Pathways Vermont's Rural Outreach and Services. - Pathways Vermont's Rural Outreach and Service (PROS) project will expand the capacity of its Housing First program to engage and connect an additional 290 Vermonters with serious mental health challenges (SMI) or co-occurring SMI and substance use (COD) who are experiencing homelessness to behavioral health services, case management, and recovery support services. The PROS team will serve individuals throughout Vermont. The target population for this grant will be individuals identified by the Coordinated Entry System (CES) with SMI/COD who have the highest needs, greatest vulnerability and are historically marginalized. Population demographics are expected to mirror Vermonters experiencing homelessness and individuals served by the Housing First program. All participants will have SMI, and 1 in 3 will struggle with substance use. English will be spoken by 95% of participants; interpreter services will be provided when necessary. More than 80% of participants will be unemployed, and 85% will live below the federal poverty line; most participants will have high school diplomas or GEDs (76%). Participants demographics will be: 55% identify as men, 44% as women, and 1% as nonbinary, 5% identify as LGBTQ2S+, 10% Black, 2% Native, 1% Asian, 5% multi-racial, and 82% white, 2.9% Hispanic or Latinx. All participants will be adults: 5% aged 18-29, 22% aged 30-39, 25% aged 40-49, 23% aged 50-59, 21% aged 60-69, and 4% aged 70+. Through assertive engagement, Critical Time Intervention, Harm Reduction, and a peer-model of service the PROS team will engage with individuals who have been reticent to connect with providers. The PROS team will coordinate somatic health, mental health and substance recovery services with various local providers in rural communities throughout Vermont. The project goals and objectives are: 1. Improve access to behavioral health services, case management and substance use recovery support for persons experiencing homelessness in Vermont. A. Outreach and screening to 365 individuals experiencing homelessness, 65 in year 1, 75 in years 2-5. Provide information and referral services to individuals found ineligible for program services. B. Enroll 290 individuals in services, 50 in year 1, 60 in years 2-5. C. Conduct training to improve utilization of evidence-based practices for serving persons experiencing homelessness. 2. Participants will have access to resources and benefits A. Within 60-days of enrollment 90% of participants will be enrolled in health insurance. B. Within 6-months of enrollment 80% of participants will have a source of income. C. Participants will access SNAP, TANF, WIC, VocRehab, childcare and/or other programs within 90 days of enrollment. 3. Ensure cultural competency and sensitivity to underserved and overrepresented populations. A. Ensure cultural competency and representation in Pathways Vermont staff through recruitment, training, and resource offerings. B. Decrease racial disparities amongst persons experiencing homelessness in Vermont through systems assessment and change C. Provide training for staff and community partners in serving persons who are LGBTQ2S+. 4. Participants will exit homelessness to permanent housing and supportive services. A. Approval for housing subsidy within 45 days of enrollment B. Access to permanent affordable housing within 90 days of subsidy approval C. Ongoing support services that meet participant needs. 5. Decrease experiences of institutionalization among participants. A. 70% decrease in psychiatric hospitalization and incarceration B. 50% decrease in ER visits C.85% housing retention. 6. Improve somatic health and social connections. A. 90% participants engaged with PCP after 6 months B. 75% decrease risk from substances through harm reduction C. 60% of participants will increase community connections.
