VITALYST INNOVATION GRANT HAND IN HAND.PDF

Hand in Hand – A Community Collaboration for Justice Involved Homeless Individuals and Families
Mission: To work hand in hand with supportive services, housing providers, physical and mental health
services, jails, and policy makers to serve justice-involved homeless individuals and families; by
connecting them with necessary supports and housing.
Background: Representatives from Maricopa County Correctional Health Services, (CHS), Justice Systems
Planning & Information (JSPI), Human Services Department (HSD), Housing Authority of Maricopa County
(HAMC), Mercy Maricopa Integrated Care (MMIC), Native American Connections (NAC), Community
Bridges, Inc. (CBI), and Arizona Behavioral Health Corporation (ABC), have created a partnership to
reduce recidivism, and connect people experiencing homelessness who are justice engaged, to
appropriate housing, and supportive services.
Data from CHS and JSPI show that 23% of the jail population reported to be homeless – “roughly
1 of every 4 persons booked into jail experienced being homeless at least once in 2015”. Within this
group are chronic offenders, or familiar faces, that have been booked into MCSO jail 15 or more times.
These individuals are more likely to experience homelessness (93%), and also have higher rates of serious
and general mental health issues (Cotter, Noggle, AZCEH 2016). Our research has shown that we have a
relatively small number of people who are high cost and high needs, falling through the cracks and not
well served through our traditional, siloed service model. Disconnected systems, and lack of data sharing
protocols, are leading to failed interventions and a lack coordinated care for this high cost/high needs
group.
Through the development of a sophisticated and person-centered continuum of services, the partnership
expects to provide improved services, leverage resources, create efficiencies, reduce recidivism, and
reduce the number of unsheltered people in Maricopa County.
Priorities:
• Community organizations seeking to reduce frequent and unnecessary utilization of healthcare, criminal
justice, and homeless systems by targeting this population for stable housing and support services
• For most of the region’s homeless, housing and healthcare providers, the individual-level goal is to
improve client/tenant resiliency and support individual efforts to achieve wellness and recovery
• Stable housing is an essential healthcare intervention, and housing is critical for ending recidivism
into the public system (healthcare, homelessness, and criminal justice)
Defining Success:
• Organizations have been successful with supporting clients/tenants in retaining their housing, and
reducing utilization of high-cost public systems (including healthcare, homelessness, and
criminal justice)
•Participants/tenants have been able to meet their personal goals of achieving wellness and recovery

Hand in Hand – A Community Collaboration for Justice Involved Homeless Individuals and Families
• Systems funders have achieved initial alignment of their funding priorities
• Healthcare funders, including the regional behavioral health authority, have expanded
healthcare resources to address homelessness
System-Level Gaps:
 Insufficient affordable and supportive housing resources in the community for eligible
population
 Lack of immediate interim housing as solution for homeless individuals and families who
are waiting to access affordable and supportive housing
 Mental health/behavioral health system providers do not have access or visibility into the
region’s homeless data system, and homeless system providers do not have access or
visibility into the region’s mental health/behavioral health systems to coordinate care for
high-cost, high needs households
 Lack of integrated services to address whole person needs of vulnerable households
 Lack of dedicated community resources to serve high-cost, high-needs households living at
the geographic fringe of Maricopa County
 Lack of transportation services to link households with community-based resources
 Lack of broad-based services funding
Roles:
CHS:
 Identify and refer eligible homeless participants for referral to housing and supportive services
 SOAR applications and facilitate in reach
 Document homelessness status, chronic homelessness
 Track recidivism
HAMC:
 Administer HOME Tenant Based Rental Assistance (TBRA) program
HSD:
 Prioritize housing for homeless and justice engaged participants (TBRA, RRH)
 Connection to relevant services within HSD (e.g. work force)
 Link service contracts and housing to priority population
 Refer participants to Rapid Re-housing programs
 Track housing stability
JSPI:
 Develop frequent user list
 Provide analysis on the intersection between homeless and justice engaged population
MMIC:
 Refer Medicaid eligible households to supportive services and housing
 Connect and align supportive service contracts for eligible individuals identified by CHS and JSPI
 Support access to services from referral agencies once an assessment and treatment plan have
been developed – update to provider manual in process
 Assign appropriate level of supportive services for participants

Community Bridges, Inc.:
 In-reach to participants identified for housing services
 Provide housing navigation and housing based case management
Native American Connections:
 Prioritized Native American, substance misuse/abuse, youth
 Provide residential treatment services (Patina Wellness Center) for eligible participants
 Provide access to PSH or affordable housing units to eligible participants
ABC Housing:
 Manage PSH referrals for participants who are eligible
o Chronically homeless
o High-needs and/or high-risk households
o Medicaid eligible
o SMI or GMH/SA
Outcomes and Evaluation:
 Develop data sharing protocols to improve service delivery, and prioritize subset of
homeless, justice engaged population who are over utilizing jail, and under- utilizing
health services
 Measure tenancy and participants housing stability
 Track cost across multiple systems (e.g. jail, physical/behavioral health, homelessness
services)
 Analyze reduction in recidivism to the justice system, a key indicator of success of adding
navigation/reach in services for people while in an out of custody
 Tracking and evaluation of Emergency Service utilization, and connection to Mental
Health and Substance Use Services for each participant
 Report on homeless service system utilization, housing stability, ability to successfully lease
community based housing, and demonstrate improvement in achieving self-supporting housing
or maintaining level of supported housing
Budget: Requesting $60,000 to provide:
 Assistance with State Identification and Birth Certificate for clients to be able to obtain
housing ($5,500)
 Hotel/Motel vouchers for individuals in need of bridge housing prior to their permanent
housing or rental assistance ($110/night x 5 nights x 85 individuals = $46,750)
 Administration and technical assistance to develop policy recommendations/program
evaluation ($7,750)