WestCare Kentucky Breaking the Cycling - services for the benefit of homeless individuals - WestCare Kentucky, Inc. is requesting funding to provide evidence-based case management and treatment services for substance use disorder (SUD) and co-occurring substance use and mental health disorders (CODs) for homeless individuals from Breathitt, Floyd, Knott, Johnson, Lee, Leslie, Letcher, Magoffin, Martin, Owsley, Perry, Pike, and Wolfe counties in KY. The program will serve 445 peoples over 5-years. Goal 1: Strengthen behavioral health (BH) care for individuals experiencing homelessness. Obj 1.1: Provide comprehensive, evidence-based, individualized continuum of BH services to homeless individuals identified as needing SUD or COD services (65 in Yr 1, 80 in Yr 2, and 100 in Yrs 3-5). Obj 1.2: 75% of clients will complete the program as evidenced by attaining the goals on the individualized reintegration plan. Obj 1.3: 100% of clients will receive a comprehensive assessment to identify and prioritize their current needs in regards to food, hygiene, housing/shelter, BH and physical health, identification and community or family support. Obj 1.4: 90% of clients who receive a comprehensive assessment will develop an Individual Service Plan (ISP) to obtain identification, housing and other necessary services. Obj 1.5: 90% of individuals in need of primary care, SUD, MH, or COD services will receive linkage to these services. Obj 1.6: 80% of program completers who required SUD services will report reduced or no substance use in the 30 days prior to program completion, and 70% will reduce or remain substance free at 6 months post admission. Obj 1.7: 80% of program completers who required MH services will report reduced symptoms in the 30 days prior to program completion, and 70% will maintain or report additional symptom reduction at 6 months post admission. Obj 1.8: 80% of program completers who required primary care will report improved health in the 30 days prior to program completion, and 70% will maintain or report additional improvements at 6 months post admission. Goal 2: Improve coordination of housing services for homeless individuals who are experiencing SUD or COD. Obj 2.1: Provide evidence-based case management, including housing coordination and linkage, to 100% of clients. Obj 2.2:75% of individuals receiving case management services will receive necessary hygiene supplies, identification, Medicaid enrollment, and/or linkage to supportive wraparound services. Obj 2.3: 80% of program completers will secure permanent supportive housing using the housing first and harm reduction models, and 70% will maintain permanent or supportive housing arrangements at 6 month follow-up. Obj 2.4: 80% of program completers will maintain or increase income prior to exiting the program, and 70% will maintain or increase that income at 6 months post admission. Goal 3: Engage and connect clients who experience SUD or CODs to enrollment resources for health insurance, Medicaid, and benefits programs. Obj 3.1: 100% of clients entering the program will receive a financial assessment, including eligibility for mainstream benefits. Obj 3.2: 95% of clients who are not already enrolled in health insurance, Medicaid, or benefits programs will complete enrollment before program completion.