Multidisciplinary Team (MDT)
Homeless Outreach, Proactive Engagement Services (HOPES) is a model that brings together existing resources to serve homeless individuals, inclusive of County and contract providers. The model utilizes an integrated multidisciplinary team that includes health providers, behavioral health providers, crisis services, outreach specialists, veteran providers and criminal justice personnel.
HOPES MDT includes:
Referral Process
Any member of the HOPES MDT can make referrals within the model. Additional referrals can be generated from the community inclusive of law enforcement, fire department, concerned citizens, local businesses, and other service providers. Referrals can be made via this form.
Engagement Process
The coordinated services include outreach and engagement from a harm reduction approach, developing rapport while identifying risks and needs. During the engagement phase, a comprehensive assessment will be completed by the active disciplines, inclusive of medical needs, psychosocial assessment, safety assessment, substance use disorder assessment (ASAM as needed), housing needs (Smart Path Coordinated Entry assessment) and other relevant areas of concern.
Each HOPES participant will be assigned a lead provider, based on the agency the individual is most identified with. For example, if an individual is concerned about a medical issue and willing to work with the Homeless Person’s Health Project, they would take the lead on coordinating the other services. All agency participants will coordinate service delivery to the individual based on need. To facilitate close coordination of services, the HOPES MDT will meet three times per week. (We are recommending a shared “Problem List” format to include areas of Physical Health, Behavioral Health – Mental Health & SUD, Housing, Benefits, Criminal Justice Issues, Social Services Issues.) Each Engagement Plan will be based on the identified needs on the Problem List and a Stages of Change Approach to move treatment intervention strategies forward.
Stabilization
Through the HOPES MDT, participants can be linked directly to stabilization services as part of the engagement process and/or as a link to ongoing services. Stabilization services are focused on a planned intervention to affect change in at least one of the engagement disciplines (physical health, mental health, substance use disorder, or homelessness.) Stabilization services include:
- HOPES beds at River Street Shelter (2 HOPES funded beds)
- Telos – Mental Health Crisis Residential facility
- SUD Residential Treatment – based on ASAM score
- Specialty Court – PACT for HOPES participants or Behavioral Health Court for MOST participants
Leveraging the progress made in stability and treatment readiness, the participant can be referred to an ongoing treatment provider when deemed appropriate by the MDT.
Integrated Treatment
Participants of the HOPES MDT will be linked to an integrated treatment service after successfully demonstrating stability. There are four tracks for treatment:
- Mild to Moderate Mental Health; Mild to Severe SUD and not court involved.
- County health clinic services with Integrated Behavioral Health and SUD services.
- Mild to Moderate Mental Health; Mild to Severe SUD and court involved.
- County health clinic services with Integrated Behavioral Health, SUD services and PACT Court.
- Serious Mental Illness; Mild to Severe SUD and not court involved.
- Specialty Mental Health, County health clinic services for participants of Innovations/Whole Person Care, and SUD Services.
- Serious Mental Illness; Mild to Severe SUD and court involved.
- Specialty Mental Health, County health clinic services for participants of Innovations/Whole Person Care, SUD Services and Behavioral Health Court.
In addition to the treatment tracks identified above, participants may qualify for additional services through Innovations and/or Whole Person Care. These supports can include:
- Health & Housing Support (MHSA Innovations)
- Housing Support Services
- Occupational Therapy
- Nursing Support
- Peer Support
- Telehealth device for health monitoring
- Whole Person Care
- Housing Navigator o Deposit assistance o Peer Support
- Telehealth device