Grants Dashboard

The Atlantic County Sheriffs Foundation in partnership with the New Jersey State Police Drug Monitoring Initiative, New Jersey MAT Center of Excellence, five of the largest substance use treatment providers in New Jersey and recovery homes and housing agencies will develop a mobile recovery coaching unit to engage 300 homeless overdose survivors in Atlantic City in treatment after naloxone rescue or within 72 hours and provide linkage to housing and support. The geographic catchment area for the project will be Atlantic County, one of 21 counties in New Jersey. Atlantic County is home to Atlantic City which has over 27-million visitors each year who utilize its world-renowned beaches and who gamble in the local casinos. However, just west of the boardwalk and the casinos, over 37-percent of its 38,466 residents live in poverty and a significant portion of the population have opiate use disorders. Atlantic County has the highest drug mortality rate of all New Jerseys 21 counties, at 36 deaths per 100,000. In 2022, there were 3,046 suspected overdose deaths in New Jersey (the tenth largest in the nation). A total of 255 of these deaths occurred in Atlantic County, a 35.6-percent increase from 2021. As of January 2023, Atlantic County had the third largest number of overdose deaths in the state. The population of focus will be homeless individuals and their families (ages 15 years and older) from all racial, ethnic, cultural, gender and lived experience groups diagnosed with a substance use or co-occurring substance use and mental health disorder who have recently survived an overdose. In 2022, there were 1,031 naloxone administrations provided by EMTs in Atlantic County, with a large number administered in Atlantic City. However, an estimated 70-percent of the 776 overdose survivors refused to be transported to an emergency room and left the scene presumably to resume taking opiates placing them at increased risk for a fatal overdose. Currently, there is a need for programs that interface with the New Jersey State Police and EMTs to engage homeless individuals at the overdose scene into treatment or within hours or days to prevent a fatal overdose. The goals of the project are to 1) Decrease substance use in homeless overdose survivors through mobile outreach and engagement strategies that will increase access to treatment and supportive housing; 2) Increase housing stability in homeless overdose survivors with substance use and co-occurring substance use and mental health disorders who are transitioning to the community from residential treatment by implementing housing support services, and 3) Increase recovery capital to support recovery and housing for homeless overdose survivors throughout their continuum of care and into the community for up to one year. The Mobile Recovery Coaching Unit (MRCU) will interface with the New Jersey State Police Drug Monitoring Initiative to deploy mobile recovery coaches with lived experience to engage homeless overdose survivors into residential treatment, immediately after revival with naloxone or within 72 hours. Coaches will provide compassionate outreach, connect homeless overdose survivors to treatment, stay engaged with the clients during their continuum of care, identify housing opportunities, assist with their transition to housing from residential treatment and provide mobile recovery support and harm reduction services for up to one year in the community. Rowan University School of Osteopathic Medicine will provide evaluation of the project.

The Damascus House Community Development Corporation (DHCDC) will implement Project HRISTORe to provide comprehensive, coordinated, and evidence-based treatment and services for unduplicated count of 500 homeless adults who are reentering Prince George’s County, Maryland after a period of incarceration. Program participants will be adults aged18 years or older; homeless; within no less than three (3) months of release from a correctional facility; assessed as being at moderate or high criminogenic risk; able to provide written consent to participate in the program; not a registered sex offender and/or an arsonist; and not having any detainers, warrants, or holds that would jeopardize participation in the program The target population has a media age of 25 years and is 95% male; 79% Black non-Hispanic; 14 % Hispanic; and 10% non-Hispanic whites. One quarter (25%) have been diagnosed with some level of mental illness and 78% of have a substance use disorder (SUD). Almost three fourths (71%) of inmates recidivate. The Prince George’s County Department of Corrections will refer reentering inmates who are homeless to the project and collaborate with DHCDC to offer pre-release assessment and services. The County’s Health Department and workforce development agencies will provide a range of recovery support services. Three experienced, licensed, outpatient mental health providers will deliver SUD and mental health services to participants. Project services will include risk assessment; assessment of social determinants of health (SDOH); placement in DHCDC or other local transitional and supportive housing; SUD, opioid use disorder, and mental health treatment including culturally and linguistically competent and gender-appropriate trauma and grief-informed care; case management, peer support; psychiatric rehabilitation programs; linkage to primary care, legal aid, workforce development, and job placement; and transportation services. The project’s goals and objectives are as follows: Goal 1) Provide recovery transitional and supportive housing to an unduplicated count of 500 individuals who reenter the community after a period of incarceration. Objective 1.1 Strengthen the referral and transition process by conducting pre-release assessment and planning for 500 inmates starting no later than three (3) months prior to release and preferably as early as six (6) months. Goal 2) Deliver behavioral health outreach, treatment and recovery-oriented services to an unduplicated count of 500 individuals who are homeless after a period of incarceration. Objective 2.1 Deliver evidence-based, trauma-informed, culturally competent and gender appropriate services to 500 participants. Goal 3) Assist a minimum of 70% of all participants to maintain sobriety, stable housing, stable employment and transportation, 12 months post discharge. Objective 3.1 Periodically assess the SDOH of an unduplicated count of 500 individuals who are experiencing homelessness after a period of incarceration Objective 3.2 Refer all (100%) participants with SDOH to appropriate SDOH mitigation services and follow up to ensure timely receipt of services. HRISTORe desired outcomes are: • 70% of participants in stable, permanent housing after 12 months in the program • 60% of participants in school or gainfully employed after 6 months in the program • 90% of participants remain in stable permanent housing 6 months after discharge • 90% of participants maintain sobriety 6 months after discharge • 10% decrease from baseline in the participant recidivism rate

The proposed project, Antelope Valley HomeUp, is a trauma-informed, integrated recovery housing model for transitional-age homeless youth residing in the western Mojave high desert region of California’s Antelope Valley. HomeUp aims to reduce substance use, improve housing stability, and support successful transitions into adulthood by engaging and connecting homeless young adults with a comprehensive array of place-based, age-appropriate services that address complex housing, behavioral health, and social service needs. The project uses a peer model of care to coordinate and facilitate access to an array of services and resources that are integrated with recovery housing and available on site or with transportation assistance. The HomeUp recovery program model and its components are designed around the four dimensions of recovery—home, health, community, and purpose. Its vision is to create an environment of stability, wellness, and support among same-age peers who share similar recovery goals. HomeUp will be implemented through a regional partnership that brings together the Children’s Center of the Antelope Valley (CCAV), Bartz Altadonna Community Health Center (BACHC), Antelope Valley Partners for Health (AVPH), and the regional CES provider, Valley Oasis. The project will also engage non-funded partners and relevant stakeholders (e.g., substance use and mental health authorities, LACDPH, HUD, and CBOs) who are seeking solutions to the homeless crisis and are committed to achieving change. The population of focus for the proposed grant includes Antelope Valley sheltered and unsheltered homeless young adults 18-24 years of age who are at risk for, or have a history of, mental illness and/or substance use disorder (SUD). The project as proposed is anticipated to reach approximately 285 unduplicated individuals over the 5-year grant funded period, enrolling 45-60 clients annually. The project identifies six overarching goals and objectives that include (1) enhancing capacity and coordination within the Antelope Valley homeless services system, (2) conducting targeted mobile outreach and engagement strategies that integrate harm reduction, (3) providing peer-led, trauma-informed case management to offer support and overcome barriers to help-seeking (4) providing interim recovery housing as a foundation for achieving stability, (5) promoting access to an array of behavioral health treatment, counseling, health, and social services, and (6) supporting exit planning and transitions to permanent housing. The project aims to achieve a 50% rate of retention in recovery housing and integrated services and for at least 60% of clients to demonstrate progress toward case plan objectives at 6-month follow-up. Intended outcomes are for at least 30% of MAT clients to achieve drug abstinence at follow-up, for 40% to demonstrate improvements in education/employment, social connectedness, and/or health and social consequences, and for at least 30% to achieve long-term housing stability by program discharge.

Recovery Network of Programs, Inc. will serve homeless adults with substance use disorders and co-occurring disorders from Fairfield County, CT through an “all in one” drop-in center in the City of Bridgeport, CT providing low/no barrier services, including co-located primary care, SUD and COD treatment, peer support, case management, and assistance with housing. With no established place in the greater Bridgeport area where homeless adults with SUD and COD and need services, clinical and other, can go for help and respite, despite the fact that the greater Bridgeport area has the highest rates of substance use and unintentional overdoses in Fairfield County. The Center is a crucial outreach strategy that addresses this need. It will be a low/no barrier public focal point where individuals can access services and respite in a welcoming and respectful space. There are no appointments, and the Center will welcome members of the POF and other adults who walk in. It will be within walking distance of area RNP treatment sites and on a bus line. One-to-one outreach will be done by peer Outreach Specialists who will engage the POF to introduce them to the Center. The catchment area, Fairfield County, is the most income-unequal county in the most income-unequal state in the U.S-Connecticut. With a mix of rural, suburban, and urban, and several large cities, including Bridgeport, Stamford, and Norwalk it has a total population of 959,768. The 2020 Census show that the largest County racial/ethnic groups are White (59.8%) followed by Hispanic (20.5%) and Black (10.7%). 51% of the population is female, 49% male. Most people of color live in Stamford, Norwalk, and Bridgeport. The Regional Planning Association (RPA) shows the median income of the towns of Darien ($210,000) and Weston ($220,000) is nearly five times that of Bridgeport ($45,000). In 2021 the Bridgeport-Stamford-Norwalk, metropolitan statistical area (MSA) was the second-least equal place in the U.S. It ranked first among metro areas. The Gini Index identifies the MSA as the second most income-unequal place in the US. Project Goal 1) Establish a low/no barrier drop-in center and expand case management service to engage and connect the POF to evidence-based SUD/COD treatment, harm reduction services, case management, and recovery support services through a single point of access. Objectives include (1) by the end of Year 1, 60% of the POF engaged will receive services through the Center; (2) 95% of the POF complete intakes within 24 hours; (3) 50% will achieve 90 days sobriety at 6-month follow-up and 60% will engage in recovery support resources engage, e.g., AA, NA, counseling, etc. Goal 2) Collaborate with the CAN, services organizations, and housing providers, to secure housing for the POF. Objectives include (1) outreach to clergy/congregants of 10 County faith communities providing educational materials on SUD/COD, harm reduction, and housing; repeat outreach to 10 additional churches each year of the grant; (2) By the end of Year 1, 80% of those who engaged with outreach efforts will have a path to or will attain permanent housing. It’s estimated that the number of people who will receive outreach will average 90 individuals each month; the number of people who are engaged by outreach efforts to be served through the Center is Number of Unduplicated Individuals to be Served with Award Funds Year 1 Year 2 Year 3 Year 4 Year 5 TOTAL 100 120 145 155 170 690

Recovery Connect provides comprehensive, coordinated, and evidence-based treatment for unsheltered community members with Substance Use Disorder (SUD) and co-occurring mental health conditions in Ramsey County, Minnesota. Recovery Connect is an interdisciplinary collaboration among four Ramsey County departments: Community Corrections, Housing Stability, Public Health, and Social Services; and two community partners: Specialized Treatment Programs (STS) and NUWAY. The project aims to serve justice-involved people entering Ramsey County correctional facilities and unsheltered community members engaging at partner programs and mobile outreach sites. Strategies include case management, the use of Medication for Opioid Use Disorder (MOUD), referrals to licensed Opioid Treatment Programs (OTPs), recovery group programming, outreach and harm reduction education, and recovery support services. Recovery Connect aims to serve 500 people over five years (50 – Year 1, 75 – Year 2, 100 – Year 3, 125 – Year 4, 150 – Year 5). Project goals include: 1) Reduce the unmet SUD treatment needs of justice-involved individuals 2) Improve behavioral health outcomes of unsheltered community members with SUD and co-occurring mental health conditions 3) Increase connection to sustainable permanent housing for unsheltered community members with SUD and co-occurring mental health conditions 4) Improve delivery of coordinated, comprehensive services to reduce substance use and improve housing stability for unsheltered community members. Measurable project objectives associated with Goal 1 include: 1) By end of project period, the RN will have provided care related to SUD including MOUD to 300 clients in Ramsey County correctional facilities 2) By end of project period, 100% of justice-involved clients with OUD will be referred to licensed Opioid Treatment Programs (OTPs) following release Measurable project objectives associated with Goal 2 include: 1) By end of project period, 50 individuals with SUD and co-occurring mental health conditions will have been enrolled in the evidence-based recovery group program 2) By end of project period, 100% of justice-involved clients on MOUD will have received harm reduction education 3) By end of project period, harm reduction education and supplies will have been distributed to 150 unsheltered community members 4) By end of project period, 100% of unsheltered individuals receiving harm reduction education and supplies will be referred to Clinic 555 for screening and treatment of STIs, Hepatitis C, and HIV Measurable project objectives associated with Goal 3 include: 1) By end of project period, 100% unsheltered clients will have been referred to Coordinated Entry housing assessment by project staff, Housing Stability, or community-based homeless services providers Measurable project objectives associated with Goal 4 include: 1) By end of project period, 500 total clients (including clients receiving MOUD, recovery group program, harm reduction education/services) will have received case management to support stability across services and housing transitions 2) By end of project period, develop iterative project performance management to ensure timely, quarterly review of data and implementation of quality improvement projects

Interfaith Community Services’ Recovery and Wellness Center (RWC) Treatment to Housing Project will address the devastating rise in fentanyl-related deaths among the homeless population, reduce barriers to accessing detox and other life-saving treatment, and connect individuals in treatment to housing resources. The project will serve adults over age 18 with Substance Use Disorders (SUDs) or Co-Occurring Disorders (CODs) who are experiencing homelessness in San Diego County, with an emphasis on North San Diego County. Primary strategies include: 1) The creation of a mobile outreach and intake team comprised of a Peer Support Specialist and a Certified SUD Counselor. This specialized team will be able to screen individuals in the field utilizing a Brief Level of Care Screening Tool which provides identification of immediate needs and a provisional level of care determination based on ASAM criteria and collaborate with a Triage Receptionist to identify open beds, schedule medical clearance, and coordinate rapid admission into treatment at RWC or other appropriate community provider. These steps will eliminate the most common barriers and delays which can be deadly to unsheltered clients with SUD and COD issues. 2) Integration with the local Continuum of Care (CoC) Coordinated Entry System (CES) and providing housing support throughout treatment with the goal of ending Participants’ homelessness. To strengthen connections to sustainable permanent housing, Interfaith will incorporate the position of a Housing Stability Case Manager dedicated to the RWC. The Case Manager will utilize the regional local CES to ensure that all homeless Participants are linked with the appropriate housing resources to obtain and/or maintain affordable permanent housing. All Participants will have access to Interfaith’s comprehensive SUD and mental health services at RWC. RWC provides services to low-income, underserved populations under the County of San Diego Drug Medi-Cal Organized Delivery System (DMC-ODS) inclusive of Level 3.2 Withdrawal Management, Level 3.1 and Level 3.5 Residential Treatment, and Level 1 and Level 2.1 Outpatient Services. Neighborhood Healthcare (NHC), a Federally Qualified Health Center that has addressed patient disparities for more than 50 years, will serve as partner in the project. NHC operates a co-located Intermittent Clinic and Harm Reduction Hub at Interfaith’s Inland Service Center. Connected services will include medical authorizations, MAT, and harm reduction outreach and education activities. Utilizing enhanced services, collaborative partnerships, and evidence-based strategies, the RWC will provide all required activities including: Outreach and engagement; SUD and mental health treatment; access to providers of medications to treat opioid use disorder (MOUD) and other medically assisted treatment (MAT); evidence-based harm reduction activities; services provided by staff with lived experience, case management and care coordination, and recovery support services. The Treatment to Housing Project will use evidence-based practices such as Motivational Interviewing, Harm Reduction, Peer Support, Trauma-Informed Care, Case Management, and culturally competent care. Key performance measures of progress towards goals will include: - Reduced time from first contact to program admission; - Increased detox and residential treatment bed utilization rates; - Increased enrollment into the Coordinated Entry System; and - Exits to permanent housing The total number of unduplicated individuals to be served with SAMHSA funds is 1,100.

Finger Lakes Area Counseling & Recovery Agency (FLACRA) is proposing funding for the One Stop Wellness Integrated Housing Support Team to support the development and implementation of an innovative, integrated team of professionals including peers, care coordinators and housing leadership to build a comprehensive system of identification, navigation, immediate access to treatments and support for individuals and families struggling with homelessness and behavioral health needs in the CoC NY-513c , covering Ontario, Seneca, Wayne and Yates counties of New York State. Funding will assure the bridge and support of 115 individuals in the first year and 535 individuals experiencing homelessness and behavioral health over the 5-year proposed grant period , covering Ontario, Seneca, Wayne and Yates counties of New York State. Funding will assure the bridge and support of 115 individuals in the first year and 535 individuals experiencing homelessness and behavioral health over the 5-year proposed grant period while they are waiting for permanent housing and to assure they can maintain that housing once placed. Project goals and objectives include outreach and engagement to sheltered and unsheltered individuals and families, culturally appropriate, trauma-informed and person-centered access to behavioral health care, harm reduction activities, case management and care coordination, recovery support, data collection and review of progress by a culturally and linguistically diverse Steering Committee. This grant will afford the resources necessary for the cross-collaboration and continued build of access to treatment, coordination of and mechanisms for referral, in-person coordination, and other resources necessary to support individuals and families in the catchment area and region who are homeless with behavioral health concerns and will provide ongoing connections to assure housing placement. FLACRA is a regional leader for both housing and behavioral health treatment and recovery services as well as a provider of Care Management, Home and Community Based Services and Recovery Community Centers in the Finger Lakes Region. FLACRA is the Lead Agency for the Finger Lakes Housing Consortium (FLHC), CoC NY-513, the Lead Agency for Finger Lakes and Southern Tier Behavioral Health Care Collaborative (FLST BHCC) and IPA, a founding member of Finger Lakes IPA, a unique partnership between FQHCs and Behavioral Health partners and is the Lead Agency for the State Opioid Response in the Finger Lakes Region, bringing a team of behavioral health providers together in the region to continue to support increased access and coordination of prevention, harm reduction, treatment and recovery services. recovery services as well as a provider of Care Management, Home and Community Based Services and Recovery Community Centers in the Finger Lakes Region. FLACRA is the Lead Agency for the Finger Lakes Housing Consortium (FLHC), CoC NY-513, the Lead Agency for Finger Lakes and Southern Tier Behavioral Health Care Collaborative (FLST BHCC) and IPA, a founding member of Finger Lakes IPA, a unique partnership between FQHCs and Behavioral Health partners and is the Lead Agency for the State Opioid Response in the Finger Lakes Region, bringing a team of behavioral health providers together in the region to continue to support increased access and coordination of prevention, harm reduction, treatment and recovery services. FLACRAs Housing Team currently uses the evidence-based Housing First model and would add training for the evidence-based Critical Time Intervention (CTI) Model to further support positive outcomes and housing stability for participants. This project will provide significant improvements and interventions to support the much-needed coordination between behavioral health, health and housing, especially for those who are currently homeless. The demand for affordable, safe housing far exceeds the resources as the concomitant factors of

Community Action Council (CAC) will provide critical health and housing services to 250 people experiencing homelessness, substance use disorder, and co-occurring mental disorders through the proposed Coordinated System for Treatment and Services (CSTS). Over the next five years, CAC will serve 50 people per year across 13 counties in Central Kentucky, helping them to achieve permanent housing and access the critical services they may need to build the self-sufficiency required to maintain that housing. Through strong community partnerships, CAC and service partners New Vista, Bluegrass Community Action Program, and Morehead State University will expand the infrastructure, capacity and resources needed to integrate behavioral health and substance abuse treatment services into housing services. CSTS' focus will be on providing wrap-around support to chronically homeless individuals, families and unaccompanied youth (ages 18-24) households, in which at least one member of the household has a substance use disorder and/or co-occurring mental disorder. Through holistic, culturally appropriate, evidence-based outpatient mental health and substance abuse treatment, CAC and other of local health and housing advocates will work to increase access to services. CAC and partners will utilize motivational interviewing coupled with trauma-informed care. Interventions will include Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT); the Hazelden Living in Balance Curriculum; and the Partners for Change Outcome Management System, or PCOMS. These interventions will be the catalyst needed to assist 40 to 50 households each year with housing support services, up to five households to receive physical or dental treatments each year, up to 25 households annually to increase their income, and up to 35 households annually to access childcare, transportation, and other services needed. To ensure optimal program efficiency and partner coordination, CAC will convene at least nine bi-annual regional team meeting to focus on identifying solutions to improve outcomes for high service utilizers as well as bi-monthly meetings to conduct case conferencing and service coordination. Stakeholders will include using CAC's Assertive Street Outreach (ASO) Team, including the Peer Support Specialist with lived experience, harm reduction specialists, case managers, SUD/COD treatment providers, recovery support services, paramedicine teams, and local law enforcement. CSTS will also monitor and work toward Continuous Quality Improvement (CQI). The Project Director and Principal Investigator will assess interim data reports and input from the Steering Committee meetings to conduct quality improvement activities. Not only is CSTS looking to improve services for program participants but also to work toward increasing community awareness and action with regard to the availability of housing and treatment services for those vulnerable populations.

LifeLong Medical Care proposes to provide SUD/COD treatment and services to a minimum of 238 individuals within the population of focus, which includes individuals, including youth and families, with substance use disorders (SUD) and/or co-occurring SUD and mental health conditions (COD) who are experiencing homelessness. Services will be provided in Alameda County, CA. The program will hire SUD Counselors who will provide SUD/COD services including assessments, group and individual counseling, case management, and recovery support services to program participants. LifeLong will use the Evidence-Based Practices (EBPs) of Harm Reduction, Relapse Prevention, Motivational Interviewing, Seeking Safety, and Contingency Management in its service delivery. Goals include: Conducting outreach activities, providing SUD/COD services including assessment, individual and group counseling, case management, recovery supports, and housing supports; conducting local performance assessments and documentation according to grant requirements and guidelines. Planning and program activities will take into account a culturally responsible, gender responsive, recovery/harm reduction oriented, trauma-informed, equity-based approach. Objectives include: • Conducting outreach activities at least twice per week at local encampments, shelters, mobile service drop-in events, and the LifeLong Adeline Recuperative Care site to increase access, participation, and retention in program services. • Providing evidence-based SUD/COD services including individual and group counseling to a total of 238 individuals. • Providing access to recovery support services including recovery housing, childcare, employment and workforce development training, and transportation to a minimum of 238 individuals. • Providing access to case management services including referral to primary care, screening for infectious diseases including HIV and viral Hepatitis (A, B, and C), mental health counseling, benefits counseling, food assistance, housing, and referrals for additional SUD/COD treatment as needed, such as Medication Assisted Treatment, and residential programs to a minimum of 238 individuals. • Implementing Brief Tobacco Screening and access to tobacco cessation treatment including NRT to a minimum of 238 individuals. • Completing health disparities statement, uploading GPRA data, participating in evaluation activities, and compiling data for semi-annual reports • Monitor race, ethnicity, sexual orientation, and gender identity of enrolled clients and present enrollment trends through monthly reports, allowing the team to ensure equity among the client population in real time, by the Research and Evaluation team.

Mountain Comprehensive Care Center will implement the Mountain Pathways Home Project to provide comprehensive, coordinated, and evidence-based treatment, recovery-oriented services, and access to housing for individuals, including youth, and families with SUD or COD who are experiencing homelessness as it expands the local infrastructure across the service area of Floyd, Johnson, Lawrence, Magoffin, Martin, Morgan, Pike, and Rowan counties in KY. Population: Based on data from the KY Balance of State CoC, which serves the catchment area, 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%. In terms of age, 67% will be adult individuals over age 24, 6% transitional-age youth (ages 18-24), and 27% will be families (61% children/youth, 39% adults). Located in eastern KY and the Central Appalachian region, the targeted population is anticipated to experience even more disparities than the general population – which is still significantly impacted by poverty, high unemployment, and recent flooding causing crisis across the region. Interventions: Staff will conduct outreach and engage potential program participants using trauma-informed care along with Motivational Interviewing (MI). Assessment will include the VI-SPDAT, Psychosocial Assessment, and ASAM while using Housing First to link clients with housing and desired treatment and recovery-oriented services as outlined in a Person-Centered Plan. Evidence-based practices include Housing First, MI, Cognitive Behavioral Therapy (including Seeking Safety and Living in Balance), peer support services, and Medications for Opioid Use Disorder/Medication Assisted Treatment (MOUD/MAT). MCCC will link clients to primary health care through its HomePlace Clinics while also providing case management/care coordination, enrollment in benefits, 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 treatment and primary health care; 2) Improve stability by providing and/or coordinating comprehensive case management, recovery and housing support services; and 3) Improve equitable and effective project implementation and evaluation by conducting CQI. Objectives achieved by end of each project year include: 1.1) conducted engagement/harm reduction services so 40 are served in Year 1 and 60 annually in Years 2-5; 1.2) coordinated access to individualized SUD treatment (and FDA-approved medications) so 60% report abstinence from substance use and/or alcohol [at 6-month follow-up]; 1.3) integrated mental disorders treatment so 50% or less report any MH symptoms; 1.4) 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 planning and 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.

“Centerstone’s Connections: Connecting with People through Home, Recovery, and Community in Indiana” (Connections) will provide comprehensive, coordinated, and evidence-based treatment and services for 235 unduplicated individuals, including youth, and families with substance use disorders (SUDs) or co-occurring mental health conditions and SUDs (CODs) who are experiencing homelessness in 6 Indiana counties (i.e., Bartholomew, Jackson, Jennings, Lawrence, Monroe, and Morgan) (Yr. 1: 35, Yrs. 2-5: 50 annually). Connections’ focus population encompasses an estimated 975 persons with SUD and an estimated 867 with COD. Focus population demographics and socioeconomics are expected to mirror those of the 3,688 individuals identified as homeless within IN-502 Continuum of Care (CoC) (e.g., 58% male, 75% ages 25+, 24% Black, 56% unemployed). Connections will serve subpopulations from among an estimated 258 rural residents; 315 Veterans; 1,000+ individuals from minority communities (e.g., 1000+ racial/ethnic minorities, 70+ LGBT adults); and 130+ juvenile system-involved/foster care and /or 1,460 criminal justice-involved adults. Connections will follow SAMHSA’s Treatment Improvement Protocol (TIP) 59: Improving Cultural Competence to guide integration of culturally- and population appropriate strategies and TIP 55: Behavioral Health Services for People Who Are Homeless to guide/inform delivery of selected evidence-based interventions/models, including a Housing First approach. Connections’ will implement Critical Time Intervention case management to facilitate community integration and provide linkage to needed services. SUD treatment will comprise therapies (e.g., Cognitive Behavioral Therapy, Motivational Interview) and trauma interventions (e.g., Seeking Safety), provided for those with COD as components of an integrated treatment approach, per TIP 42: SUD Treatment for People with COD. Key Connections’ strategies/interventions include community collaborations; in-/outreach; screening/assessment; development of Individual Care Plans; provision of Medications for Opioid Use Disorder (MOUD); harm reduction services/overdose education; tobacco/vaping cessation, care coordination, recovery support services (e.g., peer supports, linkages to housing/employment, benefits enrollment); HIV/hepatitis screening/education/linkages; assembly of a Steering Committee; dissemination of a comprehensive evaluation; and sustainability planning. Connections’ goals are to implement a comprehensive, coordinated, and evidence-based project to support the expansion of a community infrastructure that integrates services; develop/expand a sound infrastructure and capacity to support community systems’ effectiveness in providing integrated SUD/COD treatment, permanent housing, and recovery support services; improve participants’ health status/outcomes; and develop/disseminate a replicable service model. Connections will achieve the following measurable objectives: train 5 project staff in culturally-/linguistically-appropriate care; conduct outreach/engagement among 360; deliver treatment, housing navigation, and wraparound/recovery supports per comprehensive ICPs for an unduplicated in the 235 focus population; provide training/workforce development for 250 staff/community providers; collaborate with 10 local providers/organizations and 2 OTPs; establish a Steering Committee comprising 20% focus population/families, housing authorities, etc.; develop/revise 5 policies; develop linkages with 2 funding mechanisms; reduce substance use among 60%; reduce mental health symptomatology among 45%; reduce criminal justice system involvement among 25%; assist 80% to identify/secure stable housing; increase housing stability for 50%; link 100% with employment/education services; assist 100% to enroll in needed benefits; increase social connectedness among 80%; and reduce health/social consequences of substance use among 75%.

Central City Concern’s Old Town HEART (Homeless Enhanced outreach And Response Team) is a street outreach and engagement team serving individuals in downtown Portland, Oregon who are experiencing homelessness, substance use disorders (SUDs) and/or co-occurring disorders (CODs). In 2022, 20.9% of the 3,000+ unsheltered residents in Multnomah County were staying in Old Town area and surrounding neighborhoods. The neighborhood has seen a dramatic rise in street homelessness, an increasing prevalence of more dangerous substances including fentanyl and methamphetamines, and an escalating police response. Grant goals include: Reduced overdoses, addiction and mental health symptoms, increased access and retention in services, improved housing stability, and reduced trauma among the Old Town community and those who serve them. Strategies include (1) an expanded, trauma-informed infrastructure for integrated behavioral health treatment, peer support, recovery support and pathways to permanent supported housing, (2) culturally appropriate, trauma-informed SUD/COD TX to homeless individuals referred by HEART, including quality of living situation referrals, access to medical care, & transportation to services, (3) collaboration with homeless services organizations and housing providers to identify sustainable permanent housing, including public housing agencies, (4) outreach and connection to local pre-engagement services to unsheltered (including encampments) and sheltered populations, (5) support with discharge plans from Unity Psychiatric Emergency Room (assessing rising BH risk, referring to acute stabilization in support of housing stability, and (6) providing Trauma-Informed Critical Incident Debriefings to local housing providers, shelters, clinic staff, and businesses. During the 5-year grant period, HEART will provide outreach and engagement services to 750 individuals experiencing or at-risk for homelessness and case management and direct SUD/COD treatment to a subset of 200 individuals engaged through this process. PSU’s Regional Research Institute will track and assess project implementation, sharing outcomes and lessons with CCC and its Old Town HEART for program planning purposes. The anticipated project period is September 30, 2023 through September 29, 2028.

Restoration Recovery Center (RRC) is seeking to assist individuals experiencing homelessness in the city of Fitchburg, MA who do not qualify for housing under the guidelines of the Central Massachusetts Housing Alliance (CMHA) Continuum of Care (CoC). CMHA CoC is the primary housing authority assisting individuals experiencing homelessness in Worcester County, MA in which the city of Fitchburg is located. Under the CoC requirements for housing support there are four qualifications that must be met: 1) the individual is currently “street homeless”; 2) has been homeless for the past 12 months or has been homeless for 12 months or more in the past 36 months; 3) has a mental or physical disability; and 4) is on SSI or SSDI. RRC will use grant funds to assist individuals experiencing homelessness with services who would otherwise not qualify for CoC assistance. RRC has an established relationship with the CMHA and has identified an additional unsheltered homeless population that could benefit from housing supports and services. Specifically, the plan is to: 1) Utilize Outreach Specialists to engage individuals not currently accessing existing homeless services in the community; 2) Screen and assess at-risk individuals for housing needs, substance abuse, and immediate obstacles to recovery through Intensive Case Management; 2) Increase access to housing for individuals who do not qualify for CoC assistance; and 3) connect individuals to intensive case management and referrals to Peer Support and Recovery Coaches to address substance use. Restoration Recovery Center will serve the homeless population of Fitchburg, MA, and the county of Worcester. Fitchburg has an estimated population of 41,732 persons. Fitchburg residents are 73.3% White, 6.5% Black or African American, and 30.0% Hispanic/Latino; the remaining race groups (e.g., American Indian/Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, or two or more races) represent approximately 13.5% of the population. Fitchburg’s median household income (in 2021 dollars) is $60,466, $8,555 lower than the national average; 14.6% of the population lives in poverty. Worcester County, MA median household income (in 2021 dollars) is $56,746, $12,275 lower than the national average; 19.3% of the county population lives in poverty. Unsheltered homelessness continues to rise in many areas of the country, including Fitchburg. Primary concerns facing individuals experiencing homelessness are a lack of stable housing, access to basic needs, mental and physical health issues, and discrimination. A recent analysis of homelessness data shows that people experiencing unsheltered homelessness report significantly greater health challenges and experiences of trauma and violence than their sheltered peers. For those unable to qualify for CoC assistance, these concerns are unaddressed and the likelihood that they will be able to get out of their situation alone is extremely low. Restoration Recovery will fill this gap and assist those that are unable to access these services and break the cycle. To help address these concerns, RRC hopes to engage the target population through the use of this grant to achieve the following goals: 1) Increase access for unsheltered homeless to stable and affordable housing; 2) Increase access to and provide diverse services for unsheltered homeless adults that support their housing, recovery, and personal growth goals; and 3) Improve economic and health security for individuals experiencing homelessness.

The Lakes Region Mental Health Center Grant to Benefit Homeless Individuals & Families in the Lakes Region Service Area provides individuals that are experiencing homelessness with substance use and co-occurring mental health disorders, increased access to evidence-based services and treatments by providing linkages in an integrated, comprehensive system of supports to improve recovery outcomes for individuals, and overall healthier communities. Lakes Region Mental Health Center (LRMHC), established in 1966, is one of 10 Community Mental Health Centers in New Hampshire (NH), and the provider organization for direct client services. Recent trends indicate a significant increase in NH of the unsheltered (up 263%) and chronic (up 146%) homelessness from 2020 - 2021: 29% are chronically homeless, 33% have severe mental illness and 22% have a substance use disorder. The number of individuals experiencing homelessness in the county seat where LRMHC is located has risen dramatically from pre-pandemic levels. The number of public-school students experiencing homelessness is 206, or 6.6% of the NH total, higher than the state average of 1.8%, and much higher than the national average of 2.2%. To address the needs of the community LRMHC serves, the project is based on the 4 major dimensions of recovery: Health, Home, Purpose. Community. The first goal provides street outreach and increased engagement with sheltered and unsheltered individuals in the service area, to increase access and participation in treatments and services. Increased distribution of harm reduction supplies reduces the chance of the worst outcomes such as overdose fatalities, or life-threatening infections. Goal two improves outcomes for all youth, families, and adults that are experiencing homelessness with co-occurring mental health and substance use disorders, by increasing service capacity and availability of evidence-based treatment approaches and practices, increased screening and increased clinical guidelines. The third goal provides recovery services designed to improve access and retention. A flexible “No Wrong Door” model places a high priority on engagement with people with co-occurring disorders, and acts proactively to offer services in office, on the street, and in client-preferred locations to keep them from falling through cracks. Partnering area service providers and treatment organizations coordinate care delivery to provide comprehensive, integrated physical, mental, and substance use disorder recovery support services. Financial support for recovery housing, child care, and transportation reduce barriers to accessing treatment. Evidence-based treatment strategies and interventions include: Housing First, harm reduction, increased screening and assessment, motivational interviewing, supported employment, Peer Support, 7 Challenges, and case management. Continuous program quality assessment and improvement, adjustment for trauma-informed and culturally sensitive practices for the focus population, allow for programs and treatments that result in better long-term patient outcomes, sustainable recovery and housing. The objective is to serve 270, 295, 385, 435 and 530 unduplicated individuals in years 1-5, respectively, and a total of 1915 through the project term.

Special Health Resources for Texas, Inc. (SHR), a Federally Qualified Health Center in the heart of East Texas, is seeking funding to implement Project HOME2, with a population of focus on adults, youth, and families with substance use disorders (SUDs) or co-occurring mental health conditions and SUDs (CODs) who are experiencing homelessness. The proposed geographic catchment area encompasses the primarily rural and semi-rural Health Delivery Service Areas (HSDA) of Longview City, Gregg County, and Tyler City, Smith County. 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 implementation of Project HOME2 will be a continuation of the existing partnership between community stakeholders with SHR serving as the lead agency for this project providing Intensive Outpatient Treatment, coordination of care, psychiatric services, mental health services, co-occurring disorders treatment, and linkage to insurance and other benefit programs; Community Healthcore, the local mental health and intellectual disability governing authority for the target area, providing co-occurring disorder treatment services; and Hiway 80 Rescue Mission, a housing support agency providing emergency shelter, housing assistance, disability and insurance benefits, employment training and assistance, financial management, and transportation. Project HOME2 will focus on 1) behavioral health outreach, treatment, and recovery-oriented services; 2) coordination of housing and services to support the implementation and/or enhance the long-term sustainability of integrated community systems that provide permanent housing and supportive services; and 3) efforts to engage and connect individuals with SUD/COD, who are experiencing homelessness to resources for health insurance, Medicaid, and mainstream benefits programs. The proposed unduplicated numbers to be served are 50 individuals per year, for a total of 250. The main goals of the project are to strengthen the partnership's capacity and infrastructure to ensure effective planning and service delivery to the target population; to increase access to, or placement in, sustainable permanent housing, treatment and recovery support services, and Medicaid and other benefit programs; and to evaluate and measure project accountability and impact. The expected outcomes include a decrease in recent use of alcohol and other drugs among clients, enhance physical and mental health, increased self-sufficiency and social connectedness improved overall quality of, and satisfaction with, life among participants, and increased access to supportive and permanent housing among participants.

The Fortune Society’s (Fortune’s) Grants for the Benefit of Homeless Individuals (GBHI) program will serve justice-impacted adults and families experiencing homelessness in all five boroughs of New York City (NYC). All Fortune participants have prior involvement with the criminal justice system; in a typical year, 90% identify as individuals of color (primarily Black and Latino); at intake, up to 90% are unemployed, over half have no source of monthly income, and approximately half have co-occurring health, mental health, alcohol or substance use disorders. In Fiscal Year 2022 (7/1/2021-6/30/2022), 26% of new intakes reported that they were homeless or unstably housed; and in our Treatment Services unit, which provides outpatient substance use disorder (SUD) treatment, one-third (33%) of participants reported that they were homeless. The racial and ethnic demographics of our participant population reflect the neighborhoods from which they hail. Of the 10,107 individuals we served in FY22, approximately 84% identified as male, 9% as female, and less than 1% as transgender/gender non-conforming. The average participant age in FY22 was 41. The HUD Continuum of Care (CoC) providing services in Fortune’s proposed catchment area is the New York City CoC (NY-600). As a recipient of HUD Shelter Plus Care (S+C) and Supportive Housing Program (SHP) funding, Fortune is an active member of the CoC and staff representatives–many of whom have been impacted by the justice system and/or homelessness—regularly attend all NYC CoC meetings and participate on the NYC CoC Evaluation Committee. Fortune’s GBHI program will serve 275 participants over the five-year grant period (45 participants in Year 1, 50 in Year 2, 55 in Year 3, 60 in Year 4, and 65 in Year 5), enrolling them into integrated behavioral health treatment and wraparound services. Key project goals include (1) Provide behavioral health outreach, treatment, and recovery-oriented services to justice-involved adults experiencing homelessness; (2) Coordinate housing and program services to support the long-term sustainability of integrated behavioral health, peer support, recovery support, and linkage to permanent housing; and (3) Engage and connect program participants with SUD or COD to health insurance and benefits. In addition to Fortune’s existing referral pipeline, we will use peers with lived experience to outreach and engage individuals who have SUD or COD for engagement in behavioral health services. Projected outcomes include: 40% of those enrolled will have a service-level retention of 90 days or more; 100% of those enrolled in integrated behavioral health supportive services who are homeless or at risk of street homelessness will be screened for potential placement in Fortune's housing program; all GBHI program participants will be offered the following supportive services: peer services, medication assistance/linkages to healthcare, and 2010e application assistance in preparation for permanent housing placement assistance; and 100% of participants will be connected to certified applications counselors for Medicaid activation/re-activation, Fortune's Benefits Access team for assistance with SSI, SSD, SNAP, and TANF, and, when necessary, to Fortune's Behavioral Health medical practitioners for assistance with medical transportation application forms. Fortune will coordinate with the NYC Department of Health & Mental Hygiene (DOHMH), NYS Office of Addiction Services and Supports (OASAS) and NYS Office of Mental Health (OMH) to ensure that we are in alignment with all regulations, policies, priorities, and best practices, and to remain abreast of research and trends in NYS mental health and SUD treatment.

Summary. The Haitian-American Community Coalition (HCC) is proposing a program to provide comprehensive, coordinated, and evidence-based treatment and services for individuals with SUDs or CODs who are experiencing homelessness; HCC will target African Americans, immigrants, and LGBTQ+ persons in Brooklyn, NY. HCC will serve 250 unduplicated individuals annually (150 in year 1) with grant funds and 1,150 over the entire project period. Project name. Brooklyn Integrated Services for the Homeless Populations to be served. HCC’s population of focus (POF) will be individuals, including youth, and/or families with SUDs or CODs, who are experiencing homelessness. In particular, HCC will target African Americans, immigrants, and LGBTQ+ persons. The catchment area where services will be delivered will be high-need areas of Brooklyn, NYC, including Central Brooklyn (Bedford Stuyvesant, Crown Heights, and Brownsville), East New York, Flatbush-East Flatbush, and Canarsie-Flatlands; these areas have some of the highest rates of SUD and COD in NYC. Strategies/interventions. HCC’s program activities will include: 1) outreach and other engagement strategies to unsheltered and sheltered populations to increase access to, and participation and retention in, harm reduction, case management, treatment, and recovery support services; 2) direct SUD and mental health treatment; 3) access to MOUD services; 4) evidence-based harm reduction practices; 5) case management that includes care coordination/service delivery planning; and 6) staff with lived expertise to provide project services; 7) recovery support services; 8) identifying sustainable permanent housing; 9) and developing a Steering Committee, HCC will provide 3 EBPs: Intensive Case Management, Peer Support, and Community Reinforcement Approach. Project goals and measurable objectives. The program’s goal is to improve access to and delivery of coordinated, comprehensive services to reduce substance use and improve housing stability. Objectives for the proposed program include the following. Objective 1: Conduct outreach and engagement strategies to enroll at least 150 program participants in year 1 and 250 per year thereafter. Objective 2: Provide evidence-based SUD and mental health treatment services to 150 enrolled clients in year 1 and 250 per year thereafter Objective 3: Increase access to MOUD treatment services for at least 85% of clients in need of services per year Objective 4: Provide evidence-based harm reduction practices for at least 90% of clients in need of services per year Objective 5: Provide case management services to 150 enrolled clients in year 1 and 250 per year thereafter Objective 6: Provide recovery support services, including employment coaching, vocational training, recovery coaching and transportation assistance for at least 90% of program participants in need of services Objective 7: Assist in the placement of 80% of program participants in need in permanent housing through coordination with homeless service organizations and housing providers Objective 8: Convene a culturally and linguistically diverse steering committee consisting of at least 8 members to meet quarterly to monitor and advise on the program goals

Populations Served: Family Health Centers of San Diego’s (FHCSD) Mobile Harm Reduction Team (M-HRT) Program will engage, screen and enroll 350 individuals, youth, and families who are experiencing homelessness and substance use disorder (SUD) or co-occurring mental health conditions (COD) through field-based outreach and engagement in M-HRT services. Operating in conjunction with the operational hours and various site locations of FHCSD’s safe syringe program and surrounding neighborhoods, we anticipate that our population of focus (POF) will disproportionately be experiencing SUD and serious mental illness (SMI) and face significant economic, social and physical barriers to maintaining stable housing, achieving optimal SMI and SUD treatment, and accessing other supportive services. Each year, 20 high-risk M-HRT participants will also receive financial support for 3 months of Recovery Residency. Strategies and Interventions: M-HRT will establish a comprehensive and highly coordinated program that, with strong case management and participant support, will provide: 1) program services including case management, substance abuse and mental health treatment and recovery services, homeless services navigation, peer support within SUD services, and health and benefit enrollment assistance; 2) internal supported referrals to wrap-around FHCSD services for primary and dental healthcare, Medication Assisted Treatment, psychiatry, and other services provided by FHCSD; and 3) external referrals to community resources for needs such as employment assistance, legal aid, residential treatment, as well as other supportive services as indicated. M-HRT will employ evidence-based practices in all aspects of the program, including Harm Reduction (HR), Intensive Case Management (ICM), Trauma Informed Care (TIC), Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT), and Relapse Prevention (RP). Enhanced access to a hard-to-reach POF through field-based outreach in collaboration with FHCSD’s syringe services program will enhance the service experience of M-HRT participants across the continuum of care by systematically assessing client needs and service gaps, developing strategic partnerships to address those needs, and conducting careful and ongoing review of service collaborations to secure those needs. Goals and Objectives: The overarching goal of M-HRT is to reduce service barriers and increase access to high-intensity service interventions by expanding field-based services, increasing our capacity to reach the POF with robust services that impact their health and quality of life. This will reduce inequities, trauma, and stigmatization for participants as it improves their care. Offering field-based services also increases the visibility of available services to, and health education for, the POF. It will also increase access to age-appropriate services for San Diego’s rapidly growing population of older adults within M-HRT’s POF. Objectives include enrolling 350 participants over the course of the 5-year project period (45 participants will be enrolled in Year 1, and 75 in each of Years 2-5); and fundamentally addressing participant psychosocial, mental health, and medical needs through a range of services, the development of individualized care plans, internal and external referrals, and linkages to care.

The Costal Bend Wellness Foundation (CBWF), located in Corpus Christi, Texas, is a nonprofit FQHC and a Community Behavioral Health Center, serving the Texas Coastal Bend Catchment area. Project Homeless Initiative Program (HIP) will target individuals, including youth, and families with SUD/COD who are experiencing homelessness. Clients will be recruited from the Texas Coastal Bend area encompassing the semi-urban and rural counties of Nueces, San Patricio, Kleberg, and Aransas. According to the 2022 PIT the area has experienced a 70% increase in homelessness from 254 individuals in 2021 to 433 in 2022. HIP will provide comprehensive, coordinated, and evidence- based treatment and services for individuals, including youth, and families with substance use disorders (SUDs) or co-occurring mental health conditions and SUDs (CODs) who are experiencing homelessness. This program supports the development and/or expansion of the local implementation of a community infrastructure that integrates behavioral health treatment, peer support, recovery support services, and linkages to sustainable permanent housing. Project HIP will focus on 1) behavioral health outreach, treatment, and recovery-oriented services; 2) coordination of housing and services to support the implementation and/or enhance long-term sustainability of integrated community systems that provide permanent housing and supportive services; and 3) efforts to engage and connect individuals with SUD/COD, who are experiencing homelessness to resources for health insurance, Medicaid, and mainstream benefits programs. A total of 250 clients will be served over the span of 5 years. This will be accomplished with a staffing plan to include a Project Director, Project Coordinator, Recovery Peer Support Specialist, Licensed Professional Counselor, and a SOAR certified case manager. An external evaluator will be contracted to assist with data management, analyses, and reporting. HIP will ensure a culturally and linguistically diverse steering committee is developed and remains active in the community and project.

St. John's Community Health's (SJCH) Project SUP will expand and implement an effective, evidence-based, culturally competent response to extremely prevalent substance use disorder and co-occurring mental health disorders (SUD/COD) among unsheltered people experiencing homelessness (PEH) in South Los Angeles. Most clients (73%) are aged 31-54, 23% aged 55+, 12% young people 18-30 and 2% children under 18; 45% are African American and 52% Latino; 30% are immigrants best-served in Spanish/indigenous language; 75% justice-involved; and all living at/below the federal poverty level. The project will be LGBTQ-affirming and gender-responsive assuring access to underserved PEH. South residents of color experience homelessness and SUD/COD at disproportionately high rates compared to the general population as a result of a complex web of social determinants of health factors, institutional racism, intergenerational poverty, divestment of resources from South LA, soaring housing prices, limited services to meet need, and heavy policing that too often places PEH with SUD/COD behind bars instead of in treatment and housing. Project SUP will provide opportunities to interrupt SUD/COD and support clients to improve their health. functioning and stability through team-based, peer-driven, recovery-oriented, trauma-informed, and equity based treatment, harm reduction, intensive case management, recovery support, and housing navigation services. A total of 600 unduplicated PEH will be served (100 in Year 1; 125 in Years 2-5). Objectives include: building SJCH's capacity and infrastructure to support comprehensive SUD/COD services for PEH using several strategies including convening stakeholder groups, providing cross-training, expanding partnerships, and creating policies and workflows; providing harm reduction/peer-based outreach to 3,000 PEH during the course of the grant; providing screening, assessment, treatment, care coordination, and case management services for 600 individuals; linking 338 of those into the housing services continuum with an 85% rate of retention for clients obtaining permanent supportive housing; ensuring adherence to clinical treatment and progress on case management goals; increasing monthly income for a minimum of 20% of clients; providing HIV, HCV and STI screening and PrEP and linking 90% of positive screens to treatment; and reducing rates of substance misuse and improving mental health of clients.

COPE Community Services, Inc. (COPE) is proposing the Homeless Integration Project (HIP) for Pima County, AZ. HIP will serve 200 clients (40 per year) experiencing homelessness by providing harm reduction, comprehensive treatment, housing linkages and intensive case management. HIP will expand access to services by creating an intersection of coordination and providing care to homeless individuals to reduce SUD, COD and to improve housing stability. The number of people experiencing homelessness in Pima County increased by 68% between 2020-2022, and the need for Substance Use Disorder (SUD)/Co-occurring disorder (COD) treatment also continues to grow. In 2022, 27.9% of people contacted during the Point in Time (PIT) count of homelessness reported SUD, and more than 40% reported a mental health issue. COPE data supports this need: between 2020-2022, 73.4% of people experiencing homelessness entered COPE services with a COD, and 56.3% entered with a SUD. And the consequences of increasing SUD are catastrophic; overdoses in the county more than doubled from 175 in 2018 to 348 in 2021. The complex and cyclical nature of homelessness and substance use requires intensive care coordination. There are too few programs coordinating and integrating care in the community. Community stakeholders reported that treatment and this type of care coordination is a significant services gap in Pima County (Casuga, 2022). In response to this need, COPE proposes to implement HIP. HIP will conduct outreach and harm reduction education in the community; enroll adults in treatment, case management, and recovery support (including benefit assessment by SOAR certified staff) and will proactively link youth to youth-specific services. Based on county demographics and previous programming, it is anticipated that clients will identify as follows: 67% men, 33% women; 40% Hispanic/Latino and 60% Non-Hispanic/Latino; 70% White, 12% Black, 10% two or more races, 6% American Indian/Alaska Native, 1% Asian, and 1% Pacific Islander. HIP's design will establish rapport, build trust and implement care coordination to help clients access benefits they need. In addition to program services, enrolled clients will also have access to COPE's full spectrum of care. Four evidence-based treatment practices will be implemented by the fourth month of the program: Motivational Interviewing (MI), Intensive Case Management (ICM), Peer Support (PS), and SMART Recovery (SR). The combination of experienced providers, COPE's extensive experience working with the focus population, and the effectiveness of the proposed services will ensure success of HIP's goals: 1) expand SUD treatment and recovery support for people experiencing homelessness; 2) provide evidence-based SUD/COD treatment, housing service coordination, and benefit eligibility assessment; and 3) improve behavioral health and housing-related outcomes among HIP clients. outcomes among HIP clients. Research shows that the identified treatment practices demonstrate effectiveness in achieving the intended measurable outcomes: 80% maintained or improved substance use and mental health symptoms; and 70% maintained or improved housing and employment/economic status. The treatment approach will be combined with supportive recovery services (benefit eligibility assessment and enrollment, transportation, etc.), and access to higher level of care, all designed to increase engagement and bolster success. COPE is ready to expand its current services to serve additional clients with treatment that also connects historically siloed services. Implementation of HIP is crucial to meet the unmet need for evidence-based treatment, housing and coordination services in Pima County, AZ.

Project Abstract Summary (35 lines) Summary of Project: Hinds Behavioral Health Services an accredited substance use treatment, mental health provider with 51 years of experience and a 10-year proven track record of serving the population of focus, will implement Bridge to End Homelessness to serve individuals, including youth, and/or families with SUDs or CODs, who are experiencing homelessness and reside in Hinds County, Mississippi. Project Name: Bridge to End Homelessness. Populations served: Homeless individuals with SUD and/or COD treatment needs based on ASAM criteria; 50% SUD and/or COD and trauma; 80% African American; 1% Hispanic; 67% Female; 32% Male; 1% Transgender. Strategies/Interventions: 1) Engage and connect the population of focus to trauma-informed harm reduction, HIV/HVC screening, SUD/COD outpatient/IOP/MOUD treatment coupled with evidence-based services/practices (in-person and/or telehealth, telemedicine), SOAR-trained case management and care coordination, peer-led recovery supports, and linkages to housing, education/employment, healthcare, transportation and social supports; 2) Assist with identifying sustainable permanent housing by collaborating with homeless services organizations; and 3) Provide case management that includes care coordination/service delivery planning and SOAR supporting stability and housing transitions. EBPs: MI; SOAR; MAT/OUD; Critical Time Intervention; WRAP; Housing First and Permanent Supportive Housing. Goals. 1) Engage and connect the population of focus to behavioral health treatment, harm reduction services, case management, and recovery support services by providing evidence-based, gender affirming, trauma-informed, culturally and linguistically appropriate behavioral health services; 2) Work with a diverse Steering Committee to assist with identifying sustainable permanent housing by collaborating with homeless services organizations and housing providers, including public housing agencies, utilizing a Permanent Supportive Housing Model and/or Housing First Model; 3) Provide case management that includes care coordination/service delivery planning and other strategies that support stability across services and housing transitions working with jails and collaborative partners to reduce criminal justice involvement and improve employment status; 4) Utilize SOAR (SSI/SSDI Outreach, Access, & Recovery) to engage, enroll and link participants to resources for health insurance, Medicaid, and mainstream benefits programs that strengthen overall quality of life; 5) Use the Disparities Impact Statement to reduce behavioral health disparities by the end of the 5-year project period working collectively with Steering Committee. Objectives: 9/30/2023 and 9/29/28: 1) 100% will be screened/assessed for trauma, SUD/COD, HIV/HVC; 2) 60% will improve abstinence; 3) 80% will improve social connectedness; 4) 80% will reduce health/behavioral/social consequences; 5) 100% will receive an individualized housing plan; 6) 50% will improve stability in housing; 7) 80% with criminal justice involvement will reduce criminal justice involvement; 8) 60% will improve vocational, education, and/or employment status; 9)Utilize SOAR to engage, enroll and link 60% to resources for health insurance, Medicaid, and mainstream benefits programs; and 10) 80% enrolled will identify as racial, ethnic and/or LGBTQI+ minorities. #Served: 50 (Year 1-5) = 250 total.

Summary. Abounding Prosperity, Inc. (AP, Inc.) is proposing a program to provide comprehensive, coordinated, and evidence-based treatment and services for individuals with SUDs or CODs who are experiencing homelessness; AP, Inc. will focus on unstably housed cisgender and transgender Black women in Dallas, TX. AP, Inc. will serve 100 unduplicated individuals annually with grant funds and 500 over the entire project period. Project name. Dallas GBHI Program Populations to be served. AP, Inc.’s population of focus (POF) will be individuals, including youth, and/or families with SUDs or CODs, who are experiencing homelessness. AP, Inc. will focus on unstably housed cisgender and transgender Black women living with or at increased for acquiring HIV as a result of SUD, co-occurring mental health disorders, trauma and/or direct or indirect experience with the criminal justice system, though the agency will serve all individuals in need of services. The catchment area where services will be delivered will be Dallas County, TX, with a focus on underserved areas of South Dallas. Strategies/interventions. AP, Inc.’s program activities will include: 1) outreach and other engagement strategies to unsheltered and sheltered populations to increase access to, and participation and retention in, harm reduction, case management, treatment, and recovery support services; 2) direct SUD and mental health treatment; 3) access to MOUD services; 4) evidence-based harm reduction practices; 5) case management that includes care coordination/service delivery planning; and 6) staff with lived expertise to provide project services; 7) recovery support services; 8) identifying sustainable permanent housing; 9) and developing a Steering Committee, AP, Inc. will provide 3 EBPs: Screening, Brief Intervention, and Referral to Treatment (SBIRT); Motivational Interviewing (MI); and Seeking Safety. Project goals and measurable objectives. The program’s goal is to improve access to and delivery of coordinated, comprehensive services to reduce substance use and improve housing stability. Objectives for the proposed program include the following. Objective 1: Conduct outreach and engagement strategies to enroll at least 100 program participants per year Objective 2: Provide evidence-based SUD and mental health treatment services to 100 enrolled clients per year Objective 3: Increase access to MOUD treatment services for at least 80% of clients in need of MOUD services per year Objective 4: Provide evidence-based harm reduction practices for at least 100 clients per year Objective 5: Provide case management services to at least 100 program participants per year Objective 6: Provide recovery support services, including employment coaching, vocational training, recovery coaching and transportation assistance for at least 85% of program participants; Objective 7: Assist in the placement of 80% of program participants in need of housing in permanent housing through coordination with homeless service organizations and housing providers Objective 8: Convene a culturally and linguistically diverse steering committee consisting of at least 6 members to meet quarterly to monitor and advise on the program goals

The GROWTH project (Gaining Recovery by Obtaining Wholistic Treatment and Housing) proposes to screen at least 295 unduplicated individuals for SUD/COD and enroll at least 195 unduplicated individuals in SUD/COD treatment and recovery support services, including stable housing over the span of the 5-year grant. The project will expand opportunities to improve access to and delivery of comprehensive, coordinated, and evidence-based treatment and services for individuals with SUD/COD, including their families and youth (18-24), who are experiencing homelessness. The project supports the expansion of community infrastructure that integrates evidence-based behavioral health (SA/MH) treatment, peer support, recovery support services, HIV/VH testing and treatment, and linkages to sustainable permanent housing with a focus on people that identify as a racial/ethnic, sexual, and/or a gender minority.

SSG/HOPICS proposes the Homeless Treatment Program (HTP) to provide SUD/COD treatment for single adults experiencing homelessness in the South region of Los Angeles County. HTP will provide evidence-based, trauma-informed SUD/COD treatment and recovery support in the field – integrated with case management, harm reduction, and housing services – to address the high rate of SUD/COD among the population of focus and bridge existing service gaps. HTP will target single adults (18+) with substance use disorders (SUD) or co-occurring disorders (COD) who are experiencing homelessness, prioritizing those who are unsheltered and living in encampments. These adults will be predominately Black and Latino, approximately 60% male and 40% female, very low-income, and have experienced a myriad of risks and trauma associated with homelessness and behavioral health disorders, including but not limited to overdose, infectious disease, chronic homelessness, victimization and abuse, and criminal justice system involvement. The project will conduct people-centered, progressive outreach and engagement throughout homeless encampments in the region, as well as at local interim housing sites. As part of outreach and engagement, HTP will provide evidence-based harm reduction such as syringe exchange, overdose prevention education, and naloxone distribution and training. The project will conduct screening for eligibility and comprehensive assessment to guide enrollment and treatment planning. Eligible individuals will be enrolled in SUD/COD treatment services, as well as case management, housing services, and other recovery support. HTP will utilize the Trauma Recovery and Empowerment Model (TREM) as the SUD/COD treatment intervention. SSG/HOPICS will also leverage its regional leadership role in homeless services to establish a project Steering Committee that is integrated into an existing Community Design Team. HTP will serve 35 individuals in year 1 and 45 per year in years 2-5, for a total of 215 served over the five-year project. The project aims to achieve the following goals and associated objectives by the end of year 5: 1. Increase connections to and participation in behavioral health, harm reduction, and supportive services through outreach and engagement. HTP will provide outreach and engagement to 1,375 individuals experiencing homelessness, harm reduction services for 640 individuals, and referrals to needed resources for 100% of individuals engaged during outreach. 2. Expand access to evidence-based, culturally competent SUD/COD treatment. HTP will screen 700 individuals for SUDs and/or CODs, provide evidence-based SUD/COD treatment to 215 individuals, and link all eligible clients to additional treatment services, including MAT. Among clients who participate in TREM, at least 50% will report reduced substance use, at least 70% will report enhanced coping skills, and at least 70% will report a reduction in mental health/trauma symptoms. 3. Promote recovery, health, and housing stability through case management and housing navigation services. Among clients who participate in TREM, 100% will be enrolled in the local Coordinated Entry System for housing support, will be offered case management services that support recovery, and will be offered housing navigation services. Of these clients, at least 40% will have secured permanent and stable housing within 12 months of enrollment; and at least 80% of those not already connected to benefits will be enrolled in appropriate programs at discharge.