I. State Information

State Information

Plan Year Federal Fiscal Year 2017

State Identification Numbers DUNS Number 965736635

EIN/TIN 94-3473160

I. State Agency to be the Grantee for the PATH Grant Agency Name Department of Behavioral Health and Developmental Disabilities

Organizational Unit Division of Behavioral Health

Mailing Address 2 Peachtree Street NW Floor 24

City Atlanta

Zip Code 30303

II. Authorized Representative for the PATH Grant First Name Jill

Last Name Mays

Agency Name GA Dept of Behavioral Health & Developmental Disabilities

Mailing Address 2 Peachtree St, NW, Suite 23-222

City Atlanta

Zip Code 30303

Telephone 404-657-2140

Fax

Email Address [email protected]

III. State Expenditure Period From 9/1/2017

To 8/31/2018

IV. Date Submitted NOTE: this field will be automatically populated when the application is submitted. Submission Date 7/5/2017 9:23:14 PM

Revision Date 7/7/2017 11:23:43 AM

V. Contact Person Responsible for Application Submission Title Assistant Director, Office of Adult Mental Health

Organizational Unit Name GA Department of Behavioral Health & Developmental Disabilities

First Name Jill

Last Name Mays

Telephone 404-657-2140 Printed: 7/7/2017 11:2311:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017 PagePage 1 of1 231of 2 Fax

Email Address [email protected]

Footnotes:

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Assurances - Non-Construction Programs

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the applicant I certify that the applicant: 1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the non-Federal share of project costs) to ensure proper planning, management and completion of the project described in this application. 2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standard or agency directives. 3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain. 4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §§4728-4763) relating to prescribed standards for merit systems for programs funded under one of the nineteen statutes or regulations specified in Appendix A of OPM's Standard for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F). 6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §§794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended, relating to non-discrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) the requirements of any other nondiscrimination statute(s) which may apply to the application. 7. Will comply, or has already complied, with the requirements of Title II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 8. Will comply with the provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds. 9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act (40 U.S.C. §276c and 18 U.S.C. §874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§327-333), regarding labor standards for federally assisted construction subagreements. 10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetland pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Costal Zone Management Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205). 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system. 13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. Printed: 7/7/2017 11:2311:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017 PagePage 3 of1 231of 4 §470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§469a-1 et seq.). 14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance. 15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§4801 et seq.) which prohibits the use of lead based paint in construction or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984. 18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program.

Name

Judy Fitzgerald

Title

Commissioner

Organization

GA Dept of Behavioral Health and Developmental Disabilities

Signature: Date:

Footnotes:

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Certifications

1. Certification Regarding Debarment and Suspension The undersigned (authorized official signing for the applicant organization) certifies to the best of his or her knowledge and belief, that the applicant, defined as the primary participant in accordance with 45 CFR Part 76, and its principals: a. are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal Department or agency; b. have not within a 3-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false stat ements, or receiving stolen property; c. are not presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and d. have not within a 3-year period preceding this application/proposal had one or more public transactions (Federal, State, or local) terminated for cause or default. Should the applicant not be able to provide this certification, an explanation as to why should be placed after the assurances page in the application package. The applicant agrees by submitting this proposal that it will include, without modification, the clause titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion--Lower Tier Covered Transactions" in all lower tier covered transactions (i.e., transactions with subgrantees and/or contractors) and in all solicitations for lower tier covered transactions in accordance wit h 45 CFR Part 76. 2. Certification Regarding Drug-Free Workplace Requirements The undersigned (authorized official signing for the applicant organization) certifies that the applicant will, or will continue to, provide a drug-free workplace in accordance with 45 CFR Part 76 by: a. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the grantee's work-place and specifying the actions that will be taken against employees for violation of such prohibition; b. Establishing an ongoing drug-free awareness program to inform employees about-- 1. The dangers of drug abuse in the workplace; 2. The grantee's policy of maintaining a drug-free workplace; 3. Any available drug counseling, rehabilitation, and employee assistance programs; and 4. The penalties that may be imposed upon employ ees for drug abuse violations occurring in the workplace;

c. Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a) above; d. Notifying the employee in the statement required by paragraph (a), above, that, as a condition of employment under the grant, the employee will- - 1. Abide by the terms of the statement; and 2. Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction;

e. Notifying the agency in writing within ten calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted empl oyee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant; f. Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d) (2), with respect to any employee who is so convicted? 1. Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or 2. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency;

g. Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e), and (f). For purposes of paragraph, regarding agency notificati on of criminal drug convictions, the DHHS has designated the following central point for receipt of such notices: Office of Grants and Acquisition Management Office of Grants Management Office of the Assistant Secretary for Management and Budget Department of Health and Human Services 200 Independence Avenue, S.W., Room 517-D

Printed: 7/7/2017 11:2311:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017 PagePage 7 of1 231of 4 Washington, D.C. 20201 3. Certifications Regarding Lobbying Title 31, United States Code, Section 1352, entitled "Limitation on use of appropriated funds to influence certain Federal contracting and financial transactions," generally prohibits recipients of Federal grants and cooperative agreements from using Federal (appropriated) funds for lobbying the Executive or Legislative Branches of the Federal Government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each person who requests or receives a Federal grant or cooperative agreement must disclose lobbying undertaken with non-Federal (non- appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING $100,000 in total costs (45 CFR Part 93). The undersigned (authorized official signing for the applicant organization) certifies, to the best of his or her knowledge and belief, that: 1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. 2. If any funds other than Federally appropriated funds have been paid or will be paid to any pe rson for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure of Lobbying Activities," in accordance with its instructions. (If needed, Standard Form-LLL, "Disclosure of Lobbying Activities," its instructions, and continuation sheet are included at the end of this application form.) 3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 4. Certification Regarding Program Fraud Civil Remedies Act (PFCRA) The undersigned (authorized official signing for the applicant organization) certifies that the statements herein are true, complete, and accurate to the best of his or her knowledge, and that he or she is aware that any false, fictitious, or fraudulent statements or claims may subject him or her to criminal, civil, or administrative penalties. The undersigned agrees that the applicant organization will comply with the Public Health Service terms and conditions of award if a grant is awarded as a result of this application. 5. Certification Regarding Environmental Tobacco Smoke Public Law 103-227, also known as the Pro-C hildren Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, daycare, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residence, portions of facilities used for inpatient drug or alcohol treatment, service providers whose sole source of applicable Federal funds is Medicare or Medicaid, or facilities where WIC coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. By signing the certification, the undersigned certifies that the applicant organization will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The applicant organization agrees that it will require that the language of this certification be included in any subawards which contain provisions for children's services and that all subrecipients shall certify accordingly. The Public Health Services strongly encourages all grant recipients to provide a smoke-free workplace and promote the non-use of tobacco products. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people.

Name

Judy Fitzgerald

Title

Commissioner

Organization

Georgia Department of Behavioral Health and Developmental Disabilities

Signature: Date:

Footnotes:

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Funding Agreement

FISCAL YEAR 2017 PROJECTS FOR ASSISTANCE IN TRANSITION FROM HOMELESSNESS (PATH) AGREEMENT I hereby certify that the State of Georgia agrees to the following:

Section 522(a) Amounts received under the PATH Formula Grant Program will be expended solely for making grants to political subdivisions of the State, and to nonprofit private entities for the purpose of providing the services specified in Section 522(b) to individuals who: ◦ Are suffering from serious mental illness; ◦ Are suffering from serious mental illness and have a substance use disorder; and ◦ Are homeless or at imminent risk of becoming homeless. Section 522(b) Entities receiving grants under the PATH Formula Grant Program will expend funds for the following services: ◦ Outreach; ◦ Screening and diagnostic treatment; ◦ Habilitation and rehabilitation; ◦ Community mental health; ◦ Alcohol or drug treatment; ◦ Staff training, including the training of individuals who work in shelters, mental health clinics, substance abuse programs, and other sites where homeless individuals require services; ◦ Case management services, including: • Preparing a plan for the provision of community mental health services to the eligible homeless individual involved, and reviewing such plan not less than once every 3 months; • Providing assistance in obtaining and coordinating social and maintenance services for eligible homeless individuals, including services relating to daily living activities, personal financial planning, transportation services, habilitation and rehabilitation services, prevocational and vocational services, and housing; • Providing assistance to eligible homeless individuals in obtaining income support services, including housing assistance, food stamps, and supplemental security income benefits; • Referring eligible homeless individuals for such other services as may be appropriate; and Providing representative payee services in accordance with Section 1631﴾a﴿﴾2﴿ of the Social Security Act if the eligible homeless • individual is receiving aid under Title XVI of such act and if the applicant is designated by the Secretary to provide such services.

◦ Supportive and supervisory services in residential settings; ◦ Referrals for primary health services, job training, education services and relevant housing services; :Housing services [subject to Section 522﴾h﴿﴾1﴿] including ◦ • Minor renovation, expansion, and repair of housing; • Planning of housing; • Technical assistance in applying for housing assistance; • Improving the coordination of housing services; • Security deposits; • The costs associated with matching eligible homeless individuals with appropriate housing situations; • One‐time rental payments to prevent eviction; and • Other appropriate services, as determined by the Secretary. Section 522(c) The State will make grants pursuant to Section 522﴾a﴿ only to entities that have the capacity to provide, directly through arrangements, the services specified in Section 522﴾b﴿, including coordinating the provision of services in order to meet the needs of eligible homeless individuals who are both mentally ill and suffering from a substance abuse disorder.

Section 522(d) In making grants to entities pursuant to Section 522﴾a﴿, the State will give special consideration to entities with a demonstrated effectiveness in serving homeless veterans.

Section 522(e) :The state agrees that grants pursuant to Section 522﴾a﴿ will not be made to any entity that Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 11 of1 231of 6 ◦ Has a policy of excluding individuals from mental health services due to the existence or suspicion of a substance abuse disorder; or ◦ Has a policy of excluding individuals from substance abuse services due to the existence or suspicion of mental illness. Section 522(f) Not more than 4 percent of the payments received under the PATH Formula Grant Program will be expended for administrative expenses regarding the payments.

Section 522(g) The State will maintain State expenditures for services specified in Section 522﴾b﴿ at a level that is not less than the average level of such expenditures maintained by the State for the 2‐year period preceding the fiscal year for which the State is applying to receive such payments.

Section 522(h) The State agrees that: Not more than 20 percent of the payments will be expended for housing services under section 522﴾b﴿﴾10﴿; and ◦ ◦ The payments will not be expended: • To support emergency shelters or construction of housing facilities; • For inpatient psychiatric treatment costs or inpatient substance abuse treatment costs; or • To make cash payments to intended recipients of mental health or substance abuse services.

Section 523(a) The State will make available, directly or through donations from public or private entities, non‐Federal contributions toward such costs in an amount that is not less than $1 for each $3 of funds provided in such payments. The amount of non‐Federal contributions shall be determined in accordance .﴿with Section 523﴾b

Section 523(c) The State will not require the entities to which grants are provided pursuant to Section 522﴾a﴿ to provide non‐Federal contributions in excess of the .﴿non‐Federal contributions described in Section 523﴾a

Section 526 The State has attached hereto a Statement ◦ Identifying existing programs providing services and housing to eligible homeless individuals and gaps in the delivery systems of such programs; ◦ Containing a plan for providing services and housing to eligible homeless individuals, which: • Describes the coordinated and comprehensive means of providing services and housing to homeless individuals; and • Includes documentation that suitable housing for eligible homeless individuals will accompany the provision of services to such individuals;

◦ Describing the source of the non‐Federal contributions described in Section 523; ◦ Containing assurances that the non‐Federal contributions described in Section 523 will be available at the beginning of the grant period; ◦ Describing any voucher system that may be used to carry out this part; and ◦ Containing such other information or assurances as the Secretary may reasonably require. Section 527(a)(1), (2), and (3) The State has attached hereto a description of the intended use of PATH Formula grant amounts for which the State is applying. This description: ◦ Identifies the geographic areas within the State in which the greatest numbers of homeless individuals with a need for mental health, substance abuse, and housing services are located; and ◦ Provides information relating to the program and activities to be supported and services to be provided, including information relating to coordinating such programs and activities with any similar programs and activities of public and private entities. Section 527(a)(4) The description of intended use for the fiscal year of the amounts for which the State is applying will be revised throughout the year as may be necessary to reflect substantial changes in the programs and activities assisted by the State pursuant to the PATH Formula Grant Program.

Section 527(b) In developing and carrying out the description required in Section 527﴾a﴿, the State will provide public notice with respect to the description including any revisions﴿ and such opportunities as may be necessary to provide interested clients, such as family members, consumers and mental﴾ health, substance abuse, and housing agencies, an opportunity to present comments and recommendations with respect to the description.

Section 527(c)(1)(2) ,The services to be provided pursuant to the description of the intended use required in Section 527﴾a﴿, have been considered in the preparation of have been included in, and are consistent with the State Plan for Comprehensive Community Mental Health Services under P.L. 102‐321.

Section 528(a) The State will, by January 31, 2018, prepare and submit a report providing such information as is necessary for: ◦ Securing a record and description of the purposes for which amounts received under the PATH Formula Grant Program were expended during Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 12 of2 231of 6 fiscal year 2017 and of the recipients of such amounts; and ◦ Determining whether such amounts were expended in accordance with the provisions of Part C‐ PATH. Section 528(b) .The State further agrees that it will make copies of the reports described in Section 528﴾a﴿ available for public inspection

Section 529 Payments may not be made unless the State agreements are made through certification from the chief executive officer of the State.

Charitable Choice Provisions: The State will comply, as applicable, with the Substance Abuse and Mental Health Services Administration's ﴾SAMHSA﴿ Charitable Choice statutes codified at sections 581‐584 and 1955 of the Public Health Service Act ﴾42 U.S.C §§290kk, et seq., and 300x‐65﴿ and their governing regulations at 42 C.F.R part 54 and 54a respectively.

Name

Nathan Deal

Title

Governor

Organization

State of Georgia

Signature: Date:

Footnotes:

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Disclosure of Lobbying Activities

Are there lobbying activities pursuant to 31 U.S.C. 1352 to be disclosed? Yes nmlkj No nmlkji

To View Standard Form LLL, Click the link below (This form is OPTIONAL).

Standard Form LLL (click here)

Name: Judy Fitzgerald

Title: Commissioner

Organization: Georgia Department of Behavioral Health and Developmental Disabilities

Signature: Date Signed:

mm/dd/yyyy

Footnotes: No lobbying activities.

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State PATH Regions

Name Description Actions

The Region One DBHDD Office plans and oversees a network of public mental health, developmental disabilities, addictive disease and prevention services for 31 counties. Counties in this region include: Banks, Bartow, Catoosa, Chattooga, Cherokee, Cobb, Dade, Region 1 Dawson, Douglas, Fanin, Floyd, Forsyth, Franklin, Gilmer, Gordon, Habersham, Hall, Haralson, Hart, Lumpkin, Murray, Paulding, Pickens, Polk, Rabun, Stephens, Towns, Union, Walker, White, and Whitfield.

The Region Two DBHDD Office plans and oversees a network of public mental health, developmental disabilities, addictive disease and prevention services for 33 counties. Counties in this region include Baldwin, Barrow, Bibb, Burke, Clarke, Columbia, Elbert, Region 2 Emanuel, Glascock, Greene, Hancock, Jackson, Jasper, Jefferson, Jenkins, Jones, Lincoln, Madison, McDuffie, Monroe, Morgan, Oconee, Oglethorpe, Putnam, Richmond, Screven, Taliaferro, Twiggs, Walton, Warren, Washington, Wilkes, and Wilkinson

The Region Three DBHDD Office plans and oversees a network of public mental health, Region 3 developmental disabilities, addictive disease and prevention services for six counties. Counties in this region include Clayton, Dekalb, Fulton, Gwinnett, Newton and Rockdale.

The Region Four DBHDD Office plans and oversees a network of public mental health, developmental disabilities, addictive disease and prevention services for 24 counties. Region 4 Counties in this region include Baker, Ben Hill, Berrien, Brooks, Calhoun, Colquitt, Cook, Decatur, Dougherty, Early, Echols, Grady, Irwin, Lanier, Lee, Lowndes, Miller, Mitchell, Seminole, Terrell, Thomas, Tift, Turner, and Worth.

The Region Five DBHDD Office plans and oversees a network of public mental health, developmental disabilities, addictive disease and prevention services for 34 counties. Counties in the region include Appling, Atkinson, Bacon, Bleckley, Brantley, Bryan, Bulloch, Region 5 Camden, Candler, Charlton, Chatham, Clinch, Coffee, Dodge, Effingham, Evans, Glynn, Jeff Davis, Johnson, Laurens, Liberty, Long, McIntosh, Montgomery, Pierce, Pulaski, Tattnall, Telfair, Toombs, Treutlen, Ware, Wayne, Wheeler & Wilcox

The Region Six DBHDD Office plans and oversees a network of public mental health, developmental disabilities, addictive disease and prevention services for 31 counties. Counties in this region include Butts, Carroll, Chattahoochee, Clay, Coweta, Crawford, Crisp, Region 6 Dooly, Fayette, Harris, Heard, Henry, Houston, Lamar, Macon, Marion, Meriwether, Muscogee, Peach, Pike, Quitman, Randolph, Schley, Spalding, Stewart, Sumter, Talbot, Taylor, Troup, Upson and Webster.

Footnotes:

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 20 of1 231of 2 qeorgi2heprtment2of2fehviorl2relth2nd2hevelopmentl2hisilities tte2syhitri2rospitlsD2rivte2rospitls2@gontrtedA nd2gommunity2ervie2eres

State Psychiatric Hospitals (numbers in black circles) 1 - Georgia Regional Hospital - Atlanta 2 - West Central Georgia Regional Hospital - Columbus 3 - Central State Hospital (Forensics) - Milledgeville 4 - East Central Regional Hospital - Augusta hde gtoos pnnin owns nion un 5 - Georgia Regional Hospital - Savannah wurry lker hitfield I qilmer Private Psychiatric Hospitals (letters in white circles) iqsyx2I hite rershm A - Floyd Medical Center - Rome vumpkin tephens qordon B - Wellstar Cobb Hospital - Austell ghttoog ikens hwson Q C - Laurelwood - Gainesville fnks prnklin D - Peachford Hospital - Dunwoody e P rll rrt g E - Summitridge - Lawrenceville ployd frtow gherokee porsyth F - Anchor Hospital - Atlanta tkson ilert i wdison G - Willowbrook at Tanner - Carrollton *NOTE: These hospitals have been contracted by DBHDD olk go qwinnett frrow ulding f R iqsyx2Q glrke to receive individuals from counties in Region 1. h yonee yglethorpe he2ul W ilkes rrlson lton vinoln hougls V IH Tpulton I II S p glyton worgn okdle q grroll U xewton qreene liferro golumi whuffie R pyette renry rren IS gowet ihmond rerd futts tsper utnm iqsyx2P plding rnok IT qlsok weriwether Q IQ roup ike vmr tefferson furke iqsyx2T wonroe tones fldwin shington IR pson IP

fi tenkins ilkinson reven rrris lot grwfordIW wiggs tohnson wusogee ylor eh imnuel P vurens rouston flekley reutlen gndler won fulloh iffinghm ghtthoohee wrion hley IV ulski PQ hodge hooly heeler ivns IU ooms PR tewrt fryn ester umter wontgomery ttnll ghthm ilox elfir S grisp uitmn vierty errell teff2hvis ndolph vee fen2rill eppling vong urner iqsyx2S PT gly orth srwin glhoun hougherty goffee fon ift yne wsntosh irly PH PP iere fker withell etkinson golquitt ferrien re qlynn willer iqsyx2R gook PS frntley vnier PI glinh eminole gmden hetur qrdy ghrlton homs frooks vowndes ihols

Community Service Areas I222E2vookout2wountin2gommunity2ervies IH2E2edvntge2fehviorl2relth2ystems IW2E2hoenix2genter2fehviorl2relth2ervies P222E2righlnd2ivers2gommunity2ervie2ford II2E2gf2of2ist2gentrl2qeorgi2@erenity2fehviorl2relthA PH2E2elny2ere2gommunity2ervie2ford Q222E2evit2gommunity2rtners IP2E2iver2idge2fehviorl2relth2genter PI2E2qeorgi2ines2gommunity2wrwe2ervies R222E2go2gommunity2ervie2ford IQ2E2yonee2gommunity2ervie2ford PP2E2fehviorl2relth2ervies2of2outh2qeorgi S222E2hougls2gommunity2ervie2ford IR2E2ygeehee2fehviorl2relth2ervies PQ2E2gommunity2ervie2ford2of2widdle2qeorgi T222E2pulton2gounty2wrhheh IS2E2thwys2genter2for2fehviorl282hevelopmentl2qrowth PR2E2inelnd2ere2gommunity2ervie2ford U222E2glyton2gommunity2ervie2ford IT2E2wsntosh2ril2gommunity2ervie2ford PS2E2 nison2fehviorl2relth2@formerly2till2gfA V222E2heul2gommunity2ervie2ford IU2E2xew2rorizons2gommunity2ervie2ford PT2E2qtewy2gommunity2ervie2ford W222E2iew2oint2relth2@formerly2qx2gfA IV2E2widdle2plint2fehviorl2relthre BxyiX2xumered2ervie2eres2re2for2identifition2purposes2onlyF

DBHDD Office of Decision Support & Information Management (Updated: 06/17/2014) Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 21 of2 231of 2 II. Executive Summary

1. State Summary Narrative

Narrative Question: Provide an overview of the state's PATH program with key points that are expanded upon in the State Level Sections of WebBGAS.

Footnotes:

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1. State Summary Narrative

The Georgia Department of Behavioral Health & Developmental Disabilities (DBHDD), through its Division of Behavioral Health, Office of Adult Mental Health is submitting the annual application for the Projects for Assistance in Transition from Homeless (PATH) Program for federal fiscal year 2017. This application is made on behalf of Georgia to the Director of the Center for Mental Health Services, within the Substance Abuse and Mental Health Services Administration (SAMHSA) requesting the award of $1,669,441 in federal funds, with a state match of $556,480, for a total overall budget of $2,225,921.

According to the Georgia Department of Community Affairs’ 2015 Report on Homelessness, there were 1,838 homeless persons with severe mental illness and 2, 037 chronically homeless persons, out of a total 13,790 homeless persons. In 2016, according to the HUD Continuum of Care Homeless Assistance Programs Homeless Populations and Subpopulations report of data from the January 28, 2016 Point-in -Time count, on that night in Georgia there were as many as 1,475 (14%) homeless adults with severe mental illness, and as many as 1,815 chronically homelessness persons. In SFY16, a total of 3,029 homeless adults received benefits from PATH funded services. Of those enrolled, 1,433 adults (88%) with serious mental illness or co- occurring disorders received ongoing community mental health services.

Contained within this application is an overview of the activities that the State proposes to support through the PATH Program. In addition, an Intended Use Plan for each PATH-funded organization is included. DBHDD uses these funds to contract with providers for the provision of outreach and case management services in those areas across the state that present the greatest need for homeless supports.

Georgia will continue to use these PATH federal funds to support assertive outreach for homeless individuals with serious mental illness who need assistance and are not pursuing mental health treatment and other entitlements on their own. The State PATH Contact and the staff in the DBHDD, Office of Adult Mental Health will continue to monitor fund utilization to assure maximum benefit to the citizens of Georgia impacted by homelessness and mental illnesses.

1 | State Summary Narrative

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1. State Summary Narrative

According to the Georgia Department of Community Affairs’ 2015 Report on Homelessness, there were 1,838 homeless persons with severe mental illness and 2, 037 chronically homeless persons. In 2016, according to the HUD Continuum of Care Homeless Assistance Programs Homeless Populations and Subpopulations report of data from the January 28, 2016 Point-in - Time count, on that night in Georgia there were as many as 1,475 (14%) homeless adults with severe mental illness, and as many as 1,815 chronically homelessness persons. In SFY16, a total of 3,029 homeless adults received benefits from PATH funded services. Of those enrolled, 1,433 adults (88%) with serious mental illness or co-occurring disorders received ongoing community mental health services.

State Summary Narrative pg. 1

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2. State Budget

Planning Period From 9/1/2017 to 8/31/2018

* Indicates a required field

Category Federal Dollars Matched Dollars Total Dollars Comments

a. Personnel $ 0 $ 0 $ 0

No Data Available

Category Percentage Federal Dollars * Matched Dollars * Total Dollars Comments

b. Fringe Benefits 0.00 % $ 0 $ 0 $ 0

Category Federal Dollars Matched Dollars Total Dollars Comments

c. Travel $ 0 $ 0 $ 0

No Data Available

d. Equipment $ 0 $ 0 $ 0

No Data Available

e. Supplies $ 0 $ 0 $ 0

No Data Available

f1. Contractual ﴾IUPs﴿ $ 1,649,651 $ 549,882 $ 2,199,533

f2. Contractual ﴾State﴿ $ 0 $ 0 $ 0

No Data Available

Category Percentage Federal Dollars Matched Dollars Total Dollars Comments

PATH housing costs are limited to 20% and can only be PATH allowable costs. Personnel who are considered to be a housing cost should be entered here and not included in the Personnel line item. For questions, call your Program Officer.

g1. Housing ﴾IUPs﴿ 10.25 % $ 171,039 $ 57,012 $ 228,051

g2. Housing ﴾State﴿ $ 0 $ 0 $ 0

No Data Available

Category Federal Dollars Matched Dollars Total Dollars Comments

﴿h. Construction ﴾non‐allowable

i. Other $ 0 $ 0 $ 0

No Data Available

j. Total Direct Charges ﴾Sum of a‐i minus g1﴿ $ 1,649,651 $ 549,882 $ 2,199,533

Category Federal Dollars * Matched Dollars * Total Dollars Comments

k. Indirect Costs ﴾Administrative Costs﴿ $ 19,790 $ 6,598 $ 26,388 l. Grand Total ﴾Sum of j and k﴿ $ 1,669,441 $ 556,480 $ 2,225,921

Allocation of Federal PATH Funds $ 1,669,441 $ 556,480 $ 2,225,921

:Source﴾s﴿ of Match Dollars for State Funds

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Agency Organization PATH PATH PATH Counties PATH # # Type: Federal State Match Total Served Funded Proposed Proposed Funding Funding Funding Service(s) Outreach Enrolled Amount Amount Amount # literally homeless Serenity Public, non- $ 142,712 $47,570 $190,282 Richmond -Outreach 285 216 Behavioral profit, mental -Case Mgt Health health agency 271 Services Behavioral Public, non- $142,471 $47,491 $189,962 Lowndes, - Outreach 120 60 Health profit, mental Tift, Cook -Case Mgt Services of health agency 60 South Georgia

Community Private non- $161,444 $53,815 $215,259 Fulton/ -Outreach 240 156 Friendship, profit, mental DeKalb -Case Mgt Inc. health agency 240 Hope Atlanta Public, non- $304,815 $101,606 $406,421 Fulton -Outreach 480 300 ** profit /DeKalb, -Case Mgt Cobb/ 360 Douglas Community Public, non- $172,471 $57,491 $229,962 Fulton/ -Outreach 170 156 Advanced profit, mental DeKalb -Case Mgt Practice health agency 170 Nurses, Inc. Fulton-DeKalb Public, non- $131,522 $43,840 $175,362 Fulton/ -Outreach 260 120 Hospital profit, health DeKalb -Case Mgt Authority care agency 234 (Grady Health Systems) St. Joseph Private, non- $262,470 $87,491 $349,961 Fulton/ -Outreach 590 204 Mercy Care profit, health DeKalb -Case Mgt care agency 443

New Horizons Public, non- $171,646 $57,216 $228,862 Muscogee -Outreach 350 244 Community profit, mental -Case Mgt Service Board health agency 280 Chatham- Public, non- $160,095 $53,367 $213,462 Chatham -Outreach 328 229 Savannah profit local -Case Mgt Authority for governing 328 the Homeless authority GA DBHDD, State $19,790 $6,598 $26,388 Statewide -Admin. NA NA Division of Government Behavioral Health 2017 PATH -Outreach 2,823 1,685 Funding $1,669,441 $556,480 $2,225,921 10 -Case Mgt Counties 2,386 (85%)

** Hope Atlanta (formerly known as Traveler’s Aid) numbers for budget, proposed outreach, # literally homeless, and # proposed enrolled reflect numbers for two teams, Region 3 Team serving Fulton and DeKalb counties and Region 1 Team serving Cobb and Douglas counties.

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3. Intended Use Plans

Expenditure Period Start Date: 09/01/2017 Expenditure Period End Date: 08/31/2018

The state can either enter all the IUPs and associated budgets as in prior years, or they may allow IUP users to enter their own information into WebBGAS. For more information on allowing IUP users to enter their own details, please see the tutorial under the Training Tab in WebBGAS that instructs states and IUP providers on this new process.

Primary IUP Provider Provider Type Geographic Service Area Allocations Matching Funds Estimated Estimated # # # to # to Trained Assisted Contact Enroll in SOAR through SOAR

Behavioral Health Services of South Georgia Community mental health center Region 4 $142,469 $47,493 120 60 3 10

Chatham‐Savannah Homeless Authority Other housing agency Region 5 $160,097 $53,365 328 229 0 0

Health Care for the Homeless/other health Community Advanced Practice Nurses, Inc. Region 3 $172,472 $57,490 170 156 5 33 agency

Community Friendship, Incorporated Other mental health agency Region 3 $161,445 $53,814 240 156 3 26

Health Care for the Homeless/other health Fulton Dekalb Hospital Authority Region 3 $131,522 $43,840 260 120 3 0 agency

New Horizon Community Service Board Community mental health center Region 6 $171,647 $57,215 350 244 3 0

Health Care for the Homeless/other health Saint Joseph's Mercy Care Services, Inc. Region 3 $262,471 $87,490 590 204 5 21 agency

Serenity Behavioral Health Systems Community mental health center Region 2 $142,712 $47,570 285 216 1 5

Travelers Aid of Metropolitan Atlanta Other mental health agency Region 3 $304,816 $101,605 480 300 3 34

Grand Total $1,649,651 $549,882 2,823 1,685 26 129

* IUP with sub‐IUPs

Footnotes:

1. Behavioral Health Services of South Georgia Has Sub‐IUPs: No

3120 N. Oak Street Ext., Suite C Provider Type: Community mental health center

Valdosta, GA 31062‐1007 PDX ID:

Contact: Lyndi Farnham State Provider ID:

Contact Phone #: ﴾229﴿ 671‐6100 Geographical Area Served: Region 4

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Category Federal Dollars Matched Dollars Total Dollars Comments

a. Personnel $ 80,056 $ 26,686 $ 106,742

Position * Annual Salary % of time PATH‐Funded PATH‐Funded Matched Dollars * Total Dollars Comments * spent on FTE Salary * PATH *

Case Manager $ 12,750 50.00 % 0.75 $ 9,562 $ 3,188 $ 12,750

PATH Administrator $ 31,000 100.00 % 0.75 $ 23,250 $ 7,750 $ 31,000

Peer Support Specialist $ 24,480 100.00 % 0.75 $ 18,360 $ 6,120 $ 24,480

Other ﴾Describe in Comments﴿ $ 38,512 100.00 % 0.75 $ 28,884 $ 9,628 $ 38,512 Licensed Clinician

Category Percentage Federal Dollars * Matched Dollars * Total Dollars Comments

b. Fringe Benefits 34.72 % $ 37,060 $ 12,353 $ 49,413

Category Federal Dollars Matched Dollars Total Dollars Comments

c. Travel $ 731 $ 244 $ 975

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Mileage Reimbursement $ 356 $ 119 $ 475

Other ﴾Describe in Comments﴿ $ 375 $ 125 $ 500 State PATH Conference

d. Equipment $ 375 $ 125 $ 500

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Computer Lease/Purchase $ 375 $ 125 $ 500

e. Supplies $ 299 $ 101 $ 400

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Client: Outreach Supplies/Hygene kits/Misc. $ 187 $ 63 $ 250

Office: Supplies $ 112 $ 38 $ 150

f. Contractual $ 0 $ 0 $ 0

No Data Available

g. Housing $ 18,469 $ 6,156 $ 24,625

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 18,469 $ 6,156 $ 24,625 Housing Coordination Costs

﴿h. Construction ﴾non‐allowable

i. Other $ 0 $ 0 $ 0

No Data Available

j. Total Direct Charges ﴾Sum of a‐i﴿ $ 136,990 $ 45,665 $ 182,655

Category Federal Dollars * Matched Dollars * Total Dollars Comments

k. Indirect Costs ﴾Administrative Costs﴿ $ 5,479 $ 1,828 $ 7,307 l. Grand Total ﴾Sum of j and k﴿ $ 142,469 $ 47,493 $ 189,962

:Source﴾s﴿ of Match Dollars for State Funds

Estimated Number of Persons to be Contacted: 120 Estimated Number of Persons to be Enrolled: 60

Estimated Number of Persons to be Contacted who are Literally Homeless: 60

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 30 2 of 141231 Number staff trained in SOAR in grant year ending in 2017: 3 Number of PATH‐funded consumers assisted through SOAR: 10

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2301 Bull Street Provider Type: Other housing agency

Savannah, GA 31401 PDX ID: GA‐006

Contact: Janice Sheffield State Provider ID:

Contact Phone #: 912‐790‐3400 Geographical Area Served: Region 5

Planning Period From 9/1/2017 to 8/31/2018

Category Federal Dollars Matched Dollars Total Dollars Comments

a. Personnel $ $ 37,816 $ 113,448 151,264

Position * Annual Salary % of time PATH‐Funded PATH‐Funded Matched Dollars * Total Dollars Comments * spent on FTE Salary * PATH *

Peer Support Specialist $ 27,336 100.00 % 0.75 $ 20,502 $ 6,834 $ 27,336

Peer Support Specialist $ 26,928 100.00 % 0.75 $ 20,196 $ 6,732 $ 26,928

Peer Support Specialist $ 25,500 100.00 % 0.75 $ 19,125 $ 6,375 $ 25,500

Other ﴾Describe in Comments﴿ $ 46,000 100.00 % 0.75 $ 34,500 $ 11,500 $ 46,000 Mental Health Professional

Category Percentage Federal Dollars * Matched Dollars * Total Dollars Comments

b. Fringe Benefits 19.61 % $ 29,656 $ 9,885 $ 39,541

Category Federal Dollars Matched Dollars Total Dollars Comments

c. Travel $ 4,875 $ 1,625 $ 6,500

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Mileage Reimbursement $ 4,875 $ 1,625 $ 6,500

d. Equipment $ 2,700 $ 900 $ 3,600

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 2,700 $ 900 $ 3,600 cell phones

e. Supplies $ 300 $ 100 $ 400

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Office: Supplies $ 300 $ 100 $ 400

f. Contractual $ 0 $ 0 $ 0

No Data Available

g. Housing $ 0 $ 0 $ 0

No Data Available

﴿h. Construction ﴾non‐allowable

i. Other $ 4,288 $ 1,429 $ 5,717

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Client: One‐time housing rental assistance $ 600 $ 200 $ 800

Client: Transportation $ 375 $ 125 $ 500

Office: Utilities/Telephone/Internet $ 375 $ 125 $ 500

Office: Other ﴾Describe in Comments﴿ $ 1,125 $ 375 $ 1,500 HMIS User Fees

Staffing: Training/Education/Conference $ 1,813 $ 604 $ 2,417

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 3462 of 141231 j. Total Direct Charges ﴾Sum of a‐i﴿ $ 155,267 $ 51,755 $ 207,022

Category Federal Dollars * Matched Dollars * Total Dollars Comments

k. Indirect Costs ﴾Administrative Costs﴿ $ 4,830 $ 1,610 $ 6,440 l. Grand Total ﴾Sum of j and k﴿ $ 160,097 $ 53,365 $ 213,462

:Source﴾s﴿ of Match Dollars for State Funds

Estimated Number of Persons to be Contacted: 328 Estimated Number of Persons to be Enrolled: 229

Estimated Number of Persons to be Contacted who are Literally Homeless: 328

Number staff trained in SOAR in grant year ending in 2017: 0 Number of PATH‐funded consumers assisted through SOAR: 0

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CHATHAM-SAVANNAH HOMELESS AUTHORITY

1. LOCAL PROVIDER DESCRIPTION-Provide a brief description of the provider organization receiving PATH funds, including name, type of organization, region served, and the amount of PATH funds the organization will receive.

The Chatham-Savannah Authority for the Homeless (Homeless Authority) is a private, non- profit 501C3 organization established by the Georgia State Legislature 27 years ago; CSAH was created to provide a central planning and coordinating effort to address homeless needs and services. The PATH program is designed to encompass a sixteen-county area and is served by the DBHDD Region 5 Office. However, the focus of service is on the behavioral health issues of families and individuals experiencing homelessness within Chatham County (Region 5), since Savannah has one of the largest concentrations of individuals experiencing homelessness outside of Metro Atlanta. CSAH will receive $213,462 in PATH funds to address these issues.

2. COLLABORATION WITH HUD CONTINUUM OF CARE PROGRAM-Describe the organization’s participation in the HUD Continuum of Care (CoC) recipient (s)program, other local planning activities and program coordination initiatives, such as coordinated entry and coordinated assessment activities. If you are not currently working with the Continuum(s) of Care, briefly explain the approaches to be taken by the agency to collaborate with the local CoC.

The Chatham-Savannah Homeless Authority is a State-Legislated organization designated to coordinate all activities in the local Continuum of Care plan to address the needs of the homeless, including planning, collaborating, identifying gaps in services, and addressing ways to close those gaps. CSAH, in conjunction with the City of Savannah, coordinates all activities called for in the community Continuum of Care. Beginning with the writing of the homeless section of the City’s Housing and Community Development Plan, the agency is charged with all aspects of planning, service delivery coordination, and certain other roles such as evaluation and monitoring, advocacy, education, and resource development. CSAH is the Continuum of Care lead agency; it collaborates with the agencies that are the providers of behavioral health services and provides some transportation for clients enrolled in behavioral health programs. CSAH administers the PATH grant, and all case management staff of the agency is out-stationed at predetermined Continuum of Care organizations. The four peer specialists on the PATH team are also out-stationed at predetermined Continuum of Care sites including Emmaus House, Inner City, Savannah Baptist, Old Savannah City Mission, the Salvation Army, and the Social Apostolate. Since 2004, all Continuum of Care organizations have been linked to a Homeless Management Information System; the current system is ClientTrack. The PATH team is required to maintain data on consumers through ClientTrack (Eccovia Solutions), the statewide Homeless Management Information System.

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3. COLLABORATION WITH LOCAL COMMUNITY ORGANIZATIONS-Provide a brief description of partnerships and activities with local community organizations that provide key services (e.g., outreach teams, primary health, mental health, substance abuse, housing, employment) to PATH eligible clients and describe coordination of activities and policies with those organizations. Provide specific information about how coordination with other outreach teams is achieved.

The PATH Team collaborates with multiple agencies in Savannah to provide key services to PATH enrolled clients. Each of these agencies works collaboratively to ensure that those experiencing homelessness can attain and maintain self-sufficiency:

 Recovery Place Community Services for substance abuse and mental health services;  Savannah Counseling Services for ongoing mental health services (ICM) and substance abuse services;  J.C. Lewis Health Center of Union Mission for medical and dental needs;  Union Mission, Inc. (No Wrong Door and permanent supportive housing)  Housing Authority of Savannah and Union Mission, Inc. for permanent supportive housing;  Georgia Regional Hospital for access into Assertive Community Treatment for those with the most intensive needs.  Coastal Harbor for crisis stabilization and discharge planning for homeless consumers  Memorial Health University (Clark Center) and Candler/St. Joseph’s Hospital for behavioral health  AmericanWork (Savannah ACT and Chatham ACT)  Social Apostolate which assists in acquiring birth certificates so that consumers can obtain proper identification, i.e., Georgia ID card  Department of Labor and Goodwill for employment services  CSAH for street outreach and assistance with shelter placements for those who have lost housing  Department of Family and Children Services (DFCS) for mainstream benefits applications, i.e., food stamps, emergency assistance  DBHDD (Region 5) for SOAR applications, Discharge planning for Georgia Regional, and Service Provider meetings  Social Security Administration for mainstream benefits application, i.e., SSI/SSDI, Medicaid, etc.  Veteran’s Administration for Veterans benefits  Dismas Charities for Re-Entry for Returning Citizens

Additionally, the Homeless Authority has an excellent relationship with the Savannah- Chatham Metro Police Department (SCMPD), and meets regularly with the police liaison to coordinate services. Training for the Police Department’s CIT (Crisis Intervention Team) is provided on a recurring basis by an employee of American Work, Inc.

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4. SERVICE PROVISION-Describe the organization’s plan to provide coordinated and comprehensive services to PATH-eligible clients, including: How the services to be provided using PATH funds will align with PATH goals to target street outreach and case management as priority services, and maximize serving the most vulnerable adults who are literally and chronically homeless:

 How the services provided using path funds will align with PATH goals to target Street outreach and case management as priority services and maximize serving the most vulnerable adults who are literally and chronically homeless.

PATH utilizes an outreach team to go into the streets and homeless shelters to identify individuals with mental illness experiencing homelessness, engage them in treatment, and connect them to mental health services and mainstream resources needed to end their homeless cycle. In order to maximize the use of PATH funds to serve adults who are literally and chronically homeless as a priority population, PATH funds a five-person team composed of a full-time Mental Health Professional (MHP) team leader and four peer-to-peer specialists to provide Outreach and Case Management services. This team locates the hardest-to-reach individuals with a primary diagnosis of Mental Illness through mobile and fixed Outreach sites, which include the Salvation Army and Inner City Night Shelters, the Social Apostolate, Emmaus House, Savannah Baptist Center and Old Savannah City Mission (four local congregate feeding sites), shelters, and local parks. Outreach identifies PATH eligible clients, establishes a personal connection, and helps them to believe that change is possible. Once the consumer expresses a willingness to accept services, they are then enrolled in PATH funded Case Management which assists with meeting basic needs, accessing housing, and linking to ongoing mental health and substance abuse treatment. A key function of PATH funded Case Management is actively assisting clients to apply for entitlement benefits such as Social Security Disability (SSDI) and Supplemental Security Income (SSI).

 Specific examples of how the agency maximizes use of PATH funds by leveraging use of other available funds for PATH client services:

CSAH maximizes the use of PATH funds by leveraging federal, other state, and local funding for PATH client services. One peer specialist is paid through a blend of state ESG funding provided through DCA and PATH funds. HMIS support activities, including data collection, are financed through a blend of federal HUD funding and PATH funds. Housing for PATH enrollees is provided through the state Georgia Housing Voucher program and federal HUD-VASH program. Work space for PATH program staff is provided through a blend of federal HUD and local City government funding. As indicated, CSAH uses other available funding resources as much as possible to assist in the provision of PATH services.

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Gaps in services include crisis services for those 1) experiencing behavioral health issues, 2) short-term respite care, 3) the availability of resources on the weekends, and the 4) shortage of affordable, safe, permanent supportive housing for women and families. Additionally, housing for homeless persons with sex offenses and/or felonies is limited. In May, FY’14, the State expanded crisis services in Savannah to include a new 16-bed Crisis Stabilization Program and an eight (8) bed respite at Gateway Behavioral Health Services that provides 30-day respite for stabilization to assist in addressing the crisis needs in Savannah. The PATH team is actively collaborating with these providers to reduce service gaps.

 A brief description of the current services available to clients who have both a serious mental illness and a substance use disorder.

PATH enrolled clients with co-occurring issues are referred to the appropriate service provider. In addition to counseling, consumers are provided Psychosocial Rehabilitation Program services based on the Boston University Model, considered a “Best Practice” model. It addresses the level of community functioning needs for those with mental health and substance use disorders. To complement these clinic-based services, PATH consumers also link to local Double Trouble in Recovery (DTR) 12-step self-help groups and Peer groups, which are free and readily available. These two-hour groups provide a safe environment for these consumers to support each other while addressing medication issues without shame or stigma. CSAH combines counseling, rehabilitation, self-help and ongoing support as a treatment strategy for PATH clients with co-occurring disorders.

 How the local provider agency pays for providers or otherwise supports evidenced- based practices, trainings for local PATH-funded staff, and trainings and activities to support collection of PATH data in HMIS; and

CSAH pays for or otherwise supports evidence-based practices and other training for local PATH-funded staff including:

 Double Trouble in Recovery (DTR) self-help groups for individuals with co- occurring mental illness and substance use disorders.  Psychosocial Rehabilitation (PSR) which addresses the level of community functioning needs for those with mental health and substance use disorders.  SOAR training to expedite access to mainstream benefits.  Assertive Community Treatment (ACT)  Peer Support  ICM Intensive Case Management

The PATH team is required to maintain data on consumers through the Pathways Communication Network, the statewide Homeless Management Information System. Since 2004, the local Continuum of Care has been linked to a Homeless Management

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 Specific examples of how the agency serves to better link clients with criminal justice histories to health services, housing programs, job opportunities and other supports (e.g., jail diversion, active involvement in re-entry), OR specific efforts to minimize the challenges and foster support for PATH clients with a criminal history (e.g. jail diversion, active involvement in reentry)

PATH staff can link clients with criminal justice histories to many programs and services by initially verifying the individual’s homeless status. This documentation allows clients to present at J. C. Lewis and Curtis V. Cooper community health care facilities to access free health services (waiver of co-pay, etc.)

Clients are also linked to housing programs that will work with and house individuals with criminal histories on a case by case basis; they include Union Mission’s Dutchtown, Ben & Betty Barnes, Kohl Center and Eagle’s Landing projects and the City of Savannah City 54 Shelter Plus Care project.

The PATH team collaborates with the Department of Labor which maintains a list of employers who will hire individuals with criminal backgrounds. Workforce Development and Supported Employment through DBHDD (Savannah Counseling and American Work) are all partners in assisting with job opportunities for this population.

Savannah Counseling, the Homeless Court Initiative (which sometimes allows CSAH to assist with returning individuals to their homes of origin to keep them from remaining in jail or returning to jail), and staffing Mental Health, Veterans’, DUI, and Drug Courts and active involvement with the re-entry council are all efforts used to minimize the challenges and foster support for PATH clients with criminal histories.

5. DATA-Describe the provider’s status on the transition to collect PATH data in HMIS. If providers are not fully utilizing HMIS for PATH services, please describe plans to complete HMIS implementation. For providers who are fully utilizing HMIS, describe plans for continued training and how providers will support new staff.

CSAH’s PATH team utilizes Georgia’s HMIS system, ClientTrack. Since 2004, the local Continuum of Care has been linked to the Homeless Management Information System,

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6. (SOAR) -Describe the provider’s plan to ensure that PATH staff have completed the SOAR Online Course and which staff plan to assist consumers with SSI/SSDI applications using the SOAR model and track the outcomes of those applications in the SOAR Online Application Tracking (OAT) system. For the grant year that just ended, include the following data:

 The number of staff trained in SOAR; (None)

 The number of staff who provided assistance with SI/SSDI applications using the SOAR model- (None)

 The number of consumers assisted through SOAR; (Unknown)

 Application eligibility results (i.e., approval rate on initial application, average time to approve the application); (Unknown)

 The number of staff dedicated to implementing SOAR, part-and full time. If the provider does not use SOAR, describe the system used to improve accurate and timely completion of mainstream benefit applications (e.g. SSI/SSDI), timely determination of eligibility, and the outcomes of those applications (i.e., approval rate on initial application, average time to approve the application.) Also describe the efforts used to train staff on this alternative system and what technical assistance or support they receive to ensure quality applications if they do not use the SAMHSA SOAR TA Center.

CSAH has more than five staff who were previously trained on SOAR, including both regular case management and PATH peer specialists. No additional PATH staff were trained in SOAR during the grant year ended 2016. SOAR on-line training is available, and CSAH will ensure that staff avail themselves of the updated training. Also, a DBHDD two-day training is scheduled locally for November 2017, and an agency staff person has been designated to attend this training. PATH staff partner with and refer individuals to the Region 5 Medicaid specialist who completes SOAR applications at Georgia Regional.

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7. HOUSING-Indicate the strategies that will be used for making suitable housing available for PATH clients (i.e., indicate the type of housing provided and the name of the agency).

The PATH team meets and will continue to meet weekly with the Housing Team of Union Mission (the largest provider of housing in the community) and the Unified Case Management Team to determine service and housing needs, including available bed openings. There are over 600 beds available in the Homeless Continuum of Care in the Savannah region. Approximately 300 are dedicated to behavioral health needs. Memorandums of Agreement exist between the Chatham-Savannah Authority for the Homeless and most of homeless service providers in the community, including those who provide housing to PATH consumers. Because of these relationships and agreements, PATH team members are knowledgeable of space availability in the Continuum, and can immediately make referrals and reserve space, if required to do so. Team members assist consumers in completing the necessary applications and acquiring any documentation required. PATH team members also ensure that consumers make and keep necessary appointments, including assisting with transportation to those appointments. There are several housing programs that most frequently serve PATH consumers, including emergency and transitional facilities, and several Shelter + Care programs. Emergency facilities include the Salvation Army and Magdalene Project of UMI and transitional facilities include the Economic Opportunity Authority’s Thomas Austin House and SRO, and Recovery Place’s Men’s & Women’s Residential programs. In addition, there are many Shelter + Care programs that are most successful in housing PATH consumers. Dutchtown is a permanent supportive housing project. Georgia Housing Voucher Program (GHVP) vouchers are also utilized to provide housing for program participants. The team also works with the Veteran’s Administration to provide housing for qualified veterans through the HUD-VASH program. The HUD 811 program and housing (four group homes and two apartment complexes) through American Work also provide housing for PATH consumers. Through weekly meetings and contacts, the PATH team is kept abreast of any vacancies and able to make referrals on a timely basis. This allows PATH consumers to be placed on a “fast track” in their quest for stability and housing placement. This process allows PATH consumers to gain direct and immediate access to these housing resources, and the process will continue to be utilized.

Frequently, PATH enrolled clients would be able to access stable housing, but they lack the financial resources to do so. The PATH team utilizes case management funds to provide direct assistance to clients; these funds are designated to provide security deposits for utilities, rental assistance, and motel nights for crisis situations. Based on assistance criteria, PATH enrolled clients can tap these funds to access and/or maintain stable housing.

8. STAFF INFORMATION-Describe the following demographics of staff serving the clients:

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Provider Total # Female # Male # White # Black #Hisp # MH PATH Consumers Staff Savannah 5 0 5 1 3 1 4

 How staff providing services to the population of focus will be sensitive to age, gender, disability, lesbian, gay, bisexual and transgender, racial/ethnic, and differences of clients;  The extent to which staff receive differences of clients; and the extent to which staff receive periodic training in cultural competence and health disparities.

CSAH uses staff training, language services, program evaluation, and community representation to ensure that services are provided in a manner that is sensitive to the differences of those they serve. CSAH promotes cultural diversity and provides cultural competence training to all employees. Free interpreter services are available for those who do not speak English. CSAH evaluates performance satisfaction using consumer and family satisfaction surveys, including the level of satisfaction with staff sensitivity to cultural background. The organization supports community representation with employed mental health consumers operating as direct care staff.

CSAH and Region 5 DBHDD offer training in evidence and community-based best practices in cultural competence. Clinical training for case managers and behavioral health staff is routinely provided, which includes a mandatory diversity workshop to heighten awareness and increase staff effectiveness as it relates to service to protected classes. Curtis V. Cooper Community Care and collaborative community partners address health disparities by using the revised CLAS standards.

9. CLIENT INFORMATION-Describe the demographics of the client population, the projected number of adult clients to be contacted and enrolled, and the percentage of adult clients served using PATH funds to be literally homeless.

CSAH is located in Savannah, GA, which is the fourth-largest city and the sixth largest county in the state. The demographics of those enrolled in PATH services (client population) include: 58% male; 42% female; 48% between the ages 35-49 years; 44% African American; 40% White; 69% with “other psychotic disorders; 54% with co-occurring substance use disorders; and 100% literally homeless upon initial contact.

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10. CONSUMER INVOLVEMENT-Describe how individuals who experience homelessness and have serious mental illnesses, and family members will be involved at the organizational level in the planning, implementation, and evaluation of PATH-funded services. For example, indicate whether individuals who are PATH-eligible are employed as staff or volunteers or serve on governing or formal advisory boards.

The Board of Directors of CSAH is constructed to include representatives of local and state government, as well as advocates, providers of service, and homeless or formerly homeless consumers. One of the board members is currently homeless. PATH-eligible individuals are employed as peer specialists after participating in an extensive training program; two have passed a peer certification process. One of the peers sits on the advisory board of Emmaus House, a congregate feeding site, and the PATH team lead sits on the Recovery Place Community Service Board.

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Proposed PATH Annual Budget State FY 2018 CHATHAM-SAVANNAH AUTHORITY FOR THE HOMELESS

1. Personnel Costs Annualized PATH PATH Positions Salary FTE Salary Mental Health Professional $46,000 1.0 FTE $46,000 Certified Peer Specialist $27,336 1.0 FTE $27,336 Peer to Peer Specialist $26,928 1.0 FTE $26,928 Peer to Peer Specialist $25,500 1.0 FTE $25,500 Peer to Peer Specialist $25,500 1.0 FTE $25,500 5.0 FTE $151,264

2. Fringe Benefit Costs (@25%) $ 39,541

3. Transportation Costs Vehicle Operation & Personal Mileage $ 6,500

4. Training Costs $ 2,417

5. Program Supply Costs $ 4,000 Cell phones @ $300/month $ 3,600 Office Supplies (folders, paper, ink) $ 400

6. HMIS Data Collection/Management $ 2,000 1) ¼ of annual ClientTrack HMIS User Fee $ 1,500 2) ¼ of estimated internet fees $ 500

7. Housing Coordination Funds $ 1,300 -Emergency Rental Assistance $800 -Bus Passes $500

8. Administrative Costs $6,440

GRAND TOTAL: $213,462

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CHATHAM-SAVANNAH HOMELESS AUTHORITY

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 Specific examples of how the agency maximizes use of PATH funds by leveraging use of other available funds for PATH client services:

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 A brief description of the current services available to clients who have both a serious mental illness and a substance use disorder.

CSAH pays for or otherwise supports evidence-based practices and other training for local PATH-funded staff including:

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CSAH’s PATH team utilizes Georgia’s HMIS system, ClientTrack. Since 2004, the local Continuum of Care has been linked to the Homeless Management Information System,

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 The number of staff trained in SOAR; (None)

 The number of staff who provided assistance with SI/SSDI applications using the SOAR model- (None)

 The number of consumers assisted through SOAR; (Unknown)

 Application eligibility results (i.e., approval rate on initial application, average time to approve the application); (Unknown)

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7. HOUSING-Indicate the strategies that will be used for making suitable housing available for PATH clients (i.e., indicate the type of housing provided and the name of the agency).

8. STAFF INFORMATION-Describe the following demographics of staff serving the clients:

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Provider Total # Female # Male # White # Black #Hisp # MH PATH Consumers Staff Savannah 5 0 5 1 3 1 4

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 5381 of 141231  Projected number of adult clients to be Contacted:  Outreach Contacts: Contractor shall identify and have contact with at least 328 individuals who are homeless and mentally ill in PATH funded Outreach. b. Projected number of adult clients to be enrolled in PATH Case Management:  Contractor shall enroll at least 229 clients who are homeless and mentally ill in PATH funded Case Management. c. Percentage of adult clients served with PATH funds projected to be “literally” homeless (i.e., living outdoors or in an emergency shelter rather than imminent risk of homelessness):  This provider projects that 100% of the annual, unduplicated total will self-report or will be certified as “literally” homeless.

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Proposed PATH Annual Budget State FY 2018 CHATHAM-SAVANNAH AUTHORITY FOR THE HOMELESS

2. Fringe Benefit Costs (@25%) $ 39,541

3. Transportation Costs Vehicle Operation & Personal Mileage $ 6,500

4. Training Costs $ 2,417

5. Program Supply Costs $ 4,000 Cell phones @ $300/month $ 3,600 Office Supplies (folders, paper, ink) $ 400

6. HMIS Data Collection/Management $ 2,000 1) ¼ of annual ClientTrack HMIS User Fee $ 1,500 2) ¼ of estimated internet fees $ 500

7. Housing Coordination Funds $ 1,300 -Emergency Rental Assistance $800 -Bus Passes $500

8. Administrative Costs $6,440

GRAND TOTAL: $213,462

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173 Boulevard, NE Provider Type: Health Care for the Homeless/other health agency

Atlanta, GA 30312 PDX ID: GA‐023

Contact: Connie Buchanan State Provider ID:

Contact Phone #: 404‐658‐1500 Geographical Area Served: Region 3

Planning Period From 9/1/2017 to 8/31/2018

Category Federal Dollars Matched Dollars Total Dollars Comments

a. Personnel $ $ 45,673 $ 137,019 182,692

Position * Annual Salary % of time PATH‐Funded PATH‐Funded Matched Dollars * Total Dollars Comments * spent on FTE Salary * PATH *

PATH Administrator $ 58,516 100.00 % 0.71 $ 41,547 $ 13,849 $ 55,396

Peer Support Specialist $ 22,464 100.00 % 0.75 $ 16,848 $ 5,616 $ 22,464

Registered Nurse $ 30,576 100.00 % 0.75 $ 22,932 $ 7,644 $ 30,576

Registered Nurse $ 8,736 100.00 % 0.75 $ 6,552 $ 2,184 $ 8,736

Other ﴾Describe in Comments﴿ $ 65,520 100.00 % 0.75 $ 49,140 $ 16,380 $ 65,520 Program Director

Category Percentage Federal Dollars * Matched Dollars * Total Dollars Comments

b. Fringe Benefits 7.58 % $ 13,842 $ 4,615 $ 18,457

Category Federal Dollars Matched Dollars Total Dollars Comments

c. Travel $ 1,500 $ 500 $ 2,000

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Mileage Reimbursement $ 1,500 $ 500 $ 2,000

d. Equipment $ 0 $ 0 $ 0

No Data Available

e. Supplies $ 2,977 $ 992 $ 3,969

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Client: Other Supplies ﴾Describe in Comments﴿ $ 2,977 $ 992 $ 3,969 Office supplies and telecommunication

f. Contractual $ 0 $ 0 $ 0

No Data Available

g. Housing $ 9,000 $ 2,999 $ 11,999

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 9,000 $ 2,999 $ 11,999 Housing Coordination Costs

﴿h. Construction ﴾non‐allowable

i. Other $ 1,500 $ 500 $ 2,000

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Staffing: Training/Education/Conference $ 1,500 $ 500 $ 2,000

j. Total Direct Charges ﴾Sum of a‐i﴿ $ 165,838 $ 55,279 $ 221,117

Category Federal Dollars * Matched Dollars * Total Dollars Comments

k. Indirect Costs ﴾Administrative Costs﴿ $ 6,634 $ 2,211 $ 8,845

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 5684 of 141231 l. Grand Total ﴾Sum of j and k﴿ $ 172,472 $ 57,490 $ 229,962

:Source﴾s﴿ of Match Dollars for State Funds

Estimated Number of Persons to be Contacted: 170 Estimated Number of Persons to be Enrolled: 156

Estimated Number of Persons to be Contacted who are Literally Homeless: 170

Number staff trained in SOAR in grant year ending in 2017: 5 Number of PATH‐funded consumers assisted through SOAR: 33

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85 Renaissance Parkway, NE Provider Type: Other mental health agency

Atlanta, GA 30308 PDX ID: GA‐001

Contact: Christy Drummond State Provider ID:

Contact Phone #: 404‐875‐0381 Geographical Area Served: Region 3

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 6997 of 141231 Planning Period From 9/1/2017 to 8/31/2018

Category Federal Dollars Matched Dollars Total Dollars Comments

a. Personnel $ $ 34,500 $ 103,500 138,000

Position * Annual Salary % of time PATH‐Funded PATH‐Funded Matched Dollars * Total Dollars Comments * spent on FTE Salary * PATH *

Case Manager $ 35,000 100.00 % 0.75 $ 26,250 $ 8,750 $ 35,000

Case Manager $ 29,000 100.00 % 0.75 $ 21,750 $ 7,250 $ 29,000

Case Manager $ 28,000 100.00 % 0.75 $ 21,000 $ 7,000 $ 28,000

PATH Administrator $ 46,000 100.00 % 0.75 $ 34,500 $ 11,500 $ 46,000

Category Percentage Federal Dollars * Matched Dollars * Total Dollars Comments

b. Fringe Benefits 15.00 % $ 20,700 $ 6,900 $ 27,600

Category Federal Dollars Matched Dollars Total Dollars Comments

c. Travel $ 5,992 $ 1,997 $ 7,989

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Mileage Reimbursement $ 3,519 $ 1,173 $ 4,692

Other ﴾Describe in Comments﴿ $ 2,473 $ 824 $ 3,297 travel to statewide PATH trainings

d. Equipment $ 0 $ 0 $ 0

No Data Available

e. Supplies $ 750 $ 250 $ 1,000

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Office: Supplies $ 750 $ 250 $ 1,000

f. Contractual $ 0 $ 0 $ 0

No Data Available

g. Housing $ 23,520 $ 7,840 $ 31,360

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 23,520 $ 7,840 $ 31,360 Housing Coordination costs

﴿h. Construction ﴾non‐allowable

i. Other $ 6,983 $ 2,327 $ 9,310

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Client: Transportation $ 6,983 $ 2,327 $ 9,310

j. Total Direct Charges ﴾Sum of a‐i﴿ $ 161,445 $ 53,814 $ 215,259

Category Federal Dollars * Matched Dollars * Total Dollars Comments

k. Indirect Costs ﴾Administrative Costs﴿ $ 0 $ 0 $ 0 l. Grand Total ﴾Sum of j and k﴿ $ 161,445 $ 53,814 $ 215,259

:Source﴾s﴿ of Match Dollars for State Funds

Estimated Number of Persons to be Contacted: 240 Estimated Number of Persons to be Enrolled: 156

Estimated Number of Persons to be Contacted who are Literally Homeless: 240 Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 7098 of 141231 Number staff trained in SOAR in grant year ending in 2017: 3 Number of PATH‐funded consumers assisted through SOAR: 26

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 7199 of 141231 Community Friendship Inc _ Path

Personnel Costs - Position Annual Salary PATH FTE PATH Salary Total

Path Team Lead $46,000 1 $46,000 $46,000

Case Manager $35,000 1 $35,000 $35,000

Case Manager $29,000 1 $29,000 $29,000

Case Manager $28,000 1 $28,000 $28,000

Total Personnel Position $138,000

Fringe Benefits - Position Annual Salary PATH FTE PATH Salary Total

Path Team Leader $46,000 0.2 $46,000 $9,200

Case Manager $35,000 0.2 $35,000 $7,000

Case Manager $29,000 0.2 $29,000 $5,800

Case Manager $28,000 0.2 $28,000 $5,600

Total Fringe Benefit Costs @ 20% $27,600

Staff Travel Cost Number Trips/Miles Number of Staff Total

Local travel to Outreach Team $ 0.48 2,444 4 $4,692 Travel to state-wide trainings, workshops, meetings $659 5 $3,297

Total Staff Travel $7,989

Other Costs Per Unit Cost Unit- Weekly Total

Client Transportation/Benefits $490 19 $9,310

Housing coordination $600 52 $31,360

Total Other Costs $40,670

Program/Office Supplies Per Unit Cost Number of Staff Total

$ 200 5 $1,000

Administrative

Sum of Costs $215,259

Budget $215,259

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 100 72 of 141231 Community Friendship, Incorporated 85 Renaissance Parkway, NE Atlanta, GA. 30308 (404) 875-0381

1. Local Provider Description. Community Friendship, Inc. (CFI) is a comprehensive provider of recovery-based services assisting adults in metropolitan Atlanta. Incorporated in 1971, CFI is a non-profit organization that has been nationally accredited by CARF (Commission on Accreditation of Rehabilitation Facilities) International for over 30 years. Our mission is to provide a supportive community for people whose mental illness prevents them from participating in community life, employment and relationships. Services provided include intensive case management, homeless outreach, skill teaching services, vocational services, supported employment as well as a broad range of residential options to persons with psychiatric disabilities, many of whom have been homeless. CFI will provide PATH services in metro Atlanta serving Fulton and DeKalb Counties which are located in DBHDD Region 3. CFI will receive $161,444 in Federal PATH funds and $53,815 in State Match funds totaling $215,259 to support PATH services. A detailed budget is included with this application.

2. Collaboration with HUD Continuum of Care (CoC) Program. Community Friendship Inc. PATH team is an active member and participant in the City of Atlanta Continuum of Care (CoC) Program. Community Friendship Inc. Executive Director has been a City of Atlanta CoC Rank and Review committee member for the past 4 years. Community Friendship Inc. current active involvement includes: participation in quarterly CoC meetings, participated in the annual homeless census count, coordinated outreach with the Executive Director of Atlanta Homeless Continuum of Care. Current participation also includes quarterly Dekalb and Fulton County CoC meetings. CFI homeless outreach team will conduct street outreach weekly in Fulton County, Dekalb County and the city of Atlanta.

The Homeless Mental Health Team (HMHT) coordinates services within a network of regional providers by utilizing their services to stabilize and maintain the physical health, mental health and substance abuse issues of the consumer served. By working closely with these and other agencies, consumers are assisted in reaching their maximum level of successful community living. The team plays an intricate part of Atlanta’s Continuum of Care by providing emergency housing and case management services to consumers who are referred by jails, Atlanta Police Department, shelters, and area hospitals. Street outreach takes place in Dekalb and Fulton County. In addition, a VI SPDAT is done on every enrolled PATH client.

3. Collaboration with Local Community Organizations.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 101 73 of 141231 The HMHT works in coordination with other providers of community services, such as Grady ACT Team, First Presbyterian Church, Atlanta’s Women’s Day Shelter, Central Presbyterian, and the Homeless Outreach Collaboration Committee. The PATH case managers communicate and coordinate as needed with the above agencies to assist PATH consumers in obtaining needed services. CFI HMHT collaborates with Community Advance Practice Nurses to assess clients on a weekly basis. For instance, the case manager might assist a consumer in obtaining mental health treatment services from Grady Health System, Fulton County Mental Health, Northside Community Mental Health, Serene Reflections and the Georgia’s Mental Health Consumer Network (consumer support). In addition, the HMHT case managers collaborate with Welcome House, Caring Works, Quest Communities, Solomon’s Temple, City of Refuge and Gateway and identified apartment complexes throughout metro Atlanta for housing. Substance abuse treatment partners include: St Jude’s Recovery Center, Women of Gilgal and Dekalb Crisis Center.

Employment partners to assist clients with job training and placement include CFI’s Work Opportunity Department and Georgia Works.

4. Service Provision. Georgia regards Outreach and Case Management as priority services to link literally homeless individuals with serious mental illness or co-occurring disorders to permanent housing opportunities. Therefore, 100% of PATH funds are used for Outreach and Case- Management services. Both services must be delivered in accordance with the Department’s service guidelines. This PATH team currently includes (4) Case Managers who provide street outreach. The Case Managers work with local shelters to provide screenings, assessments and linkage to mental health services located downtown Atlanta. The Team targets those homeless individuals whose mental illness has remained untreated. Typically this population has a multitude of complex needs including food, clothing, housing, mental health services, health services, and income to name a few. Some clients are best served through Outreach. This service focuses on establishing a trusting relationship, building rapport, assessing immediate need, providing referral information, and coordinating linkages to resources. CFI’s homeless outreach case managers conduct daily outreach at shelters, parks, bridges, and other places not meant for habitation. The team also participates in early morning outreach with our collaborating PATH team partners to include a monthly collaborative group outreach.

Moreover, when consumers have early morning or late afternoon appointments or emergencies, the team can address their individualized needs through various components i.e. Connections to SOAR, mental health services, personal identifications, entitlements and food items. Due to the variety of consumer needs, services range from not only needing the coordination of mental health services to full array of bio-psychosocial needs. PATH staff will assist homeless individuals with filing claims by linking them to dedicated DBHDD Medicaid Eligibility Specialists. It is the goal of PATH Case Management team to successfully transition clients into mainstream mental health services. 2

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 102 74 of 141231

Gaps in service to PATH eligible clients continue to be a lack of affordable housing, lack of supportive housing, lack of available housing for individuals with mental illness who are elderly (geriatric needs), a lack of specialized services for adults aged 18 to 21, limited access to medical care/treatment. Limited affordable housing with support makes it difficult for individuals to maintain successful community integration.

Case Management is important and significant to properly assess and link consumers to mental health, medical and community services. Case Management will ensure that the needs of consumers are addressed from a holistic perspective and can provide needed support in making and keeping appointments. Although public transportation is available, many individuals need help in utilizing the MARTA system and/or need financial assistance to purchase Marta breeze cards. Physical health issues for this population are often ignored or go untreated. Consumers are provided support and encouragement to maintain sobriety and are supported in treatment participation, self-help programs and compliance with mental health service recommendations. Consumers are referred to dual diagnosis programs such as Positive Impact and Serene Reflections. The Georgia Mental Health Consumer Network provides Double Trouble peer support self-help groups to individuals with co-occurring mental illness and substance abuse.

The PATH team supports and incorporates into practice the following EBP practices: 1) Motivational Interviewing techniques to move individuals through stages of change; 2) Peer Supports to develop a wellness recovery action plan (WRAP); 3) Double Trouble to Recovery self-help groups for individuals with co-occurring mental illness and substance use disorders; 4) Supportive Housing by linking individuals to permanent housing with attached support services; 5) Intensive Case Management (ICM) Case Management (CM) and Assertive Community Treatment (ACT) linkage for those discharged from PATH with intensive treatment needs. The PATH Team co-case manages for a 90 day period to ensure a successful transition. 6) Integration of health care services via partnership with St. Joseph’s Mercy Care.

The Georgia Department of Behavioral Health & Developmental Disabilities (DBHDD) Division of Mental Health offers a Minimum Standard Training Requirement courses for Paraprofessionals online titled Georgia’s Essential Learning. The subject areas consist of Case Management, Cultural Competence, Documentation, Mental Illness – Addictive Disorders, Professional Relationships, Safety/Crisis De-escalation, and Service Coordination. A total of 29 hours of online training is necessary to fulfill the training requirements. All CFI’s Homeless Mental Health Team members are required to complete the curriculum. All HMHT staff attends the Housing 1st training.

5. Data.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 103 75 of 141231 CFI is an active member of Georgia’s HMIS known as Client Track. CFI participates in HMIS training activities and conference calls. CFI also has an agency HMIS administrator.  All services and case notes are maintained in CFI’s Client Track HMIS system.  CFI also has an internal filing system to keep track of client data.  CFI exclusively uses Client Track as our HMIS system.  All new staff are required to attend Client Track trainings that include: confidentiality, new user training and data compliance.

6. SSI/SSDI Outreach, Access, Recovery (SOAR). Currently CFI has 3 PATH staff trained in SOAR during the grant year ended 2016. Staff successfully connected 26 homeless individuals to receive benefit through the Medicaid Eligibility Specialists with DBHDD. All of CFI homeless outreach case managers staff will be SOAR trained in fiscal year 2018. CFI plans to average 24 PATH funded consumers to be assisted through SOAR referrals.

7. Housing. CFI’s homeless outreach case managers has access to residential services using various hotels and shelter beds for 30 – 90 days (dependent on available resources and client’s needs) as short-term alternative until more permanent options become available. The Budgetel Inn is often used and in close proximity to CFI which provide PATH staff the opportunity to encounter PATH clients on a daily basis to assess their immediate needs. The homeless outreach case managers also initiates housing referrals to CFI’s own residential programs. CFI’s residential programs includes, supervised group homes, HUD supervised-apartments, semi-independent apartments, O’Hern House, Phoenix House, and Presley Woods Apartments. In addition, the homeless case managers refer clients to Welcome House Shelter Plus Program, Living Room (if they are HIV positive), Atlanta Housing Authority, Georgia Housing Voucher Program, Hope Atlanta , Atlanta CoC, personal care homes and reunification with family.

8. Staff Information.

a. The agency employs a staff that is representative of the gender and racial/ethnic diversity of homeless clients served. The following is a representation of the PATH Team:

Provider # PATH # Females # Males # Caucasian # Asian # Black # MH Staff African/Am Consumers CFI 4 3 1 0 0 4 1

 Team Lead provides oversight of the PATH program, facilitate team meetings, individual and group supervision, completes monthly reports, coordinate outreaches and is responsible for data compliance and attends community meetings.  PATH staff provides homeless outreach and case management to include the following services: housing linkage, mental health linkage, medical linkage, substance abuse linkage, benefits and entitlement linkage.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 104 76 of 141231  CFI PATH team consists of (1) staff with lived experience. b. CFI uses staff training, language services, program evaluation, and community representation to ensure that services are provided in a manner that are sensitive to the differences of those they serve to include age, gender, disability, lesbian, gay, bi sexual, transgender, racial/ethnic. CFI promotes cultural diversity and provides cultural competence training to all employees. Free interpreter services are available for those who do not speak English. This organization evaluates performance satisfaction using consumer and family satisfaction surveys, including the level of satisfaction with staff sensitivity to cultural background. This organization supports community representation with employed mental health consumers operating as direct care staff.

c. Cultural sensitivity is a critical part of the CFI new hire orientation training. All employees receive annual diversity training in order to reiterate the importance of respecting individual differences. DBHDD includes cultural competence performance standards in all service contracts and requires that provider staff match the population served. 9. Client Information. a. CFI is located in downtown Atlanta which is the largest city in the most densely populated county in the state. The population that CFI serves are Fulton and Dekalb county. The client population is 70% male and 30% female; 86% African American; 70% between the ages of 35-49; 87% living on the streets or short-term shelter upon initial contact; primary diagnoses including 29% schizophrenia, 28% affective disorders, 35% other SMI; and 29% reporting co-occurring substance use disorders.

b. Projected Service Expectations for FY 2018 - 07/01/17 to 06/30/18: 1) Contractor shall identify and have contact with at least 408 individuals who are homeless and mentally ill in PATH funded Outreach. 2) Contractor shall enroll at least 204 individuals who are homeless and mentally ill in PATH funded Case Management.

10. Consumer Involvement. A Board of Directors requires consumers and family membership to participate in program planning decisions. CFI’s Board includes both consumer and family representation. Consumer participation is a vital part of the planning, implementation and evaluation of the quality of service programming. Consumer Satisfaction Surveys are used to obtain PATH client feedback related to the provision of PATH services, seeking input, feedback, and suggestions for improvement. Agency wide, approximately 20% of the employees are consumers.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 105 77 of 141231 Community Friendship, Incorporated 85 Renaissance Parkway, NE Atlanta, GA. 30308 (404) 875-0381

3. Collaboration with Local Community Organizations.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 106 78 of 141231 The HMHT works in coordination with other providers of community services, such as Grady ACT Team, First Presbyterian Church, Atlanta’s Women’s Day Shelter, Central Presbyterian, and the Homeless Outreach Collaboration Committee. The PATH case managers communicate and coordinate as needed with the above agencies to assist PATH consumers in obtaining needed services. CFI HMHT collaborates with Community Advance Practice Nurses to assess clients on a weekly basis. For instance, the case manager might assist a consumer in obtaining mental health treatment services from Grady Health System, Fulton County Mental Health, Northside Community Mental Health, Serene Reflections and the Georgia’s Mental Health Consumer Network (consumer support). In addition, the HMHT case managers collaborate with Welcome House, Caring Works, Quest Communities, Solomon’s Temple, City of Refuge and Gateway and identified apartment complexes throughout metro Atlanta for housing. Substance abuse treatment partners include: St Jude’s Recovery Center, Women of Gilgal and Dekalb Crisis Center.

Employment partners to assist clients with job training and placement include CFI’s Work Opportunity Department and Georgia Works.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 107 79 of 141231

5. Data.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 108 80 of 141231 CFI is an active member of Georgia’s HMIS known as Client Track. CFI participates in HMIS training activities and conference calls. CFI also has an agency HMIS administrator.  All services and case notes are maintained in CFI’s Client Track HMIS system.  CFI also has an internal filing system to keep track of client data.  CFI exclusively uses Client Track as our HMIS system.  All new staff are required to attend Client Track trainings that include: confidentiality, new user training and data compliance.

8. Staff Information.

a. The agency employs a staff that is representative of the gender and racial/ethnic diversity of homeless clients served. The following is a representation of the PATH Team:

Provider # PATH # Females # Males # Caucasian # Asian # Black # MH Staff African/Am Consumers CFI 4 3 1 0 0 4 1

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 109 81 of 141231  CFI PATH team consists of (1) staff with lived experience. b. CFI uses staff training, language services, program evaluation, and community representation to ensure that services are provided in a manner that are sensitive to the differences of those they serve to include age, gender, disability, lesbian, gay, bi sexual, transgender, racial/ethnic. CFI promotes cultural diversity and provides cultural competence training to all employees. Free interpreter services are available for those who do not speak English. This organization evaluates performance satisfaction using consumer and family satisfaction surveys, including the level of satisfaction with staff sensitivity to cultural background. This organization supports community representation with employed mental health consumers operating as direct care staff.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 110 82 of 141231 Community Friendship Inc _ Path

Personnel Costs - Position Annual Salary PATH FTE PATH Salary Total

Path Team Lead $46,000 1 $46,000 $46,000

Case Manager $35,000 1 $35,000 $35,000

Case Manager $29,000 1 $29,000 $29,000

Case Manager $28,000 1 $28,000 $28,000

Total Personnel Position $138,000

Fringe Benefits - Position Annual Salary PATH FTE PATH Salary Total

Path Team Leader $46,000 0.2 $46,000 $9,200

Case Manager $35,000 0.2 $35,000 $7,000

Case Manager $29,000 0.2 $29,000 $5,800

Case Manager $28,000 0.2 $28,000 $5,600

Total Fringe Benefit Costs @ 20% $27,600

Staff Travel Cost Number Trips/Miles Number of Staff Total

Local travel to Outreach Team $ 0.48 2,444 4 $4,692 Travel to state-wide trainings, workshops, meetings $659 5 $3,297

Total Staff Travel $7,989

Other Costs Per Unit Cost Unit- Weekly Total

Client Transportation/Benefits $490 19 $9,310

Housing coordination $600 52 $31,360

Total Other Costs $40,670

Program/Office Supplies Per Unit Cost Number of Staff Total

$ 200 5 $1,000

Administrative

Sum of Costs $215,259

Budget $215,259

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 111 83 of 141231 5. Fulton Dekalb Hospital Authority Has Sub‐IUPs: No

250 Auburn Avenue Provider Type: Health Care for the Homeless/other health agency

Atlanta, GA 30303 PDX ID: GA‐005

Contact: Tangi Ector State Provider ID:

Contact Phone #: 404‐616‐9239 Geographical Area Served: Region 3

Planning Period From 9/1/2017 to 8/31/2018

Category Federal Dollars Matched Dollars Total Dollars Comments

a. Personnel $ 98,748 $ 32,916 $ 131,664

Position * Annual Salary % of time PATH‐Funded PATH‐Funded Matched Dollars * Total Dollars Comments * spent on FTE Salary * PATH *

Other ﴾Describe in Comments﴿ $ 131,664 100.00 % 0.75 $ 98,748 $ 32,916 $ 131,664 total personnel

Category Percentage Federal Dollars * Matched Dollars * Total Dollars Comments

b. Fringe Benefits 15.53 % $ 20,441 $ 6,813 $ 27,254

Category Federal Dollars Matched Dollars Total Dollars Comments

c. Travel $ 2,625 $ 875 $ 3,500

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Mileage Reimbursement $ 2,625 $ 875 $ 3,500

d. Equipment $ 810 $ 270 $ 1,080

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 810 $ 270 $ 1,080 cell phones

e. Supplies $ 2,955 $ 985 $ 3,940

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Client: Outreach Supplies/Hygene kits/Misc. $ 2,580 $ 860 $ 3,440

Office: Supplies $ 375 $ 125 $ 500

f. Contractual $ 0 $ 0 $ 0

No Data Available

g. Housing $ 2,793 $ 931 $ 3,724

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 2,793 $ 931 $ 3,724 Housing Coordination Costs

﴿h. Construction ﴾non‐allowable

i. Other $ 3,150 $ 1,050 $ 4,200

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Client: Transportation $ 1,125 $ 375 $ 1,500

Staffing: Training/Education/Conference $ 2,025 $ 675 $ 2,700

j. Total Direct Charges ﴾Sum of a‐i﴿ $ 131,522 $ 43,840 $ 175,362

Category Federal Dollars * Matched Dollars * Total Dollars Comments

k. Indirect Costs ﴾Administrative Costs﴿ $ 0 $ 0 $ 0

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 112 84 of 141231 l. Grand Total ﴾Sum of j and k﴿ $ 131,522 $ 43,840 $ 175,362

:Source﴾s﴿ of Match Dollars for State Funds

Estimated Number of Persons to be Contacted: 260 Estimated Number of Persons to be Enrolled: 120

Estimated Number of Persons to be Contacted who are Literally Homeless: 234

Number staff trained in SOAR in grant year ending in 2017: 3 Number of PATH‐funded consumers assisted through SOAR: 0

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 113 85 of 141231 Fulton DeKalb Hospital Authority 10 Park Place South Atlanta, Georgia 30303 (404) 616-9189

1. Description of the provider by organization receiving PATH funds including name, type of organization, services provided by the organization, region served, and amount of PATH funds the organization will receive. Fulton DeKalb Hospital Authority (aka Grady Health System) is a public, non-profit organization contracted by the Department of Behavioral Health & Developmental Disabilities (DBHDD), Division of Mental Health to deliver comprehensive community mental health and addictive disease services to individuals and families. The professional team of psychiatrists, clinical psychologists, psychiatric nurses, mental health specialists, substance abuse specialists, counselors and specialty consultants provide such services as mental health and substance use interventions including emergency/crisis stabilization, intensive inpatient/outpatient treatment, adult mental health counseling, medication management, day treatment, and specialized outreach services.

Grady Health System will provide PATH funded services in Atlanta serving Fulton and DeKalb Counties located in DBHDD Region 3.

This provider will receive $183,135.45 annually to support PATH services. A detailed budget is enclosed with this application.

2. Participation in the HUD Continuum of Care program as well as any other local planning, coordinating or assessment activities. Grady Health System is an active participant in the City of Atlanta Continuum of Care, Fulton County Continuum of Care, and DeKalb County Continuum of Care Planning Process. The PATH Team staff will attend the bi-weekly COC case conference meetings, complete Vulnerability Index on PATH eligible individuals, participate in yearly Point & Time Count, and engage in any other outreach initiatives in an effort to develop strong working relationships with COC partners.

3. Community partnerships with local organizations that provide key services (e.g., primary health, mental health, substance abuse, housing, employment) to PATH eligible clients. A PATH funded Mental Health Clinician and two Mental Health Technicians (one of which is also a Certified Peer Specialist) will collaborate with other agencies, organizations, and sites. The team travels to multiple agencies and homeless camp sites identifying those homeless individuals with mental health and/or substance use needs. Using a fixed outreach approach, they visit local homeless shelters, service centers, jails, hospitals, and known homeless gathering sites on a routine and scheduled basis. The team receives referrals from other agencies, including jails and works closely with local homeless coalitions such as Salvation Army, Gateway, Peachtree & Pine Homeless Shelter, and Georgia state hospitals, to name a few. The team provides on-site mental health and/or substance use assessments

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 114 86 of 141231 and evaluations. With the majority of needed resources and services remaining outside the PATH service, the team must collaborate with a multitude of organizations and providers in order to access those resources needed to address the complex and extensive needs of individuals identified as homeless. Those local agencies and organizations that work in collaboration with this PATH funded team include the following: Local area PATH Teams, Atlanta Day Shelter for Women and Children, Crossroads Ministries Shelter, Atlanta Union Mission, Jefferson Place Shelter, The ROCK (homeless drop-in center), Odyssey Community Concerns (safe haven) Central Fulton Auburn Renaissance Day Treatment Center, Central Fulton Mental Health and Intake for Substance Abuse, Grady Health System’s psychiatric emergency, crisis stabilization, and inpatient services, Northside Mental Health Center, Community Friendship, Fulton County Drug and Alcohol Treatment Center, Georgia Regional Hospital at Atlanta, Bright Beginnings Residential Services, Welcome House (shelter + care), O’Hearn House, St. Joseph’s Mercy Care Health Clinic at Central Presbyterian Church, the Fulton County Jail (conflict and public defender’s offices), Atlanta City Jail, Atlanta Community Court, Mental Health America, and the Task Force for the Homeless. Grady Health Systems also partners with First Step, Inc., a SOAR provider to assist consumers with SSI/SSDI benefits enrollment. Claims are now processed within 3 months and clients are going without benefits for a much shorter period of time.

4. Service provision plan for coordinated and comprehensive services to eligible PATH clients, including:

a. Alignment with PATH goals to target adults who are literally homeless: Georgia regards Outreach and Case Management as priority services to link literally homeless individuals with serious mental illness to permanent housing resources. The PATH State Contract limits the use of PATH funds to these two (2) services which must be delivered in accordance with the Department’s approved service guidelines and specifications.

A three person team will identify those individuals who are homeless and mentally ill through fixed and mobile Outreach efforts and once engaged, will enroll individuals in client-centered Case Management, which will include access to housing and linkage to mainstream services and resources needed to remain housed.

b. Gaps that exist in current service system: There are several gaps in services for the homeless population in metro Atlanta. Some of these gaps include the screening for mental health and substance abuse issues, case management services available on-site, group outreaches for large homeless encampments, shortage of temporary & permanent housing resources, the timeframe linkage for Mental Health linkage (several months). The PATH team addresses these gaps by conducting mental health and substance abuse screenings at local homeless sites including shelters, jails, streets, and hospitals while providing service coordination to address financial, transportation, vocational, and housing needs.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 115 87 of 141231 c. Services available for clients who have both a serious mental illness and substance use disorder: Eligible PATH enrollments are screened for mental health and substance use disorders by the PATH Team who is cross trained in both disability areas. This ensures the identification of and service planning for co-occurring issues. The PATH Team refers and links consumers to those programs that combine mental health and substance use services including Auburn Renaissance Center, Fulton CARES Network, Integrated Life Center, and others. PATH consumers are also linked to local self-help groups including Double Trouble in Recovery (DTR) meetings which occur 7 days a week at various sites throughout Atlanta.

d. Agency supported and implemented Evidence-Based Practices, training, and HMIS activities: The PATH team supports the following EBP practices:  Motivational Interviewing techniques to move individuals through stages of change;  Housing Choice Training  Peer Supports to develop a wellness recovery action plan (WRAP);  Double Trouble to Recovery self-help groups for individuals with co-occurring mental illness and substance use disorders;  Supportive Housing by linking individuals to permanent housing with attached support services;  SOAR Trained Benefit Specialists to expedite access to entitlement benefits;  Assertive Community Treatment (ACT) and Intensive Case Management (ICM) linkage for those discharged from PATH with intensive treatment needs.

Grady Health System provides extensive staff training which includes cultural diversity training. The PATH Team Lead participated in the Regional Commission on Homelessness (RCOH) Case Management Academy and all three PATH staff have received HMIS training through Georgia Department of Community Affairs.

5. Data and Provider’s status on HMIS migration. Grady Health System is a member of Georgia’s HMIS, called ClientTrack and an active user. This provider has participated in HMIS training and is currently entering PATH data on those homeless clients served with PATH funds. All individuals enrolled in PATH Case Management will be entered into HMIS and instantly connected to the homeless provider network. PATH team members will continue to participate in HMIS webcasts and trainings in order to learn how to facilitate migration of PATH data into HMIS. This organization will explore the flexible use of PATH administrative funds to support HMIS activities.

6. Access to housing and strategies to make suitable housing available to PATH clients. The array of housing options that exist for PATH enrolled clients includes Georgia Housing Voucher, Housing Choice Voucher, HUD 811, Personal Care Homes, transition beds, COC beds, emergency shelter, subsidized group home placement, safe haven, shelter plus care, and permanent supportive housing. The Grady Health System PATH Team continues to utilize an array of housing options which include:

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 116 88 of 141231  Crisis and Temporary Housing: Crossroads Ministries Shelter, Peachtree & Pine Shelter, Jefferson Street Shelter, and the Atlanta Union Mission.  Transitional and Permanent Housing: Community Friendship, Welcome House, Integrated Life, O’Hearn House, and Georgia Rehabilitation Outreach.

7. Staff Information: (a) the demographics of the staff serving the clients; (b) how staff providing services to the target population will be sensitive to age, gender, and racial/ethnic differences of clients; and (c) the extent to which staff receive periodic training in cultural competence.

a. The agency employs a diverse racial/ethnic staff to serve homeless individuals. Recognizing that this is an all-male PATH team, the PATH agency administrator is female and provides female perspective to the planning and implementation of Outreach and Case Management services. The following is a representation of the PATH Team: Team Lead - Provides direction, instructions, and guidance  Case Manager - Coordinates and provides care that is safe, timely, effective, efficient, equitable, and client-centered Certified Peer Specialist - Supports consumers in living their own lives and directing their own recovery and wellness

Provider Total PATH # Female # Male # White # Black # MH Staff Consumers Grady 3 0 3 0 3 1

b. This agency uses staff training, language services, program evaluation, and community representation to ensure that services are provided in a manner that is sensitive to the differences of those they serve. FDMHC promotes cultural diversity and provides cultural competence training to all employees. Free interpreter services are available for those who do not speak English. This organization evaluates performance satisfaction using consumer and satisfaction surveys. This organization supports community representation with employed mental health consumers operating as direct care staff.

c. Cultural diversity training is a routine part of the new hiring orientation training with ongoing sensitivity training supported by supervisory monitoring. DBHDD includes cultural competence performance standards in all service contracts and requires that provider staff match the populations served.

8. Client Information: (a) demographics of client population; (b) projected number of adults to be outreached and enrolled; and (c) percentage of adults served that are literally homeless.

a. Grady Health System is located in downtown Atlanta in Fulton County which is considered the most densely populated county in all of Georgia. As a culturally diverse area, metro Atlanta inhabitants speak twenty-seven languages, with even more cultures

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 117 89 of 141231 represented. When compared to the rest of the state, African-American, Hispanic/Latino, and Asian Pacific-island communities are heavily represented. The latter two of these communities have outstripped the rate of growth of other cultural minorities. The demographics of those served using PATH funds include 43% males, 57% females, 84% African American with 55% between the ages of 35-49 years. 68% were literally homeless upon initial contact with schizophrenia being the most frequent mental health diagnoses. 33% reported co-occurring substance use disorders.

b. Projected Service Expectations for SFY 2018 - 7/01/17 through 6/30/18: 1) Contractor shall identify and have contact with at least 260 individuals who are homeless and mentally ill in PATH funded Outreach. 2) Contractor shall enroll at least 120 individuals who are homeless and mentally ill in PATH funded Case Management.

c. This provider projects that 90% of the unduplicated total will self-report as “literally” homeless.

9. Consumer Involvement, how persons who are homeless and have serious mental illnesses and any family members will be involved at the organizational level in the planning, implementation, and evaluation of PATH-funded services.

This agency places a strong emphasis on consumer satisfaction, client choice, natural support and family involvement in treatment. Samplings of consumers who receive adult mental health services delivered by Grady Health Systems participate in Consumer Satisfaction Surveys. Results from the consumer satisfaction surveys are routinely reviewed in order to identify any area of service dissatisfaction, thereby triggering a plan of correction. Program staff receives training in consumer and family related issues, including consumer rights, principles of recovery, and peer led services. Staff consults with consumer organizations such as NAMI for assistance in involving family members and assessment of procedures to increase constructive involvement. A consumer is employed full-time as a certified peer specialist to deliver direct service to PATH clients. Their involvement ensures the presence of a consumer perspective during treatment planning.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 118 90 of 141231 Fulton DeKalb Hospital Authority State Proposed FY 2018 PATH Program Budget

Annual PATH PATH 1. Personnel Salary FTE Salary

1. Salary (3.0 FTE) $131,664.00

2. Fringe Benefit Costs (20.7%) $27,254.45

3. Transportation $6,500.00 -Vehicle Operation & Personal Mileage - $3,500 -Bus Passes - $1,500

4. Staff Training $2,700.00

5. Housing Coordination $3724.00

5. Program Supply Costs $1,580.00 -Office Supplies - $500 -3 Cell Phones @ $30/month each - $1,080

6. Client Engagement Tools $ 3,440.00 - Food/Meal Vouchers - Clothing (socks, coats, hats, scarfs, gloves) - Hygiene Kits

GRAND TOTAL: $175,362.00

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 119 91 of 141231 6. New Horizon Community Service Board Has Sub‐IUPs: No

2100 Comer Avenue Provider Type: Community mental health center

Columbus, GA 31906 PDX ID: GA‐013

Contact: LaTarsha Brown State Provider ID:

Contact Phone #: 706‐596‐5500 Geographical Area Served: Region 6

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 120 92 of 141231 Planning Period From 9/1/2017 to 8/31/2018

Category Federal Dollars Matched Dollars Total Dollars Comments

a. Personnel $ $ 36,500 $ 109,500 146,000

Position * Annual Salary % of time PATH‐Funded PATH‐Funded Matched Dollars * Total Dollars Comments * spent on FTE Salary * PATH *

PATH Administrator $ 33,500 100.00 % 0.75 $ 25,125 $ 8,375 $ 33,500

Other ﴾Describe in Comments﴿ $ 25,500 100.00 % 0.75 $ 19,125 $ 6,375 $ 25,500 SST II

Other ﴾Describe in Comments﴿ $ 24,500 100.00 % 0.75 $ 18,375 $ 6,125 $ 24,500 SST II

Other ﴾Describe in Comments﴿ $ 21,000 100.00 % 0.75 $ 15,750 $ 5,250 $ 21,000 SST I

Other ﴾Describe in Comments﴿ $ 20,500 100.00 % 0.75 $ 15,375 $ 5,125 $ 20,500 SST I

Category Percentage Federal Dollars * Matched Dollars * Total Dollars Comments

b. Fringe Benefits 25.54 % $ 37,284 $ 12,428 $ 49,712

Category Federal Dollars Matched Dollars Total Dollars Comments

c. Travel $ 1,238 $ 412 $ 1,650

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 1,238 $ 412 $ 1,650 Annual statewide trainings

d. Equipment $ 900 $ 300 $ 1,200

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 900 $ 300 $ 1,200 cell phones

e. Supplies $ 1,125 $ 375 $ 1,500

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Office: Supplies $ 1,125 $ 375 $ 1,500

f. Contractual $ 0 $ 0 $ 0

No Data Available

g. Housing $ 17,850 $ 5,950 $ 23,800

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 17,850 $ 5,950 $ 23,800 Housing Coordination Costs

﴿h. Construction ﴾non‐allowable

i. Other $ 3,750 $ 1,250 $ 5,000

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Office: Rent Expenses $ 3,750 $ 1,250 $ 5,000

j. Total Direct Charges ﴾Sum of a‐i﴿ $ 171,647 $ 57,215 $ 228,862

Category Federal Dollars * Matched Dollars * Total Dollars Comments

k. Indirect Costs ﴾Administrative Costs﴿ $ 0 $ 0 $ 0 l. Grand Total ﴾Sum of j and k﴿ $ 171,647 $ 57,215 $ 228,862

:Source﴾s﴿ of Match Dollars for State Funds

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 121 93 of 141231 Estimated Number of Persons to be Contacted: 350 Estimated Number of Persons to be Enrolled: 244

Estimated Number of Persons to be Contacted who are Literally Homeless: 280

Number staff trained in SOAR in grant year ending in 2017: 3 Number of PATH‐funded consumers assisted through SOAR: 0

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 122 94 of 141231 New Horizons Behavioral Health 2100 Comer Avenue Columbus, GA 31906 (706) 596-5717

Local Provider Description – Provide a brief description of the provider organization receiving PATH funds, including name, type of organization, region served, and the amount of PATH funds the organization will receive. New Horizons Behavioral Health is a public, non-profit organization contracted by the Department of Behavioral Health and Developmental Disabilities (DBHDD) to deliver comprehensive community mental health and substance use disorder services through an interdisciplinary treatment team process. For over thirty years, New Horizons has been providing community mental health services. The array of services provided by New Horizons Behavioral Health includes: Screening, Crisis & Outreach, Outpatient, Day Treatment, Substance Abuse Intensive Outpatient, Employment, Residential, and Service Entry and Linkage Services. This PATH program is funded to serve primarily the city of Columbus located in Muscogee County. Collaboration with HUD Continuum of Care (CoC) Program – Describe the organization's participation in the HUD CoC program and any other local planning, coordinating or assessment activities. If you are not currently working with the CoC, briefly explain the approaches to be taken by the agency to collaborate with the local CoC. Susan Gallagher is New Horizon’s Development Coordinator and Cheryl Williams, LPC is the New Horizons Residential Coordinator and serves as an active member of the local HUD Continuum of Care program. LaTarsha Brown, MS is the PATH Team Lead/Program Coordinator who represents PATH in the local Homeless Coalition as well as the CoC and community liaison to other area service providers. New Horizons serves as a community stakeholder in the CoC. PATH Team Lead also sits on the Housing Navigation Team to End Homelessness. PATH staff maintains relationships with local hospital staff to help coordinate follow-up services to reduce future admissions. One PATH staff is delegated as the Housing Navigator to assist with linkage and referral for individuals who need more services and/or those with higher barriers to housing. PATH staff assists with the process for the Georgia Housing voucher and linking the client with meeting with the Regional Coordinator for an interview. PATH also links individuals to the Columbus Housing Authority to provide Moving to Work vouchers. Collaboration with Local Community Organizations – Provide a brief description of partnerships and activities with local community organizations that provide key services (i.e., primary health, mental health, substance abuse, housing, employment, etc.) to PATH eligible clients and describe coordination of activities and policies with those organizations. PATH staff works collaboratively with the local housing authority, shelter plus care providers (including New Horizons), other local housing programs (i.e., the Ralston, Stewart Community Home, and Open Door Community Home), Continuum of Care agencies, the Columbus Homeless Resource Network and the Georgia Department of Community Affairs

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 123 95 of 141231 Georgia Housing Search (which provides an update of available, affordable apartments across Georgia) to identify an appropriate and accessible array of housing options. PATH staff also collaborates with United Way of Chattahoochee Valley Housing Navigation Team to End Homelessness. Project Homeless Connect is an annual event which occurs in January that New Horizons and Open Door Community House collaboratively team up to provide resources for the homeless community. Representatives from housing, education, employment, clothing, and other services were on hand to connect homeless individuals and families with resources. The PATH program assists with the development of the resource fair, along with screening and working to get homeless individuals housed. Service Provision – Describe the organization’s plan to provide coordinated and comprehensive services to eligible PATH clients, including: A. Describe how the services to be provided using PATH funds will align with PATH goals to target street outreach and case management as priority services and maximize serving the most vulnerable adults who are literally and chronically homeless. Georgia regards Outreach and Case Management as priority services and limits the use of PATH funds to these two (2) services which must be delivered in accordance to the Department’s approved service specifications. The New Horizons PATH Team implements Street and Shelter Outreach services to identify and engage literally homeless individuals and move them towards readiness to change. Some of the outreach locations include the Bradley Center, Muscogee County Health Department, Open Door Community Home Showering Program, local hospitals, an array of areas not meant for human habitation, Safe House, St. Anne’s Outreach Ministry, Homeless Resource Network, and several other areas within the community. The PATH team has made connections with local church organizations and food banks on the South Side of Columbus to outreach individuals that are in need of services. The community continues to identify a need in South Columbus, staff continues to outreach behind recently closed stores and other services in South Columbus to ensure appropriate referral sources. The PATH Team is made available to outreach on weekends and evenings as homeless resources are sought out by local churches or other community faith-based outreach services. Once enrolled in Case Management services, individuals are assisted with access to housing and linked to mainstream services and resources. ACT and Mobile Crisis Teams may call the Georgia Crisis Access line, which is a 24 hour mobile crisis unit, 800-715-4225, to receive a higher level of care. PATH also receives daily referrals from 211 which is provided through United Way as a resource for every day challenges as well as emergencies. PATH will utilize a “Housing First” approach as well as leverage all available resources to provide the identified consumer safe, decent, and affordable housing quickly. ACT Team members participate in an interdisciplinary meeting monthly with New Horizons staff to discuss previous and new referrals to promote continuity of care for individuals served. B. Describe any gaps that exist in the current service systems. Few non-traditional mental health services exist for those consumers who resist accessing the traditional service system. New Horizons will utilize the PATH funds to enhance the provision of outreach and case management services that can be accessed through local shelters, emergency rooms, clinics, hospitals, jails, places not meant for human habitation, and food

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 124 96 of 141231 banks. An aggressive Outreach Service will utilize staff that will go into shelters, in the woods and under bridges, showering programs and churches on a regular weekly schedule. New Horizons has implemented a Mental Health Court program, diverting non-violent mentally ill persons from jail into treatment. Individuals referred to the Mental Health Court program, who are not in services and verified as homeless prior to arrest may receive PATH funded services. This will reduce recidivism by ensuring Mental Health Court participants do not immediately return to homelessness from jail. As the Columbus Housing Authority presently has a 1% vacancy rate, locating affordable housing can be very difficult for the homeless population. In 2016, numerous individuals were identified as homeless in the Muscogee County area. For this reason, there is constant communication and coordination with local agencies, realtors, and property managers to obtain and maintain resources. C. Provide a brief description of the current services available to clients who have both a serious mental illness and a substance use disorder. PATH enrollees may participate in any program provided by New Horizons, including a psychosocial rehabilitation group, individual and substance abuse intensive outpatient program specifically designed for the dually diagnosed, as well as gender-specific programming for women. Also, the Peer Drop-In program is utilized in which both homeless and New Horizons Consumers have access to co-occurring groups during the day. The PATH Team will work closely with the local ACT and Mobile Crisis Teams to ensure continuity of care for New Horizons’ eligible individuals. PATH individuals with co-occurring substance use disorders are encouraged to access local peer led self-help groups. Agape meets in downtown Columbus on a weekly basis and provides support and education to those with co-occurring issues. Celebrate Recovery is a biblical program that is structured around healing and overcoming hang-ups to discuss addictive disease issues without shame or stigma. Celebrate Recovery meets every Thursday night and offers child care services for those in need.

D. Describe how the local provider agency pays for providers or otherwise supports evidenced-based practices, trainings for local PATH-funded staff, and trainings and activities to support collection of PATH data in HMIS. Our PATH program utilizes several different practices to maximize the effectiveness of our program in Region 6. We highly believe in a person-centered (Strengths-based) approach to outreaching, engaging and assessing individual’s needs to efficiently assist the individuals served by linking them to housing and mainstream services. In addition, we practice motivational interviewing that will provide them with the benefits of enrolling into mental health services; we actively work under a Housing-First model to assist our community of chronically homeless individuals to obtain permanent stable housing. New Horizons provides Peer Supports to develop a wellness recovery action plan (WRAP). Harm Reduction Training is attended in which staff learns best practices in interactions during outreach and case management with individuals with co-occurring disorders. PATH trainings are provided through DBHDD along with several other free trainings that include Housing-First, Case management, Motivational interviewing and culturally sensitive webinars. Some DBHDD funds will be used for the annual PATH conference. HMIS is entered into Client Track which is paid for by DBHDD and DCA.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 125 97 of 141231 • Data – Describe the provider’s status on HMIS transition plan, with accompanying timeline, to collect PATH data by fiscal year 2017. If providers are fully utilizing HMIS for PATH services, please describe plans for continued training and how providers will support new staff. The PATH team is fully trained on HMIS and utilizes the system with ease for PATH services. All individuals enrolled in Case Management are entered into HMIS and instantly connected to the homeless provider network. PATH team members participate in HMIS webcasts and trainings to learn how to facilitate migration of PATH data into HMIS. This agency will explore the flexible use of PATH administrative funds to support HMIS activities. This agency uses staff training, language services, program evaluation, and community representation to ensure that services are provided in a manner sensitive to the differences of those they serve. New Horizons promotes cultural diversity by providing cultural competence training to all employees. This organization evaluates performance satisfaction using consumer and family satisfaction surveys, including the level of satisfaction with staff sensitivity to cultural background. This organization supports community representation with employed mental health consumers operating as direct care staff.

• SSI/SSDI Outreach, Access, Recovery (SOAR) – Describe the provider's plan to train PATH staff on SOAR. Indicate the number of PATH staff trained in SOAR during the grant year ended in 2016, and the number of PATH funded individuals assisted through SOAR. There are three PATH staff including Team Lead that are SOAR trained. PATH has gotten two new team members who will attend SOAR training when one becomes available in the area. PATH staff has not had much success in getting individuals approved for their benefits but continues to assist the individual in the process leading up to a determination. PATH staff assisted individuals by completing applications online, transporting individuals to the Social Security Office for appointments and their evaluations, and also assisting with the collection of documents required for the completion of the applications. After the individuals received their entitlement benefits letters, PATH staff put the individuals in connection with representative payee programs (if needed), complete budgets for them and their families and continue case management as a mediator for the payee program for continued success with their new income. PATH staff also assists individuals with obtaining permanent case management services to coach and assist the individuals with their finances. • Housing – Indicate what strategies will be used for making suitable housing available for PATH clients (i.e., indicate the type of housing provided and the name of the agency). PATH staff works collaboratively with the local housing authority, Shelter Plus Care providers (including New Horizons), other local housing programs (i.e., the Ralston, Stewart Community Home, and Open Door Community Home), Continuum of Care agencies, the Columbus Homeless Resource Network and the Georgia Department of Community Affairs Georgia Housing Search to identify an appropriate and accessible array of housing options. PATH Staff will then match the enrolled PATH client to the appropriate and available housing

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 126 98 of 141231 resources. A portion of the PATH budget is allocated to pay security deposits, cover the cost associated with emergency housing while applying for permanent housing, costs associated with matching eligible homeless individuals with appropriate housing situations, and one-time rent payments to prevent eviction. PATH now works in coordination with DBHDD Region 6 to utilize the Georgia Housing voucher to link consumers with severe and persistent mental illnesses who are chronically homeless with affordable housing while linking them with follow- up case management services prior to getting discharged from the program. PATH is also able to refer eligible individuals to the Columbus Housing Authority to be placed in the community with a Moving to Work voucher. Within this FY 2016, PATH has assisted numerous individuals with getting approved for the Moving to Work and Section 8 Rapid Rehousing vouchers. PATH staff and team lead have been meeting with the Housing Authority and United Way in keeping track with the amount of vouchers available. PATH staff work closely with numerous local property managers and rental agencies to assist consumers in obtaining affordable housing. The PATH Team will also receive referrals from the ACT and Mobile Crisis Teams and will utilize the same strategies to end the identified individual’s episode of homelessness. • Staff Information – Describe the demographics of staff serving the clients; how staff providing services to the population of focus will be sensitive to age, gender, disability, lesbian, gay, bisexual and transgender, racial/ethnic, and differences of clients; and the extent to which staff receive periodic training in cultural competence and health disparities. A strategy for addressing health disparities is use of the recently revised national Culturally and Linguistically Appropriate Services (CLAS) standards: (http://www.ThinkCulturalHealth.hhs.gov ).

Provider Total # Female # Male # Caucasian # African # MH Hispanic/ PATH American Consumers Latino/a Staff New 6 5 1 0 6 1 0 Horizons

All staff members receive agency based training regarding cultural sensitivity and diversity upon hire and annually thereafter. Every employee is required by this agency to attend training on consumer rights and consumer protection issues. PATH staff is required to complete annual training in both basic and advanced motivational interviewing, cultural sensitivity, and best practices when working with the homeless to incorporate these evidence-based practices into services provided. New Horizons evaluates performance satisfaction using individual and family satisfaction surveys. • Client Information – Describe the demographics of the client population, the projected number of adult clients to be contacted, enrolled, and the percentage of adult clients served using PATH funds to be literally homeless. New Horizon Behavioral Health is located in the city of Columbus, which is the second largest city and fourth largest city in the metropolitan area. The population demographics of those served in FY16 were predominately African American males (69%) between the ages of 31-50 with co-occurring mental illness and/or substance use disorders and literally homeless upon initial contact. Contractor will outreach at least 350 individuals who are homeless and

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 127 99 of 141231 mentally ill. Contractor shall enroll at least 244 individuals who are homeless and mentally ill. Contractor shall assist 40 individuals enrolled in PATH with the initial SSI/SSDI application and appeal process.

OUTREACH SERVICES A. Contract Performance Requirement 1. Monthly, Contractor to Outreach 29 clients. 2. Quarterly, Contractor to Outreach 87 clients, 80% Minimum Threshold of 70 clients. 3. Annually, Contractor to Outreach 350 clients. 4. Annually, Contractor to enroll 244 Outreach clients in PATH Case Management.

Contractor shall assist 40 individuals enrolled in PATH funded Case Management with the initial SSI/SSDI application process or the appeals process. This provider projects that 60% of the unduplicated total will report as “literally” homeless.

• Consumer Involvement – Describe how individuals who experience homelessness and have serious mental illnesses, and family members will be involved at the organizational level in the planning, implementation, and evaluation of PATH-funded services. For example, indicate whether individuals who are PATH-eligible are employed as staff or volunteers or serve on governing or formal advisory boards. There is currently one PATH staff who received mental health services in the past and is now a Certified Peer Specialist (CPS). She also is certified in Whole Health Action Management (WHAM) and is currently working towards certification for Certified Addiction Recovery Empowerment Specialist (CARES). New Horizons encourages the application of individuals once served to obtain employment with New Horizons as the organization agrees to uphold the mission, vision and values of the PATH program and New Horizons Behavioral Health. The New Horizons Board of Directors includes individuals and family members who are actively involved in the planning and implementation of services. Along with the staff, the other members meet monthly and collaborate on the daily functions, services provided and development of New Horizons as a whole.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 100128 of 141231 • Budget Narrative – Provide a budget narrative that includes the local-area provider’s use of PATH funds.

New Horizons Community Service Board State FY 2017 Annual PATH Budget

1. Personnel Position Annual Salary PATH FTE PATH Salary SSC-Team Lead $ 33,500 1.0 $ 33,500 SST II $ 25,500 1.0 $ 25,500 SST II $ 24,500 1.0 $ 24,500 SST I $ 20,500 1.0 $ 20,500 SST I $ 21,000 1.0 $ 21,000 SST I $ 21,000 1.0 $ 21,000 5.0 $ 146,000

2. Fringe Benefits @ 34% $ 49,712

3. Travel $ 1,650 Training/Conferences for PATH Staff

4. Supplies/Newsletter $ 1,500 Quarterly Newsletter , Office Supplies

5. HousingSecurity CoordinationDeposits; One-Time Rental $ 25,000 Payments; House Establishment Supplies

6. Telecommunications/Cell Phones $ 1,200

7. Rent/Utilities $ 5,000

TOTAL: $ 230,062

Per State PATH Contact: Housing Coordination Costs reduced to $23,800.00

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 101129 of 141231 New Horizons Behavioral Health 2100 Comer Avenue Columbus, GA 31906 (706) 596-5717

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 102130 of 141231 Georgia Housing Search (which provides an update of available, affordable apartments across Georgia) to identify an appropriate and accessible array of housing options. PATH staff also collaborates with United Way of Chattahoochee Valley Housing Navigation Team to End Homelessness. Project Homeless Connect is an annual event which occurs in January that New Horizons and Open Door Community House collaboratively team up to provide resources for the homeless community. Representatives from housing, education, employment, clothing, and other services were on hand to connect homeless individuals and families with resources. The PATH program assists with the development of the resource fair, along with screening and working to get homeless individuals housed. Service Provision – Describe the organization’s plan to provide coordinated and comprehensive services to eligible PATH clients, including: A. Describe how the services to be provided using PATH funds will align with PATH goals to target street outreach and case management as priority services and maximize serving the most vulnerable adults who are literally and chronically homeless. Georgia regards Outreach and Case Management as priority services and limits the use of PATH funds to these two (2) services which must be delivered in accordance to the Department’s approved service specifications. The New Horizons PATH Team implements Street and Shelter Outreach services to identify and engage literally homeless individuals and move them towards readiness to change. Some of the outreach locations include the Bradley Center, Muscogee County Health Department, Open Door Community Home Showering Program, local hospitals, an array of areas not meant for human habitation, Safe House, St. Anne’s Outreach Ministry, Homeless Resource Network, and several other areas within the community. The PATH team has made connections with local church organizations and food banks on the South Side of Columbus to outreach individuals that are in need of services. The community continues to identify a need in South Columbus, staff continues to outreach behind recently closed stores and other services in South Columbus to ensure appropriate referral sources. The PATH Team is made available to outreach on weekends and evenings as homeless resources are sought out by local churches or other community faith-based outreach services. Once enrolled in Case Management services, individuals are assisted with access to housing and linked to mainstream services and resources. ACT and Mobile Crisis Teams may call the Georgia Crisis Access line, which is a 24 hour mobile crisis unit, 800-715-4225, to receive a higher level of care. PATH also receives daily referrals from 211 which is provided through United Way as a resource for every day challenges as well as emergencies. PATH will utilize a “Housing First” approach as well as leverage all available resources to provide the identified consumer safe, decent, and affordable housing quickly. ACT Team members participate in an interdisciplinary meeting monthly with New Horizons staff to discuss previous and new referrals to promote continuity of care for individuals served. B. Describe any gaps that exist in the current service systems. Few non-traditional mental health services exist for those consumers who resist accessing the traditional service system. New Horizons will utilize the PATH funds to enhance the provision of outreach and case management services that can be accessed through local shelters, emergency rooms, clinics, hospitals, jails, places not meant for human habitation, and food

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 103131 of 141231 banks. An aggressive Outreach Service will utilize staff that will go into shelters, in the woods and under bridges, showering programs and churches on a regular weekly schedule. New Horizons has implemented a Mental Health Court program, diverting non-violent mentally ill persons from jail into treatment. Individuals referred to the Mental Health Court program, who are not in services and verified as homeless prior to arrest may receive PATH funded services. This will reduce recidivism by ensuring Mental Health Court participants do not immediately return to homelessness from jail. As the Columbus Housing Authority presently has a 1% vacancy rate, locating affordable housing can be very difficult for the homeless population. In 2016, numerous individuals were identified as homeless in the Muscogee County area. For this reason, there is constant communication and coordination with local agencies, realtors, and property managers to obtain and maintain resources. C. Provide a brief description of the current services available to clients who have both a serious mental illness and a substance use disorder. PATH enrollees may participate in any program provided by New Horizons, including a psychosocial rehabilitation group, individual and substance abuse intensive outpatient program specifically designed for the dually diagnosed, as well as gender-specific programming for women. Also, the Peer Drop-In program is utilized in which both homeless and New Horizons Consumers have access to co-occurring groups during the day. The PATH Team will work closely with the local ACT and Mobile Crisis Teams to ensure continuity of care for New Horizons’ eligible individuals. PATH individuals with co-occurring substance use disorders are encouraged to access local peer led self-help groups. Agape meets in downtown Columbus on a weekly basis and provides support and education to those with co-occurring issues. Celebrate Recovery is a biblical program that is structured around healing and overcoming hang-ups to discuss addictive disease issues without shame or stigma. Celebrate Recovery meets every Thursday night and offers child care services for those in need.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 104132 of 141231 • Data – Describe the provider’s status on HMIS transition plan, with accompanying timeline, to collect PATH data by fiscal year 2017. If providers are fully utilizing HMIS for PATH services, please describe plans for continued training and how providers will support new staff. The PATH team is fully trained on HMIS and utilizes the system with ease for PATH services. All individuals enrolled in Case Management are entered into HMIS and instantly connected to the homeless provider network. PATH team members participate in HMIS webcasts and trainings to learn how to facilitate migration of PATH data into HMIS. This agency will explore the flexible use of PATH administrative funds to support HMIS activities. This agency uses staff training, language services, program evaluation, and community representation to ensure that services are provided in a manner sensitive to the differences of those they serve. New Horizons promotes cultural diversity by providing cultural competence training to all employees. This organization evaluates performance satisfaction using consumer and family satisfaction surveys, including the level of satisfaction with staff sensitivity to cultural background. This organization supports community representation with employed mental health consumers operating as direct care staff.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 105133 of 141231 resources. A portion of the PATH budget is allocated to pay security deposits, cover the cost associated with emergency housing while applying for permanent housing, costs associated with matching eligible homeless individuals with appropriate housing situations, and one-time rent payments to prevent eviction. PATH now works in coordination with DBHDD Region 6 to utilize the Georgia Housing voucher to link consumers with severe and persistent mental illnesses who are chronically homeless with affordable housing while linking them with follow- up case management services prior to getting discharged from the program. PATH is also able to refer eligible individuals to the Columbus Housing Authority to be placed in the community with a Moving to Work voucher. Within this FY 2016, PATH has assisted numerous individuals with getting approved for the Moving to Work and Section 8 Rapid Rehousing vouchers. PATH staff and team lead have been meeting with the Housing Authority and United Way in keeping track with the amount of vouchers available. PATH staff work closely with numerous local property managers and rental agencies to assist consumers in obtaining affordable housing. The PATH Team will also receive referrals from the ACT and Mobile Crisis Teams and will utilize the same strategies to end the identified individual’s episode of homelessness. • Staff Information – Describe the demographics of staff serving the clients; how staff providing services to the population of focus will be sensitive to age, gender, disability, lesbian, gay, bisexual and transgender, racial/ethnic, and differences of clients; and the extent to which staff receive periodic training in cultural competence and health disparities. A strategy for addressing health disparities is use of the recently revised national Culturally and Linguistically Appropriate Services (CLAS) standards: (http://www.ThinkCulturalHealth.hhs.gov ).

Provider Total # Female # Male # Caucasian # African # MH Hispanic/ PATH American Consumers Latino/a Staff New 6 5 1 0 6 1 0 Horizons

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 106134 of 141231 mentally ill. Contractor shall enroll at least 244 individuals who are homeless and mentally ill. Contractor shall assist 40 individuals enrolled in PATH with the initial SSI/SSDI application and appeal process.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 107135 of 141231 • Budget Narrative – Provide a budget narrative that includes the local-area provider’s use of PATH funds.

New Horizons Community Service Board State FY 2017 Annual PATH Budget

2. Fringe Benefits @ 34% $ 49,712

3. Travel $ 1,650 Training/Conferences for PATH Staff

4. Supplies/Newsletter $ 1,500 Quarterly Newsletter , Office Supplies

5. HousingSecurity CoordinationDeposits; One-Time Rental $ 25,000 Payments; House Establishment Supplies

6. Telecommunications/Cell Phones $ 1,200

7. Rent/Utilities $ 5,000

TOTAL: $ 230,062

Per State PATH Contact: Housing Coordination Costs reduced to $23,800.00

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 108136 of 141231 7. Saint Joseph's Mercy Care Services, Inc. Has Sub‐IUPs: No

424 Decatur Street, SE Provider Type: Health Care for the Homeless/other health agency

Atlanta, GA 30312 PDX ID: GA‐002

Contact: State Provider ID:

Contact Phone #: 678‐843‐8500 Geographical Area Served: Region 3

Planning Period From 9/1/2017 to 8/31/2018

Category Federal Dollars Matched Dollars Total Dollars Comments

a. Personnel $ $ 59,536 $ 178,610 238,146

Position * Annual Salary % of time PATH‐Funded PATH‐Funded Matched Dollars * Total Dollars Comments * spent on FTE Salary * PATH *

Other ﴾Describe in Comments﴿ $ 68,138 100.00 % 0.75 $ 51,104 $ 17,034 $ 68,138 CM Coordinator

Other ﴾Describe in Comments﴿ $ 40,195 100.00 % 0.75 $ 30,146 $ 10,049 $ 40,195 MH Specialist

Other ﴾Describe in Comments﴿ $ 37,731 100.00 % 0.75 $ 28,298 $ 9,433 $ 37,731 Sr. MH Specialist

Other ﴾Describe in Comments﴿ $ 36,046 100.00 % 0.75 $ 27,035 $ 9,011 $ 36,046 MH Specialist

Other ﴾Describe in Comments﴿ $ 35,860 100.00 % 0.75 $ 26,895 $ 8,965 $ 35,860 Sr. MH Specialist

Other ﴾Describe in Comments﴿ $ 40,352 50.00 % 0.38 $ 15,132 $ 5,044 $ 20,176 MH Specialist

Category Percentage Federal Dollars * Matched Dollars * Total Dollars Comments

b. Fringe Benefits 18.75 % $ 44,652 $ 14,884 $ 59,536

Category Federal Dollars Matched Dollars Total Dollars Comments

c. Travel $ 1,800 $ 600 $ 2,400

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Gas $ 975 $ 325 $ 1,300

Mileage Reimbursement $ 375 $ 125 $ 500

Other ﴾Describe in Comments﴿ $ 450 $ 150 $ 600 parking

d. Equipment $ 1,650 $ 550 $ 2,200

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 1,650 $ 550 $ 2,200 computers and cell phones

e. Supplies $ 225 $ 75 $ 300

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Office: Supplies $ 225 $ 75 $ 300

f. Contractual $ 0 $ 0 $ 0

No Data Available

g. Housing $ 29,610 $ 9,870 $ 39,480

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 29,610 $ 9,870 $ 39,480 Housing Coordination Costs

﴿h. Construction ﴾non‐allowable

i. Other $ 300 $ 100 $ 400

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Staffing: Training/Education/Conference $ 300 $ 100 $ 400

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 109137 of 141231 j. Total Direct Charges ﴾Sum of a‐i﴿ $ 256,847 $ 85,615 $ 342,462

Category Federal Dollars * Matched Dollars * Total Dollars Comments

k. Indirect Costs ﴾Administrative Costs﴿ $ 5,624 $ 1,875 $ 7,499 l. Grand Total ﴾Sum of j and k﴿ $ 262,471 $ 87,490 $ 349,961

:Source﴾s﴿ of Match Dollars for State Funds

Estimated Number of Persons to be Contacted: 590 Estimated Number of Persons to be Enrolled: 204

Estimated Number of Persons to be Contacted who are Literally Homeless: 443

Number staff trained in SOAR in grant year ending in 2017: 5 Number of PATH‐funded consumers assisted through SOAR: 21

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 110138 of 141231 2017 Local Provider Intended Use Plan Mercy Care 424 Decatur Street, SE Atlanta, GA 30312 (678) 843-8500

Local Provider Description: Since 1985, Mercy Care has provided an integrated system of primary health care, education and social services to Atlanta’s homeless, new immigrants, un-insured and underinsured, becoming the medical home for thousands throughout the metropolitan area. With a fleet of vans, two fully equipped mobile medical coaches, 12 clinic sites and an experienced team of medical, dental and behavioral health providers and supportive services staff, Mercy Care provides a comprehensive continuum of care that includes primary and preventive health care, integrated behavioral health care, oral health care, vision screenings, mental health case management, culturally appropriate programs targeting the Hispanic population, health education, and a broad range of HIV prevention, primary care and supportive services. Mercy Care serves DBHDD’s Region 3 (Fulton, DeKalb, Gwinnett, Clayton, Rockdale, and Newton counties).

Mercy Care's PATH program follows a patient-centered model that provides case management to homeless men and women with behavioral health and other complex issues. Case management services are provided onsite at several Mercy Care primary care clinic sites as well as other community-based locations. In February 2015, following an extensive review by the Commission for the Accreditation of Rehabilitation Facilities (CARF), the organization received its fourth consecutive three-year accreditation.

Mercy Care will receive $Pending in PATH funds for Case Management and $Pending in PATH Funds for Outreach, for a total of $Pending in PATH Funds. A detailed program budget will be submitted after contracts are obtained.

Collaboration with HUD Continuum of Care Program There is attendance and consistent participation in the new Atlanta Continuum of Care (COC). Mercy Care's President Tom Andrews is also Chair of the COC's Governing Board. Mercy Care staff members also participate in COC-focused outreaches such as the Metro Atlanta Homeless Census Count, the Hartsfield–Jackson Airport, and the city of Decatur. Other coalitions and task forces in which agency staff participate include the following: weekly PATH Collaborative meetings, the Homeless Provider Network, quarterly provider meetings sponsored by DBHDD, and the Georgia School of Addiction Studies (also holds a position on the board). The staff will also be attending both the Decatur and Fulton counties COC meetings as part of the Region 3 focus.

Collaboration with Local Community Organizations For services beyond its scope, Mercy Care refers clients to other agencies with which it has formal and informal agreements. These include, but are not limited to Grady Health System, St. Jude's Recovery Program, Central Presbyterian Outreach Center, the Living

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 111139 of 141231 Room, Fulton County Department of Health and Wellness, Samaritan House, Georgia Law Center, Georgia Department of Family and Children Services, Legal Clinic for the Homeless, HOPE Atlanta the programs of Traveler’s Aid of Metropolitan Atlanta, First Step Staffing, QUEST Development Organization, and the Georgia Crisis and Access Line. Participation in community events such as NAMI, Arts in the Garden, Substance Abuse/ Mental Health Awareness events, and Healthcare for the Homeless activities is also supported. Mercy Care works in concert with several agencies in early morning collaborative outreach events (in and outside of Atlanta) and other impactful activities to reach PATH targeted populations. Weekly meetings are held with other PATH providers to identify "hot spots" of homelessness, new resources, etc. Teams are able to coordinate the outreach efforts for "hot spot" areas, working together to make impactful change.

Service Provision (1.) PATH funds will be used to provide outreach and case management services that will have a meaningful impact on the consumers we service. Case Managers will utilize their relationships developed in key community areas/programs that service PATH appropriate consumers. Staff will provide outreach and case management inside and outside the traditional four walls to the chronically homeless in the places where they are known to congregate including the streets, parks, shelters, soup kitchens, as well as near other provider agencies. The staff will take advantage of opportunities to reach PATH eligible consumers via the PATH Collaborative, Hartsfield-Jackson Airport police, and concerned citizens providing key sightings of new areas of the homeless. To maximize efforts, our staff will also work closely with the Gateway Center as a coordinated entry point.

Staff will educate clients about Mercy Care community resources and provide referrals to various sources for immediate care including Mercy Clinic sites for health needs. Other referrals may include available sources for food, shelter and clothing. Staff will also help address basic needs by providing hygiene kits, incentives (socks, blankets, coats, bottled water, etc.) and/or MARTA Breeze cards. Individuals will also receive “easy to carry” cards with printed information about Mercy Care programs, services and contact information.

Any individual who has a suspected mental illness that is either self-reported or observed, and is currently homeless or at immediate risk of homelessness, will be considered appropriate for enrollment into PATH services. The outreach team will utilize behavior modification and motivational interviewing techniques including the distribution of incentive items, to encourage individuals to complete required tasks such as following up with an assigned Mental Health Specialist.

A referral will then be given to the Mental Health Specialist for further follow-up. The Mental Health Specialist will obtain social security and birth date information, input the data into the Pathways HMIS, and will determine if the client has been seen previously at Mercy Care for other services.

Case Management - Within seven days of receiving the referral, the Mental Health Specialist will begin the intake process into PATH services. The Mental Health

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 112140 of 141231 Specialist will complete the Eligibility Screening and Needs Assessment form while interviewing the client during the initial intake visit. Also during this visit, the Mental Health Specialist will develop the client’s Individualized Service Plan (ISP). Included in the ISP are goals and objectives developed jointly by the Mental Health Specialist and the client, with the focus on achieving self-sufficiency by building on the client’s strengths within a timeframe of 3 to 6 months. The goals will normally be listed as a direct quote from the client to indicate the clients’ level of participation in their development. The objectives will typically be built on the client’s strengths in an effort to complete tasks that are within the client’s abilities. Mental Health Specialists will help focus the client’s goals on areas such as obtaining affordable housing, following up consistently with mental health/substance abuse needs, and increasing income. Mental Health Specialists will also utilize behavior modification through a reward system whereby when a client achieves a goal or steps toward goal achievement, he/she will receive verbal praise and a reward, i.e. a gift card to purchase housing supplies, etc.

The Mental Health Specialist will assess the client for any medical or behavioral health concerns, and refer the client into the Mercy Care system of care as appropriate. The Mental Health Specialist will also refer the client to other organizations when it cannot directly meet an individual’s needs. The Mental Health Specialist will support the client in following up on referrals by arranging transportation, accompanying the client to appointments (as needed), and assisting the client with required applications. The Mental Health Specialist may also assist the client with financial planning, developing independent living skills, and monitoring the client’s symptoms around mental illness/substance abuse to ensure that the client is remaining healthy and consistent.

The Mental Health Specialist will maintain contact with the client at least weekly to ensure that he/she is making progress toward the identified goals. During those visits, the Mental Health Specialist will document in the agency’s new electronic medical record, EPIC, the specific goal discussed and the client’s progress toward its achievement. The Mental Health Specialist will also document general progress notes within the Pathways system.

A discharge summary will be completed seven days after the client’s discharge from the program. The client will also be discharged from Pathways at this time. The client’s status and goals will be updated within the Mercy Care electronic medical record and discharge procedures completed in Pathways.

Case Management services will take place at five community-based sites that are all easily accessible and commonly visited by the homeless: Atlanta Mission, Open Door Community, St. Luke’s Episcopal Church, the Gateway 24/7 Homeless Services Center, and City of Refuge/Eden Village. Mercy Care will leverage its use of funding for PATH eligible consumers by utilizing agency resources provided by our foundation and donors. Many of these resources will be able to assist consumers with "Welcome Home Baskets", deposits, first month rent, miscellaneous fees, etc.

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 113141 of 141231 To assist GHVP recipients in maintaining success in their housing, one PATH case manager has provided long term case management. This service is contingent upon the consumers' willingness to participate. The long term case manager also operates in the traditional purpose of the PATH grant by enrolling PATH eligible consumers for services.

(2.) The state’s current mental health system continues to be plagued by lengthy delays in getting individuals admitted into state hospitals or other behavioral health facilities. These issues are made worse by budget cuts and increased demands. These deficiencies have an even greater impact on the homeless population because most do not have access to insurance, including Medicaid.

Limited housing resources, both permanent and interim, remain a challenge. The number of homeless in our state has appeared to greatly increase. The housing options are very limited along with the resources to pay for interim housing as consumers await permanent housing. Shelter or transitional housing for single women, women with children and intact families are greatly scaled down.

Access to substance abuse treatment is often a function of income, race and geography. While there are reportedly numerous substance abuse treatment programs in the metropolitan Atlanta area, programs vary considerably regarding types of treatment modalities, availability of medical care, treatment philosophy, cost, length of stay and other variables.

The limited availability of supportive employment in the community is also a challenge. Providing additional funds to help expand this vital service would be beneficial. Many consumers have an ability to work and with support they can re-enter to workforce and continue to be productive and invested citizens.

(3.) The PATH program is also closely coordinated with the agency’s substance abuse services. Individuals with dual diagnosis concerns have the opportunity to be connected with Mercy Care's Integrated Behavioral Health Program which offers substance abuse groups and individual therapy. Client’s participation in dual diagnosis groups helps them to gain a better understanding of their illness and master coping strategies. Substance abuse assessments are conducted by Mercy Care clinic staff, and when appropriate, referrals are made for counseling and/or treatment internally and externally. Mercy Care currently has agreements with several local substance abuse providers to provide residential treatment services to its patients upon referral. On a case-by-case basis, Mercy Care uses available grant funding to pay for up to two months of treatment. Mercy Care Substance Abuse Specialist follows up with the referral agency on a weekly basis regarding the patient’s progress and continued compliance. Consumers are also referred to other treatment facilities where funding is not required such as St. Jude’s Recovery Program. Clients are also offered opportunity to utilize peer support led groups, 12 step preparation groups, and smoking cessation sessions. The Mercy Care staff also utilizes additional services for those consumers that display a higher need of care. Those

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(4.) Case Management staff have access to various training and educational sessions to support their multifaceted work with consumers. Some of these have included Filed Safety Training, COC S.L.E.E.P., Resource-A-Palooza, Housing First, Trauma Informed Care, MH & SA Services, Cultural Competence, and Defining Appropriate Boundaries. Specialized CMTA Case management trainings, BECK Training-Cognitive Behavior Therapy, Motivational Interviewing, VI SPDAT, and CARES-Peer Support are also utilized. During each enrollment of a new consumer the system assessments of PATH Enrollment, Barriers to Housing, PATH Enrollment, and VI SPDAT are completed. Case and Service notes are entered to clearly identify the PATH team servicing the consumer that users may access, thus reducing duplication of service. PATH Discharge assessment of client’s placement, services connection, etc. will also be completed upon consumer transition from PATH services. With Case Managers entering the data, obtaining reporting data is possible. Staff attendance at HMIS meetings with PATH providers discussing updates in system, webinar trainings, etc. have been accomplished.

(5.) Mercy Care has established effective collaborative relationships with a number of criminal justice organizations in metro Atlanta including the city jail, the Atlanta Police Department and the Georgia Department of Corrections. Mercy Care's PATH Program will utilize these relationships however possible, in conjunction with its already broad range of programs and services including employment assistance, housing support and health referrals, to support those clients who may have criminal justice histories. The program's goal is to support these clients in making a smooth integration into society.

Data Mercy Care complies with the utilization of the HMIS system through each of its PATH Case Management staff. Case Management services will complete updates on Confidentiality and New User training as needed to remain compliant and up to date with procedures of the HMIS system. New staff completes online training in the HMIS system and hands on support from seasoned PATH users. Review of new staff entries, clarifications of use, etc. will be performed by Team Lead. Further trainings that are required will receive full participation by staff.

SSI/SSDI Outreach, Access, Recovery (SOAR) SOAR training is imperative to our objective of assisting individual's apply for benefits. We will instruct new staff to enroll for SOAR training as a pre-requisite to providing case management services. Team Lead will document all trainings, applications and referrals to ensure compliance. One hundred and twenty days is the estimated time to receive a decision for an applicant. Team Lead will follow up with Medicaid Eligibility Specialist regularly to determine outcomes due to the inconsistent time it takes for a case to be determined. No new staff have been trained by the end of '2016. One new staff person was added mid 2016. New SOAR trainings have been identified through webinar and on-line services. All other staff have been previously SOAR trained. Case Managers refer

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Housing Due to the changes that have occurred in the state, Mercy Care refers many of its consumers to the COC for housing placement. The forms of housing include individual apartments, roommates, and SROs. Those programs consist of O'Hern House, Rosalynn Apartments, Traveler's Aide, Welcome House, etc. Mercy Care has also established a Memoranda of Understanding with Quest Community Development. Transitional beds will be set aside for a small portion of Mercy Care clients in exchange for providing Case Management services specifically for referred clients. Consumers are referred to several supportive housing resources including: the Georgia Housing Voucher Program, VASH, SSVF, etc. Use of fair market rate housing/subsidized senior housing such as Peachstone, Baptist Towers, Maggie Russell, etc. are also utilized for consumers that meet specified qualifications by the housing provider. Staff also seek to develop relationships with property managers to help facilitate opportunities for consumers with challenging legal/credit histories. The DCA website, georgiahousingsearch.org, is also used to help identify affordable housing options in the community.

Staff Information:

# of # # # # # MH Provider PATH Females Males Caucasian African- Consumers Mercy Staff American Care 5 3 2 0 5 0

Mercy Care has an over 30-year track record of serving the homeless, the medically indigent and recent immigrants – individuals representing a broad cross-section of the cultural spectrum, i.e. race, ethnicity, and gender. In reaching out to these individuals through numerous programs and services, Mercy Care staff continually maintains a clear understanding of the unique issues, barriers and/or risk factors that may contribute to cultural and/or linguistic isolation. The agency is deeply committed to eliminating that isolation through respect for the individual, knowledge and appreciation of the culture, cultivation of trust and rapport between staff and clients, and access to comprehensive services that are responsive to their needs while respectful of their traditions and norms.

All staff members are required to participate in cultural competency training sponsored by Mercy Care. In addition, various continuing education sessions are routinely

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Client Information Projected number of clients to be outreached for services will be a minimum of 590 individuals and projected adults enrolled at least 204. Mercy Care anticipates that of those served during the contract period; approximately 75% will be “literally homeless”.

In 2016, the city conducted its annual homeless population point-in-time count. The homeless census consisted of two types of enumerations, an unsheltered count and a sheltered count, which together result in a comprehensive picture of homelessness. Overall, a total of 4,063 homeless people were counted during the count.

 1,782 (44%) of individuals were in emergency shelters  1,443 (36%) of individuals were in transitional housing  838 (21%) were unsheltered  13% were identified as chronically homeless

Consumer Involvement Mercy Care maintains an agency-wide Client Advisory Committee (CAC) comprised of client volunteers. The Committee’s purpose is to receive, assess and make recommendations based on client feedback. The Committee reports its recommendations at Mercy Care Board meetings. In turn, the Board uses this input to improve upon and/or implement needed services. Staff also present at the CAC to share processes, feedback, and clarity regarding case management services.

Patient satisfaction surveys are another valuable source of client input. The Mercy Care staff gives surveys to each client who is assessed as being PATH-eligible and who is willing to complete the survey. Once enrolled, the surveys are also given monthly to clients by his/her Mental Health Specialist. Mercy Care's Director of Quality and Risk Management compiles the data and provides monthly performance report during a multi- disciplinary quality improvement meeting that includes the team lead.

Proposed State FY 2017 Annual PATH Budget I. Personnel Costs Positions Annual Salary PATH FTE PATH Salary Case Management 68,138 1.0 68,138 Coordinator – L.

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Mental Health 40,195 1.0 40,195 Specialist – R. White, Sr.

Mental Health 37,731 1.0 37,731 Specialist – D. Crockett Mental Health 40,352 0.5 20,176 Specialist – S. Bronner Sr. Mental Health 36,046 1.0 36,046 Specialist- H. Floyd

Sr. Mental Health 35,860 1.0 35,860 Specialist – B. Kerr- Caesar

Subtotal 238,146

II. Fringe Benefit Costs 25% includes FICA, health, dental and life Subtotal 59,536 insurance, pension plan, disability insurance, worker’s compensation

III. Transportation Costs Parking 600 Mileage Reimbursement 500 Van Maintenance and Fuel 1,300 Subtotal 2,400 IV. Training Costs Seminars Subtotal 400

V. Housing Coordination Costs Client Assistance Subtotal 39,880

VI. Program Supply Costs Office Supplies 300 Computer Maintenance 2,200 Cellular Phones Subtotal 2,500

VII. Administrative Costs 8

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TOTAL 349,961 PATH Funds 262,471 Matching Funds 87,490

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3241 Mike Padgett Hwy Provider Type: Community mental health center

Augusta, GA 30906 PDX ID: GA‐014

Contact: Karen Paschal State Provider ID:

Contact Phone #: 706‐432‐7923 Geographical Area Served: Region 2

Planning Period From 9/1/2017 to 8/31/2018

Category Federal Dollars Matched Dollars Total Dollars Comments

a. Personnel $ 75,675 $ 25,225 $ 100,900

Position * Annual Salary % of time PATH‐Funded PATH‐Funded Matched Dollars * Total Dollars Comments * spent on FTE Salary * PATH *

Homeless Housing Counselor $ 21,500 100.00 % 0.75 $ 16,125 $ 5,375 $ 21,500

PATH Administrator $ 54,000 10.00 % 0.08 $ 4,050 $ 1,350 $ 5,400

Peer Support Specialist $ 21,500 100.00 % 0.75 $ 16,125 $ 5,375 $ 21,500

Other ﴾Describe in Comments﴿ $ 52,500 100.00 % 0.75 $ 39,375 $ 13,125 $ 52,500 MH Professional

Category Percentage Federal Dollars * Matched Dollars * Total Dollars Comments

b. Fringe Benefits 33.75 % $ 34,054 $ 11,351 $ 45,405

Category Federal Dollars Matched Dollars Total Dollars Comments

c. Travel $ 9,000 $ 3,000 $ 12,000

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Mileage Reimbursement $ 9,000 $ 3,000 $ 12,000

d. Equipment $ 0 $ 0 $ 0

No Data Available

e. Supplies $ 1,500 $ 500 $ 2,000

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Client: Other Supplies ﴾Describe in Comments﴿ $ 1,500 $ 500 $ 2,000 Office supplies and outreach supplies

f. Contractual $ 0 $ 0 $ 0

No Data Available

g. Housing $ 15,075 $ 5,025 $ 20,100

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 15,075 $ 5,025 $ 20,100 Housing Coordination Costs

﴿h. Construction ﴾non‐allowable

i. Other $ 4,200 $ 1,400 $ 5,600

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Client: Transportation $ 450 $ 150 $ 600

Staffing: Training/Education/Conference $ 3,750 $ 1,250 $ 5,000

j. Total Direct Charges ﴾Sum of a‐i﴿ $ 139,504 $ 46,501 $ 186,005

Category Federal Dollars * Matched Dollars * Total Dollars Comments

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:Source﴾s﴿ of Match Dollars for State Funds

Estimated Number of Persons to be Contacted: 285 Estimated Number of Persons to be Enrolled: 216

Estimated Number of Persons to be Contacted who are Literally Homeless: 271

Number staff trained in SOAR in grant year ending in 2017: 1 Number of PATH‐funded consumers assisted through SOAR: 5

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1. Local Provider Description - A description of the provider organization receiving PATH funds including name, type of organization, services provided by the organization and region served, and the amount of PATH funds the organization will receive. Serenity Behavioral Health Systems (SBHS) is a public, nonprofit organization governed by the Community Service Board of East Central Georgia. We are a comprehensive provider of mental health, addictive diseases and developmental disability services, accredited by CARF. We provide services under contract with the Department of Behavioral Health and Developmental Disabilities (DBHDD). Our service area covers region 2; 7 counties in east central Georgia: Richmond, Columbia, McDuffie, Wilkes, Lincoln, Warren and Taliaferro. We have clinics located in Augusta, Thomson and Washington. The PATH program operates out of the Augusta site. This PATH program shall receive $142,411.28 in PATH Federal funds and $47,870.42 in State Match funds totaling $190,281.70 to support PATH services. A detailed program budget is attached.

2. Collaboration with HUD Continuum of Care (CoC) Program - Participation in the HUD Continuum of Care program and any other local planning, coordinating or assessment activities. PATH staff attends scheduled meetings of the Continuum of Care. This meeting allows us to network with other providers of service to the homeless in a formal manner. PATH coordinates with CSRA EOA Central Intake as well. We, along with other member agencies, serve on the Mayor’s Council on Homelessness. We also participate each year in the Department of Veterans Affairs annual “Stand Down” program for the homeless. At least one staff member serves on the Housing Committee.

3. Collaboration with Local Community Organizations- Community organizations that provide key services (e.g., primary health, mental health, substance abuse, housing, employment) to PATH eligible clients: The PATH team attends scheduled meetings of the Continuum of Care (CoC) where contact is made to strengthen partnerships with the supporting agencies that serve people who are homeless. PATH team members also participate in various housing and outreach committees. PATH coordinates services with the following supporting agencies: CSRA EOA Central Intake, Augusta Task Force for the Homeless, Salvation Army, Garden City Rescue Mission, Augusta Rescue Mission, Lots Ministry, Hale House, Augusta Housing Authority, Richmond Summit Apartments, Maxwell House Apartments, and Bon Air Apartments for the purpose of housing or immediate shelter. We coordinate with Augusta Urban Ministries, Augusta Area Ministries Council, Journey Church, Stevens Creek Church, Antioch Ministries, First Baptist Church of Augusta, and Beulah Grove Baptist Church Community Center, Catholic Social Services, Church of the Good Shepherd and Faith Outreach Christian Center, Golden Harvest Food Bank, Goodwill Industries, GAP Ministries,

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4. Service Provision- Describe the organization’s plan to provide coordinated and comprehensive services to PATH- eligible clients:

 Georgia regards Outreach and Case Management as priority services and limits the use of PATH funds to these two (2) services in order to maximize the benefit of PATH funds with increased access to housing. These services must be delivered in accordance with the Department’s defined service guidelines.

OUTREACH: The average number of outreach contacts per consumer, prior to enrollment, is 1-3 contacts. The contact time may range from 15 minutes up to an hour or more depending on the individual and presenting issues. Outreach is the beginning step of case management. Problems and needs are identified and initial linkages to resources to address those needs are made. Outreach is the first step in establishing trust and hope for engaging the individual in treatment to improve their physical and mental health. The Serenity PATH Team uses four (4) outreach approaches to maximize contact with individuals who are PATH eligible which include:

Mobile outreach, which includes face-to-face interactions with literally homeless people in the streets, under bridges, in shelters, and other nontraditional settings; is intended to identify individuals who are unable or unwilling to seek services on their own. The team as a whole will engage individuals with a personal connection that encourages a desire to change. The Team Lead will utilize motivational interviewing skills to stimulate readiness to change. This may be accomplished by identifying current risks and problems related to homelessness and/or mental health issues. The Housing Specialist will assist by focusing on what the individual identifies as their wants and needs, offering immediate housing options, obtaining emergency contact information and setting up another meeting with the individual, preferably the following day. The Peer Specialist will share his/her story of recovery, remain consumer- focused and address their requests, provide helpful resource information that can be easily accessed, and provide a program brochure with contact information.

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Fixed outreach is provided by the team and includes having a routine schedule for visiting shelters, soup kitchens, Department of labor and other homeless services. The team is located at Master’s Table, the Soup kitchen, daily from 11:00 until 12:30, every Monday at the Department of Labor from 8:30- 10:30, every Tuesday at The Salvation Army from 3:00- 5:00 and they are located at Garden City Rescue Mission every Wednesday from 3:00 - 5:00 and GAP Ministry every Thursday from 9:00 – 11:00. Referred outreach is the availability of another agency to make a referral of a person experiencing homelessness by telephone. It consist of supporting agencies making contact with the PATH team on behalf of the consumer, or the consumer making contact with PATH because they were given information about the PATH program. All of the shelters, health clinics and hospitals have PATH program brochures with contact information. CSRA EOA central Intake is one of many supportive referring agencies. Walk-in outreach provides assistance to those persons who self-present at a fixed outreach location in the community. The individual is connected to the PATH team and outreach begins.

CASE MANAGEMENT: The purpose of case management is to engage with individuals to develop a plan to end their homelessness and access mental health and/or substance abuse services, medical services and Entitlement benefits. Case management services are designed to address directly the issues of consumer access to housing and service integration into mainstream mental health and substance abuse services. The team members, along with the individual, identify what is important to the individual and then develop a realistic plan for achieving the goals. The recovery plan identifies these needs and contains strategies that will be used to end the homeless cycle. The Team Lead will assist with financial planning, provide psycho- education, and provide interventions for the development of interpersonal, community coping and independent living skills. The Peer Specialist will assist with development of a Wellness Recovery Action Plan and development of symptom monitoring and self -medication strategies. Supports provided by the Peer Specialist will include empowering the individual to have hope for and participate in her/his own recovery. The Housing Specialist will identify with the individual his/her preference for housing and assist with obtaining emergency shelter and utilizing homeless resources in the community. This may include subsidized off- the-street (motel) housing, Supportive Housing Programs and Shelter Plus Care housing. The Housing Specialist may also assist with family reunification if the individual is agreeable. Case management services are provided to eligible homeless individuals involved in PATH and their recovery plans are reviewed at least once every 3 months. Discharge planning begins at enrollment via identifying specific goals the individual wants to achieve and the time frame needed to achieve these. Once the goals have been substantially reached, discharge can occur. Other reasons for discharge include transitioning to mainstream mental health services, such as Community Support Services, where the individual will receive ongoing case management services. Discharge can occur if the individual is unwilling to participate in the program, if he/she needs services not available with the PATH program, or if the individual asks to be discharged. Every effort is made to

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 Services available to clients with Co-occurring needs: Individuals who have both a serious mental illness and substance related disorder are referred to Serenity Behavioral Health Systems for treatment, as we operate an integrated, dual diagnosis- specific treatment program. Outpatient treatment (ASAM Level 1) is provided daily. Substance Abuse Intensive Outpatient (SAIOP ASAM Level II.1) is also available 5 days per week. In addition to outpatient services, The Crisis Stabilization Unit is also available for medical detoxification. Veterans are referred to the Veterans Affairs Homeless Program. The women in our Project are referred to Hope House and SHE PREVAILS. Non- Veteran males are also referred to TRANSFORM. In addition, the PATH program provides information to individuals about community based self-help recovery options such as Double Trouble, AA and NA.

 How the local provider agency pays for providers or otherwise supports evidenced-based practices, trainings for local PATH-funded staff: Serenity Behavioral Health Systems promotes cultural diversity and offers cultural competency training to all employees including PATH staff. This agency uses staff training via Essential Learning; language services, program evaluation, and community representation to ensure that services are provided in a manner that are

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Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 125153 of 141231 sensitive to the differences of those they serve. Serenity Behavioral Health Systems promotes cultural diversity and provides cultural competency training to all employees. Free interpreter services, as well as our language line, are available for those who do not speak English. This organization evaluates performance satisfaction using consumer and family satisfaction surveys, including the level of satisfaction with staff sensitivity to cultural background. This organization supports community representation in the program design with employed mental health consumers operating as direct care staff. The PATH team supports the following EBP practices: Motivational Interviewing techniques to move individuals through stages of change; Peer Supports to develop a wellness recovery action plan (WRAP); Double Trouble to Recovery self-help groups for individuals with co-occurring mental illness and substance use disorders; Supportive Housing by linking individuals to permanent housing with attached support services; SOAR Trained Benefit Specialists to expedite access to entitlement benefits; Community Support Team (CST) and Assertive Community Treatment (ACT) linkage for those discharged from PATH with intensive treatment needs. PATH funds will be used in creative ways such as Homeless resource fairs and Haircuts for the Homeless to engage individuals through outreach to obtain and report useful information through HMIS Client Track. This agency will explore flexible uses of PATH administrative funds to support HMIS activities.

 Specific examples of how the agency serves to better link clients with criminal justice histories to health services, housing programs, job opportunities and other supports: PATH works closely with Georgia Re-entry, Supported Employment and WIOA to assist individual recently released and with past criminal history get connected with employment. We also refer to GHVP to assist with funding for housing options.

5. Data- PATH actively uses HMIS as the point of communication for case management, tracking services and making referrals to other community agencies and Care Logic as the EMR (Electronic Medical Records). PATH staff regularly attends employee training for the EMR (Care Logic) and HMIS system through on and off campus training.  The Serenity PATH team uses a separate HMIS system (Client Track) for data entry from the EMR. There are no plans to integrate the systems.  PATH staff is required to document services and referrals for Individuals served through HMIS daily. PATH staff is allow time to attend training for HMIS through webinars and off campus training.  Serenity Behavioral Health uses Care Logic regularly as the EMR to track clinical services for the individuals we serve.  Serenity Behavioral Health Systems has completed the AIU (Adoption, implementation, or upgrade) in EHR adoption. 6. SSI/SSDI Outreach, Access, Recovery (SOAR)

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Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 126154 of 141231  One PATH team member attended SOAR training in December 2015. At least two PATH staff will be completing the SOAR Online course.  PATH staff has assisted with SOAR for disability assistance through Region 2 Medicaid Eligibility specialist.  PATH has referred five consumers for assistance within the last month.  SOAR application results have not been received.  PATH staff has been assisting consumers with applying for SSI/SSDI through the local Social Security office and assisting the consumers with creating a “MySocialSecurity” account to check the status of the applications. Staff has assisted with making appointments and comprising required documents for applying for SSI/SSDI. Consumers are being approved with three to six months of initial application. 7. Housing: Those eligible for housing will be linked to the following housing programs: CSRA EOA Central Intake, Bon Air Apartments, Augusta Housing Authority, Richmond Villa Apartments, Richmond Summit, Glenwood Apartments, Villa Marie Apartments, Mount Zion Apartments, Old Towne, Inc. and Trinity Manor, which are income based housing. We will also utilize the Georgia Housing Voucher program for individuals that meets the requirements for participation in the program. 8. Staff information: a. Demographics of staff: The agency employs staff that is representative of the gender and racial/ethnic diversity of homeless clients served. The following is a representation of the PATH Team: Provider # PATH # # # # Black # MH Staff Females Males Caucasian African/A Consume m. rs Serenity BHS 3 2 1 1 2 1 b. PATH services are non-discriminatory and staff is trained in sensitivity service for all clients. c. Regular training is provided to the entire staff for LGBT, Cultural competency and health disparities through all staff training, webinars and off campus training. PATH staff attends webinars and E-learning programs for (CLAS) to promote population sensitivity. 9. Client Information: The homeless population served by the PATH program in FY 2017 in Augusta was 51.93 % males ,46.67 % females, and Transgender 1.40 %, who are 67.37 % African American, 30.18 % White,1.40% other races, and 1.05 % Hispanic, with 6.32.% between the ages 18-23, 15.09% between the ages of 24-30, 53.68 % between the ages of 31- 50, 21.05 % between the ages of 51-60, 3.86 % between the ages of 61 and over; 21.75 % Veterans and 78.25 % Non-Veteran; 33.68 % were living in a short term shelter or a Safe haven, 19.30% were living in a place not meant for habitation upon first contact, 0% in

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12. Budget Narrative: Attached

Proposed Annual PATH Budget State FY 2017 Serenity Behavioral Health Systems

1. Personnel Costs Positions Annual PATH PATH Salary FTE Salary

Program Director $54,000 .1 $ 5,400 Mental Health Professional $52,500 1.0 $52,500 Housing Specialist $21,500 1.0 $21,500 Certified Peer Specialist $21,500 1.0 $21,500 4.1 FTE $100,900

2. Fringe Benefit Costs @45% $45,405

3. Transportation Costs Vehicle Operation & Personal Mileage: $12,000 Bus Passes: $600 $12,600

4. Training Costs $5,000

5. Housing Coordination Costs Rental Assistance & Emergency Housing: $6,500 Emergency Food Assistance: $600

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6. Program Supply Cost Office Supplies & Engagement tools $2,000

$2,000

7. Administrative Costs 2.25 % $4,276.70

GRAND TOTAL: $190,281.70

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75 Marietta Street, Suite 400 Provider Type: Other mental health agency

Atlanta, GA 30303 PDX ID: GA‐17

Contact: Ed Powers State Provider ID:

Contact Phone #: 404‐817‐7070 Geographical Area Served: Region 3

Planning Period From 9/1/2017 to 8/31/2018

Category Federal Dollars Matched Dollars Total Dollars Comments

a. Personnel $ $ 57,750 $ 173,250 231,000

Position * Annual Salary % of time PATH‐Funded PATH‐Funded Matched Dollars * Total Dollars Comments * spent on FTE Salary * PATH *

Case Manager $ 38,000 100.00 % 0.75 $ 28,500 $ 9,500 $ 38,000

Case Manager $ 37,500 80.00 % 0.60 $ 22,500 $ 7,500 $ 30,000

Peer Support Specialist $ 32,000 100.00 % 0.75 $ 24,000 $ 8,000 $ 32,000

Other ﴾Describe in Comments﴿ $ 55,000 100.00 % 0.75 $ 41,250 $ 13,750 $ 55,000 Team Lead R3

Other ﴾Describe in Comments﴿ $ 38,000 100.00 % 0.75 $ 28,500 $ 9,500 $ 38,000 Team Lead R1

Category Percentage Federal Dollars * Matched Dollars * Total Dollars Comments

b. Fringe Benefits 18.75 % $ 43,313 $ 14,437 $ 57,750

Category Federal Dollars Matched Dollars Total Dollars Comments

c. Travel $ 9,834 $ 3,278 $ 13,112

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Mileage Reimbursement $ 9,834 $ 3,278 $ 13,112

d. Equipment $ 5,310 $ 1,770 $ 7,080

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 5,310 $ 1,770 $ 7,080 telecommunications

e. Supplies $ 2,196 $ 732 $ 2,928

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Client: Outreach Supplies/Hygene kits/Misc. $ 846 $ 282 $ 1,128

Office: Supplies $ 1,350 $ 450 $ 1,800

f. Contractual $ 0 $ 0 $ 0

No Data Available

g. Housing $ 54,722 $ 18,241 $ 72,963

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Other ﴾Describe in Comments﴿ $ 38,276 $ 12,759 $ 51,035 Housing Coordination Costs R1

Other ﴾Describe in Comments﴿ $ 16,446 $ 5,482 $ 21,928 Housing Coordination Costs R3

﴿h. Construction ﴾non‐allowable

i. Other $ 4,500 $ 1,500 $ 6,000

Line Item Detail * Federal Dollars * Matched Dollars * Total Dollars Comments

Staffing: Training/Education/Conference $ 4,500 $ 1,500 $ 6,000

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Category Federal Dollars * Matched Dollars * Total Dollars Comments

k. Indirect Costs ﴾Administrative Costs﴿ $ 11,691 $ 3,897 $ 15,588 l. Grand Total ﴾Sum of j and k﴿ $ 304,816 $ 101,605 $ 406,421

:Source﴾s﴿ of Match Dollars for State Funds

Estimated Number of Persons to be Contacted: 480 Estimated Number of Persons to be Enrolled: 300

Estimated Number of Persons to be Contacted who are Literally Homeless: 360

Number staff trained in SOAR in grant year ending in 2017: 3 Number of PATH‐funded consumers assisted through SOAR: 34

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Travelers Aid of Metropolitan Atlanta, Inc. (dba HOPE Atlanta)

 Local Provider Description – Provide a brief description of the provider organization receiving PATH funds, including name, type of organization, region served, and the amount of PATH funds the organization will receive.

Travelers Aid of Metropolitan Atlanta, Inc.’s (dba HOPE Atlanta) is a non-profit 501 (c)3, whose mission is to provide a comprehensive approach to address homelessness and provide solutions that promote lifelong stability. The agency, founded in 1900 and CARF accredited in 2014, currently administers over fifty (50) grants to provide housing, outreach, emergency services, and homeless prevention with the ultimate goal of providing housing stability and the achievement of self-sufficiency for its clients.

HOPE Atlanta has a long history and expertise in managing federal grants targeting individuals and families who are homeless or at imminent risk of homelessness. The agency has received multiple years of funding through the FEMA Emergency Food and Shelter Program (EFSP) grant, Emergency Solutions Grant (ESG), Community Development Block Grant (CDBG), HUD Supportive Housing Program (SHP), and Housing for Persons with HIV/AIDS (HOPWA) as well as many others.

Including our PATH – Street Outreach Team, HOPE Atlanta has over 60 full-time employees providing services in the City of Atlanta and the 16 counties that comprise the five Continuum of Care (CoC’s) (GA BOS, City of Atlanta, Fulton County, DeKalb County, and Marietta/Cobb). HOPE Atlanta’s main office is located in downtown Atlanta with 11 satellite offices located throughout the metro area, including an office in the VA Community Resource and Referral Center (CRRC) in Atlanta. Six of the satellite offices are located in apartment complexes in low- income neighborhoods and are visible and readily accessible to needy families in those areas. HOPE Atlanta also provides Reunification services to individuals who have no income and whose access to stable housing is through relocation outside of the Atlanta region.

HOPE Atlanta will provide PATH-funded services in both DBHDD Regions 1 and 3 through the receipt of $209,591.90 for Region 1 and $195,701.50 for Region. A detailed budget for both regions, including direct and indirect costs, is included with this plan.

 Collaboration with HUD Continuum of Care (CoC) Program – Describe the organization’s participation with local HUD Continuum of Care (CoC) recipient(s) and other local planning activities and program coordination initiatives, such as coordinated entry and coordinated assessment activities. If you are not currently working with the Continuum(s) of Care briefly explain the approaches to be taken by the agency to collaborate with the CoC(s) in the areas where PATH operates.

HOPE Atlanta is actively involved in the Atlanta, Balance of State, Cobb, DeKalb, and Fulton Continua of Care (CoC) and receives HUD funding for its supportive housing programs. HOPE Atlanta is also an active member of the Regional Commission on Homelessness and participates

FY2018 INTENDED USE PLAN 1

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 Collaboration with Local Community Organizations Provide a brief description of partnerships and activities with local community organizations that provide key services (e.g., outreach teams, primary health, mental health, substance abuse, housing, employment) to PATH-eligible clients, and describe the coordination of activities and policies with those organizations. Provide specific information about how coordination with other outreach teams will be achieved.

The PATH Teams collaborates with other key service organizations to increase access to an array of needed services and resources for enrolled clients. These key organizations include: Region 3

Provider Type of Service Hope House Substance Abuse Community Friendship Supportive Housing Resources Behavioral Health Link Crisis and Emergency Services City of Refuge Transitional Beds Mercy Care Healthcare Grady Health Systems Primary Care, Mental Health and ACT services Continuum of Care Supportive Housing Services Gateway Center Transitional Beds HOPE House Transitional Beds First Step Staffing Employment/SOAR Services

Region 1

Provider Type of Service Cobb CSB Mental Health Services Cobb Wellstar Hospital Primary Care Services MUST Ministries Transitional Beds Charlie Branson, LLC SOAR services Vision 21 Shelter Transitional Beds

 Service Provision – Describe the organization’s plan to provide coordinated and comprehensive services to PATH-eligible clients, including: How the services to be provided using PATH funds will align with PATH goals to target street outreach and case management as priority services, and maximize serving the most vulnerable adults who are literally and chronically homeless

FY2018 INTENDED USE PLAN 2

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 133161 of 141231 Georgia regards Outreach and Case Management as priority services to link literally homeless individuals with serious mental illness or co-occurring disorders to permanent housing opportunities. These two services must be delivered in accordance with the service guidelines and available to homeless individuals and families living in places not meant for human habitation in both Fulton and DeKalb counties. The target population may be referred by the general population, shelters, hospitals, police, community courts, or upon discharge from jail. The PATH Team for Region 1 consists of two case managers and a peer specialist. The PATH Team for Region 3 consists of two case managers. Both teams have case managers who were previously homeless. The Director of PATH Homeless Outreach oversees both teams. The Director oversees outreach activities including establishing daily performance targets, site locations, engagement tactics, and identifying resources for homeless consumers. Types of resources used for engagement include food coupons and MARTA passes to assist with transportation. The teams use the HUD definition of homelessness and is trained to recognize mental illness and co-occurring substance use disorders in order to determine if an individual is PATH eligible. Outreach contacts are entered into the HMIS system (Client Track). Case Managers provide intensive support to assist clients enrolled through outreach to access housing and transition into mainstream mental health treatment. Each new client enrollment receives an eligibility screening and a needs assessment by the Case Manager that includes housing, SSI/SSDI, employment, veteran status, substance abuse, mental health, and medical. An Individualized Service Plan (ISP) is developed in partnership with the consumer to identify goals and strategies to promote change and end homelessness. The Peer Counselor assists by helping the consumer articulate personal goals for recovery and setting objectives for achieving goals. The Peer Counselor models recovery, teaches illness self-management, and connects the consumer to self-help groups including NA, CA, and DTR.

1. Specific examples of how the agency maximizes use of PATH funds by leveraging use of other available funds for PATH client services;

PATH funds are leveraged by three HUD Emergency Solutions Grants (ESG) and by outreach funds received from United Way of Greater Atlanta. ESG funds support additional Outreach Case Managers in the City of Atlanta (2) and DeKalb County (1). United Way and the Regional Commission on Homelessness also provide funds for an additional outreach worker. ESG funds received from the Georgia Department of Community Affairs (DCA) provide supplemental financial support for the PATH Teams’ street outreach activities and for costs related to HOPE Atlanta’s outreach vans. City of Atlanta ESG – Street Outreach $ 155,651 DeKalb County ESG – Street Outreach $ 40,000 DCA ESG – Street Outreach $ 40,000 United Way – Regional Commission on Homelessness $ 60,000 $295,651 2. Any gaps that exist in the current service systems;

The PATH Teams are responsible for filling gaps in services or bringing any gaps to the attention of the Continuum of Care. PATH case managers fill the gaps in the system by providing support to clients as they transition from homeless to “being housed”. Intensive case management is provided to ensure clients receive wrap around services to address housing as

FY2018 INTENDED USE PLAN 3

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 134162 of 141231 well as supportive needs. The PATH funding provides supportive services needed to successfully transition clients into housing and access ongoing services and entitlement benefits to ensure self-sufficiency. To create a seamless process, the PATH teams work in tandem with DBHDD to secure Georgia Housing Vouchers to provide permanent supportive housing for PATH clients. Other gaps include a lack of long-term case management and a shortage of available assessment beds.

3. A brief description of the current services available to clients who have both a serious mental illness and a substance use disorder;

Each person enrolled in case management is evaluated for co-occurring mental illness and substance abuse disorders and through Georgia Crisis and Access Line (GCAL). The individual is linked to local providers of addictive and mental health services. PATH consumers are also linked to self-help groups including Double Trouble to Recovery meetings which occur 7 days a week at various sites throughout Atlanta.

4. How the local provider agency pays for providers or otherwise supports evidenced-based practices, trainings for local PATH-funded staff, and trainings and activities to support collection of PATH data in HMIS; and

The PATH teams support and implement the following practices:  Motivational Interviewing techniques to move individuals through stages of change  Peer Supports to develop a wellness recovery action plan (WRAP)  Double Trouble to Recovery self-help groups for individuals with co-occurring mental illness and substance use disorders  Supportive Housing by linking individuals to a continuum of emergency, transitional and permanent housing with attached support services  SOAR Trained Benefit Specialists to expedite access to entitlement benefits  Assertive Community Treatment (ACT) linkage for those discharged from PATH with intensive treatment needs  ICM and Case Management linkages

Each member of the PATH Teams attends a Case Management Training Academy and receives HMIS training.

5. Specific examples of how the agency serves to better link clients with criminal justice histories to health services, housing programs, job opportunities and other supports (e.g., jail diversion, active involvement in re-entry), OR specific efforts to minimize the challenges and foster support for PATH clients with a criminal history (e.g. jail diversion, active involvement in reentry).

HOPE Atlanta works with collaborative partners to provide linkages to supportive services, housing programs and health services. The agency recently assisted an individual that was incarcerated for 30 years. The individual received a Georgia Housing Voucher to subsidize his

FY2018 INTENDED USE PLAN 4

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 135163 of 141231 housing. The case manager advocated on the client’s behalf to secure a lease in the client’s name. The client suffers from mental and physical health issues. The client was connected to Mercy Care to treat his mental and physical health issues. The agency also provide life skills classes at the Atlanta City jail.  Data – Describe the provider’s status on the transition to collect PATH data in HMIS. If providers are not fully utilizing HMIS for PATH services, please describe plans to complete HMIS implementation. For providers who are fully utilizing HMIS, describe plans for continued training and how providers will support new staff.

HOPE Atlanta utilizes ClientTrack HMIS system. Case managers fully utilize the system and touch all screens while conducting intake, assessments, and follow-up case management. Staff utilizes the HMIS system to ensure services are not duplicated by clients. New staff are trained on the HMIS system within the first 30 days of employment.

 SOAR – Describe the provider’s plan to ensure that PATH staff have completed the SOAR Online Course and which staff plan to assist consumers with SSI/SSDI applications using the SOAR model and track the outcomes of those applications in the SOAR Online Application Tracking (OAT) system. For the grant year that just ended, include the following data:

1. The number of staff trained in SOAR;

2. The number of staff who provided assistance with SI/SSDI applications using the SOAR model;

3. The number of consumers assisted through SOAR;

4. Application eligibility results (i.e., approval rate on initial application, average time to approve the application); and

5. The number of staff dedicated to implementing SOAR, part- and full-time. If the provider does not use SOAR, describe the system used to improve accurate and timely completion of mainstream benefit applications (e.g. SSI/SSDI), timely determination of eligibility, and the outcomes of those applications (i.e., approval rate on initial application, average time to approve the application.) Also describe the efforts used to train staff on this alternative system and what technical assistance or support they receive to ensure quality applications if they do not use the SAMHSA SOAR TA Center.

HOPE Atlanta currently has a 2 staff trained in SOAR, and 1 case manager in the PATH Program that has completed the training. During FY2018, the Director of PATH Homeless Outreach will be SOAR trained in addition to 2 PATH team members located in Region 1 and Region 3. 34 consumers were assisted with SOAR services in the 2017 grant year. In FY2018, the PATH teams will connect 30 consumers to SOAR services.  Housing – Indicate the strategies that will be used for making suitable housing available for PATH clients (i.e., indicate the type of housing provided and the name of the agency).

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HOPE Atlanta receives HUD funding and provides supportive services to individuals who receive project based vouchers through the Atlanta Housing Authority to operate “housing first” programs in metro Atlanta for homeless men, women, and children. Emergency housing is provided through funding received from DBHDD. State funds are also utilized to provide permanent supportive housing through the Georgia Housing Voucher Program. Using scattered apartment communities, each client receives on-site case management support while enrolled in the program. These housing programs include:  Sylvan Hills Apartments  Donnelly Courts  Columbia Tower Apartments  Park Commons  Quest 35, Inc.  GRO Housing  Adams House Apartments- thru Georgia Housing Voucher Program  Rogers Transitional House in Douglasville, GA  Caring Works Permanent Supportive Housing Program  Atlanta PSH (HOPE Atlanta – Mercy Care)  Gwinnett Shelter + Care

PATH clients also receive assistance locating appropriate housing using the Department of Community Affairs’ (DCA) affordable housing database at www.georgiahousingsearch.com  Staff Information – Describe the following demographics of staff serving the clients:

1. How staff providing services to the population of focus will be sensitive to age, gender, disability, lesbian, gay, bisexual and transgender, racial/ethnic, and differences of clients.

2. The extent to which staff receive differences of clients; and the extent to which staff receive periodic training in cultural competence and health disparities.

HOPE Atlanta’s PATH Teams are comprised of the following individuals: Provider # PATH # Females # Males #Caucasian # Black # MH Consumers Staff African/Am HOPE 3 1 2 0 3 1 Atlanta – Region 3 HOPE 3 0 3 0 3 1 Atlanta – Region 1

FY2018 INTENDED USE PLAN 6

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 Client Information – Describe the demographics of the client population, the projected number of adult clients to be contacted and enrolled, and the percentage of adult clients served using PATH funds to be literally homeless.

Projected Service Expectations for SFY 2018 - 7/01/17 to 6/30/18: Based on services levels provided during the current FY2017 contract, the program will serve: Region 1 1) Contractor shall identify and have contact with at least 280 individuals who are homeless and mentally ill in PATH funded Outreach. 2) Contractor shall enroll at least 168 individuals who are homeless and mentally ill in PATH funded Case Management.

Region 3 1) Contractor shall identify and have contact with at least 200 individuals who are homeless and mentally ill in PATH funded Outreach. 2) Contractor shall enroll at least 120 individuals who are homeless and mentally ill in PATH funded Case Management.

 Consumer Involvement – Describe how individuals who experience homelessness and have serious mental illness, and their family members, will be meaningfully involved at the organizational level in the planning, implementation, and evaluation of PATH-funded services. For example, indicate whether individuals who are PATH-eligible are employed as staff or volunteers or serve on governing or formal advisory boards. See Appendix I – Guidelines for Consumer and Family Participation.

The Street Outreach Team employs a Peer Specialist, who was formerly homeless. The Peer Specialist has firsthand knowledge of metro-Atlanta homeless resources and is familiar with locations where unsheltered homeless persons are known to congregate. Our PATH Teams are always receptive and responsive to the input received from consumers and their families. Their input is used to improve the program. In addition, HOPE Atlanta has a formerly homeless client serving on the Board of Directors. He and his family received rapid re-housing services through the agency's Supportive Services for Veteran Families Program (SSVF). In his capacity as a Board Member, he provides input regarding the agency's strategic plan, including governance, finances, fundraising, marketing and public relations. In addition, HOPE Atlanta employs several formerly homeless clients, who are available to provide guidance, assistance and/or insight in planning program service delivery activities agency-wide.  Budget Narrative – Provide a budget narrative that includes the local-area provider’s use of PATH funds. See Appendix C for a sample detailed budget.

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FY2018 INTENDED USE PLAN 8

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017Page 139167 of 141231 HOPE Atlanta DHR Path Budget FY18 Region 3 Region 1 Fulton/Dekalb/COA Cobb Total

Team Lead = 2 FTE 55,000.00 38,000.00 93,000.00 Case Manager = 2 FTE 38,000.00 38,000.00 76,000.00 Case Manager = 0.8 FTE 30,000.00 30,000.00 Peer Specialist = 1 FTE 32,000.00 32,000.00 Total Salaries 123,000.00 108,000.00 231,000.00

Fringe Benefits @ 25% 30,750.00 27,000.00 57,750.00

Transportation Costs 5,056.00 8,056.00 13,112.00 Vehicle Operations/Personal Mileage

Program Supplies: Telecommunications: 3,540.00 3,540.00 7,080.00 - Team Lead cell phones @ $55/month 660.00 660.00 1,320.00 - 2 Regular cell phones @ $45 each/month 1,080.00 1,080.00 2,160.00 - 5 office phones @ $50 each/ month 1,800.00 1,800.00 3,600.00

Office Supplies/Equipment 900.00 900.00 1,800.00 - $25 per employee/month - paper, pens, etc 900.00 900.00 1,800.00

Outreach Supplies 564.00 564.00 1,128.00

Housing Coordination Costs 21,928.52 51,034.67 72,963.19 Emergency Rental Emergency Food - Security Deposits - Household Items - Client Transportation -

Training/Staff Development 3,000.00 3,000.00 6,000.00

Administrative Costs (4% of grant) 7,526.98 8,061.23 15,588.21 Rent - 6 out 60 employees with annual cost of $160K (only allocating the maximum amount of admin)

GRAND TOTAL 196,265.50 210,155.90 406,421.40

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A. Operational Definitions

Term Definition

An individual who lacks fixed, regular, and adequate nighttime residence; or whose primary Homeless Individual: nighttime residence is a shelter or transitional housing designed to provide temporary living accommodations; or exiting an institution where they temporarily resided if they were in shelter or a place not meant for human habitation before entering the institution; or a place not meant for human habitation.

Imminent Risk of Becoming Homeless: Persons who are losing their primary nighttime residence and have no resources or supports to remain in housing, or are about to be discharged from a psychiatric or substance abuse treatment facility without any resources or supports for housing.

The operational definition of serious mental illness is included in the DBHDD, Division of Mental Serious Mental Illness: Health definition of consumer eligibility, which is based on disability and diagnosis. The disability criterion includes a serious impairment or behavior leading to public demand for intervention; or substantial risk of harm to self or others; or substantial need for supports to augment or replace insufficient or unavailable natural resources. The diagnosis element for adults with mental illness excludes personality disorders and V-Codes.

The term co-occurring is a common, broad term that indicates the simultaneous presence of two Co-occurring Serious Mental Illness and independent medical disorders. Within the fields of mental health, psychiatry, and addiction Substance Abuse Disorders: medicine, the term has been popularly used to describe individuals with simultaneous substance use disorder(s) and mental health disorder(s). Substance Use Disorder is defined as an individual who has been diagnosed as having substance disorder and/or substance dependence according to the ASAM Patient Placement Criteria, and as defined in the DSM IV.

Footnotes:

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B. Veterans

Narrative Question: Describe how the state gives consideration in awarding PATH funds to entities with demonstrated effectiveness in serving veterans experiencing homelessness.

Footnotes:

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Describe how the state gives special consideration in awarding PATH funds to entities with a demonstrated effectiveness in serving veterans experiencing homelessness.

In SFY16 GA PATH Teams served 97 known homeless veterans, 6% of individuals served by the program. All PATH providers must demonstrate work experience and background in working with veterans. Mental Health America and the Department of Veterans Affairs estimate that 25-40% of all adult males who are homeless are veterans. According to the Georgia Department of Community Affairs 2015 Report on Homelessness, 12% of the state’s homeless population are veterans. A 2012 Metro Atlanta Veterans Services Report that examined the quality and quantity of services available to Veterans in the Metro Atlanta area highlights the challenges faced by the state’s Veterans. A total of 92 surveys (64% response rate) were completed by national and local nonprofits in a 10 county metro Atlanta area that provided services for Veterans. Approximately 82% of survey respondents working with Veterans believed that homelessness was a major problem in the veteran community. The major causes of homelessness cited by respondents included mental health disorders, substance abuse issues, and overall economic conditions (Georgia Center for Nonprofits, Metro Atlanta Veterans Services Report, 2012).

Approximately 75% of the 90 veterans surveyed in the above study reported known mental or physical health issues. About 58% had either a mental or physical disability. Approximately 32% of the disabled veteran respondents indicated they had a mental disability. Almost 29% of survey respondents had physical or mental health issues resulting from combat. Thirty-two percent of the veteran respondents who had been or were currently homeless after military service indicated that substance abuse was the cause of their homelessness, but less than 4% had sought substance abuse treatment services. (Georgia Center for Nonprofits, Metro Atlanta Veterans Services Report, 2012)

PATH Outreach Teams identify, assess, link, and support homeless veterans who have a serious mental illness. Outreach staff collaborate with case managers from the Veterans Administration to engage homeless veterans in services, including regularly scheduled combined outreach activities. During these special outreach efforts all identified Veterans who agree to accept services are placed in VA Domiciliary emergency shelter and assisted in accessing all VA and other benefits they are eligible for. Regional gatherings of PATH providers and VA providers have resulted in greater collaboration to serve homeless veterans. For example, the New Horizon PATH Team has an annual homeless outreach event, with several vendor booths manned by VA and other veteran-serving agencies in the Columbus area. The Serenity PATH Team in Augusta hosts a similar event. During routine PATH site visits, providers are reminded of the special consideration regarding veterans as specified in Section 522 (d) of the Public Health Service Act.

PATH Staff are well-trained in military culture, PTSD, suicide prevention, and other topics needed to work effectively with homeless veterans. In FY 2014, PATH providers had the opportunity to participate in a statewide training curriculum, in cooperation with the CABHI State Supplement grant staff, specifically designed to increase skills and knowledge in

1 | Veterans

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 Tier One provides an introduction to military culture and information about the deployment cycle. Open to all service providers and community members.  Tier Two provides education about specific challenges and difficulties that are often associated with military service. Open to all service providers who have attended Tier One.

The National Coalition for Homeless Veterans (NCHV) is the resource and technical assistance center for a national network of community-based service providers and local, state and federal agencies that provide emergency and supportive housing, food, health services, job training and placement assistance, legal aid and case management support for hundreds of thousands of homeless veterans each year. The New Horizons PATH Team is a member of this Coalition, as are several of the agencies that PATH Teams partner with for housing and support services for individuals receiving PATH case management and housing support services, including Action Ministries, Gateway Center, Hope House, Decatur Cooperative Ministries, and the Salvation Army.

In 2012, Atlanta Mayor Kasim Reed signed on to President Obama’s White House Mayor’s Challenge to End Veterans Homelessness in 2012. As part of a national campaign with 14 cities, Atlanta not only exceeded the goal of re-housing 100 chronically homeless veterans in 100 days, but also housed more homeless veterans than any other city as part of this challenge in the United States. On May 20, 2015 Mayor Reed announced that the City of Atlanta had made significant progress in its effort to move all homeless veterans into permanent supportive housing, putting the city on a path to meet President Obama’s goal of ending veteran homelessness across the country by 2015. The City of Atlanta Continuum-of-Care continues to work with federal, state and regional partners, including DBHDD and its Region 3 PATH Teams on campaigns to house veterans.

In December of 2016 DeKalb County Continuum of Care officials announced that DeKalb is the first county in Georgia to achieve “functional zero” for veteran homelessness, meaning any homeless veteran who will accept housing will receive it. According to The Atlanta Journal and Constitution (December 11, 2016) by September of 2016, 378 veterans were placed in permanent housing through the distribution of federal supportive housing vouchers and connecting veterans to other programs. Homeless veterans with SMI may also apply for DBHDD’s permanent supportive housing option, the Georgia Housing Voucher Program with assistance directly from a PATH Team or through a DBHDD-contracted Comprehensive Community Provider.

2 | Veterans

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C. Recovery Support

Narrative Question: Describe how the services to be provided using PATH funds will reduce barriers to accessing effective services that sustain recovery for individuals with mental and substance use disorders who experience homelessness.

Footnotes:

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Describe how the services to be provided using PATH funds will reduce barriers to accessing effective services that sustain recovery for individuals with mental and substance use disorders who experience homelessness.

DBHDD’s Office of Recovery Transformation supports efforts to create a recovery-oriented system of care that fully integrates the principles, practices, and values that allow the people we serve to live lives of recovery and independence in the community. This model signifies a shift from crisis-driven services to a prevention-focused, strength-based continuum of care that provides sustained support and is based on the strengths, the wellness, and hopes of the person in recovery.

Recovery accepts that the conditions with which a person lives, be it severe and persistent mental illness, substance use, or co-occurring disorders, are long-term situations that a person will be managing for life. The principles, practices, and values of recovery must be claimed and owned across DBHDD's service-delivery system and by community providers, including PATH Teams.

PATH services support the guiding principles of recovery. PATH funded outreach supports Georgia’s overarching philosophy of Hope and Recovery and the movement toward more person-centered and operated services. PATH services target literally homeless adults with mental illness who are unable or unwilling to seek services on their own. Through outreach, Certified Peer Specialists (CPSs) on all 10 teams share their personal stories of recovery from homelessness, criminal justice involvement, mental illness, and substance use disorders. Homeless individuals learn from CPSs that recovery is possible and then consider change toward health and wellness for themselves. Each PATH Team includes at least one CPS. Employing a mental health consumer, especially those with lived experience of homelessness, to provide outreach has had a positive effect on the engagement process. As someone “who has been there”, CPSs are better able to relate in a more experiential and relevant manner. CPSs serve as role models of “recovery”, a living demonstration that it is possible to escape the streets and regain a meaningful life in the community. Offering this hope fosters motivation to change. Individuals are empowered to drive the case management process, and PATH interventions focus on the ultimate integration of the individual in their community.

Many PATH agencies offer multiple services, creating shortcuts for PATH clients to access these services internally. For example, Behavioral Health Services of South Georgia, and Serenity CSB and Community Friendship, Inc. are all contracted providers of DBHDD’s Peer Support Services Program. This service provides structured activities within a peer support center that promote socialization, recovery, wellness, self-advocacy, development of natural supports, and maintenance of community living skills. Activities are provided between and among individuals who have common issues and needs, are consumer motivated, initiated and/or managed, and assist individuals in living as independently as possible. Activities must promote self-directed recovery by exploring individual purpose beyond the identified mental illness, by exploring possibilities of recovery, by tapping into individual strengths related to illness self-management (including developing skills and resources and using tools related to communicating recovery

1 | Recovery Support

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Since many of Georgia’s PATH Teams are with a DBHDD contracted Comprehensive Community Providers (Cobb CSB, Serenity Behavioral Health, Behavioral Health Services of South Georgia, and New Horizons), individuals enrolled in PATH have direct access to all available Core and Specialty behavioral health services. Three of the teams are located at agencies that offer direct access to primary care services (Grady Hospital, Mercy Care, and Community Advanced Practice Nurses). With agreements and partnerships among PATH providers and other local providers, individuals enrolled in PATH gain expedited access to other key services including primary health, mental health, substance abuse, housing, and employment. Timeliness for providing these services is set within the agency contract agreement. Partnerships are established between PATH and ACT agencies to ensure rapid referrals and smooth transition into this intensive person-centered multi-disciplinary mental health service. Housing barriers are minimized with the use of State funded Medicaid Eligibility Specialists to obtain SSI/SSDI and medical insurance for eligible individuals. Using SOAR strategies, these Benefit Specialists increase access to SSI/SSDI benefits by using high outcome practices that dramatically expedite the application process and reduce the disability determination period. CPSs help homeless individuals with severe mental illness to navigate through the journey from the streets to independence and recovery in the community.

2 | Recovery Support

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D. Alignment with PATH Goals

Narrative Question: Describe how the services to be provided using PATH funds will target street outreach and case management as priority services and maximize serving the most vulnerable adults who are literally and chronically homeless.

Footnotes:

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Describe how the services to be provided using PATH funds will target street outreach and case management as priority services and maximize serving the most vulnerable adults who are literally and chronically homeless.

The tables below outline growth in statewide outreach and case management efforts of GA’s PATH Teams and reach to literally homeless persons over the past six years. PATH funding has been utilized thoughtfully and efficiently each year to expand and enhance services to the target population. The 2015 Report on Homelessness seems to indicate that the efforts of Georgia’s PATH Teams to end homelessness through implementation of PATH goals have been effective. Based on the January 2015 Point-in-Time Count (PIT), at least 13,790 people were literally homeless, which is a 19% decrease from 2013. However, even though the number of literally homeless persons has decreased, the PATH Teams showed an increase in the number of individuals enrolled in case management services.

Utilization Rate of PATH Funded Case Management (from PATH Annual Reports)

Year Total # Literally # Receiving # Enrolled in Case Outreached Homeless a PATH Service PATH Case Management Management Utilization

2001 1776 514 403 78% 2002 1367 733 564 77% 2003 1726 830 322 39% 2004 3043 1355 630 46% 2005 3262 1287 837 65% 2006 2812 1109 928 84% 2007 3223 1289 969 75% 2008 3071 1741 1415 81% 2009 2795 1221 1163 95% 2010 2444 886 (70%) 2563 1385 54% 2011 2354 844 (69%) 2406 1272 53% 2012 4036 1722 (75%) 4053 2320 57% 2013 3748 1340 (65%) 2141 1848 86% 2014 3269 1008 (66%) 2853 1598 56% 2015 3029 930 (58%) 3029 1627 54%

1 | Alignment with PATH Goals

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3300 3200 3100 3000 2900 2800 2700 2600 2500 2400 2300 2200 2100 2000 1900 1800 1700 % Increase 2010 to 2015 1600 2010 1500 2014 1400 1300 2015 1200 1100 1000 900 800 700 600 500 400 300 200 100 24 5 17 0 0 # Outreached # literally # enrolled in Case homeless Case Management served Management Utilization Rate

2 | Alignment with PATH Goals

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E. Alignment with State Comprehensive MH Services Plan

Narrative Question: Describe how the services to be provided using PATH funds are consistent with the State Comprehensive Mental Health Services Plans.

Footnotes:

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Describe how the services to be provided using PATH funds are consistent with the State Comprehensive Mental Health Services Plans.

The State Mental Health Plan incorporates PATH funded services in response to:

I. Criterion 1--Comprehensive Community-Based Mental Health Service System providing for the establishment and implementation of an organized community based system of care; A. Non-traditional mental health services specifically designed for the homeless mentally ill, such as Intensive Case Management (ICM), Assertive Community Treatment (ACT), and Community Support Teams (CST) have been shown to be successful in engaging this group. The pillar of the PATH program is easy access and face-to-face contact to help obtain services and resources needed by homeless people with serious mental illness. Case Management provides an assigned and accountable professional or paraprofessional (e.g. CPS) staff person who is known to that consumer and who serves as point of contact and advocates in obtaining services he or she needs within or outside the agency. By providing active treatment with ongoing contact between consumer and staff person, the likelihood decreases for a homeless individual to drop out of service prior to transitioning into mainstream resources.

II. Criterion 4--Targeted Services to Homeless Populations with outreach to and services for individuals who are homeless; A. Substance Abuse and Mental Health Services Administration (SAMHSA) indicates 20% to 25% of the homeless population in the United States suffers from some form of severe mental illness. According to Georgia’s 2015 Report on Homelessness the January 28, 2015 point in time count identified 13,790 sheltered and unsheltered homeless individuals. According to DBHDD encounter data for 2016, 5,948 homeless persons accessed mental health services (5,851 adults; 97 children). Georgia is committed to ending homelessness by implementing strategies that increase access to permanent housing and mainstream services for chronically homeless individuals and families with severe mental illness.

The costs of homelessness are great for individuals as well as for states and communities. Estimates of up to $4 billion is spent annually on homelessness by local and state governments, health care providers, correctional facilities, emergency shelters, and other providers of services to people who are homeless. Social Security Administration oversees Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) benefit programs for people with physical and/or mental

1 | Alignment with State Comprehensive MH Services Plan

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DBHDD supported a SOAR Demonstration Project between 2007-2011 to demonstrate increased access to SSI/SSDI for mentally ill adults experiencing homelessness; and to teach others how to use SOAR techniques to dramatically expedite the application process and reduce the disability determination period. The SOAR Demonstration Project filed 250 applications representing various populations, and demonstrated a 74% approval rate within an average of 118 days.

Since income and healthcare benefits provide a foundation on which consumers can build their recovery and integrate into the community, expediting access to SSI/SSDI for eligible individuals discharged from state hospitals became a priority for the Department. In 2013, DBHDD entered into a formal agreement with the Department of Community Health (DCH) to hire six (6) Medicaid Eligibility Specialists (MES) to actively assist individuals coming out of state hospitals with accessing Medicaid/Medicare. Since a primary route to Medicaid is through SSI for adults with disabilities, these Medicaid Eligibility Specialists use SOAR techniques to dramatically expedite the application process and reduce the disability determination period. In FY16 MES’s maintained a 92% first time approval rate for all applications files. DBHDD continues to provide SOAR training using SAMHSA’s ‘Stepping Stones to Recovery” curriculum to contracted providers throughout the state.

DBHDD participates in Georgia’s Homeless Interagency Council to review the State of Georgia Action Plan to End Homelessness in Ten Years, implement strategies, and report annual progress. The focus of the plan is to:

 Expand access to mainstream housing, services, and benefits.  Provide supportive housing for chronically homeless individuals and families.  Develop and adopt state policies to end the discharge of institutionalized individuals directly to homeless faculties.  Develop a local community planning model integrating housing and homeless service delivery strategies.  Engage State leadership in adopting strategies, allocation of resources, and implementation of these recommendations.  Fully utilize available federal and other funds available to address the needs of the homeless.

2 | Alignment with State Comprehensive MH Services Plan

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DBHDD tracks the number of mental health consumers who self-report as homeless when authorized for services by age, gender, and region. The Behavioral Health Planning and Advisory Council tracks this data quarterly as part of their state monitoring responsibilities. In FY16, 5,851 adults self-reporting as homeless accessed state supported mental health services. 49% (n=6,730) of the state’s total homeless population is located in Region 3 which includes Atlanta.

It is the overall goal of the Projects to Assist in Transition from Homelessness (PATH) program to effectively and efficiently reduce homelessness for individuals with mental illness who do not access traditional mental health services on their own. The primary functions of PATH program are to identify, engage, and link homeless individuals to mainstream mental health services, housing resources, and other needed community resources. The strategy of linking engaged individuals to mainstream providers rather than establishing a parallel service system for homeless consumers conserves Georgia’s scarce mental health resources. The success of the transition of individuals from PATH programs to mainstream services requires a good relationship between PATH funded agencies and mainstream agencies. PATH funding supports Outreach services that goes into communities to identify and engage “literally" homeless individuals who are unable or unwilling to access mainstream mental health services on their own. Georgia uses hired Consumer Practitioners with homeless experiences to share their personal story of recovery to help establish client rapport and a client commitment to change. A large percentage of those receiving PATH services are successfully transitioned into mainstream service systems where they receive the resources necessary to end their homelessness.

DBHDD embraces the desired outcome of PATH programs to end chronic homelessness. In FY16, 3,029 homeless individuals received benefit from PATH funded services which are located in metro-Atlanta, Savannah, Columbus, Valdosta, and Augusta. Georgia uses outcome measures to identify the effectiveness of PATH services on ending homelessness by the percentage of those discharged from PATH that access housing and link to mainstream behavioral health services. Of the total number of individuals discharged from PATH services in FY 2017 (as of May 31, 2017) (n=862), 28% (n=240) linked to mainstream behavioral health services but remained homeless, and 61% (n=525) accessed housing AND linked to mainstream behavioral health services.

It is Georgia’s vision for FY17 through FY18 to increase PATH effectiveness at ending homelessness for adults with mental illness. PATH Teams use the vulnerability index survey developed by Common Ground Institute, to identify those most at risk of

3 | Alignment with State Comprehensive MH Services Plan

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A Statewide PATH Training Summit (“On the Right PATH”) was held May 16- 18, 2017 in Savannah, GA. All ten PATH teams attended, as well as representatives from the DBHDD Regional and State Offices, Savannah Police Department, Department of Community Affairs (DCA), City of Atlanta Continuum of Care, Mental Health America/Georgia, and providers of other state intensive services such as Assertive Community Treatment (ACT) and Supported Employment (SE). Attendees had the opportunity to participate in an interagency homeless outreach project (“Feet to the Street”) at seventeen (17) different sites across Savannah, distributing hygiene kits and snacks, as well as setting assessment appointments for those homeless individuals who expressed interest in enrollment in PATH case management services. Summit participants attended workshop sessions on:

 Personality Disorders  The Positive Impact of Supported Employment in the Homeless Community  Teambuilding  Taking Care of Business. . .YOURSELF  Georgia’s New Supportive Housing Unit: Pathways to Permanent Housing  Skillbuilding: Locating Resources in Your Community  Who, What, When, Where, Why, and How to Connect Successfully with Assertive Community Treatment (ACT)  Working Against Stigma  CABHI in Georgia Update  Tips for Encounters with Homeless Individuals with Criminal Justice Involvement

In partnership with the Department of Community Affairs (DCA), DBHDD works with core providers to identify target populations and areas of the state in need of Shelter Plus Care housing. DBHDD also creates supportive housing using Section 8 vouchers with attached mental health services. This has been an effective collaboration

4 | Alignment with State Comprehensive MH Services Plan

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B. DBHDD has steadily increased numbers of homeless individuals enrolled in PATH services since 2001. As more homeless individuals are identified and engaged, more are linked to mainstream services and resources that end the homeless cycle. Local service providers use multiple outreach strategies to identify and engage those consumers who have not historically accessed services on their own and need extended contacts over time to develop trust and acceptance of more traditional social and mental health services. These multiple outreach approaches include mobile outreach to streets, parks, transportation hubs, and homeless gathering sites, fixed outreach to shelters, soup kitchens, and indigent health care clinics, and referral and walk-in outreach at the agency.

III. Criterion 5--Management Systems that support training for mental health providers. A. Using PATH funds to provide Peer Outreach supports, the State Mental Health Plan as well as Georgia’s overarching philosophy and vision of the mental health system focus on Hope and Recovery for the people who receive service. Hope and Recovery are embraced in the movement toward more consumer directed and operated services. The state developed a training and certification program for Peer Specialists to assure a qualified consumer workforce. The training curriculum includes two 4-day sessions followed by a written and oral certification testing session. The program addresses issues specific to recovery, self-help, employment, and peer support. Currently, all 10 PATH Programs employ Certified Peer Specialists as equal members of the PATH Team to deliver direct care.

B. PATH Teams are provided access to ongoing state funded training, including but not limited to:

1. Teams have ongoing access to DBHDD’s Case Management Toolkit, which can be found online at https://dbhdd.georgia.gov/sites/dbhdd.georgia.gov/files/related_files/site_page/CM_T oolkit-final6-15-13.pdf

2. In 2016-17, PATH Teams attended statewide training sessions and follow up webinars regarding the new ClientTrack™ HMIS and data migration implementation, in addition to ongoing technical assistance.

3. Housing First Model Training for Community Providers (January 2017)

4. Mental Health First Aid (April, May, and June 2017)

5 | Alignment with State Comprehensive MH Services Plan

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6. Connecting Paradigms: Trauma Informed Care, and the Neurobiology Behind Trauma, Particularly for Those Individuals Experiencing Homelessness (Feb 9-10, 2017)

7. SOAR Training (February, May, October, and November 2017)

8. HHRN Spotlight Series 2016-2017

9. Inmate Guidance for Medicaid- Webinar on Recently Released CMS Guidance (May 2016)

10. Administering DBHDD’s Housing Need & Choice Survey (July 2016)

11. United Way’s Cultural Competency, Immigration, and Ethics (June 2016)

12. Annual Community Behavioral Health 2-Day Symposium, Change & Opportunity: Sharpening the Vision (October 6-7, 2016)

13. Trauma Informed Care for Homeless Veterans (May 2015; combined with CABHI State Supplement Grant staff)

a) Cognitive Processing Therapy (CPT)

b) PTSD & DSM 5

c) Military Culture

d) Impact of Stigma on Outreach and Engagement of Homeless Veterans

14. STAR Behavioral Health Providers Military Culture Tier 1 Training (June 2015)

15. Housing First and Community Integration for Community Service Providers (February, March 2016)

16. Safety and Violence Education (SAVE) Training (March 2016)

17. Seeking Safety (EBP for trauma and substance abuse) (May 2015)

18. Collaborative Documentation (May 2015)

6 | Alignment with State Comprehensive MH Services Plan

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F. Alignment with State Plan to End Homelessness

Narrative Question: Describe how the services to be provided using PATH funds are consistent with the State Plan to End Homelessness. Describe how the PATH program supports the efforts to reduce/eliminate chronic homelessness in the state. Describe how the PATH program integrates disaster preparedness and emergency planning into their continuity of care planning and the process of updating and testing their emergency response plans.

Footnotes:

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Describe how the services to be provided using PATH funds are consistent with the State Plan to End Homelessness. Describe how the PATH program supports the efforts to reduce/eliminate chronic homelessness in the state. Describe how the PATH program integrates disaster preparedness and emergency planning into their continuity of care planning and the process of updating and testing their emergency response plans.

The Georgia State PATH Contact is a member of the Interagency Council on Homelessness. Chaired by the GA Department of Community Affairs (DCA), this Council is charged with the review and implementation of Georgia’s 2013 Homeless Action Plan. The 2015 Report on Homelessness seems to indicate that Georgia’s efforts to end homelessness have been effective. Based on the January 2015 Point-in-Time Count (PIT), at least 13,790 people were literally homeless, a 19% decrease from 2013. Also of note is the fact that “2013 marked the first year in which just under 50% of the homeless individuals and families were unsheltered. In 2015 the number of people who were unsheltered homeless continued to decline with just 42% of the state’s overall homeless population being unsheltered.”

DBHDD’s PATH Project aligns itself closely with several of the Plan’s goals, for example:

Goal 1: Expand access to and use of the Federal mainstream housing and support service programs by homeless families and chronically homeless individuals. HUD-identified mainstream service programs include Medicaid, TANF, SSI, CHIP, Workforce Investment Act, Food Stamps, Adult Literacy, Vocational Rehabilitation, and Veterans Benefits. Mainstream housing programs include the affordable and supported rental and homeownership programs administered by HUD, the Georgia Department of Community Affairs (DCA), and local agencies.  In partnership with the Department of Community Affairs (DCA), DBHDD works with core providers to identify target populations and areas of the state in need of Shelter Plus Care housing. DBHDD recently signed an MOU with DCA for a shared position, Director of Supportive Housing. This position acts a bridge between DBHDD and DCA housing resources and operations to improve access to federal supported housing options, such as Housing Choice Vouchers, the 811 Program, etc. This has been an effective collaboration that helps consumers who are homeless to quickly access safe, decent and affordable housing and receive community-based recovery services.  PATH teams help to decrease the average amount of time it takes homeless individuals to obtain disability benefits (SSI/SSDI), by identifying them through outreach and getting them linked quickly to DBHDD’s Benefits Specialists. In addition, in 2017 Georgia’s SOAR Project scheduled four, 2-day SOAR trainings across the state.  Georgia PATH Programs Outreached 3,029 homeless individuals and enrolled 1,627 into PATH funded Case Management. These individuals were linked to community mental health services, supportive housing, and mainstream benefits.

1 | Alignment with State Plan to End Homelessness

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Goal 3: Develop and adopt state policies to end the discharge of institutionalized individuals (to include discharge from correction facilities, public health or mental hospitals, treatment facilities, foster care, or juvenile justice programs) directly to homeless facilities which are unprepared and unable to meet the supportive service needs of the individual.

In ongoing efforts to decrease discharges of individuals with serious mental illness from institutional settings to emergency shelters, in 2016 DBHDD instituted a protocol with our state psychiatric hospitals to refer individuals ready for discharge to the PATH Teams for assistance with placement in extended stay lodging and transitional housing programs. PATH Teams provide case management services to enrolled individuals, including completing linkage to community mental health services and placement into permanent supportive housing. The state has identified residential program funding to support this protocol, and PATH Teams will pursue MOUs with housing providers to ensure priority placement of individuals transitioning from institutions. PATH Teams will provide outreach services to state hospitals and local jails to keep staff aware of PATH services and the referral process.

In 2015, Georgia began a pilot program to improve re-entry outcomes for individuals with serious mental illness coming out of our prison system. Forensic Peer Mentors (FPM) work on site and assist correctional facility mental health program staff at Lee Arrendale State Prison, Baldwin State Prison, Phillips Transition Center, and Pulaski State Prison (2 additional sites since the beginning) with placement of individuals with serious mental illness being released from incarceration. FPMs are assigned to work with Returning Citizens within 12 months prior to release and assist them in setting housing and other goals that will facilitate successful

2 | Alignment with State Plan to End Homelessness

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Disaster Preparedness and Emergency Planning

Under DBHDD Policy 04-102, DBHDD ensures the safety of individuals served and staff by establishing requirements for providers, including PATH providers, to have a plan for emergency and disaster situations. State of Georgia Behavioral Health Emergency Preparedness Planning Kits, located on Georgia’s disaster mental health web site at www.georgiadisaster.info may serve as a guide for PATH providers in the development of emergency plans. The kits contain instructions and worksheets that assist facilities with the following:

 Hazard Vulnerability Analysis

 Continuity of Operations Planning

 Surge Capacity Planning

 Personnel Planning for Continuity of Operations and Surge Capacity

 Other Response Capabilities (including Financial Resiliency)

 Planning for Support of the Community Response

DBHDD’s Disaster Mental Health Coordinator provides technical assistance to all contracted providers and coordinates coverage of the Mental Health Station within the Emergency Operations Center (EOC). Georgia’s State PATH Contact is a member of the EOC Team and is available to provide TA and guidance to shelters and behavioral health providers serving homeless individuals. In 2016 Georgia’s ten (10) PATH Teams will participate in an overview of services and access to mass care training provided by the American Red Cross, which provides essential basic services and the majority of mass care services for residents of Georgia affected by disaster.

3 | Alignment with State Plan to End Homelessness

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G. Process for Providing Public Notice

Narrative Question: Describe the process for providing public notice to allow interested parties, such as family members; individuals who are PATH-eligible; mental health, substance abuse, and housing agencies; and the general public, to review the proposed use of PATH funds (including any subsequent revisions to the application). Describe opportunities for these parties to present comments and recommendations prior to submission of the State PATH application to SAMHSA.

Footnotes:

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The PATH Grant Application is posted annually on the Department of Behavioral Health and Development Disabilities website (www.DBHDD.Georgia.Gov ) for public viewing. The PATH State Contact email address is included, and viewers are encouraged to submit comments or suggestions regarding the use of PATH funds by email. This ensures direct communication between stakeholders and the PATH State Contact.

1 | Process for Providing Public Notice

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H. Programmatic and Financial Oversight

Narrative Question: Describe how the state will provide necessary programmatic and financial oversight of PATH-supported providers, such as site visits, evaluation of performance goals, audits, etc. In cases where the state provides funds through intermediary organizations (i.e., County agencies or regional behavioral health authorities), describe how these organizations monitor the use of PATH funds.

Footnotes:

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Describe how the state will provide necessary programmatic and financial oversight of the PATH-supported providers, such as site visits, evaluation of performance goals, audits, etc. In cases where the state provides funds through intermediary organization (i.e., County agencies or regional behavioral health authorities), describe how these organizations conduct monitoring of the use of PATH funds.

The State PATH Contact conducts site visits and/or desktop audits with each PATH funded program in order to evaluate compliance with the agreements required under DBHDD provider standards and PATH legislative guidelines. Desktop reviews and site visits includes interviewing the program administrator, direct care PATH funded staff, observation of the provision of PATH services, and may include interviews with individuals served by the program. The site visit also includes a review of randomly selected PATH participant records. Through the site visit and ongoing phone/video conferencing, the State PATH Contact in partnership with the six (6) DBHDD Regional Offices focuses on the following objectives:  To provide technical assistance in reporting PATH data in the annual report;  To monitor the performance of the agreed upon PATH funded services as stated in the IUP and Proposed Budget;  To evaluate compliance with the agreements required under the program including the Public Health Service Act and Terms and Conditions of the Award;  To review PATH participant records;  To ascertain strengths of the PATH program; and  To determine opportunities for improvement related to the PATH Program and service delivery at the National, State, and local levels.

The PATH Site Visit Monitoring Tool developed by the PATH Administrative Workgroup (AWG) in 2004 is used to gather information prior to the site visit related to personnel and staff development, policies/procedures/quality assurance and improvement activities, services, fiscal management, cultural competency, consumer involvement, and service processes. Additional information is gathered during the on-site visit when meeting with the PATH Team Lead, Team Members, and the PATH Administrator.

Using the Five (5) Performance Goals for an Effective PATH Program developed by the AWG, discussions focus on: 1. Targeting services to literally homeless individuals; 2. Provision of active management and oversight; 3. Use of Quality Data and Reporting; 4. Use of Exemplary Practices; and 5. Transition to Mainstream.

A written report summarizing the site visit with findings and recommendations is submitted to the related DBHDD Regional Office and PATH provider.

1 | Programmatic & Financial Oversight

Printed: 7/7/2017 11:2311:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 194 of2 of231 3 Accurate and reliable data is imperative for the success of the DBHDD’s quality management program. PATH Providers are required to utilize the Homeless Management Information System (HMIS) which includes data elements such as demographics, service utilization, outcomes measures, individualized care plans, and diagnoses. DBHDD requires contractors who provide monthly programmatic reports including data for calculation of key performance indicators to use standardized report templates and methodology for quality management data reporting. The standardization of reporting ensures consistency in collection and reporting of critical data elements across providers for improved analysis on a statewide level. These monthly programmatic data reports are each reviewed and validated by the SPC prior to acceptance.

Georgia uses a performance based PATH Contract Annex with monthly performance expectations that includes a minimum number of outreach contacts, minimum number of individuals to be enrolled, and a minimum number of PATH enrolled individuals transitioned into mental health/substance use services and housing upon discharge. Providers must submit monthly performance reports to the State PATH Contact which are reviewed prior to approval of provider payment. Providers that fail to meet the PATH monthly performance expectations receive a lower adjusted payment reflecting only those PATH individuals who were enrolled.

Financial and Programmatic Compliance oversight is accomplished through DBHDD’s Office of Budget and Finance and Office of Internal Audit and Risk Management, respectively. On site financial audits are conducted with selected PATH providers each fiscal year. Providers are selected for audit either randomly or at the request of the State PATH Contact. All providers have a PATH-specific audit at least biennially.

In March of 2017 DBHDD’s Office of Accountability and Compliance created the Policy 13- 901: PATH Program Federal Award Internal Controls. This policy is applicable to DBHDD's Office of Budget and Finance, Contracting and Procurement, Human Resources, Information Technology, Medicaid and Health Systems Innovation, ASO Coordination/DBHDD Chief of Staff, Director of Prevention, Division of Accountability and Compliance, and the Program Manager. This policy is intended to assist each relevant program and DBHDD's auditors in complying with Office of Management and Budget Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (OMB 2 CFR part 200) by describing for each type of compliance requirement, the objectives and certain characteristics of internal control activities that, when present and operating effectively, may ensure compliance with program requirements.

2 | Programmatic & Financial Oversight

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I. Selection of PATH Local-Area Providers

Narrative Question: Describe the method(s) used to allocate PATH funds to areas and providers with the greatest number of individuals who experience homelessness with serious mental illnesses or co-occurring substance use disorders (i.e., through annual competitions, distribution by formula, data driven or other means).

Footnotes:

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Describe how PATH funds are allocated to areas and providers with the greatest number of individuals who experience homelessness with serious mental illnesses or co-occurring substance use disorders (i.e., through annual competitions, distribution by formula, or other means).

DBHDD is charged by law to: 1) provide adequate mental health, developmental disabilities and substance use disorder services to all Georgians; 2) provide a unified system which encourages cooperation and sharing among government and private providers; and 3) provide service through a coordinated and unified system that emphasizes community-based services. The governance of Georgia’s public mental health system operates using a six (6) regional authority design that includes both hospital and community service management. Each of the six DBHDD regions has responsibility for informing the state Central Office about resource allocation needs in their area. This facilitates the state process of contracting for services through a network of local providers. The decision to expand or support new services using PATH funds is based upon a demonstration of need, provider experience, program compliance with PATH guidelines, availability of funds, and may be triggered by an interested provider, the DBHDD regional office, or the State PATH Contact (SPC).

A provider may trigger this decision by requesting consideration of PATH funding based upon the submission of an Intended Use Plan (IUP) and related budget describing their proposed PATH activities. DBHDD regional office staff reviews all submitted proposals and forwards those that comply with regional planning and PATH guidelines to the SPC for further funding consideration. A Regional Office may trigger selection of a provider by contacting the SPC and requesting regional consideration for PATH funding based upon presented need. The SPC may trigger this decision by issuing a notification of funds available to the DBHDD regional offices and requesting support information for PATH funding, including provider availability.

Once a region with the greatest service need is established, the competitive Request For Proposal (RFP) bidding process is used to select and award a contract to the PATH provider within that region. Regional staff, the Director of the Office of Adult Mental Health, and the SPC jointly participate in the selection process.

Provider contracts may be renewed on an annual basis as long as the provider continues to meet annual performance indicators set forth by the State. When the outcomes are not met or when there is need for a new team, selection may be triggered by any of the means listed above, including the SPC initiating the competitive bidding process to select a new PATH vendor by releasing a written request for proposals (RFP). Each year, the PATH Grant Application is posted on the Department’s website at www.dbhdd.georgia.gov for public viewing and comment regarding the use of PATH funds and the availability of new funding opportunities. In addition, the regional offices annually announce the availability of PATH funds and invite public comment through local collaborative meetings.

1 | Selection of Local Area Providers

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According to the US Census Bureau vintage year 2016 population estimates, Georgia has a population of 10,310,371 with a 6.4% population growth since 2010. The table below identifies the ten (10) areas in Georgia with the largest population, including prevalence estimates for need of mental health services. Included also are two additional PATH catchment areas (#11 & #12).

County Ranking with Prevalence Estimate for Need of Mental Health Services

Areas Adult Population Total Population # Homeless PATH Team (s) > 18 years of age Persons per Serving this Area County Populatio MH Prev. Population MH Prev. 2015 PIT n Est. Est. Count Georgia 6,997,02 279,881 8,259,667 330,387 14,000 5 1 City of Atlanta 382,743 15,310 472,522 18,901 4,317 Community Friendship; Hope Atlanta, Fulton- DeKalb Hospital Authority; Mercy Care Services; Community Advanced Practice Nurses 2 Fulton** 787,969 31,519 1,023,336 40,933 473 Community (Atlanta) Friendship; Hope Atlanta, Fulton- DeKalb Hospital Authority; Mercy Care Services; Community Advanced Practice Nurses 3 Gwinnett 653,137 26,125 907,135 36,285 792 Note: due to lack of emergency shelter, homeless persons tend to migrate and/or are referred to housing and other available resources in Fulton County/City of Atlanta 4 DeKalb** 562,644 22,506 740,321 29,613 684 Community (Atlanta) Friendship; Hope Atlanta, Fulton- DeKalb Hospital Authority; Mercy Care Services; Community Advanced

2 | Selection of Local Area Providers

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Georgia’s PATH funding allocation is based on an urban population formula, with funding priority going to those urban locations with the greatest concentration of homeless individuals (**), as well as availability of other necessary resources to accomplish housing and stability (employment, housing stock, proximity to VA Medical Center or VA Clinic, public transportation, etc.). These priority locations include Fulton (includes the City of Atlanta) and DeKalb Counties (includes parts of the City of Atlanta); Cobb County; Augusta/Richmond County; Columbus/Muscogee County; and Savannah/Chatham County. The State also uses data generated by the Statewide Performance Management System to identify service needs by region.

A comparison of the 2015 PIT Count of Homeless Persons map (Image 1) and the PATH Local Area Providers map (Image 2) below, demonstrates that current PATH teams are located in areas of the state with the greatest number of individuals who experience homelessness with serious mental illnesses or co-occurring substance use disorders.

3 | Selection of Local Area Providers

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4 | Selection of Local Area Providers

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J. Location of Individuals with Serious Mental Illnesses who are Experiencing Homelessness

Narrative Question: Indicate the number of individuals with serious mental illnesses experiencing homelessness by each region or geographic area of the entire state. Indicate how the numbers were derived and where the selected providers are located on a map.

Footnotes:

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Indicate the number of individuals with serious mental illnesses experiencing homelessness by each region or geographic area of the entire state. Indicate how the numbers were derived and where the selected providers are located on a map.

Historically, few definitive counts of the homeless population existed at the local, state, or national level. Homeless data was tabulated using many different methods. These methods may have included prevalence estimates using the quantitative data collected from several resources providing a baseline to begin an estimate of need. Currently, homeless data includes the tracking of administrative data as part of a statewide performance management system; the tracking of service usage through a computerized homeless provider communication system (HMIS); and through the use of emergency shelter, street, and institutional census counts. These efforts to estimate the number of individuals in Georgia who are homeless with a serious mental illness (SMI) have proven beneficial in the service planning and resource allocation process.

GA Department of Community Affairs’ (DCA) Point-in-Time Homeless Count

A homeless “point-in-time” count is conducted every two years and serves as the primary source of data to understand and track homeless trends across the state. Even though Georgia conducted its first count in 2003, more consistent and reliable practices for counting sheltered and unsheltered homeless began in 2007. The 2015 Report on Homelessness seems to indicate that Georgia’s efforts to end homelessness have been effective. Based on the January 2015 Point-in- Time Count (PIT), at least 13,790 people were literally homeless, a 19% decrease from 2013. Also of note is the fact that “2013 marked the first year in which just under half of the homeless individuals and families were unsheltered. In 2015 the number of people who were unsheltered homeless continued to decline with just 42% of the state’s overall homeless population being unsheltered.” The “1996 National Survey of Homeless Assistance Providers and Clients” indicates that 45% of homeless individuals have mental health needs. SAMHSA indicates 20 to 25% of the homeless population in the US suffers from some form of severe mental illness. Based on Georgia’s 2015 PIT count of 13,790, there were 1,838 (13%) Georgians who were homeless with mental health needs. An additional 2, 600 reported substance use disorders, however, the report did not indicate what percentage of these may have been co-occurring disorders.

According to the HUD 2016 Continuum of Care Homeless Assistance Programs Homeless Populations and Subpopulations Report, 10, 672 (77%) were adults age 18 and over. Additional data from the 2015 PIT count includes:

Homelessness by Sleeping Location (%):  The number of people counted sleeping in emergency shelters/transitional housing was 7,987 (58%).  The number of people found in unsheltered locations was 5,803 (42%).

1 | Location of Individuals with Serious Mental Illness Who are Experiencing Homelessness

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 202 of2 of231 5 These findings reflect a homeless population that predominately lives in metropolitan areas and are literally homeless. Results continue to confirm the ranking density of homeless population concentration by city/county as City of Atlanta (4, 317), Savannah/Chatham County (1,100), Gwinnett (792), DeKalb (684), Fulton (473), Cobb (415), Augusta/Richmond County (407), and Columbus/Muscogee (371). With the exception of Gwinnett County, Georgia’s PATH Teams serve in the densest areas where the greatest concentrations of homeless individuals with mental illness are likely to be. Efforts are in place to identify a suitable agency to provide services in Gwinnett County in state FY19, as PATH funding allows.

ClientTrack™ Homeless Management Information System (HMIS)

DCA operates as the state housing authority and supports the newly adopted ClientTrack™ Homeless Management Information System (HMIS). Since its beginning in 2002, Pathways Compass, the HMIS system utilized by the majority of homeless service providers in the state tracked services provided to over 207,946 homeless or at-risk Georgians by its more than 386 HMIS members statewide. Now that all CoC’s within the state have all transitioned to ClientTrack™ it is expected that agencies in addition to the previous 386 will contribute to the state’s understanding of the dynamics of Georgia’s homeless population. All PATH providers actively participate in Pathways; tracking outreach contacts and entering clients into HMIS upon enrollment in PATH funded services.

Statewide Performance Management System

DBHDD’s information system tracks the number of mental health consumers who self-report as homeless when authorized for community mental health services. The Behavioral Health Planning and Advisory Council (BHPAC) tracks this data quarterly as a part of their state monitoring responsibilities. It is interesting to note that in 2013 47% of the adults reporting their living condition as homeless when authorized for mental health services are located in Region 3, which includes Atlanta/Fulton and DeKalb Counties. Therefore, Georgia dedicates nearly 50% of PATH funds to provide Outreach and Case Management services in Atlanta/Fulton and DeKalb Counties.

Number of Adults with Serious Mental Illness Reporting Homelessness by Region, Gender, Age SFY 2013 from July 1, 2012 through June 30, 2013, Coinciding with January 2013 Point-in-Time Count Geographic Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Total Region Age Group F M F M F M F M F M F M F M 9-17 0 0 0 0 0 0 1 0 0 1 0 0 0 0 18-20 16 20 14 18 35 40 6 5 10 10 9 9 1 1 21-30 11 12 54 10 207 298 47 51 41 45 49 57 90 102 5 8 2 31-40 13 13 77 14 258 407 64 56 42 43 61 70 513 681 4 2 1 41-50 11 18 99 21 368 663 56 65 58 85 66 11 636 849 5 9 3 8

2 | Location of Individuals with Serious Mental Illness Who are Experiencing Homelessness

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3 | Location of Individuals with Serious Mental Illness Who are Experiencing Homelessness

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F//Fulton Richmond County

Muscogee County

Savannah/Chatham County

4 | Location of Individuals with Serious Mental Illness Who are Experiencing Homelessness

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K. Matching Funds

Narrative Question: Describe the sources of the required PATH match contributions and provide assurances that these contributions will be available at the beginning of the grant period.

Footnotes:

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Describe the sources of the required PATH match contributions and provide assurances that these contributions will be available at the beginning of the grant period.

Georgia remains committed to serving homeless individuals with a serious mental illness. The State PATH Contact participates in Georgia’s Interagency Council on Homelessness to oversee the implementation of the State Homeless Action Plan, which includes support and advocacy for the PATH Program. The State of Georgia agrees to comply with the maintenance of effort by making available state contributions toward homeless services in an amount that is not less than $1 for every $3 of Federal PATH funds provided in the FY 2018 allocation, which are available at the beginning of this grant period. The State of Georgia will maintain state expenditures for services specified in Section 521 of the Public Health Service Act at a level that is not less than the average level of such expenditures maintained by the State for the 2-year period proceeding this fiscal year.

1 | Matching Funds

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L. Other Designated Funding

Narrative Question: Indicate whether the mental health block grant, substance abuse block grant, or general revenue funds are designated specifically for serving people who experience homelessness and have serious mental illnesses.

Footnotes:

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Mental Health Block Grant (MHBG) Funds

Georgia’s MHBG funds are used to finance Peer Support Services and Supported Employment. No MHBG funds support PATH services.

Substance Abuse, Prevention and Treatment Block Grant (SAPTBG) Funds

In 2003, MHBG funds were matched with SAPTBG funds to develop the first consumer- operated PEER Centers for consumers with co-occurring disorders. These services provide structured activities within a peer support model that promotes socialization, recovery, self- advocacy, development of natural supports, and maintenance of community living skills. Activities are provided between and among individuals who have common issues and needs, and assist individuals in living as independently as possible. This service is available to assist and support any homeless person, including PATH clients, with co-occurring disorders in acquiring skills needed to manage their illness and access community resources.

State General Revenue Funds

Any adult with a behavioral health diagnosis in accordance with the DSM V with a significantly affected level of functioning due to mental illness and/or addictive diseases and financially unable to pay for all or part of the needed service and has no third party source of payment is deemed eligible to seek assistance and receive any service available within the public delivery system. Individuals who are homeless are identified in mental health provider contracts as a priority population to receive State funded mental health services, and shall be seen immediately in compliance with their needs. Additional state funds are used to support residential programming for the homeless or formerly homeless.

1 | Other Designated Funding

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M. Data

Narrative Question: Describe the state’s and providers’ status on the HMIS transition plan, with an accompanying timeline for collecting all PATH data in HMIS. If the state is fully utilizing HMIS for PATH services, please describe plans for continued training and how the state will support new local-area providers.

Footnotes:

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Describe the state's and providers' status on HMIS transition plan, with accompanying timeline for collecting all PATH data in HMIS by FY 2016. If you are fully utilizing HMIS for PATH services, please describe plans for continued training and how you will support new local-area providers.

In 2017 The Department of Community Affairs (DCA) coordinated transition to a new statewide Homeless Information Management Information System (HMIS) known as ClientTrack™. Georgia’s Homeless Management Information System is intended to provide a community with an unduplicated count of its homeless population. In addition to collecting data ClientTrack™ facilitates collaborative case management, thus giving each PATH Team a more comprehensive client history and preventing the duplication of services. All providers of homeless services and/or shelter are encouraged to participate. Georgia is dedicated to using data to reduce homelessness and improved coordination of care and services for individuals experiencing homelessness. Georgia selected ClientTrack HMIS in order to improve the ability to track their clients, streamline intake processes, provide data visibility between Continuums of Care (CoC) and ensure compliance with federal HMIS Data Standards.

This single state HMIS system collects the PATH HMIS Universal Data Elements required by FY16, and is compliant with PATH Annual Report requirements. The statewide HMIS database will incorporate 1,800 users in 450 agencies across eight Continuums of Care (CoC). Users enter client information to connect them to a homeless provider network. All ten (10) PATH Teams use ClientTrack™, have completed user and ethics training, and actively enter client data during outreach and when enrolling a homeless individual into PATH supported services.

DCA provided ongoing one-on-one follow-up, training (web-based and on site), and technical assistance for agencies, as well as group training on hot topics and/or FAQs at the annual PATH Training Summit. The state’s HMIS Coordinator from DCA attends regular PATH Coalition Meetings to provide updates on system operations and performance, as well as field questions from PATH users.

1 | Data

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N. Training

Narrative Question: Indicate how the state provides, pays for, or otherwise supports evidenced-based practices, peer support certification, and other trainings for local PATH-funded staff.

Footnotes:

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Indicate how the state provides, pays for, or otherwise supports evidenced-based practices, peer support certification, and other trainings for local PATH-funded staff.

Georgia recognizes the importance and value of training for PATH and behavioral health treatment providers across the state. Multiple approaches offering technical assistance and programmatic improvement strategies are in place through the use of PATH funds and other DBHDD training dollars. Training is made available on an agency basis through routine site visits, on a regional basis through local forums, and offered statewide via multiple formats and in varied locales to provide access to providers in all regions. More and more training opportunities are coming available through technical advancement, including webinars and videoconferencing.

The State PATH Contact visits each PATH Program as needed, providing individualized training based upon program performance and assessed need. In addition to the annual visits, the State PATH Contact is readily available to all PATH funded staff throughout the year for telephone or email consultation. Information regarding national teleconferences, funding opportunities, and Continuum of Care information are relayed by listserv to all PATH providers. Providers may use PATH funds to send Peer Specialists to Certification training to build a competent consumer workforce.

In Region 3, the Regional Office PATH Coordinator conducts bi-weekly Metro PATH Collaborative meetings with the five (5) PATH programs to discuss cases, share information, and organize outreach events. Training and local resource presentations are a part of the collaborative meetings.

Each year, the State PATH Contact organizes a statewide PATH Training Summit, as well as engages PATH Teams in other DBHDD-funded Training opportunities. Highlights include, but are not limited to:

 Teams have ongoing access to DBHDD’s Case Management Toolkit, which can be found online at https://dbhdd.georgia.gov/sites/dbhdd.georgia.gov/files/related_files/site_page/CM_Tool kit-final6-15-13.pdf  In 2016-17, PATH Teams attended statewide training sessions and follow up webinars regarding the new ClientTrack™ HMIS and data migration implementation, in addition to ongoing technical assistance.  Housing First Model Training for Community Providers (January 2017)  Mental Health First Aid (April, May, and June 2017)  Annual PATH Training Summit and Combined Outreach Practicum (May 16-18, 2017) o Multi-agency Homeless Outreach in Savannah Metro Area o Personality Disorders o The Positive Impact of Supported Employment in the Homeless Community o Teambuilding

1 | Training

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2 | Training

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O. SSI/SSDI Outreach, Access and Recovery (SOAR)

Narrative Question: Describe how the state encourages provider staff to be trained in SOAR. Indicate the number of PATH providers who have at least one trained SOAR staff. If the state does not use SOAR, describe state efforts to ensure client applications for mainstream benefits are completed, reviewed, and a determination made in a timely manner.

Footnotes:

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O. SSI/SSDI Outreach, Access, Recovery (SOAR)

Describe how the state encourages provider staff to be trained in SOAR. Indicate the number of PATH providers who have at least one trained SOAR staff. If the state does not use SOAR, describe state efforts to ensure client applications for mainstream benefits are completed, reviewed, and a determination made in a timely manner.

Georgia utilizes SOAR to ensure that client applications for mainstream benefits are completed, reviewed, and a determination made in a timely manner. During state FY16, SOAR trained Eligibility Specialists, who work directly on consumer applications within DBHDD’s six (6) Regional Field Offices, including PATH applicants, maintained a 92% first time approval rate.

Since a primary route to Medicaid is through SSI for adults with disabilities, these Medicaid Eligibility Specialists use SOAR techniques to dramatically expedite the application process and reduce the disability determination period. In 2009 PATH (Projects for Assistance in Transition from Homelessness) funds supported a three-year project to increase the number of successful SSI/SSDI applications for Georgians experiencing homelessness, to facilitate their recovery and enable them to become contributing members of their communities. GA’s premier SOAR training initiative was among the most effective in the nation, according to an outcome report released by Policy Research Associates, Inc. For homeless individuals, the average approval rate for Supplemental Security Income/ Social Security Disability Income (SSI/SSDI) is less than 20 percent.

DBHDD continues to provide SOAR training using SAMHSA’s ‘Stepping Stones to Recovery” curriculum to contracted providers, including PATH providers, throughout the state. PATH Teams may also take SAMHSA’s online SOAR Training. All PATH teams are required to have at least one SOAR trained team member of their own, in addition to their access to DBHDD Eligibility Specialists to facilitate individuals’ applications for SSI/SSDI benefits.

1 | SSI/SSDI Outreach, Access, Recovery (SOAR)

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P. Coordinated Entry

Narrative Question: Describe how PATH is engaged with the local coordinated-entry processes of the CoC(s) in the jurisdictions in which PATH operates and roles of key partners.

Footnotes:

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Describe the state's coordinated entry program and role of key partners.

The Georgia Department of Community Affairs (DCA) oversees the efforts of all the state’s Continuums of Care’s in developing and implementing centralized or coordinated assessment systems, which are defined to mean a centralized or coordinated process designed to coordinate program participant intake, assessment, and provision of referrals. A centralized or coordinated assessment system covers the geographic area, is easily accessed by individuals and families seeking housing or services, is well advertised, and includes a comprehensive and standardized assessment tool. This definition establishes basic minimum requirements for the Continuum’s centralized or coordinated assessment system. All housing programs that receive HUD funding are required to utilize the coordinated entry system designated by the CoC for the geographic location of their program. All DBHDD PATH Teams are participants in their designated CoC and are key participants in the development and implementation of coordinated entry programs. Several state CoC coordinated entry plans and programs are highlighted below:

I. City of Atlanta

Partners for HOME is a 501(c)(3) leading a coordinated effort to end homelessness in the City of Atlanta, which has the densest population of homeless individuals within the state. Partners for HOME serves as the administrative and operational body for the City of Atlanta’s Homeless Continuum of Care (CoC). A primary objective of the organization is to leverage additional dollars to execute the priorities of the CoC.

 Partners for HOME launched Clear Path, its pilot Coordinated Entry Project (“CE”), in July of 2015. Clear Path targets chronically homeless individuals in need of permanent housing. The coordinated entry process prioritizes those households with the most intensive service needs and housing barriers (e.g. chronically homeless households and households with multiple episodes of homelessness) using the HUD definition of Chronic Homelessness - as an individual or family with a disabling condition who has been continuously homeless for a year or more or has had at least four episodes in the past 3 years which total 12 months or more. o VI SPDAT score of 10+ - referred to permanent supportive housing o VI SPDAT score of 5-9 – referred to rapid rehousing o VI SPDAT score of 0-4 – not referred for housing options at this time

As of July 1, 2017, current assessment tool will be replaced by the VI SPDAT 2.0.

 Individuals (and families) may access the system of services and housing interventions through outreach on the streets, in the jail, local hospital emergency

1 | Coordinated Entry

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 218 of2 of231 8 room, abandoned buildings and libraries, under bridges, in parks, and at the bus station and airport. They can also access the system as walk-ins to designated Coordinated Access Points (CAPs - service organization facilities which act as a point of entry for those seeking services and/or housing) (See CE protocol attached)

 The Region 3 PATH Teams continue to work collaboratively with the City of Atlanta ESG and now CABHI-funded Outreach Workers and serve as mobile Coordinated Access Points to provide entry into the homeless system. The PATH team members conduct scheduled outreach throughout downtown Atlanta and the surrounding area. Their target populations are singles and families experiencing homelessness who also have severe and persistent mental illness.

 The on-going Coordinated Entry Implementation Committee has been meeting regularly since September 2015. This committee has gathered and considered feedback of agencies participating in coordinated entry and weekly case conferencing meetings in order to make recommendations to improve the effectiveness of the Coordinated Entry Process. The committee has recommended the addition of a Coordinated Access Point.

Partners for HOME released an RFP on March 2, 2016 for eligible and qualified 501c3 non- profit organizations that are interested in submitting proposals for the Atlanta Continuum of Care’s Coordinated Entry Pilot Project called Clear Path. The award recipient serves as a Coordinated Access Point (CAP) for individuals and/or families experiencing homelessness in the City of Atlanta and works in close partnership with the Partners for HOME Deputy Director of Housing and Resource Coordination and the PATH teams who currently serve as mobile CAPs in order to expand the Clear Path pilot.

II. Augusta/Richmond County

Augusta/Richmond County has designated CSRA Economic Opportunity Authority Inc., as the lead agency for the coordinated intake and assessment for its continuum, the site location is 730 E. Boundary, Augusta, GA 30901. This program will remedy many of the challenges that consumers face when seeking access to the homeless prevention and response services system Coordinated Intake will reduce the length of time persons experience homelessness, promote a more efficient use of limited resources, and help to stabilize households and communities The Coordinated Intake Program will serve the interest of consumers by helping them locate the housing and service they need; providers, by minimizing time spent assessing people that are not right for their programs; and funders, by ensuring that the right housing and services are connected to the right people, at the community-wide level.

Once engaged, clients will complete and individual assessment with a project case manager and have that assessment reviewed with them to determine their specific needs relative to achieving

2 | Coordinated Entry

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 219 of3 of231 8 permanent housing. These needs and the related barriers are then formulated by the case manager into a client-centered individual service plan. The level of service and/or assistance needed by the client will then be compared to the available resource inventor and a qualified and appropriate referral for placement and/or services will be made by the project case manager. Consumers will then be provided intensive, on-going case management by Coordinated Intake staff to ensure service goals are met and permanent housing is achieved.

The Path Program is an essential part of this effort to make those persons living on the streets our first priority.

III. Chatham-Savannah Authority for the Homeless The Savannah-Chatham County CoC has not yet gone live with our Coordinated Entry plan; however, CoC members have met, set community priorities and have agreed upon a number of items. There are several components in place, including the type of coordinated entry model the CoC will use, what agency will be the lead in the implementation of the process, the focus population, the referral process, the data system to be used, and the staffing model. Also, a flow chart of services (which includes all homeless service providers in the CoC) has been developed. The Barriers to Housing Stability Assessment, a simple tool to rapidly assess participants’ needs, will be utilized as a pre-screening tool. The Vulnerability Index-Service Prioritization Decision Assistance Tool or the VI-SPDAT is a triage tool which will also be used to quickly assess the health and social needs of homeless persons and match them with the most appropriate support and housing interventions that are available. The CoC is working with Pathways Compass Rose, our HMIS provider, to configure the tool in the Management Information system to meet the needs of the local community.

TIMELINE OF COORDINATED INTAKE/ASSESSMENT ACTIVITIES

ACTIVITY DATE  Initial Meeting September 2013  Focus group Session October 2013  Community Systems Design/Mapping January 2014  Community Conversations February-August 2014  Coordinated Assessment Model Selection August 2014  Continued Community Conversations September 2014-December 2015  Finalize Assessment Tool July 2016  Community Training Sessions August-November 2016  Implementation October 2016  Process Evaluation November-December 2016

It may be necessary to revise the above timeline dependent upon issues that may arise during the finalization of the assessment tool and project implementation.

How the PATH Team interacts with/supports the local CoC:

3 | Coordinated Entry

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 220 of4 of231 8 The Chatham-Savannah Authority for the Homeless (CSAH) is the Continuum of Care lead agency; it collaborates with the agencies that are the providers of behavioral health services and provides some transportation for clients enrolled in behavioral health programs. CSAH administers the PATH grant and manages the local PATH team. The five peer specialists on the PATH team are also out-stationed at predetermined Continuum of Care sites including Emmaus House, Inner City, Savannah Baptist, Old Savannah City Mission, and the Social Apostolate. Since 2004, all Continuum of Care organizations were linked to a Homeless Management Information System called Pathways, and the PATH team is required to maintain data on consumers through this statewide Homeless Management Information System.

 Recovery Place Community Services for substance abuse services;  Savannah Counseling Services for ongoing mental health services (ICM);  J.C. Lewis Health Center of Union Mission for medical and dental needs;  Union Mission, Inc. (No Wrong Door and permanent supportive housing)  Housing Authority of Savannah and Union Mission, Inc. for permanent supportive housing;  Georgia Regional Hospital for access into Assertive Community Treatment for those with the most intensive needs.  Coastal Harbor for crisis stabilization and discharge planning for homeless consumers  Memorial Health University (Clark Center) for behavioral health  AmericanWork (ACT I and Chatham ACT)  Savannah Justice Law Center (SJLC) which assists in acquiring birth certificates so that consumers can obtain proper identification, i.e., Georgia ID card  Union Mission, Department of Labor, and Goodwill for employment services

IV. GA 502 – Fulton County CoC

The GA 502 – Fulton County CoC encumbers an area 74.6 miles from the northernmost point to the southernmost point outside of the city of Atlanta. They recently received funding, via the FY2015 NOFA competition, to implement the Coordinated Intake and Assessment System (CIAS), composed of mobile outreach teams serving the southern and northern parts of Fulton County, with respect to their relative uniqueness. The outreach teams, staffed by MSWs and formerly homeless outreach workers will recruit and assess those in need, and utilizing that assessment, connect electronically to the coordinated entry data base of CoC service providers to match identified needs and suitability with system resources. All contracted service providers will be required to inventory their capacities and non-contracted providers will be encouraged to commit to interacting with the system. System coordination is obviously critical as is integration of resources and ideas. The Fulton County CoC expects to begin the initial rollout phase,

4 | Coordinated Entry

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V. GA-506 Marietta/Cobb Continuum of Care

GA-506 Marietta/Cobb Continuum of Care has not yet implemented Coordinated Entry. They are in the initial stages of forming a CE Committee and plan to begin implementation of CE, at least on a limited basis, during 2016.

The PATH Team led by Hope Atlanta participates in CoC activities including the Point-in-Time counts and Housing Inventory updates, General Membership meetings, and bi-monthly HMIS User Group meetings. A representative from Hope Atlanta serves on the CoC Board of Directors.

VI. DeKalb CoC

The DeKalb County Continuum of Care has developed a coordinated, systems approach to prevent and end homelessness in DeKalb County, GA. The DeKalb Continuum of Care has instituted a coordinated intake and assessment system which utilizes a “No Wrong Door” approach to streamline and expedite the entry of individuals and families at-risk or experiencing homelessness into the homeless service system. Each system entry point (“front door”) uses a common pre-screening tool and makes referral decisions based on a common set of factors. This “no wrong door” approach means that homeless individuals, families and youth, are identified early, comprehensively assessed and referred to the services and housing that best meets their needs. The DeKalb CoC completed a 90-day pilot of CIA for homeless individuals and families and is preparing for full system implementation.

Highlights of the DeKalb Coordinated Intake and Assessment System are noted below:

 The DeKalb CIA system allows homeless individuals and households facing housing loss to quickly access needed services without having to call multiple social service programs. Coordinated intake and assessment prevents unnecessary duplication, makes better use of resources and staff time, and connects homeless persons with the housing and supportive services they need and are eligible for.  Individuals and families fleeing domestic violence are triaged and referred immediately to local Domestic Violence agencies for assessment and safe haven.  Veteran households facing housing loss may present at any agency within the continuum and trained staff and volunteers will screen and immediately refer applicants to the VA’s Community Resource and Referral Center (CRRC) at Fort McPherson for full assessment.  Families with children are pre-screened and immediately referred to Decatur Cooperative Ministry for a comprehensive assessment and referral to housing and services.

5 | Coordinated Entry

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 222 of6 of231 8  Pathways Community Network Institute (PCNI) provides on-going training and technical assistance to case managers, throughout the continuum, on the use and entry of the DeKalb Coordinated Intake and Assessment Pre-Screening information into the Homeless Management Information System (HMIS). Agencies not utilizing HMIS are provided paper hard copies of the Pre-Screening form to complete and fax to the referring agency.

PATH Team Interface with the DeKalb CoC

Georgia’s Region 3 PATH Teams provide outreach services by going to the streets, woods, and homeless shelters to identify homeless individuals with mental illnesses, engage them in treatment, and connect them to mental health services and mainstream resources needed to end their cycle of homelessness. One target population for this program are DeKalb County’s chronically homeless, those who suffer from severe mental illness, and those who have been homeless for longer than one year.

The Outreach Teams collaborates with the Veterans Administration, Mercy Care Services, Grady Health Systems, police departments, behavioral health services, a dedicated outreach worker funded by DeKalb Emergency Solutions Grant Program (ESG), and other service partners to identify and assist homeless persons in the DeKalb area. PATH Team Members are active participants in the DeKalb CoC, serving on workgroups, steering committees, and conducting outreach during the biennial Homeless Point in Time Counts. The PATH Teams and the ESG Outreach worker assist homeless persons on the streets by providing case management, and information and referrals for supportive housing, public assistance, shelters, and treatment programs. All ensure that appropriate supplies are available to assist the homeless on the streets by providing basic necessities such as public transportation cards, blankets, care packs, drinks, snacks, etc.

Once engaged, all eligible consumers are afforded the opportunity to begin receiving services and case management, including housing placement or referral to a treatment program. During the intake and assessment process, which is completed using Pathways HMIS, a wide variety of information is gathered in order to learn more about each individual's unique circumstances that led to their homelessness. This information is also used to effectively construct a meaningful ISP that addresses their barriers to self-sufficiency and housing, and sets goals to overcome those obstacles. Some of the types of information gathered include length of homelessness, previous housing status, recent hospitalizations or incarcerations, medications they may be taking, substance abuse and/or mental health treatment history, circumstances that caused homelessness, and the individual's level of commitment to success within the program.

6 | Coordinated Entry

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 223 of7 of231 8 At regular outreach collaborative meetings, the PATH Teams and ESG Outreach Worker note trends and "hot spots" in DeKalb, and also help identify the special needs of the chronically homeless.

VII. Balance of State CoC

As of its November 16, 2016 meeting, the Georgia Balance of State CoC was just beginning to prioritize development of its Coordinated Entry System.

7 | Coordinated Entry

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Q. Justice Involved

Narrative Question: Describe state efforts to minimize the challenges and foster support for PATH clients with a criminal history, such as jail diversion, reentry and other state programs, policies and laws.

Footnotes:

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Describe state efforts to minimize the challenges and foster support for PATH clients with a criminal history such as jail diversion and other state programs, policies and laws. Indicate the percent of PATH clients with a criminal history.

While Georgia PATH Teams do not currently collect and/or report any data pertaining to the number of PATH clients with criminal history, DBHDD and Georgia’s PATH Teams are keenly aware of the need for services and supports to be provided to individuals who have been or are currently involved with the criminal justice system. This increased awareness of the plight of PATH clients involved in the criminal justice system assists Georgia in planning for and addressing the needs of this subpopulation through collaboration with state and local partners.

DBHDD, Criminal Justice and Law Enforcement Collaboration

DBHDD recently entered into a Memorandum of Agreement to fund the Georgia Public Safety Training Center to provide Crisis Intervention Team (CIT) training to Georgia’s law enforcement officers using the Memphis CIT model. In an effort to reduce the stigma associated with mental illness, the Georgia CIT Program's vision is a Georgia where citizens with serious mental illness receive medical treatment in lieu of incarceration. Georgia adopted a top-down approach to training law enforcement by forming a collaborative with executives from key departments of state government, mental health providers and NAMI Georgia, a local advocacy organization.

From December 2004 through June 2017, DBHDD funded 686 classes, training approximately 9,500 law enforcement officers across the state in identifying and understanding signs and symptoms of various mental illnesses, substance use disorders, and developmental disabilities, utilizing de-escalation techniques to divert persons from incarceration to behavioral health treatment and supports, working with community-based organizations to help consumers stay within the community. Additionally, The Department funds behavioral health services for seven Mental Health Treatment Courts across the state, with focus on diverting individuals with a mental illness away from jail and into appropriate mental health treatment.

Specialty Services

As part of the Department of Justice settlement agreement, Georgia was required to provide expanded and enhanced community services for approximately 9,000 individuals with severe and persistent mental illness who are currently being served in state operated hospitals; frequently readmitted to state operated hospitals; frequently seen in emergency rooms due to mental illness; chronically homeless; and/or released from jails or prisons. Many of these individuals were homeless and subsequently served by the PATH Teams across the state. The services provided and aimed to improve outcomes for justice involved and other individuals with serious mental illness include Assertive Community Treatment (ACT), Community Support Teams, Case

1 | Justice Involved

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 226 of2 of231 6 Management, Supported Employment and an array of crisis services. Georgia was found to be in compliance with settlement goals (see chart below) in May of 2016. As part of an extension agreement with the DOJ, Georgia will continue to focus on expanding supportive housing options for individuals with mental illness, including PATH clients who are or have been justice involved.

# Settlement Agreement Adult Mental Health Community-Based Services Description 22 Assertive Community Treatment Teams 8 Community Support Teams 14 Intensive Case Management Teams 45 Case Management Services 3 Crisis Stabilization Programs 6 Crisis Service Centers 2,000 Persons receiving state funded Housing Assistance 540 Persons receiving Bridge Funding 550 Persons receiving Supported Employment Services 835 Persons receiving Peer Support Services 18 Crisis Respite Apartments 159 Counties with Mobile Crisis Service coverage

Additionally, all ACT, CST and ICM teams regularly provide in-reach to jails in the areas that they serve, receiving referrals from jails and linking eligible individuals to the full array of treatment and support services including housing. These services receive referrals from PATH Teams and other community agencies for homeless mentally persons and have facilitated housing via access to the DBHDD GA Housing Voucher for previously homeless, mentally ill persons and persons who were referred from either jail or prison who have a mental illness:

Year # Homeless Individuals with SMI # Individuals with SMI from Placed in Permanent Supportive Jail/Prison Placed in Permanent Housing Supportive Housing 2011 55 0 2012 212 4 2013 225 7 2014 387 43 2015 480 59 2016 524 71 2017 338 21 Total 2,221 205 Housed

2 | Justice Involved

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DBHDD participates in several intra- and inter-agency initiatives to address the needs of justice involved individuals with behavioral health issues. DBHDD is advised by a Behavioral Health Coordinating Council (BHCC), which is administratively attached to DBHDD. The Council members include the Commissioners of the Departments of Corrections, Human Services, Juvenile Justice, Labor, Public Health, Community Affairs (Housing) and Community Health (Medicaid authority); the State Superintendent of Education; the Chairperson of the State Board of Pardons and Paroles; one Senator, one Representative, one family member of a consumer, one parent representative and one adult consumer. The BHCC established an initiative in 2013 whereby a Transition Workgroup was developed to address the needs of persons transitioning from the correctional/justice system into the community. The State PATH Contact (SPC) is an active participant in this Workgroup. The Workgroup is co-chaired by DBHDD’s Director of Adult Mental Health and a member of the Department of Community Supervision’s leadership team, and early outcomes are fostering inter-agency partnerships to address barriers and infrastructure challenges for persons in the criminal justice system. The SPC advocates regularly for the inclusion of the voice of lived experience from individuals who have experienced both homelessness and involvement in the criminal justice system. This advocacy resulted in development of the Forensic Peer Mentor (FPM) Program, which now employs several Certified Peer Specialists (CPS) and Certified Addiction Recovery Empowerment Specialists (CARES) who have the unique experience of being in recovery from mental illness and being both formerly homeless and incarcerated. FPMs work with persons who have mental illness and are justice system involved, either in prison or who are under supervision at a Day Reporting Center. FPMs facilitate transition and community re-entry for this population, including assistance with housing and employment goals.

Local PATH Team Initiatives

PATH Teams have specific outreach and case management efforts to support the subpopulation of PATH clients with a criminal history. Examples of initiatives in major urban locations throughout the state, which have the highest concentrations of homeless individuals with a criminal history include the following:

 Community Advanced Practice Nurses (CAPN) has been involved in prisoner re-entry over the past several years. They perform physical exams and TB screening for Fulton County Drug Court routinely and referrals to the PATH program are attained via this primary contact with prospective clients. Primary care nurse practitioners are well versed in screening for chronic mental health issues and homelessness. Intra-agency referrals are fluid and common in their holistic approach to medical and mental health treatment of clients. They also maintain regular contact with the Georgia Department of Community Supervision (DCS) and the Atlanta Community Impact Program to assist with re-entry needs of Returning Citizens. Referrals to their PATH team are assessed for assistance with entry into mainstream mental health services, emergency, and permanent housing.

3 | Justice Involved

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 228 of4 of231 6 Income needs are assessed and referral to SOAR or vocational pre-employment counseling is completed. Furthermore, one of CAPN’s nurse practitioners has recently started offering Community Resiliency Model training to the staff at jails and prisons in the Atlanta area, as the population encountered has often experienced trauma in their lives. As an outcome of this staff training referrals to the PATH team will most likely occur as the jail and prison staff associate the trainer with CAPN and their PATH services.

 Community Friendship, Inc.’s PATH team has established relationships with key persons who identify inmates with mental illness prior to being released from jail (or shortly thereafter). Through the below mentioned contacts, referrals are made to CFI PATH team. Those wanting services are immediately housed in a transitional setting. These individuals are afforded the opportunity to be connected to mental health services and mainstream benefits.

 Atlanta Community Impact Program (Prison Re-entry)  Atlanta Detention Center.  Fulton County Detention Center.  Caring Works Inc/Atlanta City Offender Re-entry Program (CORP)

 New Horizon’s PATH Team meets bi-weekly with the Muscogee County Mental Health and Veterans Court. Additionally, the Muscogee County jail staff sends them information/referrals when individuals are about to be released out of jail and need PATH services. The Team also maintains regular contact with the Department of Community Supervision Prison Re-entry Services Unit. Periodically, they send referrals for individuals in need of PATH services.

 The Team Lead for the Chatham-Savannah Authority for the Homeless PATH Team provides advocacy services for the Accountability Courts in Savannah, including Mental Health Court, DUI Court, and Drug Court. He assists with the case planning for homeless participants.

 The Hope Atlanta Team presently works with individuals being released from local and state correctional facilities who have no home or stable housing to return to. They receive referrals from City of Atlanta and Fulton County jails, as well as Coastal Prison located in Savannah and Phillips State Prison in Buford. Additionally, the Hope Atlanta PATH Team has received referrals from the federal prison system in Pennsylvania. Outreach Workers speak over the phone or go in person to assess individuals in the facilities to determine if they are PATH eligible. Upon release, individuals who are eligible and would like to enroll in PATH Case Management services are transported by referring agency staff directly to Hope Atlanta’s facility, are met at the Greyhound bus station, or they are picked up by a PATH Team member.

4 | Justice Involved

Printed: 7/7/2017 11:24 AM - Georgia - FY 2017 PATH FOA Catalog No.: 93.150 FOA No.: SM-17-F2 Approved: 05/05/2017 Expires: 07/05/2017PagePage 229 of5 of231 6  The Grady PATH Team assumes primary responsibility for outreach efforts, along with support from other Grady community programs. The team receives assistance with jail/prison outreach services from Grady Re-Entry Case Manager, who provides care coordination within local jails and courts. The PATH team provides outreach and care coordination on an as needed basis when contacted by local justice authorities. The Path Team also collaborates with Atlanta Police monthly to address the homeless population to prevent/avoid incarceration, particularly at Atlanta Hartsfield Airport to prevent homeless individuals from being arrested for loitering or violating no trespass orders. Special linkages are identified to assist with housing, employment assistance, mental health and substance abuse treatment providers, medications, and applications for disability benefits/insurance.

Training DBHDD’s new Behavioral Health Treatment Court Liaisons provided training to all PATH teams at the May 2017 Annual PATH Training Summit. The workshop, entitled Tips for Encounters with Homeless Individuals with Criminal Justice Involvement, was designed to assist PATH team members in understanding the connection between homelessness, mental illness, and criminal justice involvement; better engagement of individuals with criminal justice involvement; and identification of unique needs of this population.

Respect in Recovery 5K Run/Walk In FY16 DBHDD instituted its first annual Respect in Recovery 5K Run/Walk. This community event was founded through an inter-agency partnership to end stigma, promote mental health, and highlight Georgia's successful prison re-entry programs and resources. Returning Citizens with lived experience of homelessness, behavioral health disorders, and criminal justice involvement shared their stories of recovery with a crowd of over 200 people in Atlanta’s Grant Park. This event did a tremendous job of raising community awareness of the fact that people do recover, even individuals who were formerly incarcerated. The second annual event is planned for October 13, 2017.

5 | Justice Involved

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Charitable Choice for PATH

Expenditure Period Start Date: 7/1/2015 Expenditure Period End Date: 6/30/2017

Notice to Program Beneficiaries - Check all that apply:

gfedc Used model notice provided in final regulation. gfedc Used notice developed by State (please attach a copy to the Report). gfedc State has disseminated notice to religious organizations that are providers. gfedc State requires these religious organizations to give notice to all potential beneficiaries.

Referrals to Alternative Services - Check all that apply:

gfedc State has developed specific referral system for this requirement. gfedc State has incorporated this requirement into existing referral system(s). gfedc SAMHSA’s Treatment Facility Locator is used to help identify providers. gfedc Other networks and information systems are used to help identify providers. gfedc State maintains record of referrals made by religious organizations that are providers. gfedc Enter total number of referrals necessitated by religious objection to other substance abuse providers ("alternative providers"), as defined above, made in previous fiscal year. Provide total only; no information on specific referrals required.

Brief description (one paragraph) of any training for local governments and faith-based and community organizations on these requirements.

Footnotes:

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