Homeless Service Programs HOST & CONNECT

Program Description

Project HOST (Healthy Outcomes and Supported Transitions) is funded through the NYS Department of Health while Project Connect is funded through SAMSHA. These projects provide outreach and case management services to adult men and women with mental health and/or substance use disorders experiencing chronic homelessness in Albany County, New York. They engage the most vulnerable street homeless population in substance abuse and mental health treatment, give them access to permanent housing, assist in enrollment in Medicaid and other mainstream benefits and connect individuals to recovery-oriented supports. HOST and Connect staff conduct intensive street outreach as well as meet individuals in emergency rooms and shelters using Motivational Interviewing to engage individuals in case management services provided through the Critical Time Intervention model and connect participants to mainstream benefits using the SSI/SSDI Outreach and Recovery (SOAR) model. Through collaboration with local health homes, case managers support enrollment in mental health, substance abuse and health services, as well as provide supports that remove barriers to service retention. Homeless services staff also facilitate access to permanent housing through the Coordinated Entry process, and provide housing supports. Project Connect includes Peer Specialists who will help build community connections and recovery supports for participants.

Creativity

Individuals who are homeless have disproportionately high rates of mental health and substance use disorders, have high rates of chronic and acute medical conditions and use the emergency room more frequently with higher cost then the general population. Prior to HOST and Connect, there were no outreach services targeted to individuals experiencing street homelessness in our region. This means that individuals who were homeless and not utilizing emergency shelter services or connected with a community provider were effectively left out of the service system and effectively excluded from the local housing process. HOST and Connect are inspired by the knowledge that positive behavioral health outcomes are directly linked with permanent housing. Intuitively we knew we had to reach individuals where they were, offer a hot coffee or a sandwich and start conversations and relationships that would lead to trust and ultimately lead to housing and stability.

Leadership

The key to our innovative program design is “client focused services.” Through the implementation of evidence based practices such as motivational Interviewing, Critical Time Intervention, Harm Reduction and Housing First. Project HOST and Connect have had remarkable outcomes that can be duplicated, transferred and adapted. This year we were asked to present our case management model at two conferences for community based organizations participating in Value Based Payment. We also presented for the 2nd time at the Housing & Special Needs Population Conference & Leadership Institute held in Niagara Falls. We also serve as members on several committees in the Capital Region which include Albany County Mental Health. Albany Police, local emergency rooms and psychiatric units to collaboratively plan to meet the needs of the most vulnerable in the community. We are leaders in innovative strategies to successfully engage individuals who are often under-served.

Sustainability

In 2015, we received funding through NYS Medicaid Redesign Team to provide housing and intensive case management service to our most vulnerable homeless population, adults who suffer from a serious mental illness and/or addiction. In 2016, SCCC launched our Children’s Health Home funded through NYS Medicaid. We are currently negotiating contracts with Alliance for Better Health (St. Peter’s Hospital) and Better Health for Northeast New York (Albany Medical Center) to provide case management services for frequent emergency room individuals. We are also negotiating contracts with the Capital District Physicians Health Plan (CDPHP) to provide intensive case management to their members who have high needs. SCCC will continue to explore local, state and federal funding to ensure that high need individuals receive coordinated care through the integration of housing and healthcare resulting in healthier individuals, lower healthcare costs and improve the overall quality of life of those serves.

Replicability

The key to successfully replicating our program are driven by “client focused services”, and the use of evidenced based assessment and practices. We lead by example by identifying and prioritizing service to the most vulnerable. The VI-SPDAT is a survey and analysis methodology for identifying the street homeless population for housing according to the fragility of their health, it is also free and open for public use. The Case Managers who are responsible to connect and engage with this challenging population are trained in evidence based practices such as motivational Interviewing, Critical Time Intervention, Harm Reduction and Housing First. All models that are nationally recognized with training opportunities in almost every major city. Our last step in this work is a proper transfer of care, working our clients to independence and sustained connection to services. Once again, this is a method that can be duplicated in many settings.

Results/Outcomes

St. Catherine’s homeless services case managers have worked to locate and connect with over 250 homeless or unstably housed individuals and families in the capital region. We have successfully housed over 60 clients through Coordinated Entry. These outcomes are a combination of the efforts in both projects HOST and Connect. Specifically in Project HOST we have received the following outcomes from the Department of Health: Pre-Average Inpatient Stay 2.5 days Post Average Inpatient Stay 1.1 days Pre Average Inpatient Spending $10,485.00 Post Average Inpatient Spending $2,642.00 Pre-Average Emergency Room Visits 26.7 days Post Average Emergency Rooms Visits 8.7 days Pre Average Emergency Room Spending $2,559.00 Post Average Emergency Room Spending $134.00 The outcomes represented here, both through the connections, housing achieved, and reduction of hospital stays and cost demonstrate an increase in stability and health for the individuals and families we serve.