The Seneca TIEH Initiative provides comprehensive, coordinated, evidenced-based services for individuals/children/youth/families with a serious mental illness/serious emotional disturbance, or co-occurring disorder who are or are at imminent risk of experiencing homelessness. The focus population is rural & suffers poor mental health, social health determinants, substance use & homelessness. The project will serve 544 people (75-Y1, 94-Y2, 108-Y3, 124-Y4, 143-Y5). Project goals (interventions/strategies) are to (1) Engage and connect the focus population to behavioral health treatment, case management, and recovery support services via (A) Hiring a Project Director, Evaluator, Youth/Adult Crisis Specialists, Case Managers, Peer Recovery Support Specialists (PRSS), Therapist & Training Coordinator to expand focus population services; (B) Conducting community outreach in areas where unhoused individuals congregate to offer services; (C) Providing annual training to community partners to increase partner ability to identify and serve clients with SMI/SED/COD; (D) Working with referral partners to obtain program referrals; (E) Partnering with area schools to identify and obtain program referrals for families at risk of or experiencing homelessness; (F) Working with the state crisis line to obtain program referrals; (G) Identifying culturally competent referral pathways for disparity group members & (H) Referring and following-up on referrals for individuals who are deemed ineligible for TIEH services. (2) Assist with identifying sustainable permanent housing for the focus population by (A) Working with area housing providers to identify safe permanent housing for clients; (B) Linking 100% of clients to housing resources & (C) Conducting a landscape analysis to determine all available resources for the unhoused. (3) Provide case management that includes care coordination & service delivery planning that supports stability across services and housing transitions for the focus population via (A) Purchasing an initiative vehicle to be used to provide outreach, services & telehealth for clients; (B) Creating a person-centered service delivery plan with each client; (C) Providing case management services to clients; (D) Providing PRSS services to clients & (E) Ensuring clients receive infectious disease screening & education. (4) Improve focus population mental health, social & substance use outcomes via (A) Serving 544 clients; (B) Empowering clients to have statistically significant improvement in stable housing outcomes at 6-month follow-up; (C) Empowering clients to have statistically significant improvement in NOMs mental health outcomes at 6-month follow-up; (D) Empowering clients to exhibit a statistically significant decrease in substance misuse at 6-month follow-up; (E) Empowering clients to exhibit a statistically significant improvement in NOMs social outcomes at 6-month follow-up; (F) Empowering clients to remain in treatment for at least 6-months throughout the life of the grant; (G) Monitoring disparity group outcomes to ensure equal access/service/outcomes/retention; (H) Completing a social determinant of health survey to identify needs based on disparity group status & (I) Implementing the national CLAS Standards. (5) Sustain TIEH services for the focus population post-grant funding via (A) Initiating a Steering Committee which will oversee the program & (B) Creating a program sustainability plan to be updated annually.