Summary. Housing Works, Inc., in partnership with its affiliate, Intercambios Puerto Rico (Intercambios), is proposing to support the development of local implementation of a community infrastructure that integrates behavioral health treatment and services for substance use disorders (SUD) and co-occurring mental and substance use disorders (COD), permanent housing, and other critical services for individuals (including youth) and families experiencing homelessness.
Populations to be served. The population of focus will be Hispanic individuals (including youth) and families experiencing homelessness. Intercambios will focus on serving substance misusers—particularly persons who inject drugs (PWID), cocaine users (both crack and powder), sex workers, and persons experiencing chronic homelessness. The catchment area will be eastern Puerto Rico, including San Juan (Puerto Rico’s largest city), Carolina, Juncos, Canóvanas, Loíza, Río Grande, Luquillo, Fajardo, Ceiba, Naguabo, Humacao, and Las Piedras. The service area population is mostly Hispanic, and suffers from extremely high rates of homelessness, SUD, COD, and chronic diseases.
Strategies/interventions. Program activities will include: outreach and other engagement strategies, direct treatment (including screening, assessment, and care management),
case management to link with and retain clients in permanent housing and other services, engaging and enrolling the population of focus in enrollment resources for Medicaid and other benefits programs, and providing “wrap-around”/recovery support services, including peer services, care coordination, transportation to appointments, Medicaid office, and job training.
Project goals and measurable objectives. The program’s goals are 1) Improve access to behavioral health and other recovery-oriented services, 2) Enhance the sustainability of integrated community systems through the coordination of housing and services, and 3) Increase enrollment in health insurance, Medicaid, and mainstream benefits programs. The program’s objectives are to: conduct outreach and enroll at least 75 participants per year; conduct screening and referral activities using SBIRT for at least 75 program participants; provide Case Management services, incorporating Motivational Interviewing, to 70 participants per year; provide referrals to substance use treatment services and primary care and other supportive services; retain at least 40 program participants in permanent housing; develop and/or enhance linkages with 5 homeless shelters and housing facilities; convene a steering committee to meet quarterly with 8 local providers and other stakeholders; link at least 35 program participants to permanent housing; provide peer-based support activities to increase retention in housing and treatment services; provide entitlement enrollment assistance to all enrolled participants in need of assistance; provide information about peer- and community-based support activities to all enrolled participants; increase access to housing support services by providing housing services referrals to all enrolled participants in need of such referrals; and provide educational/vocational program referrals to all enrolled participants in need of such referrals.