Transaction Description:
PATHWAYS HOME - MOUNTAIN COMPREHENSIVE CARE CENTER WILL IMPLEMENT THE PATHWAYS HOME PROJECT TO OFFER COMPREHENSIVE, COORDINATED, AND EVIDENCE-BASED SERVICES FOR INDIVIDUALS, YOUTH, AND FAMILIES WITH SMI, SED OR COD WHO ARE EXPERIENCING HOMELESSNESS OR AT IMMINENT RISK IN THE SERVICE AREA OF FLOYD, JOHNSON, LAWRENCE, MAGOFFIN, MARTIN, MORGAN, PIKE, AND ROWAN COUNTIES IN EASTERN KY. POPULATION: BASED ON DATA FROM THE KY BALANCE OF STATE COC, WHICH SERVES THE CATCHMENT AREA AND WILL COORDINATE WITH MCCC ON OUTREACH, TREATMENT, AND SERVICES, IT IS SURMISED THAT 85% OF THE TARGETED POPULATION WILL IDENTIFY AS WHITE WITH MINORITY POPULATIONS HIGHER THAN THE GENERAL PUBLIC INCLUDING 12% BLACK, 2% MULTIRACIAL, 1% OTHER RACES, 2% HISPANIC, AND 0.5% LEP. MEN WILL ACCOUNT FOR 58%, WOMEN 41%, TRANSGENDER 1%, LGBTQ+ 6%, AND VETERANS 3%. REGARDING AGE, 67% WILL BE ADULTS AGES 25+, 6% TRANSITIONAL-AGE YOUTH (AGES 18-24), AND 27% FAMILIES (61% CHILDREN/YOUTH, 39% ADULTS). THE PROJECT WILL TARGET UNDERSERVED PERSONS WHO ARE RURAL, IDENTIFY AS LGBTQ+, AND DEVELOP INCLUSIVE STRATEGIES TO INCREASE ACCESS FOR RACIAL AND ETHNIC MINORITIES. LOCATED IN EASTERN KY AND APPALACHIA, THE TARGETED POPULATION IS ANTICIPATED TO EXPERIENCE EVEN MORE DISPARITIES THAN THE GENERAL POPULATION WHICH IS STILL SIGNIFICANTLY IMPACTED BY POVERTY, UNEMPLOYMENT, AND RECENT CRISIS ACROSS THE SERVICE AREA. INTERVENTIONS: STAFF WILL CONDUCT OUTREACH/ENGAGE POTENTIAL PARTICIPANTS USING TRAUMA-INFORMED CARE AND MOTIVATIONAL INTERVIEWING. ASSESSMENT WILL INCLUDE THE VI-SPDAT, PSYCHOSOCIAL ASSESSMENT, AND LOCUS/CASSI WHILE USING HOUSING FIRST TO LINK CLIENTS WITH HOUSING AND DESIRED TREATMENT/RECOVERY SERVICES AS OUTLINED IN A PERSON-CENTERED PLAN. LINKAGES WILL BE MADE TO EXISTING AGENCY RESIDENTIAL, IOP, AND OUTPATIENT TREATMENT PROGRAMS WITH EBPS TO INCLUDE HOUSING FIRST, MI, COGNITIVE BEHAVIORAL THERAPY, PHARMACOTHERAPY, PEER SUPPORTS, AND MEDICATION ASSISTED TREATMENT. MCCC WILL COORDINATE PRIMARY CARE AND KEY INTERVENTIONS SUCH AS PHARMACOTHERAPY AND MAT WITH ITS HOMEPLACE CLINICS WHILE ALSO OFFERING CASE MANAGEMENT, BENEFITS ENROLLMENT, PEER/COMMUNITY/RECOVERY SUPPORTS, AND AFTERCARE UPON EXIT. GOALS: MCCC WILL SERVE 40 CLIENTS IN YEAR 1 AND 60 ANNUALLY IN YEAR 2-5 (TOTAL 280). GOALS FOR THE TARGETED POPULATION INCLUDE: 1) IMPROVE HEALTH BY ENGAGING WITH AND COORDINATING CARE TO EVIDENCE-BASED AND POPULATION-SPECIFIC BEHAVIORAL HEALTH AND PRIMARY HEALTH CARE; 2) IMPROVE STABILITY BY PROVIDING AND/OR COORDINATING CASE/CARE MANAGEMENT, RECOVERY, AND HOUSING SUPPORTS; AND 3) IMPROVE EQUITABLE, INCLUSIVE, AND EFFECTIVE PROJECT IMPLEMENTATION AND EVALUATION BY CONDUCTING CQI. OBJECTIVES ACHIEVED BY END OF EACH PROJECT YEAR INCLUDE: 1.1) CONDUCTED INCLUSIVE OUTREACH/ENGAGEMENT SO AT LEAST 40 ARE SERVED IN YEAR 1 AND 60 ANNUALLY IN YEARS 2-5; 1.2) COORDINATED ACCESS TO INDIVIDUALIZED MENTAL HEALTH AND COD TREATMENT (AND FDA-APPROVED MEDICATIONS) SO 50% OR LESS REPORT ANY MH OR COD SYMPTOMS [AT 6-MONTH FOLLOW-UP]; 1.3) PROVIDED LINKAGES TO INTEGRATED PRIMARY CARE SO 65% REPORT HEALTH AS “GOOD” OR ABOVE; 2.1) PROVIDED AND/OR COORDINATED ACCESS TO PEER SUPPORTS SO 60% REPORT POSITIVE SOCIAL CONNECTIONS; 2.2) COORDINATED ACCESS TO RECOVERY SUPPORT SERVICES SO 50% REPORT ENGAGEMENT IN EMPLOYMENT/EDUCATION, AND/OR BENEFITS ENROLLMENT; 2.3) PROVIDED PERSON-CENTERED CASE MANAGEMENT SERVICES SO 50% REPORT HOUSING STABILITY AND 60% NO FURTHER ARRESTS; 3.1) MONITORED INDICATORS OF ENROLLEES EACH QUARTER TO ENSURE EQUITY/INCLUSION AMONG ALL GROUPS AND REVISE OUTREACH AS NEEDED; 3.2) CONDUCTED STEERING COMMITTEE MEETINGS AT LEAST QUARTERLY TO COORDINATE SERVICES, MONITOR GOALS/OBJECTIVES, AND CQI. MSU WILL CONDUCT AN INDEPENDENT EVALUATION.
