Careplus NJ: treatment for individuals experiencing homelessness - cpnj's treatment for individuals experiencing homelessness (TIEH) will provide comprehensive case management and clinical services to…

Careplus NJ: treatment for individuals experiencing homelessness - cpnj's treatment for individuals experiencing homelessness (TIEH) will provide comprehensive case management and clinical services to individuals, including youth and families with serious mental illness (SMI), serious emotional disturbances (SED), or CO-occurring disorder (COD) who are homeless or at imminent risk of homelessness. Cpnj will provide services in bergen county, and the population of focus will be individuals 18 years and older with SMI, SED, and/or COD who are homeless or at imminent risk of homelessness. We aim to serve disproportionately marginalized community members who may be at highest risk of harm. The HUD point in time survey (2022) found that the catchment area's homeless population is 26.1% white (non-HISPANIC/LATINO), 31.6% HISPANIC/LATINO, 36.6% black/african american, 2% asian, non-HISPANIC/LATINO. TIEH will allow case managers (CM) and a clinician to conduct persistent outreach and intensive case management necessary to engage and retain clients in cpnj and partners comprehensive array of SMI, SED/COD clinical, primary health, recovery supports as well as housing and eligibility assistance. The proposed program will be staffed by a project director, project evaluator, 2 FTE BA-level CMS, a clinician, prescriber, and an administrative assistant. TIEH will serve a total of 285 unduplicated individuals over the project period. In year 1, 45 unduplicated individuals will be served, and in years 2-5, 60 unduplicated individuals will be served each year. Project goal: expand community-based outreach and ongoing intensive case management and clinical services to connect the POF to cpnj and partners comprehensive array of clinical, primary health, housing and eligibility assistance. OBJ 1: by the end of month 3 of year 1, hire 2 CMS and 1 clinician trained in project evidence-based practices (EBPS) who will provide consistent contact to 100% of individuals served from initial contact through stable recovery and housing. OBJ 2: by month 12 of year 1, CMS conduct outreach at 10 community service/shelter sites and encampments, offering assistance with basic needs to 100 % of individuals contacted. OBJ 3: by month 4 of year 1, CMS will begin outreach twice per month to individuals in the county jail identified as homeless upon release who also have SMI/SED/COD needs; 50% will receive CM and clinical services immediately upon release to prevent loss to care. OBJ 4: by month 12 of year 1, CMS screen 45 individuals where they are in the community utilizing validated instruments; facilitate clinical assessment for 75% of those screened; assist 100% of those assessed in developing an individual recovery plan that outlines services, benchmarks and responsible staff for all domains, including housing; and accompany each individual through the care planning and service delivery, especially attending to transitions with 80 % of individuals retained in treatment after 6 months. OBJ 5: within 24 hours of initial contact 100% of individuals served will be linked to clinical services (i.e. psychotherapy or medication management). OBJ 6: 100 % of individualized service plans will reflect project EBPS such as motivational interviewing and integrated treatment for CO-occurring disorders, recovery-oriented services and access to primary health care through cpnj or community partners. OBJ 7: CMS will provide direct support to 100% individuals served in applying for financial benefits, e.g., medicaid, SSI/SSD, GA/tanf, snap. OBJ 8: 100% of individuals served will receive direct assistance in establishing eligibility for housing resources including placement on the bergen COC HPL; 100 % will be assisted in securing emergency shelter as needed, and 25% of individuals served will enter permanent housing. OBJ 9: to ensure that the project is meeting goals and addressing disparities, by month 4 of year 1 enlist a culturally/linguistically diverse steering committee whose findings are reviewed by cpnj leadership.