services must be enhanced with occupational therapy to optimize the independent living skills of adults with SMI and reduce homelessness. Accordingly, we will use SAMHSA funds to integrate occupational therapy into CECMH services and assertive outreach initiatives. The diversity in race, ethnicity, rural and urban living, income, and education in the CECMH consumer population presents an opportunity to expand our delivery of person-centered and culturally competent care to address housing, physical health, behavioral health and deficits in independent living skills in a cost-effective way that improves the participation and quality of care for individuals with SMI.

PILLAR, a Certified Community Behavioral Health Center, in partnership with Bethany House, Laredo Housing Authority and the City of Laredo Health Department, proposes the implementation of Project New Beginnings with a population of focus of adults, families and youth diagnosed with a serious mental illness, serious emotional disturbance, or co-occurring disorders who are experiencing homelessness, or at risk of imminent homelessness in the catchment area of Webb, Jim Hogg, and Zapata counties in the Laredo-Mexico border region. The purpose of the project is to support the expansion of local implementation of a community infrastructure that integrates behavioral health treatment, peer support, recovery support services, and linkages to sustainable permanent housing. The proposed unduplicated numbers are a total of 310 participants: 50 Yr1, 60 Yr2, 70 Yr3, 80 Yr4, and 50 Yr5. The rate of homelessness in the area has been greatly affected by this rapid population growth and the presence of significant socioeconomic disparities with a staggering 163% increase in homeless counts, from 213 in 2018 to 397 in 2022. The selected culturally appropriate evidence-based practices include Assertive Community Treatment, Seeking Safety, and Cognitive Behavioral Therapy. The principal goals of the project are: 1) strengthen agency partnerships, infrastructure and expand service compendium to ensure effective planning and service delivery to the priority population on the Texas/Mexico Border; 2) increase access to, or placement in, sustainable permanent housing, treatment, and recovery support services, to include Medicaid and other benefit programs to 310 persons/families experiencing homelessness; and 3) implement a comprehensive evaluation and data collection plan to assess client-level outcomes and project performance measures. Staffing plan includes a Project Director, Project Coordinator, 2 Licensed Professional Counselors, 1 Recovery Peer Support Specialist, 2 Patient Navigators/Case Managers, and Evaluator.

Zepf Center, in collaboration with Neighborhood Properties, Inc. (NPI) present the HOPE Project (Homeless Outreach and Person-Centered Engagement) targeting individuals with serious mental illness (SMI), serious emotional disturbance (SED), or co-occurring disorders (CoD) experiencing homelessness living in Lucas County. The purpose of HOPE is to provide comprehensive, coordinated and evidence-based services for the target population. Zepf and NPI are long-term partners, having TIEH funding in 2018.

The Center for Housing Solutions, Inc. and key partners in Tulsa, Oklahoma will implement a multi-disciplinary, integrated care team to serve vulnerable households experiencing unsheltered homelessness in Tulsa County. The proposed project will provide comprehensive, coordinated and evidenced-based services for individuals, youth, and families with a serious mental illness (SMI), serious emotional disturbance (SED) or co-occurring disorder (COD) who are experiencing homelessness or at imminent risk of homelessness. Engaging the most underserved, hardest-to-reach individuals residing in unsheltered locations and using assertive outreach, this project aims to reduce racial and ethnic disparities and increase equitable outcomes at the program and system levels. Working to make homelessness rare, brief, and non-recurring, this project will provide services to at least 290 individuals over 5 years providing access to needed services and obtain housing. Annually, this project will serve 50 individuals in the first year, then 60 each year after. Strategies and Intervention are as follows: This program, led by Housing Solutions in coordination with Grand Mental Health, adheres to a Housing First model and partners with Coordinated Entry to house the most vulnerable individuals by reducing barriers and providing housing navigation services. Recovery support services will be offered using a person-centered and strengths-based approach by identifying areas of need as a part of developing the Plan of Care with the program team and the client. Other approaches we will use include Integrated Dual Disorder Treatment, Assertive Outreach, and Motivational Interviewing. Project Goals and Measurable Objectives: (Goal 1) Reduce length of homelessness for individuals with SMI, SUD, and/or COD through assertive outreach and engaging people in recovery services through a harm reduction and housing first approach using a multi-disciplinary team. Program participants will have the opportunity to engage in recovery services through program enrollment to support obtaining permanent housing and remaining in stable, permanent housing. Objective A. 290 unduplicated persons are enrolled in the program in HMIS over the 5- year operating period as a result of being outreached in unsheltered locations and engaged in recovery services for SMI, SYD, and/or COD. (Plan of Care established). Objective B. 100% of participants have completed an assessment through the local Coordinated Entry System within 1 month of enrollment in Street Outreach services (HMIS report). (Goal 2) Participants will increase their income by obtaining mainstream benefits from program entry through Street Outreach and SSI/SSDI through SOAR services. Objective A. 50% of enrolled clients will demonstrate an increase in income through Mainstream Benefits (SSI/SSDI) 12 months after program entry. Objective B. 60% of participants demonstrated an increase in total income (earned and non-employment) from program entry to annual assessment. This information will be collected by program staff at program entry and during interim assessments at 6-month intervals. (Goal 3) Reduce the length of homelessness for individuals with SMI, SUD, and/or COD through assertive outreach and engaging people in recovery services through supportive housing navigation and housing stability education. Objective A. 60% of program participants will be navigated into temporary or permanent housing destinations or exited the program to a Permanent Housing Destination over the 5-year operating period. Note: deaths are excluded from calculations. Objective B. 50% of program participants will be enrolled in SMI/SUD related services and/or peer support recovery services over the 5-year operating period.

Project Name: VOA Spokane TIEH Strategies and Population to be Served: Volunteers of America Eastern Washington & Northern Idaho (VOA Spokane) is one of the largest housing providers in the project catchment area in Spokane County, Washington State. In the TIEH project, we will build on our recent roll-out of an innovative Certified Community Behavioral Health Clinic (CCBHC) model to provide treatment for individuals with serious mental illness (SMI), serious emotional disturbance (SED), or co-occurring disorders (COD) who are also unhoused. Over the 5-year implementation period, our project will purposefully enroll 900 young adults and women into low barrier, comprehensive treatment services, integrated at two VOA shelters, Hope House for women and our Young Adult Shelter. We selected these entry points for TIEH services because young adults and women in our service area who are homeless face unique disparities related SMI, SED, COD, disabilities, and family violence. Project Goals and Measurable Objectives: Our project will achieve goals and objectives as follows: Goal 1: TIEH participants obtain and retain permanent housing. Objective 1.1: Within 6 months of enrollment in TIEH services, 75% of program participants obtain housing. Objective 1.2: Of VOA participants who have obtained housing, at least 90% will maintain housing for 6 months. Goal 2: TIEH participants experience whole-person health that encompasses physical and behavioral wellbeing. Objective 2.1: Within 1 month of enrollment in TIEH, 85% of program participants who are assessed to have unmet mental health needs will have engaged with and enrolled in behavioral health services. Objective 2.2: Within 6 months of enrollment in TIEH, 75% of program participants who are assessed as having a COD and completed an ASAM Assessment will have engaged in SUD treatment. Objective 2.3: Within 6 months of enrollment in TIEH, 85% of program participants who are assessed to have unmet medical needs and do not have a primary medical provider will have enrolled in primary care. Objective 2.4: Within 6 months of enrollment, 90% of participants who do no have medical insurance will have enrolled in Medicaid. Number of People to be Served: VOA Spokane TIEH will reach 180 unduplicated participants per year, or 900 unduplicated people over the 5-year implementation period.

Rhode Island's System Engagement and Navigation (RISEN) will provide Treatment for Individuals Experiencing Homelessness. The program's goals will address system collaboration to expand access to mainstream resources as well as create pathways to treatment, eviction prevention, affordable and supportive housing. The goals will be accomplished by expanding teams that focus on persons experiencing homelessness and those at imminent risk of homelessness. The team will have new positions defining expanded services and be constructed using the innovated practice of interagency staffing to leverage broader support and collaboration. Additionally, a state level steering committee will leverage existing resources, strengthen relations via the development of memorandums of understanding between state departments, foster warm handoffs and eliminate barriers to services. It was estimated that the total homeless population in RI was 1,071 individuals making up 0.1% of the state population. The RI homeless population increased by 48% from 2020 to 2022 (AHAR) and was among the highest in the nation. RI was also the third state with the largest percentage increase in chronic patterns of homelessness (115% or 225 individuals) from 2020 to 2022. In RI State Fiscal Year 2022, 4.9% of individuals receiving mental health treatment services at a BHDDH licensed facility were homeless or living in shelters compared to 2.8% nationally (BHOLD/URS). However, only 2.5% of adults with Serious Mental Illness (SMI) were receiving treatment. The RI Continuum of Care identified 125 SMI, recently housed individuals that had a history of chronic homelessness, that are in danger of eviction as well as a potential cohort from 800 individuals referred from the public housing authority as having potential behavioral health conditions and housing instability, needing screening. RISEN will focus on 3 priority populations: individuals/families who had experienced homelessness and have been housed but need assessment and navigation to treatment services to maintain their housing as a preventative measure; unsheltered; sheltered. RI will use the strategy of increasing positions on the homeless service teams at 3 strategically located providers. Expanded positions will include residential, stabilization and housing services, health navigator including an RN, intensive case managers, and clinicians. Additionally, this grant will provide the vehicle of a statewide steering committee that will improve collaboration and statewide oversight. RISEN has 3 primary goals 1) increase retention from eviction due to untreated mental illness and substance use conditions through engagement, screening and referral to treatment 2) increase outreach, screening and referrals to treatment for the unsheltered and those living in shelters 3) increase collaboration between health and human services agencies and housing agencies to reduce barriers and increase capacity for supportive housing. The estimated total # of outreach contacts are estimated at 1,800. For #1, RISEN will begin screening 75% of the referrals within 3 months of the award and retain a 100% screening rate for the duration of the project, estimating 1,350 screenings. For #2, RISEN will screen 75% of those unsheltered and sheltered by 6/30/25, with the expectation of screening 100% of this population throughout the 5 year grant period, estimating an additional 1,350 screenings. For goals #1 and #2, an estimated 675 will be enrolled in treatment. For #3, RISEN's objectives by 1.30/25, 5 new Housing Stabilization Services providers certified by the state and 75% of existing providers will increase billing by 25%. Annually, increase collaboration and resource sharing among providers and all of the RISEN providers by the end of the grant, to enhance services statewide.

Integrated Services of Kalamazoo’s (ISK) Project TIEH (Treatment for Individuals Experiencing Homelessness) uses a diverse Team providing community-based services at shelters, transitional housing sites, drop-in centers, encampments, and at ISK’s Behavioral Health Urgent Care and Access Center. TIEH will use Critical Time Intervention and Motivational Interviewing to provide outreach, engagement in treatment, and linkage with housing opportunities and benefits. Target Population: Project TIEH’s population of focus is adults experiencing homelessness or at imminent risk of homelessness and diagnosed with a serious mental illness, substance use disorder and/or co-occurring substance use disorder in Kalamazoo County, Michigan. The population is racially diverse with 56% Black/African American, and 2% multiple races with ethnicity being 4% Hispanic/Latino. Black/African American individuals have been identified as underserved individuals within the Population of focus, based on disparities in housing outcomes. Strategies/Interventions: Services will be culturally sensitive, and trauma informed. Evidence based practices used will include Critical Time Intervention and Motivational Interviewing. TIEH offices will be in Kalamazoo County’s primary shelter site and ISK’s Urgent Care Program site. TIEH will maintain walk in or drop-in hours at these locations to avoid waiting lists and complicated eligibility criteria, and to provide flexible service schedule. TIEH staff will partner with shelter, PATH outreach, Emergency Mental Health, and OORP staff to provide outreach and engagement to individuals onsite, at shelters and encampments. A total unduplicated count of 200 individuals will be enrolled in the project over 5 years; Year 1 = 25, Year 2 = 50, Year 3 = 50, Year 4 = 50, and Year 5 = 25. Goals/Objectives: Goal 1: Increase Access to culturally competent, integrated behavioral health treatment for individuals experiencing/at imminent risk of homelessness. Obj1.1: Conduct outreach and engagement throughout Kalamazoo County to 500 individuals. Obj1.2: Provide evidence based, integrated mental health/substance use treatment for 200 people. Obj 1.3: Link and coordinate primary care services to 100% of enrolled individuals. Goal 2: Improve housing status by coordinating services through the Kalamazoo Housing Continuum of Care. Obj 2.1: Link and coordinate 200 housing referrals through the Kalamazoo County CES. Obj 2.2: Assist 125 enrolled individuals with enrollment in benefits. Obj 2.3: Assist 75 enrolled individuals to transition from homelessness to permanent housing options. Goal 3: Increase equitable access to housing supports and behavioral health treatment for people of color. Obj 3.1: Quarterly gather, analyze, and report data to Steering Committee to further identify TIEH disparities. Obj 3.2: Each year an increasing number of people of color with lived experience will inform project strategies. Obj 3.3: Each year staff will enroll an increasing percentage of Black/African American individuals who are homeless or at imminent risk of homelessness into the project.

Mountain Comprehensive Care Center will implement the Pathways Home Project to offer comprehensive, coordinated, and evidence-based services for individuals, youth, and families with SMI, SED or COD who are experiencing homelessness or at imminent risk in the service area of Floyd, Johnson, Lawrence, Magoffin, Martin, Morgan, Pike, and Rowan counties in eastern KY. Population: Based on data from the KY Balance of State CoC, which serves the catchment area and will coordinate with MCCC on outreach, treatment, and services, it is surmised that 85% of the targeted population will identify as White with minority populations higher than the general public including 12% Black, 2% Multiracial, 1% other races, 2% Hispanic, and 0.5% LEP. Men will account for 58%, women 41%, transgender 1%, LGBTQ+ 6%, and veterans 3%. Regarding age, 67% will be adults ages 25+, 6% transitional-age youth (ages 18-24), and 27% families (61% children/youth, 39% adults). The project will target underserved persons who are rural, identify as LGBTQ+, and develop inclusive strategies to increase access for racial and ethnic minorities. Located in eastern KY and Appalachia, the targeted population is anticipated to experience even more disparities than the general population which is still significantly impacted by poverty, unemployment, and recent crisis across the service area. Interventions: Staff will conduct outreach/engage potential participants using trauma-informed care and Motivational Interviewing. Assessment will include the VI-SPDAT, Psychosocial Assessment, and LOCUS/CASSI while using Housing First to link clients with housing and desired treatment/recovery services as outlined in a Person-Centered Plan. Linkages will be made to existing agency residential, IOP, and outpatient treatment programs with EBPs to include Housing First, MI, Cognitive Behavioral Therapy, Pharmacotherapy, peer supports, and Medication Assisted Treatment. MCCC will coordinate primary care and key interventions such as Pharmacotherapy and MAT with its HomePlace Clinics while also offering case management, benefits enrollment, peer/community/recovery supports, and aftercare upon exit. Goals: MCCC will serve 40 clients in Year 1 and 60 annually in Year 2-5 (total 280). Goals for the targeted population include: 1) Improve health by engaging with and coordinating care to evidence-based and population-specific behavioral health and primary health care; 2) Improve stability by providing and/or coordinating case/care management, recovery, and housing supports; and 3) Improve equitable, inclusive, and effective project implementation and evaluation by conducting CQI. Objectives achieved by end of each project year include: 1.1) conducted inclusive outreach/engagement so at least 40 are served in Year 1 and 60 annually in Years 2-5; 1.2) coordinated access to individualized mental health and COD treatment (and FDA-approved medications) so 50% or less report any MH or COD symptoms [at 6-month follow-up]; 1.3) provided linkages to integrated primary care so 65% report health as “good” or above; 2.1) provided and/or coordinated access to peer supports so 60% report positive social connections; 2.2) coordinated access to recovery support services so 50% report engagement in employment/education, and/or benefits enrollment; 2.3) provided person-centered case management services so 50% report housing stability and 60% no further arrests; 3.1) monitored indicators of enrollees each quarter to ensure equity/inclusion among all groups and revise outreach as needed; 3.2) conducted Steering Committee meetings at least quarterly to coordinate services, monitor goals/objectives, and CQI. MSU will conduct an independent evaluation.

Steppingstone Incorporated’s (SS) Focused Achievements in Housing and Recovery Project (FAIHR) proposes to provide treatment, housing placement and other recovery support for homeless persons with SMI, SED or co-occurring disorders (MHD & SUD) in Fall River and New Bedford, MA. FAIHR will provide supportive housing combined with substance use and integrated co-occurring disorder treatment and wrap-around services. FAIHR will serve 450 individuals and families over the five-year grant term and will prioritize transitional age youth. FAIHR will perform outreach in SS’s FR First Step Inn shelter and NB homeless shelters, as well as street outreach including known encampments of the hard-to-reach homeless and young adult/transitional age youth population. Other outreach venues will include soup kitchens, emergency care settings and other places frequented by the homeless. Once enrolled, FAIHR’s 1 FTE Mental Health Clinician (MHC) will provide on-site treatment. Other FAIHR project staff include 1 FTE Project Director, .25 Evaluator, 1 FTE Project Coordinator, .25 FTE Nurse Practitioner, 2 FTE Integrated Care Facilitators (Case Managers) and 2 Outreach Workers. FAIHR’s caseworkers will follow the evidence-based CTI case management model and develop individual service plans, driven by FAIHR participants’ needs and goals. FAIHR CMs will connect individuals to all services and supports needed, such as peer recovery coaching, housing, mainstream benefit programs, health insurance and healthcare, educational and vocational programs and other supports. FAIHR collaborates with both HUD CoC MA-505 (New Bedford) and CoC MA-515 (Fall River) and is a member of both continuum’s homeless provider network groups with the goal of improving housing and other outcomes for the homeless. FAIHR connects with both FR and NB “The Call” (FR & NB’s HUD coordinated entry system) to place clients in housing. Steppingstone offers over 100 permanent supportive housing-first units (HUD-funded) and operates two graduate recovery homes, available to eligible FAIHR clients. FAIHR will promote recovery through implementation of evidence-based practices including Housing-First, Integrated Treatment for Co-Occurring Disorders and Critical Time Intervention. Other services will include medication for opioid use disorder (MOUD), peer recovery coaching, independent living skills training, discharge planning, and assistance obtaining entitlements, employment, and childcare. FAIHR will operate a Racial Equity Assessment & Action Planning (REP) Steering Committee, which will meet monthly and include representatives from state substance abuse and mental health authorities, housing authorities, the Veteran’s Office, local police and health department, educational and vocational reps, the state Medicaid Agency, and other stakeholders including homeless individuals and persons in recovery from SUD/CODs.

ABSTRACT The Aliviane Project Strong will provide comprehensive and integrated evidenced-based outreach, engagement, treatment, case management, housing, and peer recovery support services for individuals, youth, and families with Serious Mental Illness (SMI), Serious Emotional Disturbances (SED), or Co-Occurring mental health and substance use disorder (COD) experiencing homelessness or at imminent risk of homelessness in El Paso County. The 2020 U.S. Census population estimate for El Paso County was 865,657, with 82.9% identified as Hispanics, 11.4% White, 4.2% African Americans. The same reports establishes that 20.1% of people in the county are living below the poverty level, which is higher than the percentage in the state of Texas (14.2%) and the U.S. (11.6%). HUD’s 2022 Point-in-Time (PIT) count of homeless individuals in El Paso County estimated that “on any giving day in our community” there are 839 homeless individuals, from which 180 are living on the streets, 537 in emergency shelters, and 119 in transition housing. The 2022 PIT also identified that of the total homeless population 295 persons are in families and 68 families were homeless, 56.9% of children and families were reported as first time homeless, and 10% were Veterans. During 2022, 28.5% of the total homeless population in El Paso reported having a mental health condition sometime in their lifetime, and 16.3% reported a problem with drugs/alcohol. Project Strong will conduct outreach and harm reduction strategies with homeless individuals, youth and families and engage program participants in behavioral health treatment for mental health, substance use, and/or co-occurring disorders and recovery-oriented services including peer supported recovery services, comprehensive case management, and coordination of recovery, supportive, and permanent housing. In addition, Aliviane works closely with the local homeless coalition working to develop a community infrastructure that integrates behavioral health treatment, peer support, recovery support services, and linkages to sustainable permanent housing. Project Strong will utilize support from the EPHC to identify and support program implementation, identify best practices for building an integrated community infrastructure, and support sustainability of comprehensive services. Project Strong will work with the El Paso Homeless Coalition to create an outreach protocol that includes coordinating with crisis and 988 systems to connect people in crisis experiencing homelessness or at risk of imminent homelessness. Additionally, the Project Strong will work to increase knowledge and practice of Culturally and Linguistically Appropriate Services (CLAS) standards across multiple agencies serving the target population to enhance the service system. The program goals include: Goal 1: Increase access to integrated, recovery-oriented, and evidence-based, trauma informed, culturally competent and client centered outreach, engagement, harm reduction, and screening for homeless individuals, youth, and/or families residing in El Paso, Texas. Goal 2: Increase access to integrated, recovery-oriented evidence based, trauma informed, culturally competent, and client centered mental health, substance use, and/or co-occurring treatment services via in person or telehealth to 380 individuals over the course of the project. Goal 3: Increase access to integrated, trauma informed, culturally competent and client centered recovery-oriented peer recovery support services and comprehensive case management for 380 homeless individuals, youth, and/or families residing in El Paso, Texas over the project period. Goal 4. Identify and coordinate supportive, and/or permanent housing for enrolled individuals and their families. The project wills serve 150 individuals annually for a total of 700 individuals over 5 years with outreach, screening, and mental health and substance use harm reduction. The project will enroll 80 individuals per year.

La Maestra’s Treatment for Individuals Experiencing Homelessness project will engage and connect the population of focus to behavioral health treatment, case management, and recovery support services; assist with identifying sustainable permanent housing by collaborating with homeless services organizations and housing providers, including public housing agencies; and provide case management that includes care coordination/service delivery planning and other strategies that support stability across services and housing transitions. The goal of La Maestra’s Treatment for Individuals Experiencing Homelessness project is to provide comprehensive, coordinated and evidenced-based services for individuals, youth, and families with a serious mental illness (SMI), serious emotional disturbance (SED) or co-occurring disorder (COD) who are experiencing homelessness or at imminent risk of homelessness (e.g., people exiting jail or prison without a place to live) in San Diego County, California. The project will be implemented before the beginning of the fourth month of award. The organization expects to achieve this goal by reaching the following objectives: 1) increase the exposure of La Maestra services to homeless populations by outreaching to a total of 400 individuals annually (2,000 over the project period) through community events, health fairs, and street outreach; 2) screen at least 250 patients annually (1,250 over the project period) for SMI, SED, SUD, and/or COD using evidence-based screening tools; 3) provide direct SUD, behavioral health treatment, and recovery support services to a minimum of 125 individuals annually (625 over the project period); 4) link at least 90% of program participants to sustainable permanent housing through partnerships with homeless service organizations and housing providers; and 5) enroll at least 80% of individuals with positive SUD, OUD, or co-occurring screens into case management and public program enrollment assistance. In 2022, La Maestra served 40,654 patients. According to 2022 clinic data, 86% of patients served are living at or below 200% of the federal poverty level, 23% of patients are uninsured and 73.5% are underinsured. In addition, 79.7% of patients belong to a racial or ethnic minority and 58.3% identified as being best served in a language other than English. A According to the 2022 System Performance Measures collected by the San Diego Regional Task Force on Homelessness (RTFHSD), 12,270 persons in San Diego County were reported living in Emergency Shelters (ES), Safe Havens (SH), and Transitional Housing (TH), in addition to 4,106 living unsheltered. Overall, this is a 10% spike countywide since 2020, or the beginning of the COVID-19 pandemic. In central San Diego, where La Maestra’s main clinic is located, the unsheltered population increased by 9.2%. In other parts of La Maestra’s service area, such as south and east San Diego County, percentages have increased by 24.2% and 24.7%, respectively. Furthermore, 43% of homeless people living on the streets in San Diego County were reported to have mental health issues and the National Alliance to End Homelessness suggests that approximately 35% of individuals experiencing homelessness struggle with some form of substance abuse. La Maestra will adhere to current Evidence Based Practices and expand its Wellness Clinic to ensure that all patients seeking TIEH services receive the comprehensive, culturally appropriate and linguistically competent care they require to achieve recovery. In addition, performance assessment services for this program will be conducted by Dr. Andrew Sarkin, Ph.D., a third-party evaluator from the University of San Diego’s Health Services Research Center (HSRC). HSRC is a comprehensive research unit that was established in 1991. Dr. Sarkin has over two decades of evaluation experience in behavioral health medicine and clinical psychology.

The Harmony House TIEH Initiative provides comprehensive, coordinated, evidenced-based services for individuals, children, youth & families with a SMI/SED, or COD who are or are at imminent risk of experiencing homelessness. The focus population is poor, lacks education & suffers from high rates of trauma, poor mental health, substance use, infectious disease, homelessness & stigma. The project will serve 250 people (50/year). Project goals (interventions/ strategies) include: (1) Expand access to and delivery of coordinated comprehensive mental health services to improve housing stability by building a continuum of care for the focus population by (A) Initiating a Project Director to build an integrated continuum of care for the unhoused; (B) Completing a community needs assessment; (C) Expanding the continuum of care in response to the community needs assessment; (D) Partnering with the WV Behavioral Health Training Center to enhance continuum workforce development; (E) Partnering with the continuum of care re: stigma/outreach/engagement in response to the community needs assessment; (F) Identifying community agencies/stakeholders who ally with disparity group communities to develop culturally competent outreach/services; (G) Hiring 2 Therapists to serve the focus population; (H) Hiring an Evaluator to monitor disparity group outcomes to ensure equal access/service/outcomes/retention & (I) Hiring a Psychiatric Nurse Practitioner. (2) Increase community capacity to engage & connect the focus population with behavioral health services to improve behavioral health outcomes by (A) Hiring a Community Engagement Specialist to partner with street outreach/community efforts to engage clients care; (B) Expanding Medical Director time to engage the focus population in behavioral health & COD services; (C) Implementing a universal mental health screening process for all individuals with agency intakes; (D) Partnering with local psychiatric hospitals for intakes; (E) Referring ineligible people to partners & following-up to ensure access; (F) Providing mobile clinic outreach days; (G) Coordinating with crisis systems to obtain referrals; (H) Initiating provision of therapy & psych services in the field; (I) Having 50% of treatment compliant clients report a reduction in substance use at 6-months; and (J) Clients having statistically significant improvements in NOMs mental health outcomes at 6-months. (3) Collaborate with area housing providers to ID sustainable permanent housing for the focus population by (A) Partnering with the CHWCoC to identify additional supportive housing partners; (B) Assisting clients with identifying supportive housing; (C) Liaising with local landlords & The Public Housing Authority to address property damage/advocate for clients; (D) Carrying out behavior support plans to assist with stable housing based on ACT principles & (E) Having clients exhibit a statistically significant increase in days housed at 6-months. (4) Increase case management, care coordination & recovery support service capacity to support focus population stability across services and improve housing transitions by (A) Hiring 2 Navigators to help clients navigate the continuum of care; (B) Assisting all clients with SDOH action plans; (C) Providing recovery support services; (D) Serving 50 clients/year; (E) Holding emotion life skills/ emotion regulation classes & (F) Reducing client HIV/AIDS risk factors. (5) Sustain the continuum of care for the unhoused beyond grant funding by (A) Establishing a Steering Committee to create a sustainability plan; (B) Ensuring clients are enrolled in applicable social services; (C) Working with the MU College of Health Professions Behavioral Health Center (MUSW) to initiate practicums & internships to sustain service provision; (D) Considering formalizing an ACT Team to enable billing for client services; and (E) Ensuring CLAS Standard adherence.