The BHS Homeless Outreach and Engagement team consists of the Whole Person Care (WPC) pilot program, the Law Enforcement Assisted Diversion (LEAD) program, and Projects for Assistance in Transition from Homelessness (PATH).
Program objectives are to engage and link homeless individuals with a serious mental illness (SMI) and or co-occurring substance use disorder (SUD) to community resources.
The Project for Assistance in Transition from Homelessness (PATH) is a formula grant from the State of California that funds community based outreach, mental health and substance abuse referrals and treatment, case management and other support services.
Eligible program participants must be homeless and have a suspected serious mental illness (SMI) or be homeless with a suspected SMI and a co-occurring substance use disorder (SUD). The target population are consumers who are not already receiving BHS mental health services and are homeless or in imminent risk of homelessness.
The PATH team connects members to BHS treatment services. Members are linked to a continuum of appropriate housing and support services like primary health care, education supports, and case management to ensure warm-hand-offs to treatment teams at BHS.
The PATH team is part of a comprehensive, countywide homeless outreach program that also includes the Whole Person Care (WPC) pilot, the expanded BHS Mobile Crisis Support Teams, and the Law Enforcement Assisted Diversion (LEAD) program. PATH also provides support, screenings, and consultations at area homeless shelters. It is a partner in the SJC Continuum of Care (CoC) for the homeless population and a partner in the Encampment Response Team (ERT), which serves homeless encampments on county land.
The most fundamental goal for PATH is outreach and engagement to persons who would otherwise not receive services due to the combined conditions of homelessness and SMI. PATH programs work to connect individuals with existing mainstream mental health, substance use, housing, and other programs.
Whole Person Care (WPC) is a pilot program designed to improve the health of high-risk, high-utilizing Medi-Cal beneficiaries, or those eligible for Medi-Cal benefits, through the coordinated delivery of physical health, behavioral health, housing support, food stability, and other critical community services. BHS operates the Behavioral Health Navigation Team as part of the Health Care Services WPC pilot.
WPC targets the following overlapping populations: 1) Medi-Cal beneficiaries who are high-utilizers of emergency services like hospitals, jails, or psychiatric facilities; 2) adult Medi-Cal beneficiaries with a mental health and/or substance use disorder; 3) adult Medi-Cal beneficiaries who are at risk of homelessness upon discharge from WPC participating medical facilities or the county jail; and 4) qualified individuals who are not currently enrolled in Medi-Cal but are eligible for Medi-Cal benefits. The latter criteria enables members to pre-enroll in WPC services while their benefits are pending.
The WPC Behavioral Health Navigation Team receives referrals from the community, the District Attorney’s office, hospitals, jails, homeless shelters, crisis services, and the Health Care Services Agency, which is the hub of the pilot. The Navigation Team also performs outreach to and engagement of homeless individuals who are high utilizers of multiple social systems who may have a mental illness and or a co-occurring substance use disorder.
The Navigation Team’s objectives are to stabilize the individual’s housing, connect them to services, and optimally create a plan that improves their overall health outcomes. The goal is to decrease the usage of emergency services for non-emergency care and to link members to the most appropriate treatment and community services. These services include BHS mental health and substance use services, stable housing and placements, food stability, and securing enrollment into entitlement programs.