Homeless Mental Health Initiative

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Homeless Mental Health Initiative Pilot Summary

Our community was one of three to receive funding for a Mental Health Initiative. Below is a
description of the program:

Target Population:
The target population for the pilot project includes individuals or heads of household, who are
homeless and have a history of cycling through prisons, jails, mental health hospitals, or emergency
rooms. Cycling through publicly funded systems is identified as at least 4 admissions in 3 years or
one admission lasting 12 consecutive months. Additionally, the target population includes youth in
custody of family or unaccompanied youth (under age 18) who are homeless and have been
discharged from foster care, the juvenile justice system or a mental health hospital within the past
Upon discharge from the system, at least 75% of all participants should be receiving/eligible for
community based enhanced mental health/substance abuse services - Assertive Community
Treatment Teams (ACTT), Community Support Teams (CST) or Community Support Adult (CS)
for adults and Intensive In-Home (IIN) and Community Support Child and Adolescent (CS) for
youth. Up to 25% of the caseload could be individuals with the same history of homelessness but
who may not be eligible for these services. This portion of the target population would include
persons with primary substance abuse disorders with or without co-occurring personality disorders.
As with the primary target population, these persons must be homeless and have a history of cycling
through publicly funded systems.
Population Criteria:
All program participants must be individuals or heads of household who are homeless and have a
history of cycling through publicly funded systems. In addition, families who have a history of
homelessness and who have a youth who cycles through publicly funded systems would be eligible.
Priority is given to people with schizophrenia, other psychotic disorders, bipolar disorders, organic
brain syndrome, and Post Traumatic Stress Disorder. Seventy-five percent of program participants
must meet this criteria and should be linked with community based service agencies. If not already
actively on a community based service agency caseload, facilitating access to those services should
be part of the early intervention efforts.
Up to 25% of the caseload may include persons not eligible for community based services but with
disorders which may include substance abuse disorders, with or without co-occurring personality
disorders. Among this population, priority should be given to persons who have been homeless at
least 12 months.
Services Provided:
The Housing Initiative funds a minimum of 3 Housing Support Team (HST) members that are a
specialized, knowledgeable staff focusing on housing outcomes available 24 hour a day/ 7 day a
week to provide services and interventions necessary for individuals to maintain their own home.
HST will provide services such as linkage to medical services; applying for eligible benefits like
food stamps, SSI or SSDI; linkage to employment services like Vocational Rehabilitation; and other
services needed to remain housed. These activities are intended to be primarily non-clinical skills,
and 75% are to be provided in the home or community, outside of the agency offices. Once the
individual served is referred to a community based enhanced service provider, the services provided
by HST will be limited and focus on those services involving housing. In addition, HST will
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perform a teaching role with the community based services agencies and assisting the enhanced
provider network to increase their housing support skills.
Pilot Contractors:
Durham LME – partnering with Housing for New Hope.
Guilford LME - partnering with Open Door of High Point, Greensboro Housing Coalition and
Family Services of the Piedmont.
Western Highlands LME – partnering with Homeward Bound of Asheville..

Requirements for Funding:
   1) All housing that is identified for consumers must be permanent, affordable and long-term.
   2) Contractors provided MOAs that detailed the HST staff’s role working with the community
      based enhanced service providers, and their responsibilities for assisting HST staff and
      consumers. The MOAs clarified that the HST staff’s initiatives will enhance but not
      supplant existing services provided by the community based enhanced service providers.
   3) Contracts require entry of all relevant client data in CHIN and aggregate client data project
      reports will be produced by CHIN.
   4) Contracts require documentation of cost benefits from public systems. Contractors provided
      MOAs from publicly funded systems ensuring that the institution or system will allow for
      and facilitate the collection of needed aggregate data.
   5) Contracts require that HST staff participate in local Housing Support Committees (if one
      exists for the jurisdiction), Continuum of Care, and local 10 Year Plan to End Homelessness
   6) Contractors must participate in a Learning Collaborative, coordinated by the ICCHP, with
      each funded position participating in 70% of scheduled meetings. Members of community
      based enhanced service providers linked to the HST are also welcome to participate.

Performance Measures:
Performance measures (data) involving evaluation of outcomes and cost benefit will be collected
and analyzed.
Additional Information:
Contact: Martha Are, (919) 733-4534
Homeless Policy Specialist
North Carolina Department of Health and Human Services
Office of Housing and Homelessness
101 Blair Dr., Adams Building
2001 Mail Service Center

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