Research demonstrates that SDOH (Social Drivers of Health) influence health equity and outcomes. Some of the risk factors for developing more complex needs and issues within the unhoused, severe mental illness, and substance abuse populations are a lack of support, lack of care coordination, lack of trust of the system of care, the need for rapport, and a need for building professional and social supports and connections as well as a need for fostering and improving protective factors. These contribute to positive treatment outcomes and measures.
Going into the community to offer services in locations such as on the street, in shelters, in encampments and offering intensive care coordination, basic needs, linkage, engagement, food, clothing, housing support, MH (Mental Health) and SAS (Substance Abuse Services) treatment, as well as physical health providers, is not only a need but also a gap within our community and system of care continuum.
Research indicates SMI/SAS affects at least 30% of those experiencing homelessness and complex issues. To address the specific nuances of the unhoused population, this program is designed to provide intensive small caseloads for individuals who have not otherwise been served in our system of care.
The goal of this program is to provide engagement, intensive care coordination along with case management, screening, linkage, treatment, and transportation to ensure that the basic needs are addressed as they navigate the systems in their lives and to ensure they have the necessary tools needed to remain in treatment and improve overall health outcomes.