Saturday, March 22, 2025
3/22/2025
The purpose of the El Rio Health Behavioral Health Expansion Project for People Experiencing Homelessness is to provide high quality, compassionate, and coordinated care to people experiencing homelessness, substance use disorders (SUD), and other co-occurring disorders (COD) in Pima County, Arizona working in collaboration with street medicine outreach teams. El Rio Health will expand our integrative consultative services to the community using both our Integrated Behavioral Health (IBH) and Specialty Behavioral Health (SBH) teams offering behavioral health services, medications for opioid use disorder (MOUD) and addiction services. Patients will be provided integrated, patient-centered care, by a team who commits to meeting them where they are, promoting resiliency, recovery, and safety, and trauma informed care. El Rio currently provides primary care to 1 in 8 Tucsonans, BH services to 13,548 adult patients annually, SUD services to 197 patients, and 11% of patients identify as being at risk for or currently experiencing homelessness (n=13,848) (UDS 2023). Between 2015-2019, the overdose mortality rate in Pima County was 37.8 (deaths per 100,000 population ages 15-64), and in 2020, there were 446 overdose deaths in the county, over twice the rate it was back in 2011. Fentanyl accounted for 28% of overdose deaths in 2020 and is the leading cause of death for young adults under age 19 (3.8% of overdoses in 2020). Our goal is to expand our BH and SUD services for people experiencing homelessness by working with our existing primary care street medicine outreach teams (Family Nurse Practitioner, Medical Assistant, Care Coordinator, and BH Consultant), and to provide them with comprehensive trauma-informed care that considers their SUD status and barriers to care. We envision a model that allows a patient to receive seamless integrated care from their treatment team, starting with initial engagement, building rapport, and providing primary car e and BH services in the community, at homeless encampments, on the streets, in shelters, and in other locations. Our MOUD, Family Medicine, Street Outreach, Pharmacy, Laboratory, Nursing, Health Insurance and Community Resources, external housing partners, and SBH team all work collaboratively for patient care coordination and treatment planning. Patients will receive Screening, Brief Intervention, and Referral to Treatment (SBIRT), ACE Survey (Adult Childhood Experiences), PHQ 2/9 depression screenings, and the Columbia-Suicide Severity Rating Scale (C-SSRS), at the point of care during their primary care appointment with their El Rio Health Street Medicine clinician. All positive screens for BH/SUD issues that indicate clinically significant findings will be referred to the BHC for further evaluation and referred to SBH for intake and services. Based on this initial intake, the patient will be quickly connected to follow up with a MOUD clinician (primary care or psychiatric depending on individual needs and preferences) and will have ongoing case management services throughout the duration of their treatment with El Rio. Our MH-SUD Program will primarily be housed at our Grant Health Center site and will include two (2) Psychiatrists (one as Medical Director/Project Director), (2) BH CM (2) Peer Recovery Support Specialists (PRSS), and Licensed Behavioral Health Professional (BHP). Together, they will provide medical, BH and addiction medicine care, MOUD services, and patient education. BH case managers and PRSS will also support individuals referred for SUD/COD screening, treatment, and follow-up BH/SUD care. Oversight will be provided by the Project Director/Medical Director, Chief of Behavioral Health and Integration, BH Clinical Director, Chief of Grants and Research, and Senior Accountant.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).