One Charlotte Integrated Care Team - This team-based, coordinated approach decreases the access and service use disparities persons experiencing serious behavioral disorders can face when trying to locate and navigate multiple systems of care. The project will serve 300 vulnerable homeless individuals, youth, and families who also have a substance abuse disorder (SUD) and/or co-occurring mental and substance use disorder (COD). Special project populations will include those experiencing chronic homelessness, unaccompanied transition aged youth (18-24), pregnant and parenting youth, survivors of domestic violence and human trafficking, Veterans, and LGBTQ+ persons. The team will use multiple Evidence Based Practices (EBPs) including Assertive Community Treatment (ACT), Cognitive Behavioral Therapy (CBT), Seeking Safety (SS), SSI/SSDI Outreach, Access, and Recovery (SOAR), Housing First (HF), Motivational Interviewing (MI) and Assertive outreach combined with peer recovery supports to support this population’s transition into permanent housing. Through Street Outreach, Engagement, and Coordinated Entry, the One Charlotte Team will assess clients using mental and substance abuse screening and assessment in addition to the VI-SPDAT, VI-F-SPDAT, or TAY-VI-SPDAT to determine the level of housing and behavioral intervention required. Each client will work with a certified peer recovery specialist – case manager that formerly experienced homelessness and SUDs or CODs., Housing Navigators will assist in accessing permanent housing, SOAR Specialists will assist in enrollment for health insurance, Medicaid, SSI/SSDI, TANF, SNAP, and other mainstream benefits. The team’s Licensed Clinical Therapist will ensure access to recovery supports, outpatient treatment, and direct treatment for substance use and co-occurring disorders. Project Goals include Expanding treatment and recovery support services, Coordinating housing and services to support permanent housing stability and sustainability, and engaging and connecting individuals (including youth and families) experiencing homelessness with SUD and COD to enrollment resources for health insurance, Medicaid, and mainstream benefits programs. The One Charlotte Integrated Care Team will serve 300 people during the five years of the grant with 60 or more persons per year receiving comprehensive housing, coordinated treatment, and recovery services. Data will be collected from participants via face-to-face interviews during outreach and intake, six months post intake, and at discharge. Data will be locally collected using the Continuum of Care’s Community Information System (CIS) as well as Charlotte Behavioral Health Care’s Electronic Medical Records System and reported electronically utilizing SAMHSA’s SPARS System.
