EL RIO health - health, home, hope (H3) project - the purpose of the health, home, hope (H3) project is to end the cycle of homelessness for households currently experiencing long term unsheltered…

EL RIO health - health, home, hope (H3) project - the purpose of the health, home, hope (H3) project is to end the cycle of homelessness for households currently experiencing long term unsheltered homelessness in tucson and pima county through the expansion, integration, and coordination of local community BH, physical health and housing support systems. We will provide BH and other recovery-oriented services to those experiencing long-term unsheltered homelessness through (1) intensive street outreach, (2) navigation designed to rapidly connect individuals with substance use disorder and or COD to mainstream treatment and recovery services including mat, and (3) coordinate housing and services that support sustained recovery and wellness within permanent housing. Our goal is to move 150 of the most vulnerable unsheltered homeless individuals into permanent supportive housing, while increasing their wellness, to include their ability to manage their addictions, mental health symptoms, and acute and chronic physical conditions. This will be accomplished through a continuation of the existing EL RIO/opcs outreach teams, an integrated multidisciplinary community team, including a FNP, medical assistant, care coordinator, navigator, and peer guide; making bidirectional referrals between opcs and the EL RIO specialty BH team (MD/psychiatrist, BH professionals, and BH CMS); and coordinating the provision of mainstream services through collaboration with emergency shelter providers. This team will initiate approximately 200 contacts with unsheltered homeless individuals each year, offering non-emergency medical assistance, screening for the presence of addiction and mental health concerns, SA/COD treatment and medication monitoring/ mat, and immediate enrollment into mainstream benefits, such as medicaid, tanf, and snap. This initial interaction will be facilitated by a certified peer guide who was recently homeless from this same geographical area. All staff will be guided by motivational interviewing and trauma informed practices. Additionally, we will provide intensive navigation assistance to a minimum of 50 individuals per year, to include same-day transportation to benefits offices, enrollment/intake offices of mental health providers, non-emergency medical and BH appointments, and appointments with potential landlords. This navigation assistance will include assistance with completion of documentation and applications needed to gain housing, benefits, and treatment for mental health, addiction, and physical health conditions. This will result in 30 individuals entering permanent housing per year, or a total of 150 persons over the five-year period. A minimum of 50 patients per year will be seen for medical and MH services for a total of 250 over 5 years. As a result, at follow-up, we expect 45% of participants to experience a reduction in days using drugs or alcohol, 50% a reduction in criminal activity, 75% increase in social connectedness, 50% reduction in emergency room usage, and a 50% increase in income from all sources, which is based on our previous 4+ years of similar work. The project will be led programmatically by the project director (PD) with assistance from leadership at both EL RIO and opcs, and our evaluator, the UA sirow. The integrated project team will meet quarterly to review progress toward our housing goals, engagement in addiction, mental health, and physical wellness supports, as well as our general impact on unsheltered homelessness in tucson and pima county, and to review all the data collected from participants.