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The Yolo County Health and Human Services Agency's Extended Hope Project aims to serve approximately 75 people experiencing homelessness and co-occurring disorders (CODs) annually. The project will advance client recovery through a two-year integrated treatment approach that focuses on the five key areas of: housing stability; behavioral and physical health; self-sufficiency; criminal justice involvement; and purpose and community. In Yolo County, a local assessment of the largest homeless encampment found that 49 percent of the residents had CODs. The reverberating effects of homelessness can challenge a person's capacity for recovery and pose significant barriers to accessing services. In an effort to bridge this service gap, Extended Hope will consist of three major components: (1)Identification, Assessment, and Triage where two Outreach Workers will identify at least 150 homeless persons each year and administer the Vulnerability Index and Service Prioritization Decision Assistance Tool and link clients to the region's local coordinated entry system; (2)Intensive Case Management and Treatment where a Clinical Program Manager and two Case Managers will partner with 75 clients to create and implement individualized case plans, and four Peer Recovery Support Specialists will provide recovery support through mentorship and educational sessions; (3)Housing Navigation and Permanent Placement where a Housing Navigator will facilitate permanent housing placements for 100 percent of the chronically homeless and/or veterans and provide eviction prevention aftercare to ensure at least 80 percent remain stably housed and a Supported Employment Specialist will further assist with aftercare by conducting job readiness assessments and finding gainful employment for at least 50 percent of the clients. Overall, Extended Hope will implement a comprehensive continuum of integrated treatment to address major disparities in Yolo County's homeless services system.

The West Virginia's Cooperative Agreement to Benefit Homeless Individuals, in partnership with four Continuums of Care, proposes to enhance and expand the infrastructure and mental health and substance abuse treatment services for the homeless and chronically homeless. The program will serve individuals and families who are experiencing homelessness and have substance use disorders (SUDs), serious mental illnesses, serious emotional disturbances, or co-occurring disorders. This includes chronically homeless individuals, homeless or chronically homeless veterans, and homeless families and youth. Goals include: (1) enhance the State's infrastructure to provide effective, accessible treatment and recovery support services to the homeless and chronically homeless and create a more integrated and collaborative system of care for veterans, nonveterans, families, and youth experiencing homelessness who have mental health disorders and SUDs; (2) homeless individuals or families will access sustainable permanent housing; (3) housed participants will sustain permanent housing; (4) participants will receive direct mental health and/or substance abuse treatment; (5) participants will receive case management and peer support recovery services designed to improve access to and retention in services; and (6) participants will enroll in mainstream benefits they qualify for, including Medicaid, SSI, SSDI, TANF, SNAP, and veteran benefits. On the state level, the program will enhance the existing West Virginia Interagency Council on Homelessness to coordinate efforts across service areas and develop statewide strategies to end homelessness. On the local level, 245 individuals will be served annually, using evidence-based practices, including the Vulnerability Index-Service Prioritization Decision Assistance Tool, Services Prioritization and Decision Assistance Tool, Housing First strategies, Critical Time Intervention, Trauma-Informed Care, and Motivational Interviewing.

Safe Refuge, in collaboration with Urban Community Outreach (UCO), the City of Long Beach Department of Health and Human Services, Homeless Services Division/Multi Services Center, proposes the Enhanced Network of Recovery Interventions for Chronically Homeless adults (ENRICH) Project. The population of focus are chronically-homeless adults diagnosed with co-occurring mental health and substance use disorders. The ENRICH Project will provide participants with access to an integrated services approach that provides substance abuse treatment, mental health services, and medical care implemented within a single location. The ENRICH Project seeks to enhance and expand the infrastructure in Long Beach that addresses behavioral and medical services for chronically-homeless adults with the overall goal of assisting project participants as they transition into Supportive Permanent Housing. Supportive Housing Case Management will be provided by UCO. The project will implement an integrated system at Safe Refuge, which includes on-site access to primary care through a partnership with Lestonnac Free Clinic. This program will provide services to participants without access to funding for substance abuse treatment services, mental health services, and other recovery related supportive services. The project will serve 25 chronically homeless adults with co-occurring substance use and mental health disorders per year. The ENRICH Project seeks to: create an ENRICH steering committee comprised of community providers, stakeholders, and participants, including agencies involved in substance abuse treatment, mental health, housing, primary care, and other entities experienced in providing services to the population of focus; establish an integrated system of care for 25 chronically homeless adults, per year, diagnosed with co-occurring mental health and substance use disorders at Safe Refuge; and expand and enhance aftercare services for ENRICH participants.

The Behavioral Health Center of Nueces County (BHCNC) proposes to implement Project CHIP, serving a total of 150 (50 annually) individuals/families experiencing homelessness by increasing local capacity for the proposed project to provide accessible, effective, and comprehensive, integrated, and co-located evidence- based treatment services. Project CHIP will target primarily minority adults/families who meet one of the following criteria: individuals experiencing chronic homelessness with a SUD, SMI, SED, or COD; veterans who experience homelessness or chronic homelessness with a SUD, SMI, SED or COD; or families experiencing homelessness with one or more family members with SUD, SMI, SED or COD. Project CHIP proposes to enhance BHCNC's current service delivery model by collocating and integrating mental health and substance abuse services while addressing the housing needs of the target population. Project CHIP will also adhere to a trauma-informed service delivery model addressing the multiple, varied, and sensitive needs of the target population. Evidence based interventions proposed are NIDA Outreach Model, Assertive Community Treatment, Seeking Safety, and Recovery Dynamics. Project goals include to: strengthen the partnerships capacity and infrastructure to ensure effective planning and service delivery to the target population; increase access to, or placement in, sustainable permanent housing, treatment and recovery support services, and Medicaid and other benefit programs; and evaluate and measure project accountability and impact. In order to enhance services and increase sustainability, the proposed services will be co-located at Charlie's Place. Project collaborations include Charlie's Place, substance abuse treatment facility, Oxford Housing, permanent housing, and the City of Corpus Christi. Project CHIP projects to start direct service implementation by the 4th month after award.

Mountain Comprehensive Care Center (MCCC) will implement the Big Sandy Community Integration Program to provide culturally/gender-competent, outpatient, evidence-based SUD, SMI, SED, and COD treatment integrated with health care, trauma-informed care, case management, peer and recovery-oriented supports, linkages to public benefits, and permanent housing for homeless persons. This infrastructure will increase the number of homeless persons placed in permanent housing with the supports to ensure recovery from behavioral health issues and maintain long-term outcomes. The proposed program will prioritize services first for homeless/chronically homeless veterans with SUD, SMI, and COD, and secondly for chronically homeless individuals, families and youth all of which also have a SUD, SMI, SED, or COD. The project will utilize the evidence-based practices of Pathways' Housing First Model, Motivational Interviewing, and Cognitive Behavioral Therapy which are effective for outreach, retention, and outpatient behavioral health treatment along with the recovery support services of peer support and SSI/SSDI Outreach, Access and Recovery. Treatment will be integrated with health care, case management, peer and recovery oriented supportive services, and follow-up for up to three months post discharge as desired for stability. MCCC will serve 42 persons annually. Goals include to: expand and enhance the infrastructure, and mental health and substance use treatment services of the Big Sandy region; improve access to and utilization of effective comprehensive, coordinated, integrated and evidence-based mental health and substance abuse treatment services, housing support, and other recovery-oriented services; increase engagement and enrollment of eligible individuals in insurance, Medicaid, and other benefit programs; and ensure that project implementation and evaluation adhere to targeted goals, objectives and outcomes, and facilitate CQI.

The Returning Home Program is a collaboration between ServiceNet, Hilltown CDC, Soldier On, and community partners to provide trauma-informed, integrated substance abuse and mental health treatment, supported PH, and case management utilizing the Integrated Dual Disorders Treatment model to address the needs of veterans who experience homelessness and adults who experience chronic homelessness. ServiceNet RHP plans to establish a Clinical Case Management team composed of licensed mental health and substance abuse counselors, a nurse, and peer outreach staff sited in Pittsfield, Northampton, and Greenfield, Massachusetts. This team will provide outreach and engagement utilizing Motivational Interviewing, screening, assessment, service planning, an array of integrated services, referral, evaluation, and follow up. The team will provide integrated dual disorders treatment to address the complex interplay between mental health, behavioral, and substance abuse disorders and psychological trauma that affects the homeless to a high degree. We will assist in identifying and acquiring a range of benefits and resources designed to meet the complex needs of the homeless: housing and the means to pay for housing, medical care and insurance, food and resources to acquire food, and education/training/public benefits to secure the means for self-support. The Returning Home Program will serve 112 individuals over the three year grant period with approximately 50 active participants at any point in time. The Returning Home Team will be guided by a community Steering Committee composed of persons served or those with lived experience of homelessness, and agencies representing the needs of the homeless: housing, mental health, substance abuse, and public benefits. Lastly, the program will incorporate a robust training and evaluation component to ensure that the Returning Home Team remains focused on the objectives of ending chronic homelessness and have the means to do so.

The Homeless Veterans Reintegration Program by Focused Outreach Richmond (FOR) will serve chronically homeless veterans, veterans that are recently released from incarceration, female homeless veterans, homeless veterans with families, and veterans at risk of homelessness who have a substance use disorder, serious mental illness or co-occurring mental and substance use disorders in the urban area of Richmond City. FOR's Specific Aims are: Aim 1) expand current infrastructure by Sub-aim 1A: expanding the number of members in VET-LINK, a consortium of agencies that provide services to homeless veterans and their families within the Greater Richmond Metro area by four members in each 12 months of the project and by eight over the life of the grant, and by Sub-aim 1B: expanding the number of partner agencies that are a part of the Homeward Community Information System by four members during the first 12 month project and by eight over the life of the grant; and Aim 2) FOR will increase the capacity to provide accessible, effective, comprehensive, coordinated, evidence-based treatment services and permanent supportive housing through direct person-centered outreach, engagement, and intensive case management by Sub-aim 2A: FOR will assist 55 veteran participants in receiving mental health and/or substance abuse treatment, Sub-aim 2B: assist 55 veterans in obtaining permanent employment and Sub-aim 2C: assist 55 veterans in obtaining permanent housing during each 12 month project period. Over the three year project period, FOR expects to serve 165 unduplicated veterans.

The Cleveland Department of Public Health (CDPH), in partnership with FrontLine Service, proposes to reduce family homelessness in Cuyahoga County and Cleveland, Ohio, by providing comprehensive, trauma-informed, evidence-based treatment and supportive services to families that are homeless and the head of household has a severe mental illness (SMI), substance use disorder (SUD), or co-occurring disorder. Utilizing the evidence-based practices of Permanent Supportive Housing, Motivational Interviewing, Trauma-Informed Care, Trauma-Adapted Family Connections, and Supported Employment, this program will serve 165 families during the three year grant term. Evidence strongly suggests that if families that are homeless receive wrap-around services designed to address their mental health, substance use, employment, and daily needs, these families have a decreased risk of returning to homelessness. This compelled CDPH to propose a collaborative program with FrontLine to provide housing services, case management, assertive outreach, access to mainstream benefits, and linkage to ongoing services for families who have not been able to become self-sufficient through Rapid Re-Housing or Transition In Place models, and are in need of Permanent Supportive Housing to end their housing insecurity. The CDPH will work with FrontLine personnel to develop protocols for service provision, protection of the privacy of participants' personal information, and training of direct service staff. Families in this program will largely be African-American, headed by a female between the ages of 25-34 who is diagnosed with SMI or SUD, living in poverty, have at least one dependent child, and have been engaged in the Progressive Engagement homeless program. Participants in this program will receive mental health and substance use treatment, supported employment, peer recovery services, linkage to mainstream benefits, and ongoing community resources, as needed.

Avalon Housing proposes to provide permanent supportive housing, and care coordination for 200 chronically homeless adults annually who have significant behavioral health issues such as mental health, substance use disorder (SUD), or co-occurring disorders. The Washtenaw CABHI project prioritizes the highest needs, highest risk, and highest cost households who present particular challenges to stability and recovery. This includes people who have experienced long-term homelessness, spent multiple years unsheltered, and who have had frequent involvement with emergency health systems and the criminal justice system. The Washtenaw CABHI project builds on existing community partnerships that were initially engaged through a federal Social Innovation Fund demonstration project targeting homeless frequent-users of emergency health services. A Steering Committee made up of stakeholders will expand and coordinate the project's efforts. The project follows evidenced based practices that align with SAMHSA's recovery and housing goals, and includes two behavioral health providers, both of whom have significant experience serving this challenging population. The project also includes a strong evaluation component that will identify service gaps and build evidence for supporting the long term service needs of clients. Services provided include intensive case management, peer recovery support, supported employment and community building activities, all of which are informed by a philosophy grounded in housing-first, harm reduction and assertive engagement. Housing and services staff are trained in motivational interviewing, trauma informed care, and relationship building. Care coordination among multiple providers will be an essential component of this project to support clients in achieving recovery and housing stability. Clients will be referred through our HUD centralized intake process.

This project will end chronic homelessness in Lincoln, Nebraska by addressing the needs of persons experiencing chronic homelessness and have SUD, SMI, SED, or COD. The project will enroll and retain 60 chronically homeless persons in the first year. Permanent Supportive Housing will be used as the model within which outreach, screening, housing, treatment, and support services will be delivered. The project will leverage existing services and programs to provide the critical supports necessary for persons to receive and retain housing. Currently Lincoln's services system lacks the ability to provide immediate supportive services, based on consumer choice, and also lacks key housing, employment, and peer supports to help retain housing. Clients will be identified and prescreened using Lincoln's existing, successful Lincoln All Doors Lead Home system, Lincolns Continuum of Care homeless coordinated entry system. The target population will be invited to enroll in the project to receive immediate, prioritized housing. Consumers will be provided a choice of scattered site housing through a housing first low demand approach. After the immediate priority of housing is accomplished, a diagnostic interview is completed by a psychiatrist or APRN and a biopsychosocial assessment by a LIMHP for the purpose of service planning and referral to appropriate levels of care. The client and Care Manager work together toward rehabilitation and skills building and ensure enrollment in appropriate benefits programs and referrals to all appropriate services. The Care Manager and Peer Supporters will stay in regular contact with clients and will use Lincoln HMIS to monitor all services including prioritized SOAR, Supportive Employment, medication management, and other mainstream resources with a focus of housing retention. The project will be led by the region's Behavioral Health Authority in partnership with the two leading organizations providing services to this population.

Through the Village of Hope Project, Homeless Health Care Los Angeles (HHCLA) will provide comprehensive behavioral health treatment and permanent supportive housing linkage to transitional age youth (TAY) ages 18 to 25 in L.A. who experience chronic homelessness and have a substance use disorder (SUD), mental illness, or co-occurring disorder (COD). Annually, Village of Hope will engage at least 150 homeless TAY through outreach, enroll 30 TAY, and provide comprehensive integrated treatment and permanent supportive housing for 20 TAY. The purpose of Village of Hope is to develop and streamline an integrated system of care specifically designed to increase access and utilization. The program will provide linkage to permanent supportive housing through HHCLA's vast network of housing opportunities, trauma-informed behavioral health treatment, primary health care, and holistic wellness. Village of Hope leverages multiple youth-focused evidence-based practices such as Critical Time Intervention functions at the heart of the program. TAY will benefit from the project's Integrated Treatment Program that provides trauma-informed behavioral health services through a unique melding of dialectical behavioral therapy, trauma-focused CBT, motivational interviewing, and other youth-centered treatment approaches. Strategies for retention include a Healing Arts and Wellness program for art, music, dance, gardening, meditation/mindfulness, TRE somatic exercises, yoga, tai chi, and other enrichment services. The youth served in the Village of Hope Project will: 1) have access to housing; 2) secure permanent supportive housing; 3) participate in trauma-informed, youth-specific behavioral health treatment; 4) receive medical care, HIV, STD, and HCV prevention and/or treatment; 5) gain and practice life-skills to facilitate self-sufficiency; and 6) enjoy free access to a range of holistic wellness activities.

King County will implement Cooperative Agreements to Benefit Homeless Individuals with two comprehensive behavioral health organizations to provide Assertive Community Treatment (ACT) and Housing First permanent supportive housing in geographically underserved regions. Program participants will be single adults experiencing chronic homeless and co-occurring serious mental illnesses and substance use disorders (SUDs). Approximately 350 individuals will be identified, screened and referred by King County's Coordinated Entry for All (CEA) program to SHARP over the life of the grant. This is expected to result in 224 individuals outreached and 140 individuals enrolled in intensive services. Participants will all have serious mental illnesses and co-occurring SUDs. SHARP will provide: 1) outreach, engagement, screening, and clinical assessment through an ACT model; 2) direct treatment, with trauma-informed practices, to address COD by the ACT team; 3) case management, ACT, SOAR methods, and supportive housing to enroll participants in SSI/SSDI, Medicaid, and other benefits and retain participants in housing and services; 4) peer recovery support to facilitate COD recovery as part of the ACT team; 5) collaboration across care entities to build bridges among partners in care; 6) recovery support services within ACT to improve retention and continue treatment gains; 7) Housing First permanent supportive housing through CEA; and 8) implementation of a steering committee for SHARP that will meet quarterly and monitor the goals and objectives of the program. Program objectives will include the degree to which referrals are outreached and enrolled, participants obtain Medicaid and other benefits, interventions have been implemented to fidelity, and participants increase housing stability while reducing COD symptoms, and use of crisis and emergency medical and psychiatric services, sobering and detox services, and jail.

The City of Atlanta proposes the Atlanta Cooperative Agreement to Benefit Homeless Individuals (Atlanta CABHI) program to provide permanent housing, behavioral health treatment, and recovery supports to 480 chronically homeless persons. Atlanta CABHI will focus on serving those who are living in places not meant for human habitation. Local partner providers experienced in serving chronically homeless individuals with severe mental health and substance use disorders will provide services to program participants. Participants will be placed into permanent housing at enrollment. Of those housed, at least 70% will remain housed for 12 months or longer. Program participants will have access to behavioral health services and recovery supports as well as access to physical health care with services that are delivered directly to the individual right where outreach is conducted. Peer Support Specialists will walk clients through each step and provide a hand off to supportive services once placed in permanent housing. Eligibility for mainstream benefits will be determined at enrollment and assistance will be provided in accessing benefits including SSI/SSDI, SNAP, VA Benefits, and Medicaid. Atlanta CABHI will provide funding to ensure needed services are available when not covered by benefits. Trauma Informed Care, an evidence based practice, will guide the planning and achievement of client-centered goals in the transition from homelessness to stable permanent housing. Atlanta CABHI will implement a Steering Committee which will oversee the goals and objectives of the project; increase coordination with other entities such as the HUD CoC, ESG recipients, the HUD Coordinated Entry system, other active SAMHSA homeless grantees, stakeholders involved in implementing local plans to end homelessness, and the Atlanta Housing Authority; and ensure the provision of direct treatment and recovery support services to the population of focus.

The Home for Recovery project proposes to increase capacity in Georgia to provide accessible, effective, comprehensive, coordinated/integrated, and evidence- based recovery support services, and peer supports and peer navigator services and other critical services to persons who are experiencing chronic homelessness with a substance use disorder (SUD), severe mental illness (SMI), and/or co-occurring disorder (COD) and who are in Shelter Plus Care or in other permanent housing slots. All individuals will be screened to ensure they meet the qualifications for HUD Shelter Plus Care or other permanent supportive housing and receive a comprehensive intake assessment. In addition to CORE clinical behavioral health services, project providers will determine client eligibility for benefits assistance and link to benefit programs for which they are eligible. They will receive recovery-oriented services including peer specialist services. Home for Recovery proposes to use the Trauma Recovery and Empowerment Model (TREM) (women) and M- TREM (males) group intervention as its evidence-based practice. This project will increase the delivery of behavioral health, housing support, peer, and other recovery-oriented services not covered under Georgia's Medicaid plan for individuals with a SUD, SMI, and/or COD and who are chronically homeless, with a preference given to veterans. Project services should be provided a minimum of six months, but to support recovery, length of services can last longer than six months, based on the needs of each participant. Over the three year project period, Home for Recovery will: 1) provide screening, assessment, treatment, and recovery support services for 330 adults age 18 and older that are in Shelter Plus Care or other permanent housing slots and have a SUD, SMI, and/or COD; and 2) assess 100% of participants to determine eligibility for Medicaid and other entitlement program and link them to benefit programs for which they are eligible.

Fortune Society's Residents in Recovery program will enroll a total of 90 individuals (Year 1: 20; Year 2: 35; Year 3: 35) in New York City with histories of criminal justice involvement and who are: individuals who experience chronic homelessness and have a substance use disorder (SUD), serious mental illness (SMI), serious emotional disturbance (SED), or co-occurring disorders (CODs); veterans who experience homelessness or chronic homelessness and have a SUD, SMI, or COD; families who experience homelessness with one or more family member that have a SUD, SMI, or COD; and youth, primarily those involved in our alternatives to incarceration program, who have a SUD, SMI, SED, or COD. We will provide behavioral health services using evidence-based interventions, including Moral Reconation Therapy, Motivational Interviewing, and Seeking Safety. We will also connect participants to permanent housing. Program goals include: effectively transitioning individuals in need of behavioral health treatment out of homelessness into permanent housing; stabilizing participants in recovery from SUD, SMI, SED, and CODs; assisting participants to become fully functioning parents, employees and citizens; and strengthening partnerships and systems of care for reentry populations. Services will include bi-weekly counseling and evidence-based groups, entitlements enrollment assistance, psychiatric medication management (where appropriate), permanent housing placement or linkages, ongoing peer support, 24/7 crisis coverage, and referrals to needed reentry services in the community, as well as at Fortune (including lifetime aftercare).

Beaver County - Housing Opportunities Managed with Evidenced-based Services (BC-HOMES) proposes to enhance and expand the infrastructure and mental health and substance use treatment services to provide accessible, effective, comprehensive, coordinated, integrated, and evidence-based treatment services; permanent supportive housing; peer supports; and other critical services for individuals, veterans, families, and youth who experience chronic homelessness and have substance use disorders, serious mental illness, serious emotional disturbance, or co-occurring mental and substance use disorders. Program goals will be to: identify and engage the population of focus in order to connect individuals with the services and supports they need to find and maintain permanent housing; increase sobriety; treatment follow-up; benefits acquisition; employment; individual satisfaction; and program evaluation. Case management and recovery oriented peer support, provided by someone with lived experience, will be responsible for establishing these linkages. All treatment and recovery-oriented supports will have mobile components able to meet participants at a location of their choosing, including a licensed professional counselor. Individuals with lived experience will be involved in planning, implementation, and evaluation. BC-HOMES staff will be trained in Cultural and Linguistic Competence, knowledgeable of the target population's culture and values, representative of the target population's age, race, gender, and ethnicity, and familiar with locations in the County where individuals who are homeless tend to gather. BC-HOMES will establish strong ties with local faith-based organizations, grass roots providers, other natural supports, and the justice system. The Housing and Homeless Coalition will coordinate efforts to identify the population of focus, promote engagement, and share resources. BC-HOMES plans to serve 90 individuals annually.

The Healthy Housing Outreach (H2O) program is designed to enhance and expand the infrastructure for and services within the mental health and substance use treatment system for individuals experiencing chronic homelessness, and families, veterans, and youth experiencing homelessness who need behavioral health supports. H2O will reduce homelessness and increase access to supports for people in or in need of permanent supportive housing by ensuring that participants receive access to or placement in sustainable permanent housing, treatment, recovery supports, and Medicaid and other benefit programs. The program goal is to increase capacity to provide accessible, effective, comprehensive, coordinated, integrated, and evidence-based mental health and drug and alcohol treatment services, eliminating unaddressed behavioral health needs as a barrier to entering and/or sustaining permanent housing. H2O will enroll 466 unduplicated participants in year one and participants will be homeless or permanently housed and have substance use disorders, serious mental illness, serious emotional disturbance, and/or co-occurring mental and substance use disorders. The program will build and sustain a program with the following objectives: 1) outreach, engage, and assess 100% of chronically homeless individuals and veterans and connect 70% to the Community Engagement Centers (CECs) and other supports; 2) provide direct and accessible behavioral health treatment and housing supports at mobile CECs to 413 unduplicated clients experiencing homelessness; 3) provide in-home behavioral health supports to 105 participants in permanent supportive housing in order to increase their ability to sustain housing; 4) engage and enroll 75% of participants, who are not enrolled in Medicaid and other entitlement programs, in these programs; 5) create a strategic plan for providing an integrated and collaborative system of care for homeless individuals and families with behavioral health needs.

The Health and Hospital Corporation of Marion County proposes the Indianapolis Homelessness Outreach and Services Team (iHOST) collaboration comprised of Indianapolis organizations serving individuals experiencing homelessness who have mental health and/or substance use issues. This collaboration will represent two Indianapolis mental health centers, a homeless youth service organization, a homeless day center, and a homeless service organization. iHOST will: build rapport among organizations and individuals experiencing homelessness; stabilize individuals with psychiatric symptoms; address addiction; assess the needs and barriers to treatment, housing, and employment in the community; provide services or linkage to address those needs and barriers; help individuals obtain and maintain permanent housing and employment; link individuals to ongoing mental health and/or addiction services; and follow housed clients to ensure needs are addressed and to provide resources. For each client, participating service providers will develop an individualized care/intervention plan that utilizes a strengths-based approach. iHOST and its organization of services, including data collection of evaluation measures, will rely on service providers communicating daily via a shared cloud-based client tracking software system, email, telephone, and/or face-to-face meetings. iHOST will create a steering committee of service providers, government agencies, homeless advocates, and housing specialists to oversee the planning and implementation of all proposed activities. iHOST's population of focus will be individuals who have a substance use disorder, serious mental illness, serious emotional disturbance, and/or co-occurring mental and substance use disorders, and are either youth under 18 years of age, young adults between 18 and 24 years of age, or chronically homeless, including those residing in jail or in the process of re-entry. Thirty clients will be served the first year.

Pinellas County proposes the Pinellas County Cooperative Agreement to Benefit Homeless Individuals program to increase capacity of services and evidence based mental health and substance abuse treatment services to approximately 125 individuals annually who have, or are currently experiencing homelessness, and have a serious mental illness (SMI), substance use disorder (SUD), serious emotional disturbance (SED), and/or co-occurring disorder (COD). The County will partner and contract with three provider organizations for treatment services and is looking to increase supportive wraparound services including peer recovery and SOAR specialists. By assisting clients' entry and continued residence in permanent housing, the County will provide a stable foundation to receive treatment for underlying SUD and mental health disorders. If awarded, the County's homeless population will be on a path to secure housing, coordinated behavioral health services and reduce their likelihood to use the emergency room for behavioral health and linkage services. The population of focus is primarily male/female adults who are or have experienced chronic homelessness who have a SMI, SUD, SED, and/or COD. This population includes veterans, and youth, especially those aging out of foster care. The County is seeking to focus on the population who is entering permanent housing or has recently been housed in permanent housing or permanent supportive housing. Program goals are to: reduce chronic homelessness; strengthen behavioral health care for individuals experiencing chronic homelessness; and reduce behavioral health disparities among racial and ethnic minorities. The County, through its contracted provider organizations, will utilize the following Evidence Based Practices to meet program goals and objectives: Technology Assisted Care; Biopsychosocial Assessment; Cognitive-Behavioral Therapy; Motivational Interviewing; and Seeking Safety.

Cornerstone Services' SAMHSA Recovery and Wellness Program will expand the mental health and substance abuse services available in Will County, Illinois. The agency will be able to successfully house and support 37 people during the first year who have experienced homelessness and have a mental health disorder, substance use disorder, or co-occurring substance use and mental health disorder. The program anticipates serving 51 people over the life of the three-year grant. The goal of the program is to use evidence-based practices and resources to support individuals who were homeless on their road to recovery, and further support efforts to end homelessness nationwide. This award will help address the disparity of access to services for a complex population of homeless individuals including families, veterans, and persons with co-occurring mental health and substance use issues. Through the use of Certified Recovery and Support Specialists, Cornerstone will be able to integrate peer recovery supports to improve their quality of life, as well as provide outreach efforts to a population that experiences a lack of access to vital community based supports. Cornerstone Services is a leading provider of mental health and substance abuse services in Illinois and has successfully housed and supported people who were homeless since the early 1990s. Permanent Supportive Housing is an evidence-based practice that has been used to successfully house individuals who were homeless, and Cornerstone utilizes this model as the foundation to recovery. Other evidence-based practices incorporated into Cornerstone's service model include Housing First, Individual Placement and Support, Wellness Recovery Action Planning, Mental Health First Aid, Motivational Interviewing, Seeking Safety, and other useful interventions to help individuals who are homeless with a mental health and co-occurring substance use disorder achieve a better quality of life.

The New Orleans Equity and Inclusion Initiative will provide Permanent Supportive Housing services, treatment and recovery support services, and assistance in obtaining Medicaid and other benefits for 120 individuals who are chronically homeless and 20 vulnerable homeless families with children, thereby ending their homelessness. The Initiative will play a vital role in addressing persistent inequality in New Orleans' recovery from Hurricane Katrina and in helping to achieve New Orleans' goals of becoming the first city to reach a "functional zero" in family homelessness by the end of 2016 (setting a standard of permanently housing all homeless families within an average of 30 days) and ending chronic homelessness by July 4, 2017. With 65 percent of New Orleans' chronic homeless population lacking any health insurance and a marked racial disparity in access to health insurance, the Initiative is critical to addressing disparity in access to care and ensuring that Louisiana's delayed Medicaid expansion, slated to begin in July 2016, is accessible to a highly vulnerable, difficult-to-reach population.

Project Homecoming joins together a leading provider of integrated behavioral healthcare services and three permanent housing agencies to provide permanent supportive housing services for substance use or mental disorders, or co-occurring disorders. Key outcomes include stability in permanent housing, abstinence, reduction in symptom severity, and social connectedness. Tarzana Treatment Centers, Inc. (TTC) will target a racially, ethnically, and culturally diverse population of homeless adults in Los Angeles County's Service Planning Area 2 (SPA 2), who experience chronic homelessness and behavioral healthcare needs. SPA 2 is one of eight service planning areas in Los Angeles County, and includes cities and unincorporated communities in the San Fernando and Santa Clarita valleys. TTC will annually provide 180 days of residential treatment to approximately 60 participants for an average of 30 days each and, 7,200 days of intensive outpatient treatment to 60 participants, for an average of 120 days each. These two levels of care will include: focused outreach, in-reach to chronically homeless adults, and coordination with the local Coordinated Entry System; a relatively lower caseload of patient to counselor ratio of 20/1; case management for an ongoing caseload of 20; scheduled van transportation services to and from the permanent housing sites and to and from the VA Hospital in Westwood or other sites where program participants receive medical and or other services; veteran specific groups; and, greater emphasis on individual counseling to better respond to patients with PTSD and patients with other mental and emotional challenges. Evidence based service/practices include: Cognitive Behavioral Therapy, Motivational Enhancement Therapy, Individual Drug Counseling, Relapse Prevention Training, Contingency Management and Incentives, 12- Step Facilitation, Case Management, Seeking Safety, Curricula/Guided Discussion, and Dialectical Behavioral Theory.

In Baltimore, individuals who are homeless have higher rates of substance use, mental health conditions, and are more likely to die prematurely due to an accidental overdose than the general population. Health Care for the Homeless (HCH) will provide integrated behavioral health services and supportive housing assistance to individuals who are chronically homeless in Baltimore City. Using evidence-based practices, HCH will assess and provide services to over 100 individuals, 50 of whom will obtain permanent supportive housing and receive the health care and peer support necessary to maintain their housing stability. This project will serve primarily African American men (60%) with severe mental health and substance use disorders, including schizophrenia, depression, anxiety, and bipolar disorder. A system for data collection and analytics will be developed in order to understand the correlation between housing status and health status and to adjust the model of care accordingly. Simultaneously, HCH will convene a steering committee composed of public agencies, providers, landlords, and consumers. This committee will research best practices, analyze the current status of access to housing and behavioral health care for chronically homeless individuals and produce recommendations to strengthen the Baltimore City Coordinated Access system. For over 30 years HCH has been the leading provider of quality, integrated services to thousands of individuals and families experiencing homelessness in Maryland. We provide primary care, HIV care, dental care, vision care, case management, supportive housing, outreach, benefits assistance, respite care, and behavioral health services. We are the only freestanding Health Care for the Homeless in the United States that is accredited by the Joint Commission for both ambulatory and behavioral health care. In 2014, we were also certified as a Primary Care Medical Home by the Joint Commission.

The proposed project, Housing, Employment, and Recovery Support (HERS), purpose is to provide gender-focused, comprehensive and collaborative permanent supportive housing and recovery support services to chronically homeless women and/or women with children who are homeless in the Saint Louis Metropolitan Statistical Area, who have substance use disorders (SUD) and/or co-occurring disorders (COD). The HERS project purpose will be accomplished through the provision of trauma-informed housing support, employment, and health services aimed to: reduce substance use and mental health symptoms; improve daily living; increase retention in permanent supportive housing; and increase employment and educational opportunities. Through the provision of gender-specific, culturally sensitive services which are individually tailored to maximize outcomes, it is hoped the cycle of homelessness can be broken, substance use can be reduced, and other behavioral health symptoms can be improved. In order to create sustainable change, culturally sensitive services and evidenced based practices will be offered to women who are chronically homeless and/or homeless with children. The goal of the project is to prepare and support the population of focus with the resources and skills to maintain independent community living. Annually, 100 women will be enrolled in HERS and 48 women will participate in permanent supportive housing and onsite recovery support services offered at Queen of Peace Center to include; trauma-informed housing support services, employment services, and health services offered through intensive case management, peer support, and therapeutic services.

The Appalachian Regional Coalition on Homelessness (ARCH) Project proposes to permanently house and provide mental health and substance abuse treatment to chronically homeless individuals, and homeless and chronically homeless veterans, with a substance use disorder (SUD), serious emotional disturbances (SME), and serious mental illness (SMI) or co-occurring disorder (COD). In year one, ARCH will rapidly rehouse 135 veterans and 40 chronically homeless and homeless individuals. ARCH will conduct outreach and screening to engage homeless veterans and individuals, and perform in-reach and screening of incarcerated individuals, utilizing its CARE Coordinated Entry VI-SPDAT and CSAT Client Assessment Tool. Clients without income will be connected to an ARCH SOAR Specialist for accelerated access to SSDI and/or referred to community employment partners. Clients with assessments indicating SUD, SED, SMI and/or COD will be referred to East Tennessee State University (ETSU) Johnson City Downtown Clinic (JCDC) PATH-funded agency, TennCare (Medicaid) provider, and Tri-West Choice Program (Third-Party Veteran Health Benefit) provider, who will assist clients with enrollment into appropriate healthcare benefit programs. ESTU JCDC will use evidence-based practices to provide outpatient substance abuse and mental health services, primary and psychiatric care, medication management, psychosocial rehabilitation and discharge planning to veterans. Monthly Peer Support Group sessions will be provided at ETSU regional clinics and ARCH Access Sites to prevent and reduce prescription drug and illicit opioid misuse and abuse. ARCH will provide HIV education to reduce HIV/AIDS risk behaviors, coordinate with Hope for TN and ETSU Infectious Disease Physicians' Ryan White Program for HIV drug access and connect with Housing Opportunities for Persons with AIDs permanent supportive housing.