Centerstone’s Finding Home, Health, and Community (FHHC) will provide services to 360 unduplicated adults (18+) with serious mental illness (SMI) or co-occurring SMI and substance use disorder (COD) who are experiencing homelessness in 10 predominantly rural Indiana counties(Yr 1: 40; Yrs 2-5: 80 annually). FHHC will provide integrated behavioral health treatment and recovery support services to help individuals identify permanent housing, recover from mental illness, and connect meaningfully with their communities.
Indiana’s 2017 Point in Time (PIT) count identified 498 individuals experiencing homelessness in FHHC’s catchment area of Bartholomew, Brown, Decatur, Fayette, Jackson, Jennings, Monroe, Morgan, Rush, and Wayne counties, Indiana. The focus population comprises 14% of catchment area individuals experiencing homelessness who report having SMI and includes the estimated 32% who have COD. Among FHHC’s focus population, 54% are male, 45% are female, 81% are White, and 11% are African American. In 2017, 59% of individuals with SMI went without adequate treatment, and the area has too few recovery programs/specialists to meet the treatment need. Fayette County has twice the State’s rate of drug overdose deaths, and the area’s total overdose death rate exceeds the State’s by 26%. FHHC’s population experiences multiple disparities (e.g., high poverty, unemployment, lack of affordable housing, limited healthcare access) contributing to homelessness and untreated/undertreated SMI/COD.
FHHC will provide outreach and housing navigation using a Housing First approach to provide housing as a top priority and without precondition or service participation requirements. FHHC will follow SAMHSA’s Treatment Improvement Protocol (TIP) 55 to guide/inform delivery of selected evidence-based interventions/models. FHHC will implement Critical Time Intervention (CTI) case management; provide direct SMI/COD/trauma treatment via Integrated Dual Diagnosis Treatment (IDDT); and ensure access to federal income supports via SSI/SSDI Outreach, Access, and Recovery (SOAR). Other FHHC program components include screenings/assessments; individualized and integrated primary, substance use, and mental health treatment planning; linkages to primary/specialty care; peer and wraparound/recovery supports (e.g., employment/education services, hepatitis/STI/HIV/AIDS screening/education/ counseling/referral, benefits engagement/enrollment), and dissemination of comprehensive evaluation. An advisory council comprising stakeholders and focus population members will support FHHC’s goals, which include providing treatment, recovery support, and access to housing; developing/expanding the infrastructure/capacity of an integrated community service system; improving client health status and outcomes; increasing permanent housing and related support services; and developing/disseminating a replicable service model. Measurable objectives include: outreach to 450 individuals experiencing homelessness to increase project participation/access to services; training for staff/community providers; stakeholder outreach/engagement/education to strengthen collaborative relationships; reduced criminal justice system involvement, substance use, mental health, and trauma symptomatology; reduced SMI/COD-related costs; increased treatment access and recovery capital; improved housing retention/stability, social connectedness, and independent living skills; increased employment readiness; and increased enrollment in health insurance/benefits programs. Key project partners (e.g., housing authorities, community health providers, support service organizations) will serve as FHHC linkage/referral sources, participate in service provision, and take part in training, Advisory Council, and evaluation activities.