enhancing and expanding the service delivery ...€¦ · enhancing and expanding the service...

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