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Project Name: Entre Nosotros Abstract Summary: Entre Nosotros aims to reduce racial/ethnic disparities related to mental illness, substance use disorders, and HIV/STI/HCV infection and care. The program seeks to increase health-promoting behaviors and early detection, diagnosis, and treatment among NYC Hispanic MSM. The program utilizes Evidence-Based Practices (EBPs) to address various ecological levels, including behavioral health services and HIV/STI/HCV screening and testing. Focus population/geographic area: LCOA aims to increase engagement in HIV and behavioral health care among NYC Hispanic MSM, regardless of their HIV status, including Spanish speakers and undocumented immigrants. We will focus on Hispanic MSM at high risk or experiencing substance use disorders and/or co-occurring SUDs and mental health conditions. We will focus in the Bronx, Kings, New York, and Queens. Strategies/interventions: The following Evidence-Based Practices (EBPs) will address various ecological levels: health information dissemination, behavioral health screenings and HIV/STI/HCV screening and testing, SBIRT, NIDA Community-Based Outreach Model, and Motivational Interviewing-based psycho-educational sessions, and navigation services. The program will provide services to approximately 100 Hispanic MSM (70 the first year). Over the course of the 5 years, the program will provide direct individual-level services to approximately 470 Hispanic MSM. The program will also distribute health information and social marketing messages to at least 1,000 Hispanic MSM. Overarching goal: Increase early detection, diagnosis, and treatment of mental illness, substance use disorders, and HIV/STI/HCV infection among Hispanic Goal 1. Increase behavioral health literacy & reduce stigmatization of behavioral health Objective 1a Distribute behavioral health sheets (printed and electronically) to 1,000+ Hispanic MSM Objective 1b Provide two individual behavioral health sessions to 125 Hispanic MSM Goal 2. Increase awareness of mental illness, substance misuse, and HIV/STI/HCV risks Objective 2a Provide individualized behavioral health education to 100 Hispanic MSM Objective 2b Provide HIV/STI/HCV education to 100 Hispanic MSM to increase awareness of biomedical interventions (i.e., U=U, PrEP/PEP, testing) and intention to reduce condomless sex Goal 3. Increase adoption of health-promoting and help-seeking behaviors Objective 3a Provide substance misuse prevention education to 75 Hispanic MSM Objective 3b Provide HIV/STI/HCV prevention education to 75 Hispanic MSM Objective 3c Provide 1 to 2 psycho-educational sessions on mental health education to 75 Hispanic MSM Objective 3d Conduct behavioral screenings of 70 Hispanic MSM Objective 3e Conduct comprehensive health and socioeconomic assessments of 75 Hispanic MSM Goal 4. Increase access to and utilization of care and treatment for mental illness, substance use disorders, and HIV/STI/HCV Objective 4a Provide HIV Fourth Generation Rapid Tests to 100 Hispanic MSM and HCV screening to 25 Hispanic MSM to increase awareness of HIV and HCV status Objective 4b Provide navigation services to 10 Hispanic MSM living with HIV and out of care Objective 4c Provide navigation services to STI services to 75 Hispanic MS Objective 4d Link 2 newly HIV-diagnosed or out-of-care Hispanic MSM to HIV care (within a week) Objective 4e Provide education and navigation services to PrEP/PEP health providers to at least 50 Hispanic MSM with a non-reactive HIV result Objective 4f Provide navigation and follow-up services to behavioral health services to 75 Hispanic MSM Objective 4g Provide 75 Hispanic MSM with navigation and follow-up services to key health, social, and economic support services impacting utilization of behavioral health services

Center for Health Justice proposes to implement Project Hope in the priority jurisdiction of Los Angeles County (LAC) to reach 18–35-year-old justice-impacted Latinx and Black/African American (B/AA) men and women, including those identified as Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and Two-Spirited (LGBTQIA2S+) communities with substance use disorders (SUDs) and/or co-occurring SUDs and mental health conditions (COD) who are at risk for or living with HIV. Project Hope’s catchment area will cover the Metro and South region of LAC and provide services to individuals being released from the LAC Men’s Central Jail located in Downtown Los Angeles, California. Project Hope will screen 1,000 (Y1: 125, Y2-Y4: 250, Y5: 125) adults transitioning from incarceration to community or on parole for HIV testing, as well as provide on-site or linkage to confirmatory HIV testing for individuals that test positive. Project Hope will enroll 375 (Y1-Y5: 75) into appropriate SUD and/or COD person-centered treatment and recovery support services. Project Hope will use Motivational Interviewing and Living in Balance as the interventions to address SUD and/or COD.

AIDS Alabama, Inc. (AAI) proposes to implement the Living in Balance Project, a co-located (multiple services provided under the physical and administrative infrastructure of AAI) and integrated (multidisciplinary service coordinator) care model that includes psychiatric services; nursing; substance use treatment; vocational/recreational rehabilitation; HIV/STI prevention, testing, and treatment; PrEP assessment and treatment; linkage to care; peer support services; permanent housing support/planning/placement; and case management to people with or who have indicators for HIV/AIDS and have a Substance Use Disorder (SUD) diagnosis or Co-Occurring Diagnosis substance use and mental health disorder(s) (COD). The Living in Balance Project will target disproportionately impacted populations in the Greater Birmingham Area and fill existing gaps in services for minority individuals, and LGBTQ+ individuals identified through existing AAI programs and community partners. The Living in Balance Project will include provisions to fully integrate care to ensure participants report improvements in substance use symptoms and major life areas, linked to HIV care (through AAI or partner agencies), and linked to PrEP evaluation and care if appropriate. The Living Well Project will include three (3) unique levels of intervention tailored to the participant's individual needs focused on improving health outcomes. 1. Level 1 - The Rectory and Living in Balance Chemical Addiction Intensive Outpatient Program is an Alabama Department of Mental Health (ADMH) certified Substance Use Program. The program is open to adults aged 19 and up who are HIV-positive. Enrolled participants will have access to individual/family/group substance use therapy, mental health evaluation and therapy, case management, peer support, and linkage to medical care. Participants will be continuously monitored and assessed to ensure they meet the medical necessity requirements for this level of care. AAI anticipates serving three hundred fifty (350) individuals in this level of care over the course of the grant, with a retention rate of 75%. 2. The Living Well Outpatient Center (LWOC) is an ADMH-certified mental health and substance use program. The program is open to adults aged 19 and up who are living with or have indications for HIV/AIDS. LWOC can provide assessment/evaluation for mental health and substance use treatment, psychiatric evaluation and medication management/monitoring, nursing assessment, peer support, case management, psychoeducational groups, and linkage to additional services. Participants will be continuously monitored ad assessed to ensure they are appropriate for and benefit from services. AAI anticipates reaching five hundred (500) individuals over the course of the grant. 3. Level III - The Living Well Health Clinic will provide testing, education, and treatment to individuals in the community. The Living Well Health Clinic provides state-of-the-art HIV testing and treatment, STD/STI testing and treatment, and PrEP assessment and treatment to anyone over the age of 18 who has indications for acquiring HIV/AIDS; regardless of sex, race, gender, sexual orientation, gender expression, economic status, or ability to pay. The Clinic also operates a Mobile Medical Unit, allowing AAI to reach underserved and homeless individuals in the Greater Birmingham area. AAI anticipates reaching five thousand (5,000) individuals over the course of the grant. The Living Well Project will provide psychiatric, nursing, behavioral, peer support, and case management services using programs recognized by NREPP, including Living in Balance, Intensive Case Management, and Motivational Interviewing. The program is designed to improve engagement, maintenance, and access to mental health, substance use, medical, case management, peer support, housing, and vocational skills.

The Women's Collective (TWC) is dedicated to providing exclusive programs and services for low-income, Black women and girls aged 13 and above in the Washington, DC Eligible Metropolitan Area (DC EMA), which encompasses Maryland and Virginia. TWC holds the distinction of being the sole provider in the region that offers HIV prevention, care, and support services specifically tailored for women, including both cisgender and transgender individuals. TWC’s catchment area in the DC EMA for this proposed effort is Washington DC and its surrounding suburbs of Prince George’s County, and Montgomery County, Maryland – all are identified by SAMHSA as highly impacted by HIV. DC has some of the highest rates of drug abuse in the nation, often ranking in the top 5 most addicted places. Both mental health and substance use significantly impacts an individual living with HIV/AIDS. TWC will utilize its key partnerships to implement the proposed program, thus increasing TWC’s ability to provide more comprehensive services and interventions designed to address the needs of women experiencing HIV and CODs and those at risk for HIV. Services will be provided in-house and through TWC’s collaborations, referral network, and existing MOUs. TWC is a Ryan White service provider and will leverage those resources, funding, and relationships to ensure prompt implementation of this proposed program (within 2 months of funding award). Along with its in-house services, TWC links women to needed services, such as: 1) primary and infectious disease medical care; 2) insurance navigation and enrollment; 3) mental health services; 4) substance abuse treatment; 5) housing; 6) spiritual supports/pastoral care; 7) harm reduction services; 8) food; 9) transportation; and 10) employment training services.

The population of focus for the proposed initiative is racial/ethnic minorities that identify as People Who Use Drugs (PWUD) and those most at-risk for HIV/AIDS or living with HIV, that have fallen out of care, that reside in Detroit, Highland Park, and Hamtramck area. The purpose of Health, Empowerment, Acceptance, Recovery, Treatment (HEART) is to further engage Black individuals that are entering SUD/COD services, or identity as a Person Who Uses Drugs (PWUD) to increase access to HIV testing, HIV prevention tools, HIV Linkage to Care (LTC), and to ensure linkage and retention to SUD/COD services. Goal 1: Provide linkage to SUD/COD treatment and/or recovery services for 80% of participants most at risk for HIV. Goal 2: Prevent: Increase access to HIV testing and linkage to care for individuals that are accessing recovery, and/or People Who Use Drugs (PWUD) by testing 625 individuals over the life of the grant. Goal 3: Diagnose: Using the approved dual rapid process, DRP will provide a second rapid AB/AG HIV Test to confirm the individual's HIV diagnosis for 100% of all participants that receive an initial reactive HIV rapid test. Goal 4: Treat: Ensure 100% of participants are engaged in HIV care within the first 30 days of diagnosis or re-engagement for those that have fallen out of HIV Care.

The Community Action Partnership of San Luis Obispo County, Inc., (CAPSLO) leads San Luis Obispo Homeless Recovery Hub (SLO-HUB), which integrates both treatment and services for homeless individuals, youth, and families with co-occurring mental health and substance abuse disorders. It provides integrated treatment and intensive case management, permanent housing, recovery supports, employment, and education to set a path for self-sufficiency. Community partners provide evidence-based, co-occurring treatment, primary health care, reproductive health care, and community support on-site at CAPSLO’s 40 Prado Homeless Services Center (40PHSC), and short-term residential recovery, tobacco cessation, additional mental health counseling, and permanent housing in the community. In spite of four homeless shelters operating in the county, San Luis Obispo County’s temperate climate allows over 80% of the homeless population to remain unsheltered. SLO-HUB’s outreach worker will engage unsheltered and sheltered participants at either the 40PHSC or during outreach activities in the community at Safe Parking sites, encampments, parks and other public locations and sites, as well as by referral from community agencies (including all project partners), or a family member. SLO-HUB will serve 30-clients annually, totaling 150 throughout the five-year project period. Participants are estimated to be 55% male, 84% White, 34% Latino, 55% ages 45-60, 18% over age 61, and 12% LGBTQ, in accordance with the last PIT Count. Socioeconomically, only 14% of the unhoused population had some form of employment, with 68% of the unemployed unable to work or not looking for work. A majority (84%) were receiving some form of government service or assistance. Self-reported data from the 2022 PIT Count shows 46% of those surveyed disclosed PTSD, 43% psychiatric or emotional conditions, 35% alcohol and drug use, 31% chronic health problems, and 3% suffer from HIV/AIDS-related illnesses. Support for homeless residents with mental health conditions and drug and alcohol abuse is a pressing need locally. The opioid drug overdose mortality rate for CA is 18.03, while in SLO County the rate is 27.9 (2) Anecdotally, the Lead Case Manager at 40 Prado HSC reports the most frequently presenting conditions at SLO-HUB are alcoholism, methamphetamine and fentanyl use disorders. To meet the needs of this diverse population, SLO-HUB’s two goals are to maintain a co-located multi-agency system of integrated services, and to deliver participants a wrap-around recovery program to improve the quality of their lives through recovery support that increases opportunities for permanent housing. These goals will be achieved through a steering committee with consumer representation which focuses on increased service integration throughout the community, counseling services, short-term residential recovery, and access to many community-based recovery services and supports, such as on-site primary medical care, access to a mobile reproductive health clinic, housing, benefits enrollment, tobacco cessation programs, and all services to meet basic needs offered at 40HSC. In addition, CAPSLO will hire, train, and gain certification for at least two SLO-HUB graduates to be Peer Support Specialists each year. SLO-HUB services are culturally and linguistically appropriate, and respectful of and responsive to the health beliefs, practices, and needs of the diverse client population. Treatment plans are culturally appropriate, trauma-informed, and evidence-based. An independent evaluator will lead the local performance assessment.

Atlanta/Fulton County Prearrest Diversion is seeking a total of $1,500,000 in grant funding, payable over five years. The Policing Alternative & Diversion (PAD) Initiative will utilize the grant funding to support our Care Navigation efforts to support individuals experiencing homelessness in metro Atlanta. The project will serve approximately 750 individuals during the five-year grant period. PAD provides outreach and case management for people who are experiencing extreme poverty, problematic substance use, or mental health concerns. Through proactive outreach to individuals referred through the City of Atlanta 311 line as well as pre-arrest diversion from law enforcement, PAD engages people who are disconnected from community supports, vulnerable to criminal legal system contact, and often excluded from traditional s services. The overwhelming majority (95%) of people who PAD serves are experiencing homelessness at the time of initial engagement. PAD works with each person enrolled into Care Navigation services to develop Individual Service Plans (ISPs) that support their goals using a trauma-informed, harm-reduction-based framework. While we work alongside our participants through community-based case management, we also provide direct services including emergency housing and facilitate warm connections to treatment, healthcare, and other services. Our services do not exclude people with prior criminal convictions, active substance use, or untreated mental health conditions and are not time-limited.

Aboha translates to the Chahta word for house, or room. Project Aboha, if awarded, will prioritize shelter and recovery for at-risk or homeless individuals in the TSA. The project will increase the Choctaw Nation Health Services Authority Behavioral Health capacity to provide assessment, service, and stabilization for those experiencing or at risk for homelessness (Goal 1). Project Aboha will also create an integrated community support network for permanent housing and supportive services across the Tribal Service Area (TSA) (Goal 2). The Choctaw Nation of Oklahoma (CNO) is a federally recognized Native American (NA) Tribe located in rural southeastern Oklahoma. The reservation hosts a tribal member population of 47,671, accounting for more than 75 percent of the population in many communities. The TSA is geographically isolated and has high rates of poverty, unemployment, low educational attainment, and severe mental health conditions including substance abuse disorders. The target population to be served will include Native individuals residing on the CNO reservation with a special focus on those referred from CNO Behavioral Health, Judicial Branch, and/or Veterans Affairs experiencing substance use disorders (SUDs) or co-occurring mental health conditions and SUDs (CODs). Project Aboha will serve 95 patients in Year 1, 115 in Year 2, 135 in Year 3, 155 in Year 4, and 175 in Year 5.Throughout the lifetime of the project, we will serve 675 total unduplicated individuals. Case Managers will assess patients receiving treatment from CNHSA Behavioral Health for the risk factors associated with homelessness (Objective 1.1). Through collaboration with Project Aboha, the CNO tribal services and referral network will refer patients to CNHSA Licensed Mental Health Providers for mental health treatment for conditions placing them at risk for homelessness (Objective 1.2). Case Managers will also connect at-risk patients reporting homelessness with sustainable permanent housing and healthcare (Objective 1.3). Case Managers will maintain structured contact with patients experiencing homelessness or at risk for experiencing homelessness (Objective 1.4). Case Managers will provide patients with evidence-based harm reduction practices for homeless and/or at-risk individuals including a plan for the fulfillment of the four dimensions of recovery: home, health, community, and purpose (Objective 1.5). Case Managers will also manage training and education for at-risk and homeless individuals to develop their life skills to support the sustainability of their housing. The Project Director will join the Service Team provided by CNO Outreach Services (Objective 2.1). Case Managers will establish a referral network to engage CNO programs in direct contact with at-risk individuals and/or individuals experiencing homelessness. These partners will include the following CNO programs: the Recovery Center, Project EMBRACE, Project HOUSE, Chi Hullo Li, Judicial Branch, Tribal Opioid Response Program, Veterans Housing Program, and Food Distribution (Objective 2.2). Case Managers will also work with patients to integrate and restore their family unit to support their holistic well-being and increase their chances of maintaining housing (Objective 2.3). The Project Evaluator will report all required program performance on abstinence, stability in housing, crime or criminal justice involvement, employment/education, social connectedness, and health/behavioral/social consequences (Objective 2.4). These efforts will provide CNO Tribal Members supported by this grant funding with a comprehensive network of resources to support of their recovery.

PROJECT SECOND CHANCE ABSTRACT NEW BREED CREATION LIFE CENTER New Breed Creation Life Center (NBC) plans to partner with Community Rehabilitation Center, Joshua Christian Academy, The Sulzbacher Center, and the Jacksonville Housing Authority for the implementation of Project Second Chance. Project Second Chance 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. The proposed unduplicated numbers to be served: 30 year 1, and 80/year years 2 thru 5, for a total of 350 participants served. Project Second Chance 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 SUD/COD treatment and permanent housing; 2) increased number of clinic patients receiving housing and treatment services leading to reduction of SUD/COD and homelessness among participants; 3) a comprehensive evaluation of processes and outcomes as measured by successful collection of GPRA, and service dosage data supporting an increase of SUD/COD treatment and supportive housing services and decrease in substance use and misuse and an increase in permanent housing. Safe Horizons will accomplish its goals by implementing the following required activities: Outreach and engagement activities, SUD/COD and Opioid Use Disorder (OUD) treatment, evidence-based harm reduction practices; SOAR Case Management; Recovery support services; availability of permanent housing; and establishing The Jacksonville Homeless Steering Committee.

Realistic Education in Action Coalition to foster Health (REACH LA) in collaboration with Arming Minorities Against Addiction and Disease (AMAAD) is applying for SAMSHA FY 2023 Grants for the Benefit of Homeless Individuals in Los Angeles County, California. REACH LA will provide comprehensive, coordinated, and evidence-based services for Black and Latinx youth and families with substance use disorders (SUDs) or co-occurring mental health conditions and SUDs (CODs) who are experiencing homelessness. For over 30 years, REACH LA has been a trusted community organization that has engaged and empowered young Black and Latinx LGBTQ+ in the Downtown Corridor Produce District near Skid Row and is centrally located between South LA (SPA 6), East LA (SPA 7), and Pomona (SPA 3). REACH LA serves 2,000 LGBTQ+ youth of color annually between the ages of 13-35 years old. For 13 years, AMAAD has been a fundamental grassroots nonprofit Recovery Community Organization for Black LGBTQ+ individuals. AMAAD operates 2 transitional housing units and has its DHCS Certification for Outpatient Services for Drug-Medi-Cal. With SAMHSA funding, REACH LA and AMAAD will 1) engage and connect the population of focus to behavioral health treatment, harm reduction services, case management, and recovery support services; 2) Assist with identifying sustainable permanent housing by collaborating with homeless services organizations and housing providers, including public housing agencies; and 3) Provide case management that includes care coordination/service delivery planning and other strategies that support stability across services and housing transitions. Motivational Interviewing, Intensive Case Management, and Harm Reduction evidence based practices will be integrated into the program. On a yearly basis, REACH LA in collaboration AMAAD will reach 125-150 persons providing them with Case Management, Mental Health, and/or Substance treatment. Over the 5-year project period, REACH LA will serve 700 Black and Latinx youth and young adults experiencing homelessness. The goals of the program are to: 1) improve linkages to sustainable permanent housing by implementing a community infrastructure that integrates behavioral health treatment, peer support, recovery support services, and linkages to sustainable permanent housing and 2) improve access to and delivery of coordinated, comprehensive services to reduce substance use and improve housing stability for Black and Latinx youth and young adults with substance use disorders (SUDs) or co-occurring mental health conditions and SUDs (CODs) who are experiencing homelessness.

Alameda County Health Care Services (HCSA) Health Care for the Homeless Program (HCH) proposes to reduce substance use-related mortality among people experiencing homelessness in Alameda County through 1) Direct provision of MOUD medicated assisted treatment and SUD recovery services in homeless settings, 2) System coordination to increase homeless access to MAT and SUD services; and 3) Systemwide targeted interventions to prevent overdose deaths. To increase direct access to MOUD and SUD services, HCH will expand existing teams of substance use clinicians and Substance Use Navigators, creating a SUD Team to provide MOUD and SUD treatment services at homeless interim housing and services centers in Alameda County. These activities will be linked to systemwide efforts to increase SUD services and coordination, and with harm reduction interventions to reduce the incidence of overdose and drug-related mortality and morbidity.

Bexar County, Texas (includes the city of San Antonio) proposes to develop and implement the Bexar County Community Court. The mission of the Community Court will be to generate better outcomes for justice-involved individuals experiencing homelessness and co-occurring substance abuse and mental illness. This Court will have a caseload of forty (40) individuals at any given time. These individuals will have been charged with a non-violent Misdemeanor Class A or B offense. The total number of individuals to be served over the grant period is 200 individuals. With grant funding, these individuals will receive on-demand, evidence-based treatment and case management. These services and supports include Illness Management and Recovery case management, Trauma Recovery and Empowerment Model, Cognitive Processing Therapy (CPT), and Cognitive Behavioral Therapy (CBT). These individuals will also receive housing services and will even receive rental assistance for those who would like to live in an Oxford Home. Ancillary services include bus passes, peer recovery coaching, harm reduction strategies and supports, and access to medication assisted treatment. The program will be strictly pre-trial and will result in individuals not having a criminal conviction upon successful completion from the program. Key stakeholders include the local homeless shelter, the local mental health authority, and the County Courts. All stakeholders will participate in an Advisory Council that will include the voices of the target population. The Advisory Council will focus on the various policies and procedures surrounding the program as well as the program evaluation. Program evaluation will meet all of the requirements set forth by SAMHSA but will also assess all performance metrics that lend themselves to finance and sustainability once the grant funding has been exhausted. Bexar County anticipates that the Community Court will become a national model worthy of replication.

Summary. The Pride Center of Maryland (PCOM) is proposing a program to provide comprehensive, coordinated, and evidence-based treatment and services for individuals with SUDs or CODs who are experiencing homelessness; PCOM will target LGBTQ+/SGM populations in the Baltimore MSA. PCOM will serve 100 unduplicated individuals annually with grant funds and 500 over the entire project period. Project name. Baltimore GBHI Program Populations to be served. PCOM, in partnership with the Black Men’s Xchange (BMX) and Black Mental Health Association (BMHA), population of focus (POF) will be individuals, including youth, and/or families with substance use disorders (SUDs) or co-occurring mental health conditions and SUDs (CODs), who are experiencing homelessness, with a focus on LGBTQ+/SGM (sexual and gender minority) populations. The catchment area where services will be delivered will be Baltimore Metropolitan Service Area (MSA) which includes Baltimore City, Baltimore County, and surrounding counties; these areas have some of the highest rates of SUD and COD in Maryland. Strategies/interventions. PCOM’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, PCOM will provide 3 EBPs: : Motivational Interviewing, SBIRT, and Critical Thinking and Cultural Affirmation (CTCA). 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 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 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 90% of program participants; Objective 7: Assist in the placement of 85% of program participants in need of services 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

Summary of Project: CADA Prevention and Recovery Center an accredited substance use treatment, mental health and HIV provider with 62 years of experience and a 5-year proven track record of serving the population of focus, will implement New Directions to serve individuals, including youth, and/or families with SUDs or CODs, who are experiencing homelessness and reside in Orleans and Jefferson parishes. Project Name: New Directions. Populations served: Homeless individuals with SUD and/or COD treatment needs based on ASAM criteria; 40% COD and trauma; 55% African American; 4% Hispanic; 49% Female; 50% Male; 1% Transgender. Strategies/Interventions: 1) Engage and connect the population of focus to trauma-informed harm reduction services, HIV/HVC screening, SUD/COD outpatient/IOP treatment coupled with evidence-based practices/programs (in-person and telehealth), strengths-based case management, and peer-led recovery support services, and linkages to housing, education/employment, healthcare, 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 that support stability and housing transitions. EBPs: S-BIRT; Strength-based Case Management; SOAR; Seeking Safety; Living in Balance; Matrix; MAT; Recovery Coaching; Housing First/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 trauma-informed, inclusive evidence-based culturally responsive 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 Housing First and Permanent Supporting Housing; 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) 59% enrolled will identify as racial, ethnic and/or LGBTQI+ minorities. #Served: 50 (Year 1-5) = 250 total.

Individuals who are chronically homeless with co-occurring mental health and substance use disorders (COD) often have substantial challenges obtaining and maintaining housing and have limited access to culturally responsive wraparound services. This project proposes to develop the Supporting Treatment Access and Recovery for Homelessness (STAR-H) Program to fill this gap. STAR-H will offer specialized housing support and wraparound services to 175 individuals who are chronically homeless and have a COD in the Springfield metro area of Massachusetts. This region has limited funding for homeless services, few behavioral health resources, and disproportionately suffered from the pandemic and the economy. Behavioral Health Network, a clinical provider in the region, and the Mayor’s Office in Springfield both collaborate on co-chairing the Regional Network HUB (HUB). The HUB tracks a “by name list” of individuals who are chronically homeless and convenes a weekly meeting with local Continuums of Care for housing vouchers and local social service providers for client referrals. However, neither Housing First nor intensive wrapround supports are available through the HUB, and the community providers are plagued with service delays. Therefore, the STAR-H Program proposes to fill this gap by hiring 1.75 Case Managers, 1.75 Peers Support Specialists, and a .15 Nurse Practitioner. The newly hired Case Managers and Peer Support Specialists will attend HUB meetings for referrals and deliver real-time Housing First and Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION) wraparound services. MISSION is a multicomponent intervention that systematically combines Housing First, Critical Time Intervention, Integrated Mental Health and Substance use Disorder Treatment, Peer Support, Vocational Support, Trauma Informed Care, and supports clients with COD medication needs. Both Housing First and MISSION have extensive evidence, and in 2016, MISSION was listed in the Substance Abuse and Mental Health Service Administration-National Registry for Evidence Based Practices (SAMHSA-NREPP). In this proposed project, the University of Massachusetts Chan Medical School will be the Local Lead Agency and Evaluator, and Behavioral Health Network will be the clinical provider. The 175 individuals who are homeless with a COD and served in the STAR-H program (Year 1=35, Year 2=35, Year 3=35, Year 4=35, Year 5=35) will receive a rapid assessment, 12-months of housing support, and culturally responsive MISSION COD treatment and wraparound services. MISSION wraparound supports will also include key linkages to community-based, state, and federal mainstream benefit programs such as the MassHealth (state Medicaid authority), and the state Departments of Mental Health and Public Health services. This project will also prioritize Hispanic/Latinx and Black/African American individuals who are underrepresented and underserved. We anticipate that the 175 chronically homeless individuals with a COD who receive STAR-H services will have: 1. fewer days homeless; 2. fewer days of substance use; 3. improved mental health symptoms and functioning; and 4. greater linkage to culturally responsive services. This project has been developed with significant input from local and state agencies, providers, people with COD, and is consistent with the Massachusetts’ Plan to End Homelessness.

The Board of Alcohol, Drug Addiction & Mental Health Services will implement Project HOME (Housing, Outreach, and Meaningful Engagement) to provide comprehensive and integrated services for individuals and families with youth with substance use disorders or co-occurring disorders who are experiencing homelessness in Hancock County, Ohio. Subpopulations will include: young adults (18-24 years old), LGBTQ+, and veterans. Hancock County is home to about 75,000 people, with more than half (about 40,000) residing in the “micropolitan” county seat of Findlay. It is a mostly rural area with a population density of about 140 residents per square mile. The overall unemployment rate is 3.7% but depending on where one lives in Hancock County, the rate is as high as 9%. About 1 in every 5 resident (20.9%) spends more than 30% of their income on housing or rent; overall, 11% of residents live below the federal poverty line. Almost 15% of adults in the county reported having 4 or more adverse childhood events and about 3% (about 2,280) residents said they had someone who is homeless living with them. Project HOME will expand and enhance a local implementation of a community infrastructure that integrates behavioral health treatment, peer support, recovery support services, and linkages to sustainable permanent housing. Project HOME will utilize evidence-based practices (EBPs) such as medication for opioid use disorder (MOUD), motivational interviewing, intensive case management (ICM), community reinforcement approach (A-CRA), peer supports, trauma-informed care, and harm reduction strategies. The proposed Project will establish a sustainable 7-days a week /365 days per year low-barrier shelter to address the gap in much needed services. The overarching goal of Project HOME is to serve as a point of access to direct services for individuals with SUDs or CODs who are experiencing homelessness. The goals of the project are: 1) Expand outreach and meaningful engagement with individuals and families who are homeless and have SUD/COD; 2) Implement evidence-based practices across City Mission, including the fully operational low-barrier shelter; and 3) Increase access and warm hand-offs to comprehensive community resources to low-barrier shelter guests, including long-term stable housing, BH treatment, and recovery support services. Measurable objectives over the project period will include: a) conduct engagement activities with 60 homeless individuals and 8 families; b) provide telehealth/telebehavioral health services to 75 individuals; c) refer 75 individuals to recovery/transitional housing; d) refer 280 individuals to peer recovery support services; e) decrease jail admission among GPRA participants by 15%; f) improve service satisfaction among GPRA participants by 80%; g) decrease self-reported substance use among GPRA participants at by 10%; h) improve housing stability among GPRA participants by 70%. Project HOME aims to serve 500 individuals through direct and indirect services over the 5-year project period; we will target 40 individuals in year 1, 60 in years 2-5 for a total of 280 unique individuals who receive direct services.

Summary. Intercambios Puerto Rico (IPR) is proposing a program to provide comprehensive, coordinated, and evidence-based treatment and services for individuals with SUDs or CODs who are experiencing homelessness. IPR will target serve the Puerto Rico Metropolitan Area and Eastern Puerto Rico. IPR will serve 50 unduplicated individuals annually with grant funds and 250 over the entire project period. Project name. Puerto Rico GBHI Program Populations to be served. IPR’s population of focus (POF) will be individuals, including youth, and/or families with SUDs or CODs, who are experiencing homelessness. In particular, IPR will target injection drug users, sex workers, LGBTTQ population, and people with a positive diagnosis of HIV or HCV. The catchment area where services will be delivered will be the Puerto Rico Metropolitan Area (San Juan, Bayamon, Carolina, Cataño, Guaynabo, Toa Baja and Trujillo Alto) and the Eastern Puerto Rico Metropolitan Area (Canóvanas, Rio Grande, Loíza, Luquillo, Fajardo, Naguabo, Humacao, Juncos, Gurabo and Caguas); these areas have the highest rates of SUD/COD in Puerto Rico. Strategies/interventions. IPR’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, IPR will provide 6 EBPs: SBIRT, Cognitive Behavior Therapy (CBT), Seeking Safety, Motivational Interviewing (MI), Relapse Prevention Therapy (RPT), and Trauma Informed Care in Behavioral Health Settings. IPR will also implement HIV testing and screening and referral to FQHCs for Hepatitis C testing, and HIV and Hepatitis C treatment, and in-reach services. 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 50 program participants per year. Objective 2: Provide evidence-based SUD and mental health treatment services to 50 enrolled clients per year. 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 50 clients per year. Objective 5: Provide case management services to at least 50 program participants per year. Objective 6: Provide recovery support services for at least 80% of program participants;. Objective 7: Assist in the placement of 85% of program participants in need of services 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.

Project Abstract Summary Project Name: Crittenton Center Street Outreach Program (SOP) for Youth Applicant: Florence Crittenton Home DBA Crittenton Center Project Summary: The proposed program is designed to provide street-based out-reach services to runaway, homeless, and street youth up to the age of 26 to help them out of homelessness and move them into safe and stable housing, rebuilding connections with caring adults and creating pathways to access other community services and supports. Target Population: The target population is runaway, homeless, and street youth up to the age of 26 who are experiencing homelessness or housing instability due to a substance abuse disorder (SUD), co-occurring disorder (COD), and/or other behavioral health conditions. Demographic Characteristics of Target Population: The primary geographic service area is Sioux City (85,617), Woodbury County, Iowa (105,506). Referrals may be accepted from five surrounding counties: Cherokee (11,503), Crawford (16,193), Ida (6,596), Monona (8,574), and Plymouth (25,650), with a five-county population of 68,516 (Census Estimates, July 2021). Strategies and Interventions: Outpatient Behavioral Health Therapy, Intensive Case Management, Screening and Assessment, and Training and Education. Evidence-Based Strategies and Interventions: Motivational Interviewing (MI), Screening, Brief Intervention, and Referral to Treatment (SBIRT), Brief Interventions and Brief Therapies for Substance Abuse, Cognitive Behavioral Therapy (CBT), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Dialectical Behavioral Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT). Project Goals: Goal I: To create the organizational capacity to implement grant activities, ensuring the required elements of the grant are delivered on time and as intended, and develop and advance interventions through collaboration with housing and other local community partnerships. Goal 2: To equip project staff with skills, knowledge, and resources to provide high quality, evidence-based, trauma-informed, and culturally responsive services, for youth experiencing or at-risk for homelessness. Goal III: To ensure youth are able to easily access trauma-informed behavioral health services, resources, and supports along a continuum of prevention, early intervention, treatment, and follow-up. Goal IV: To collaborate with other youth serving systems, such as behavioral health, child welfare, law enforcement, juvenile justice, housing, and other community agencies to raise awareness on trauma-informed practices and program services, enroll and serve youth, and enhance program services. Number to be Served Annually and Over Five-Year Project: Year 1-30, Year 2-40, Year 3-50, Year 4-50, Year 5-50, Total-220. (Unduplicated Count)

For the REACH project, 4C Health’s population of focus is individuals, couples, and families with Substance Use Disorders or Co-occurring Disorders who are experiencing homelessness. This project will serve 3 rural counties in northcentral Indiana: Cass, Howard, and Miami. The GBHI project will 1) increase access and capacity to connect to behavioral health treatment, harm reduction services, case management, and recovery support services for individuals and families experiencing homelessness in the targeted rural communities; 2) increase the communities’ capacity to provide stable permanent housing to individuals and families experiencing homelessness; and 3) increase stability of care and housing transition for individuals and families experiencing homelessness by implementing strategies that deliver case management, care coordination, and service delivery planning. 4C Health plans to serve 475 individuals over the course of the 5-year grant, with 80% of program participants entering permanent housing within 12 months of engagement. 80% of program participant entering treatment for SUD or COD within 6 months of program engagement, and by the end of the grant period, 80% of program participants will complete at least one vitals/wellness check. 4C Health will accomplish these goals and objectives by developing Street Outreach Teams that provide outreach and other engagement strategies to unsheltered (including encampments) and sheltered populations to increase access to, and participation and retention in, harm reduction, case management, treatment, and recovery support services. All services available through 4C Health will be available to individuals engaged in the GBHI program, including comprehensive case management; substance use and mental health services, including medication-assisted opioid treatment; recovery support services such as help with securing childcare, transportation, education and vocational support, and recovery housing; and identifying sustainable permanent housing opportunities. 4C Health will use evidence-based treatment as well as evidence-based harm reduction practices and serve consumers with staff trained in trauma-informed care, no wrong door, and suicide prevention. Housing First, Harm Reduction, and Permanent Supportive Housing are overarching principles under which EBPs are applied for consumers experiencing homelessness. The GBHI project will also seek to increase permanent supportive housing options and have at least 1 additional option available in each of the targeted counties by the end of the grant period. 4C Health actively coordinates its activities with appropriate state and local health agencies. Executive staff attend a regular collaborative conference call with the Director of Integration from Indiana’s Division of Mental Health and Addiction to discuss current efforts and provide a touchpoint for collaboration with DMHA. In addition, 4C Health and GBHI staff will participate in Indiana’s Region 5 CoC (Continuum of Care to address homelessness) and coordinated entry processes for enrolled consumers. Finally, 4C Health will convene a culturally and linguistically diverse steering committee that meets at least quarterly to monitor the goals outlined in the project. Membership will include local or regional representatives from substance use and mental health authorities; health department; public housing authorities; service providers; community members, employees, individuals (including youth) and/or families who are currently experiencing homelessness or have experienced homelessness and are recovering from SUDs or CODs; and the SAMHSA Government Project Officer.

Abstract for the ADEL Program Impact Behavioral Health Partners (“Impact”) and its partner, Erie Family Health Centers (“Erie”), propose the Apoyo de Empleo Latino (ADEL) program. ADEL aims to address employment disparities among low-income adults with serious mental health illness (SMI) or co-occurring SMI and substance use disorders (COD). The program will predominately serve low-income Hispanic and African American females in Erie community areas around Chicago, IL. ADEL will build on and replicate the success of existing SEPs by reaching more under-resourced areas served by Erie using the evidence-based Individual Placement and Support (IPS) model of employment services. ADEL aims to improve functioning and enrichment of clients with SMI and COD by referring clients to care and providing comprehensive, individualized employment services. Activities include a vocational assessment, benefits counseling, a job search plan, integrating with mental and behavioral health treatment providers, networking with employers, and determining specific needs such as transportation and interview skills. Services are time-unlimited, and once the client receives an offer of employment, employment specialists shift to job maintenance support. The population of focus (POF) for ADEL is Hispanic females (70%), and another 15% African American females, including those best served in a language other than English (50%) and uninsured (25%). The remaining 15% will be individuals from other groups living below the poverty line in need of these services. These populations have systematically experienced greater obstacles to health and socioeconomic mobility based on their ethnicity, geographic location, socioeconomic status, and gender identity. With the additional presence of SMI and COD, the population of focus has an employment rate significantly below national average. ADEL will address the employment disparities with tailored services for the POF. Since implementing IPS employment services 11 years ago, Impact has become a nationally recognized leader in the field for their innovative approach to providing services in partnership with Federally Qualified Health Centers (FQHCs) like Erie. Impact was recently nominated by the IL Division of Rehabilitation Services and Department of Mental Health for ""Most significant improvement in the number of people who have received good fidelity IPS supported employment services."" Clients in current Impact SEP programs have successfully obtained competitive employment and retained their positions, with 83% retaining employment for at least 90 days and 70% retaining employment for at least 180 days. Similar outcomes are expected from ADEL since we will be replicating the successful components of our existing program. The goals of ADEL include facilitating entry into treatment for those with SMI and COD by referring them for services, and conducting outreach and providing employment support materials to 550 clients each year (2,750 total); conducting entry activities such as vocational assessments to 120 clients the first year and 200 clients each year thereafter (920 total); make initial contact with prospective employers within 30 days of entry into ADEL for 95% of clients 114 the first year and 190 each year thereafter (874 total); retaining 90% of clients in competitive employment for 3 months (108 first year and 180 thereafter [828 total]); retaining 70% of clients in competitive employment for 6 months (84 first year and 140 thereafter [644 total]); growing the employer network by 10% annually; training 100% of program staff in Diversity, Equity, and Inclusion; and improving quality of life measures such as housing and support recovery. ADEL will reach these goals by employing a comprehensive strategy of outreach, assessment, the evidence-based IPS employment model, and referrals.

Summary: Jordan Community Residential Center proposes to implement, monitor and sustain an evidence-based Individual Placement Support (IPS) employment program for adult women with co-occurring substance use and mental health disorders and who may have been sexually exploited. The Ohio Department of Mental Health and Addiction Services will support the project by serving as content expert, providing technical assistance and staff training and conducting fidelity assessments. Project Name: Supported Employment Project Population to be Served: The target population for the proposed project is adult women with co-occurring mental health and substance use disorders, histories of sex trafficking and/or sexual exploitation and criminal justice involvement and who reside in Cuyahoga County and specifically, the City of Cleveland. A specific focus are Black/African American women. Goals and Objectives: The goal of this project is to implement, monitor and sustain the evidence-based employment model Individual Placement Supports for adult women with co-occurring disorders (COD) and histories of human trafficking, sexual exploitation and criminal justice involvement.- Obj. #1: By November 1, 2023, Convene a Project Management Team to implement, maintain fidelity and sustain the IPS project. Obj. #2: By February 1, 2023, begin service delivery by providing evidence-based individualized supports to 40 women (annually) with COD to choose, acquire and maintain competitive employment. Obj. #3: Within 90 days after service delivery begins, conduct a supported employment fidelity assessment. Obj. #4: By February 1, 2024, provide training on behavioral health implementation on the national Culturally and Linguistically Appropriate Services (CLAS) for all project staff. Obj. #5: By February 1, 2024, provide a comprehensive array of COD treatment and recovery support services, including recovery housing, to 40 women (annually) in conjunction with IPS services. Obj. #6: By April 30, 2024, develop and implement a comprehensive employer strategy. Obj. #7: By March 1, 2024, develop conflict and grievance resolution that are culturally and linguistically appropriate. Obj. #8: By June 1, 2024, develop a sustainability plan that identifies strategies for sustaining activities and services, after the grant period ends. Number of Unduplicated Individuals to be Service with Award Funds Year 1 Year 2 Year 3 Year 4 Year 5 Total 40 40 40 40 40 200

Yakima Neighborhood Health Services (YNHS) proposes to provide Supported Employment services, utilizing the Individual Placement and Support (IPS) model, to 75 homeless individuals with a diagnosed SMI or COD and who do not qualify for the State FCS program each grant year, for a total of 375 individuals over the course of the 5 year project. In addition to a 50% Project Director, the program will be staffed by 5 Employment Specialists, 1.5 FTE Benefit Specialists, a Behavioral Health Specialist and 3 Peer Counselors. All services will be provided in the language preferred by the client, usually English or Spanish by bilingual/bicultural staff. In addition to the required deliverables YNHS has established the following goal and objectives: GOAL: To provide Supported Employment (SE) services to 75 adults, 18 years of age or older, experiencing homelessness and diagnosed with a SMI or COD, for each year of the five year SAMHSA SE program. OBJECTIVES: 1. 80% of program participants have an established written employment plan which identifies their employment goals within the first month of program entry. 2. Each ES makes at least 5 face to face job development employer contacts per week to build relationships, market the program, and promote program participants as a good match for their needs. 3. 80% of program participants have at least one face-to face employer contact within the first month of program entry. 4. The ES conducts individualized job search contacts with employers for 80% of program participants each year aimed at making a good job match based on the participant’s preferences. 5. 80% of program participants meet with a Benefit Specialist prior to starting a new job so they are fully informed about the impact employment, hours, wages, and employee benefits can have on the benefits they may currently be receiving. 6. Case conferences with each participant’s team of providers are conducted weekly for 80% of program participants. 7. 80% of program participants are employed or receiving further education/training each year. 8. 80% of program participants receive on the job follow-up from the ES, BHS and other team members as desired by the participant. 9. 80% of program participants who remain unemployed at 120 days have completed an updated employment plan to achieve their desired employment.

The Central Iowa Health and Housing Project will provide support for 60 participants annually and 280 total adult individuals in Central Iowa who experience homelessness and have substance use disorders (SUDs) or co-occurring mental and substance abuse disorders (CODs). The project will provide a comprehensive system of integrated services to support placement in permanent housing. Primary Health Care, Inc. (PHC), a Federally Qualified Health Center and Health Care for the Homeless grantee, will lead the project in collaboration with UCS HealthCare and will build on the successful Centralized Intake and Coordinated Entry system to provide increased access to permanent housing, behavioral health services, and other supportive services for individuals and families experiencing homelessness. This project will help clients improve their quality of life and achieve self-sufficiency by supporting them in their efforts to maintain recovery from mental health and substance use disorders. The project will utilize the Critical Time Intervention (CTI) model to provide emotional and practical support during the transition to stable housing. Grant funds will be used to hire three full-time Case Managers to help clients find housing and link them to supports, including primary care, mental health care, substance abuse counseling, and other services. This project will use evidence-based protocols and engage an extensive network of providers to ensure clients have access to a full continuum of services. Grant funds will also be used to hire two full time Peer Support Workers. Project goals and objectives include: increasing the number of obtain and maintain permanent housing, enrolling clients in benefits, screening and referring clients to mental health and sub stance abuse services, providing clients with supportive services that improve their chances in at long term recovery and housing, and establishing care for clients physical health. The project's progress toward achieving goals will be monitored by Steering Committee and an experienced evaluator that will oversee data collection and analysis.

Episcopal Community Services (ECS) will provide evidence-based supported employment programming in the City of San Francisco. The target population is formerly homeless adult individuals with serious mental illness (SMI) or co-occurring disorders (COD) who are living in permanent or interim supportive housing. The population of focus will include individuals with intersecting marginalized identities, including but not limited to: people who inject or use drugs (PWUD), people of color, people with disabilities, people who identify as LGBTQ+, those with limited or no income or health insurance, and people who have been recently released from incarceration. The Transforming Lives through Supported Employment for Adults with SMI/COD in San Francisco Project will serve 250 unduplicated individuals over the course of the grant. The goals of the project are: -Goal 1: Increase competitive employment among formerly homeless adults with serious mental illness or co-occurring disorders living in supportive housing in San Francisco. -Goal 2: Increase access to comprehensive treatment and recovery support services for formerly homeless adults with serious mental illness or co-occurring disorders living in supportive housing in San Francisco. In order to achieve these goals, Episcopal Community Services will implement the Individual Place and Support (IPS) model of supported employment. IPS is a highly successful, evidenced-based model of supported employment that promotes a "recovery through work" philosophy whereby individuals with sever and persistent mental illness and co-occurring disabilities achieve competitive, integrated employment when assisted with ongoing support services. Measurable objectives include but are not limited to: -Provide supported employment services to 250 targeted individuals over 5 years. -Perform targeted outreach to 100 potential clients per year within ECS properties. -Place 60% of job seekers (150) in their first job within 5 months. -40% of first job placements will provide more than a minimum 20 hrs/week. -75% of first job placements will provide a minimum $20/hour. -Connect 100% of enrolled clients (250) to mental health services. -60% of enrolled clients (150) will experience increased functioning in 3 identified areas. -80% of enrolled clients who experience a Psychiatric Emergency Services (PES) episode will not be followed by a readmission to PES within 30 days. -Link 100% of clients in need of housing services with Coordinated Entry. -Provide benefits counseling to 100% of enrolled clients (250). ECS will serve 40 unduplicated individuals in Year 1, 60 unduplicated individuals each year during Years 2-4, and 30 unduplicated individuals in Year 5. Demographic data shows that the 555 residents of ECS permanent supportive housing with SMI are: 39% White, 34% Black, 22% Latinx, 10% American Indian, 6% Asian, and 4% Native Hawaiian/Pacific Islander; 63% are male, 34% are female, and 3% transgender; 17% identify as LGBTQ+; 2% are between the ages 20-29, 14% between ages 30-39, 19% between ages 40-49, 29% between ages 50-59, and 35% are age 60 or above; 9% self-report alcohol use disorder; 25% self-report drug use disorder; and 25% self-report both alcohol and drug use disorders.

New Mexico's (NM) Supporting Underserved Communities Capture Employment Stability Successfully (SUCCESS) Program will implement and sustain Individual Placement and Support (an evidence-based model of supported employment) in rural and tribal communities in NM so adults with serious mental illness (SMI) or co-occurring mental/substance use disorders (COD) can achieve competitive employment and build paths to self-sufficiency and recovery. Our population of focus is adults, ages 18 and older, with SMI or COD who live in the geographic catchment areas served by our direct service provider partner organizations: the NM Behavioral Health Institute (NMBHI) and the Canoncito Band of Navajos Health Center (CBNHC). By focusing on these areas we will refine, implement and sustain supported employment services to some of the most rural and underserved minority populations (i.e., Native Americans and Hispanics) in NM. The NMBHI is in San Miguel County. This county has 27,150 people, 83% of whom are over age 18, 50% female, 77.6% Hispanic, 17.8% White (non-Hispanic), 3.4% Native American, and 2.2% Black, with 54% speaking a non-English language in the home. 25% of the population lives below the poverty level, 5.4% are without healthcare coverage, and the median household income is $36,492. The CBNHC is located on the To'Hajiilee Indian Reservation, which is a non-contiguous section of the Navajo Nation lying in the rural parts of the western Bernalillo, eastern Cibola, and southwestern Sandoval Counties. It covers 78,877 acres and is about 45 minutes from metropolitan Albuquerque. To'Hajiilee has approximately 1,562 residents, with 52% female and 48% male, 69% 18 years old and older, and is 97% Native American. Most residents speak English and Dine and approximately 10% speak very little English. The median household income is $22,619 and 38% of residents do not have healthcare coverage. The NM SUCCESS Program is a collaboration between the NM Behavioral Health Services Division, the NMBHI Department of Health, the CBNHC, the NM Division of Vocational Rehabilitation, Public Education Department, the Navajo Nation Office of Special Education and Rehabilitation Services, and the University of New Mexico, Division of Community Behavioral Health. Together, we will (1) Implement Individual Placement (IPS) and Support in NMBHI and culturally modified IPS in CBNHC; both with high fidelity; (2) Provide specialized and individualized support to individuals with SMI or COD to choose, acquire and maintain competitive employment; (3) Provide comprehensive treatment and recovery support services in conjunction with vocational services; (4) Develop and implement an employer engagement strategy; (5) Provide program outreach and accessibility to IPS/CM-IPS for under resourced populations; (6) Develop a strategic employment plan to ensuring long-term employment stability and aid people unsuccessful in finding employment; (7) Develop a sustainability plan that identifies mechanisms for sustaining activities funded by this grant; and (8) Ensure program and program materials are culturally and linguistically appropriate. The number of people served by the NM SUCCESS Program is 25 in the first year, and 40 annually in years two through five. Throughout the lifetime of the five-year program the NM SUCCESS Program will serve 185 individuals (140 at NMBHI and 45 at CBNHC).