enhancing and expanding the service delivery ...€¦ · enhancing and expanding the service...
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Enhancing and Expanding the Service Delivery Infrastructure for Individuals and Families who are Homeless who need behavioral health supports
Working together to reduce barriers to housing for individuals and families who are homeless
Healthy Housing Outreach (H2O) is dedicated to reducing barriers to housing
for individuals and families who are homeless by providing access to
behavioral health treatment and other supports
HEAD WATERS
H² Priorities
1. Develop data-driven service interventions2. Develop an integrative model
CABHI grant: H2O3. Improve access to and utilization of services and
treatment Discharge from hospitals, jails, and D&A
treatment facilities4. Maximize use of MA (Medicaid) & other existing
resources
Increase capacity in Allegheny County to provide accessible, effective, comprehensive, coordinated, integrated, and evidence-based mental health and drug and alcohol treatment services to the target populations, thereby eliminating unaddressed behavioral health needs as a barrier t sustained permanent housing.
1. Outreach, engage and assess chronically homeless individuals and vets and connect them to Community Engagement Centers (CECs).
2. Provide direct BH assessment and treatment (as well as referrals) to target population at CECs.
3. Provide in-home BH supports to target population who is permanently housed so that they remain housed.
4. Enroll target population in Medicaid and other entitlement programs.
5. Create a strategic plan for providing an integrated and collaborative system of care for individuals experiencing homelessness with BH needs.
SAMHSA/CABHI grant – NOA July 2016
800,000/year up to 3 years
Enroll 408 unduplicated participants
Services:
OUTREACH
COMMUNITY ENGAGEMENT CENTERS (CECS)
ENHANCED HOUSING SUPPORT SERVICES (EHSS)
H2O services
1. Outreach/Case management services
2. Peer Support Services
3. Physical health care services (nurse practitioner)
4. Behavioral Health Assessments (Psychiatrist, Nurses, & other licensed clinicians)
5. Medication education and management
6. D&A support services
7. One to one supportive therapy
8. Individual service coordination services
9. Enhanced in-home supports once housed
Staff
2 FTE Outreach (CHS & OSN)
3 FTE Peer Support (OSN, WPIC, CC)
.3 FTE Nurse Practitioner (OSN)
.20 FTE Psychiatrist
1.5 FTE RNs (WPIC, CC)
3 FTE D&A Specialists/Service Coordinators (WPIC, CC)
.5 CEC Project Coordinator (WPIC)
1 FTE H2O Project Coordinator (DHS)
H2O Flow
CHS and OSN
Outreach and
Engage
WPIC
CEC
Treatment and
Support
CC
Enhanced Housing
Support
PSH ProvidersFamily Shelters
VA Outreach
Youth Outreach
Streets
Shelters
Strategy:
Seek out target population on the streets, screen and assess, enroll, connect to CECs and other supports. Work in partnership with OSN to target enrollees to medical care
Providers:
Pittsburgh Mercy (OSN), CHS
Strategy:
Provide mental health treatment and supports to those waiting to receive benefits
Provide needs assessment to augment those conducted by housing proivider
Accept referrals from providers who need an entry poing to maintain services and/or who have receive names of prospective clients from Coordinated Intake
Connect clients to Coordinated Intake
CH homeless individuals and vets will be referred to CECs by OSN and CHS. Homeless vets, youth, & families referred by other providers. CECs can be mobile and located in areas of need/accessibility to enrollees.
Provider: WPIC
Strategy:
Create and “Enhanced Housing Support Team” to target individuals who accessed housing as a result of H2O or those you are at risk of exiting PSH b/c of unaddressed BH needs. Team will travel to homes to provide services.
Providers:
Chartiers Center
Strategy:
Link target population to public benefits at outreach, at the CECs, and in-home (via Chartiers). Connect to SOAR Benefit Counselors and Particularly use peer supports to help facilitate this process
Providers:
CHS, Pittsburgh Mercy (OSN); WPIC; Chartiers Center
Strategy:
Design and implement a plan to create an environment in Allegheny County that supports integrated, evidence-based, collaborative treatment and supports for target populations.
Providers:
Steering committee, & H2O Leadership team (CHS, Mercy, WPIC, CC, Coordinated Entry System, +)
Quarterly Steering Committee
Twice Monthly Leadership Operations Meetings
Program Development and Implementation
System Integration and collaboration
Continuous Quality Improvement
Weekly Team Meetings (with all H2O Direct Care Staff)
Mini-staff trainings
Review of new referrals
Review status of enrolled clients
H2O services begin at outreach, prior to a client having any verified diagnosis from a psychiatrist – when clients are often at most vulnerable and symptomatic and in need of support services.
Most MA-funded services require a diagnosis for a client to receive services. And there are other regulations such as licensing of facilities.
H2O uses a simple screening form to determine if a client is eligible. A client is screened for homelessness and evidence of a behavioral health issue based on self-report or staff observation.
H2O can wrap intensive services around client almost immediately with the goal to link clients to mainstream services. Psychiatry services are essential to verify diagnosis so clients can access mainstream services.
H2O provides multi-disciplinary team based services to vulnerable homeless individuals & families prior to them meeting eligibility criteria for mainstream services and/or are disconnected from their treatment support system (e.g. no verification of diagnosis; clients who have dropped out of treatment or poorly engaged).
H2O provides in-home behavioral health supports to individuals & families already in PSH who are at risk for losing housing.
H2O’s structure promotes collaboration between providers and systems via the weekly team meetings and the twice monthly leadership meetings. Already, H2O has seen improved system collaboration between:
The 4 partner providers and by extension the myriad of services of services offered by these providers
Integration with the Coordinated Entry System (CES)
Beginning to collaborate with D&A system with plans for future trainings to homeless providers about OD prevention
Beginning to look at involvement of H2O clients in criminal justice system
Members of H2O leadership team are represented on HOCC, medical respite, HAB, and H2.
Motivational Interviewing
Peer Support Services
Trauma Informed Care
Multi-disciplinary team approach to service delivery (principles of ACT/ECSC)
GPRA/SCI interviews (client outcome surveys mandated by SAMHSA)
H2O Master List
HMIS records
CIPS records
Meeting Minutes & Quality Improvement Activities
H2O Target Numbers Year 1
Enrollment Criteria
Enrolled in
Mar
Enrolled in
Apr
Enrolled in
May
Enrolled in
Jun
Enrolled in
Jul
Enrolled
August to
08/25/17 Sept Target
Year 1
Goals
Currently
Enrolled as
of
8/25/2017
Goal
Progress in
Enrollment
Category to
08/25/2017
Chronic Homeless 4 5 13 15 6 7 2 10 50 500%
Veterans 0 0 3 1 1 2 1 5 7 140%
Families 5 4 8 2 3 4 7 35 26 74%
Youth 0 1 0 0 1 1 4 20 3 15%
From PSH 7 6 2 0 0 2 14 17 121%
Total Enrollments to 08/25/2017,
Unduplicated Count 8 8 19 15 9 11 84 70 83%
Benefits
Easy access to behavioral health services and other supports for target population
Accountability to enrolled clients
Fills behavioral health service gap
Addresses barriers so clients can access housing and other services
Not mired by regulations – staff love this
Challenges
Communication challenges (no shared EHR)
Role clarification and transition points
Multi agency collaboration (different cultures)
Maintaining adequate psychiatry coverage
Space issues for CEC
Ensuring fidelity to EBP such as the use of MI and TIC
Sustainability