MHMR of Tarrant County proposes to enhance our comprehensive system of care through an integrated service delivery framework and improve homeless individuals’ experience through care coordination and promote overall health and wellbeing through the Mobile Outreach and Treatment Services for Homeless Individuals (MOTSHI). Research indicates that providers in the Tarrant County area identify substance use services and mental health/behavioral health care as the most challenging to access for homeless and/or low-income individuals. During the 2019 Tarrant County Homeless Point in Time count, 2,028 persons were experiencing homelessness – a 0.6% increase from 2018. This often mobile population has had negative experiences with mental health care and programs, and is determined not to accept further treatment. For these reasons, individuals can be slow in receiving services and ambulatory treatment is preferred in most cases. Therefore, MHMR will expand its Care Coordination model of services to improve primary and behavioral health outcomes for this population. The purpose of MOTSHI is to provide robust outreach and mobile services to increase the accessibility to behavioral and primary health care to homeless individuals living in Tarrant County. The MOTSHI team will include a Project Director, a RN Practice Manager, a RN Community Wellness Nurse, four Outreach Specialists, a Licensed Therapist, a Prescriber, two Wellness Navigators, a Transportation Navigator, an AOT Personal Service Coordinator, a Peer Support Specialist, a Veteran Mental Health Peer Specialist, and a Substance Use Counselor. MHMR will also contract with Acclaim to provide a mid-level Physical Assistant and Medical Assistant to provide medical services in the field. This team will provide services to address primary and behavioral health issues, including linkage to internal and outside resources, follow up to referrals, and nonclinical support from Peers. The MOTSHI Team will place staff in the designated sites to provide assessment for behavioral health diagnoses and indicators of medical risk, and they will provide linkage to clinics. The RN Practice Manager will work with the Outreach Specialists and RN Community Wellness Nurse to make appropriate linkages to treat identified concerns, within the agency or externally if specialized services are required. Staff will provide ongoing support and follow up for people in services to facilitate access to care and to ensure continuity across all involved providers of services. Peers will also provide appropriate support and linkage to community resources. All people linked to MHMR integrated services will receive care using evidence-based practices, and their needs will be assessed as needed to determine the most appropriate type of care. As certified CCBHC and the largest provider of behavioral health care in Tarrant County, MHMR has an established ability to effectively provide care for behavioral health, SUD, or primary health care needs. Though the agency will work with its community partners, no Designated Care Organizations will be used to provide services. Through this opportunity, MHMR plans to expand access to 300 unduplicated individuals, age 16 and over, by the end of the grant.