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Reaching Out, Engaging, Serving, and Treating Chronically Homeless People

We will implement multi-disciplinary approaches to moving people quickly from shelters and the streets into permanent housing with on-site or linked services. Linkages to coordinate with local faith communities to train volunteers to mentor homeless persons who desire faith-based support in their recovery plans will be developed. Initiation and relationship-building Street Outreach Teams will focus upon homeless people living in the open (streets, parks, beaches, and in vehicles), and foster youth without next-step housing arrangements. The Street Outreach Teams will have an Outreach Worker who will assist in access to income subsidies, benefits programs, and entitlements and a Field Worker who will respond to medication, mental health, and substance abuse issues.

Street Outreach Teams will be mobile, going where chronically homeless people are, and have a client-centered approach. They will operate out of Community Centers, similar to the Transition Centers, which will provide basic housing assistance. This will reduce the number of people who remain homeless for lengthy periods of time. Through cross-training and multi-disciplinary we will provide coordinated, holistic care to persons with co-occurring disorders to ensure they do not fall through the cracks of our traditional service systems.

The Outreach Teams will coordinate with the Integrated Services Teams as chronically homeless individuals are placed in permanent supportive housing. The Integrated Services Teams will ensure that services and treatment are provided as needed to chronically homeless individuals in permanent supportive housing. The Integrated Services Teams will provide person centered case management, relationship building, life skills counseling, money management, access to benefits and employment, and peer support. Treatment shall include mental health services, substance use management counseling based on a harm reduction philosophy, medication management, and assistance with getting physical health and primary care needs met. It will also be important to identify and make available incentives such that long-term homeless individuals are motivated to move off the streets and share responsibility for progress towards goals that they set for themselves.

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