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C. Local Provider Intended Use Plan:
1. Local Provider Description:
Name of the Organization: Gracepoint (formerly Mental Health Care, Inc.)
Type of Organization: Private Not for Profit Community Behavioral Health Center
Address of Provider: 5707 North 22nd Street, Tampa, FL 33610
Local Continuum of Care Lead Agency: Tampa Hillsborough Homeless Initiative
PATH Contact Name/E-Mail/Phone #: Francisca Ortiz, [email protected],
(813) 239-8389.
Region Served: SunCoast/ Hillsborough County
Indicate the amount of federal, state and local PATH funds the organization will
receive.
Federal: $240,470
Match: $ 80,157
Total: $320,627
2. Collaboration with HUD Continuum of Care Program: Describe the organization’s
participation in the HUD Continuum of Care and any other local planning, coordinating or
assessing activities:
Gracepoint works closely with the Tampa Hillsborough Homeless Initiative, the lead agency
for the Tampa-Hillsborough Continuum of Care, to end homelessness in the area. Employees
of Gracepoint contribute their time through various activities that include, but are not limited
to: attending monthly general meetings and sub-committee meetings; chairing the UNITY
(HMIS) Advisory Group; and participating in the community-wide planning process to
develop and implement the Continuum of Care Strategic Plan along with other key
stakeholders in the community. Gracepoint also planned for and provided five staff who
participated in the Point In Time (PIT) Count, as well as serving as a deployment site for that
activity.
3. Collaboration with Local Community Organizations: Provide a brief description of
partnerships and activities with local community organizations that provide key services (i.e.,
outreach teams, primary health, mental health, substance abuse, housing, employment, etc.)
to PATH eligible consumers and describe coordination of activities with each of these
organizations (describe all that apply):
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There is an extensive array of community services available for PATH-eligible individuals.
These programs have various sources of funding that include city, county, state, federal
government, and private trusts. Area organizations provide services including food, shelter,
vocational training, education, health care, housing assistance, income support,
detoxification, inpatient and outpatient mental health and substance abuse treatment, and
crisis intervention. Gracepoint’s case managers assist persons in accessing community
services and in completing applications for entitlement programs which include, but are not
limited to, Social Security Administration, Medicare, Medicaid, Hillsborough County Health
Care Plan, food stamps, and Veterans’ Benefits, to provide a means of financial support and
increased access to services.
Organizations in the area that provide services to individuals who are homeless include:
Homeless Helping Homeless, Mary & Martha House, Metropolitan Ministries,
ACTS, New Beginnings, the Salvation Army, and The Spring operate emergency
shelters.
ACTS, Alpha House, DACCO, Metropolitan Ministries, New Beginnings, the
Salvation Army, The Spring, Tampa Cross Road, and Volunteers of America provide
access to transitional housing.
Two housing authorities within Hillsborough County, the City of Tampa and the
Plant City Housing Authority, provide units of public housing and housing choice
vouchers (Section 8).
ACTS, Volunteers of America, Project Return, Northside Mental Health Center, and
Gracepoint operate Permanent Supported Housing.
Tampa Family Health Center (TFHC) provides primary health care services to low-
income families who are eligible for the Hillsborough County Healthcare Plan and for
Medicaid.
Northside Mental Health Center and Gracepoint offer inpatient and outpatient mental
health treatment services.
ACTS, DACCO, Tampa Crossroads, and the Center for Women provide outpatient,
detoxification, intervention, education, and residential substance abuse treatment
programs.
The State Division of Vocational Rehabilitation and Tampa Bay Workforce Alliance
assist individuals obtain and maintain jobs.
Hillsborough County Sunshine Line and MMG Transportation, Inc., provide
transportation to medical and therapy services.
Hillsborough Area Regional Transit Authority (HART) offers discount fares to
individuals with disabilities.
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Metropolitan Ministries, Gracepoint, and Project Return make adult basic education
classes available.
Metropolitan Ministries provides assistance with obtaining birth certificates, IDs,
clothing, furniture, and household supplies.
Bay Area Legal Services provides legal counsel, advice, and representation in all
phases of the application for benefits process.
The Health Care for Homeless Veterans’ Program at James A. Haley VA Hospital has
over 20 years of experience in outreaching to veterans who are experiencing
homelessness.
4. Service Provision: Describe the organization’s plan to provide coordinated and
comprehensive services to eligible PATH consumers, 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:
There are four designated PATH-funded Case Managers who are dedicated to
providing outreach and case management services. They are capable of conveying
these services in the field by using agency-owned vehicles, cell phones, and
laptops with internet access. This reduces the burden on enrolled participants to
travel to the office location. When in-office services are necessary participants are
given a bus pass.
Gracepoint’s outreach and case management effort is concentrated to serve
individuals who are homeless or chronically homeless. Each Case Manager
provides outreach on the street in Hillsborough County. The Case Manager looks
for people living on the street and tries to engage them in further services through
repeated contacts. Once an eligible participant is willing to receive further
services s/he is enrolled in the PATH Program and receives case management
services. Gracepoint maintains a list of encampment locations, shelters, and meal
sites and focuses outreach efforts around these locations.
According to the 2016 PIT count, there are more than 1,817 individuals who are
homeless reported to HUD, and over 691 of them are chronically homeless.
Gracepoint is dedicated to providing assistance to this population through its
PATH and housing services.
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b) Provide specific examples of how the agency maximizes use of PATH funds by
leveraging use of other available funds for PATH client services:
Gracepoint also utilizes CoC funds to individuals eligible for the HOME 3
Permanent Supportive Housing Program who were outreached and assisted by
PATH Program staff. Gracepoint works closely with Metropolitan Ministries,
which assists PATH-funded participants attain food, clothing, incidentals,
furniture, and household supplies; Sunshine Line, which assists consumers with
31 day bus passes for transportation to appointments and employment search;
Bikes for Christ which assists with providing bicycles to individuals receiving
PATH-funded services; Hillsborough County Healthcare Plan which assists with
insurance so that consumers receiving PATH-funded services can seek medical
and mental health assistance if they are indigent; and Veteran’s Affairs, Tampa
Crossroads, and St Vincent de Paul, which assists veterans with housing through
VASH or SSVF programs
c) Describe any gaps that exist in the current service systems:
There are not sufficient emergency shelter beds, transitional housing beds, or
Permanent Supportive Housing units for individuals who are homeless and
families. According to 2016 FL-501 Tampa Hillsborough County CoC Housing
Inventory, there are 1,378 emergency shelter beds, 740 transitional housing beds,
and 1,415 Permanent Supportive Housing beds, 800 of which are solely for
veterans, while there are 1,817 persons who continue to experience homelessness
in the community, 181 of which were veterans. There is no local health care plan
for which low-income individuals and families qualify. In Hillsborough County
individuals with three felony charges are not eligible for Hillsborough County
Health Care Plan.
Services and/or housing options are very limited for violent felons and registered
sex offenders. Housing vouchers provided by Housing Authorities are not
available for recent violent felons or registered sex offenders. Many private
landlords in the community will not accept persons with extended criminal
histories.
Low-income housing, or housing for which rent is based on an individual’s
income, is very limited. Often individuals who obtain a fixed income, such as
Supplemental Security Income, have difficulty finding rental properties that fall
within their budgets.
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d) Provide a brief description of the current services available to consumers who
have both a serious mental illness and a substance use disorder:
Gracepoint is a provider of mental health and substance abuse services:
Case Managers are required to complete co-occurring training modules
within 90 days of being hired.
Each individual enrolled in the PATH Program is assessed for co-occurring
disorders using the Minkoff Co-Occurring Screening form.
Program Participants’ current stage of change regarding mental health,
substance abuse, and co-occurring disorders are assessed and addressed in
intervention plans.
Case Managers are responsible for coordinating referrals, scheduling
appointments, and advocating for access to the most appropriate services to
meet the individuals’ identified needs.
e) Describe how the local provider agency pays for providers or otherwise supports
evidence-based practices, trainings for local PATH-funded staff, and trainings and
activities to support collection of PATH data in HMIS:
Gracepoint provides PATH-funded services that are person-centered, solution-
focused, and sensitive to co-occurring disorders and trauma. At new hire
orientation PATH staff members learn about role recovery, trauma informed care,
and co-occurring disorders. Staff receive continued education, through in-class
and online training, on these evidence-based practices, as well as on Motivational
Interviewing and Housing First. Staff also receive training in cultural diversity at
new hire orientation and through the use of videos, handouts, and web-based
programs in order to remain aware of personal attitudes, beliefs, biases, and
behaviors that may influence their assessments and actions. Staff attend multiple
Homeless Outreach events in the community where they can network with other
providers, engage individuals who are homeless who are eligible to receive
PATH-funded services, and utilize HMIS to gather further information on
consumers and to input newly gathered data. The data system, HMIS helps staff
identify agencies and programs that provide or have provided services to the
person, shows resources available such as shelter vacancies, and facilitates
communication with other case workers in the community who are also involved
in the care of the person.
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f) 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).
When working with individuals who have involvement with the criminal justice
system, the staff at Gracepoint provide individualized treatment to ensure the
consumer is linked with appropriate services. Once enrolled, an intervention plan
is created and applied in a person-centered manner. Gracepoint makes sure that
eligible consumers with criminal backgrounds are referred to appropriate housing
programs, whether it is Permanent Supportive Housing, Rapid Rehousing,
Transitional Housing or Shelter. As new consumers are enrolled and in need of
health services, they are referred to the Tampa Family Health Center. Staff work
closely with consumers in order to complete health care applications and advocate
whenever criminal history becomes a barrier. During the time that applications are
being reviewed, the care managers refer consumers to various clinics and health
centers that accept those without health insurance with criminal backgrounds at
no cost to the consumers. The Gracepoint Main Center for psychiatric services
also serves as an avenue of linkage for those who are in need of mental health
services. Once consumers are engaged, staff advocate for the consumer and
explore the possibility of having initial appointment fees waived. Gracepoint staff
work with the consumers to refer to Vocational Rehabilitation programs, assist
with resumes, and job searches. Additionally, Gracepoint staff has access to
HMIS to assist with identifying and coordinating engagement with programs such
as the Jail Diversion Program that could be beneficial to consumers. Case
managers will coordinate referrals, schedule appointments, and advocate for
access to the most appropriate services to meet the individuals’ identified needs.
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Please check all services to be provided using PATH funds:
Outreach Services
Screening and diagnostic treatment services
Habilitation and rehabilitation services
Recovery Support Services such as Peer Support/Recovery Coaching
Community Mental Health services
Alcohol and drug treatment services
Assisting individuals to connect with Community Mental Health Services and
alcohol or other drug treatment services
Staff training (including training of individuals who work in shelters, mental
health clinics and substance abuse programs and other sites where individuals
who are homeless require services)
Case management services (see PATH eligible services document)
Supportive and supervisory services in residential settings
Referral for Primary healthcare
Referral for job training
Referral for educational services
Referral for housing services
5. Data: a. Describe the provider’s status on the HMIS transition plan, with accompanying timeline,
to collect PATH data by fiscal year 2017:
Historically PATH data has been collected in HMIS as well as Excel spreadsheets. This
is the second year that reports have been prepared through HMIS. PATH assessment data
is collected on a paper form when HMIS is not available (i.e., when an assessment is
completed on the street), and the data is entered into HMIS when staff return to the
office.
b. If providers are fully utilizing HMIS for PATH services, please describe plans for
continued training and how providers will support new staff:
Gracepoint has fully utilized HMIS since the system was implemented in the
Hillsborough-Tampa Continuum of Care in 2005. Newly hired PATH staff receive day-
long HMIS training. The PATH Program Supervisor monitors data entered by PATH
staff members on a daily basis and provides feedback when a correction is necessary.
Follow-up training is scheduled as needed. PATH staff are encouraged to attend the
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monthly UNITY/HMIS user group meeting of the CoC lead agency to obtain up-to-date
information, as well as to network with HMIS users from other agencies.
6. SSI/SSDI Outreach, Access, and Recovery (SOAR):
a. Describe the agencies plan to train PATH staff in SOAR:
Each staff is required to complete SOAR training online and obtain certification of
completion. Further training and assistance after the SOAR online course is
completed includes face-to-face trainings from supervisor and training/assistance
from other SOAR-trained staff. Staff are also trained and required to use the Online
Application Tracking (OAT).
b. Indicate the number of PATH staff trained in SOAR during the grant year ending in 2016
(2015- 2016):
There were four staff members trained in SOAR.
c. Indicate the number of PATH funded consumers assisted through SOAR (include all
distinct consumers whether approved, denied, or initiated on appeals):
Forty-two customers were assisted with applications for SSA entitlement benefits.
d. Indicate the number of PATH enrolled consumers your program proposes to assist with
SOAR applications in FY 16/17:
Gracepoint proposes to assist 50 customers with SOAR applications in FY 16/17.
e. Does the agency PATH program have a SOAR specialist who does all PATH SOAR
cases or does each PATH staff handle their own SOAR cases? Please describe the
rationale for this decision:
Each PATH staff handles his/her own SOAR cases. Most customers who require assistance
with SOAR applications have others needs to be addressed. By having each PATH staff
handle his/her own SOAR cases, that staff member can simultaneously work on all treatment
plan objectives.
f. If the provider does not use SOAR, describe the system used to improve accurate, timely
completion of mainstream benefit applications and timely determination of eligibility.
Also, describe efforts used to train staff on this system. Indicate the number of staff
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trained, the number of PATH funded consumers assisted through this process, and
application eligibility results:
N/A
g. Application eligibility results (i.e., approval rate on initial application, average time to
approve the application).
During grant fiscal year 15-16, 42 individuals were assisted with applications for SSA
entitlement benefits. Out of these 42 individuals, five were approved, twelve were denied
and twenty-five individuals failed to follow through with SSA application due to lost
contact or continued application progress with assistance from a lawyer. Many of the 42
individuals had previously submitted preliminary applications and are in the waiting
period for decisions or hearings. The average time a decision was provided by SSA is
three months.
h. Describe how the providers plan to ensure that PATH staff have completed the SOAR
online course.
New staff are required to complete SOAR training online and obtain certification of
completion within 90 days of employment.
i. Describe which staff plan to assist consumers with SSI/SSDI application using the SOAR
model.
All four Network Project PATH Care Managers assist consumers with SSI/SSDI
application using the SOAR model.
j. Describe which staff plan to track the outcomes of those applications in the SOAR Online
Applications (OAT) system.
All four Network Project PATH Care Managers track the outcomes of SSI/SSDI
applications through SOAR OAT. Staff are trained and required to use OAT to track
changes in SSA to indicate the efficacy of SOAR implementation and case management
engagement for the approval of benefits.
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k. The number of staff dedicated to implementing SOAR, Is SOAR their part-time or full-
time job duty?
Staff responsible for implementing SOAR include four Network Project PATH Care
Managers. Each Care Manager handles SOAR cases. Most customers who require
assistance with SOAR applications also have other needs to be addressed in their
treatment plan that are non-SOAR related. By having each PATH staff handle SOAR
cases, the staff member can simultaneously work on all treatment plan objectives;
therefore, SOAR is one of their part-time duties.
l. 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.)
N/A
m. 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.
n. N/A
7. Housing:
a. Indicate what strategies are used for making suitable housing available for PATH
consumers (i.e., indicate the type(s) of housing provided and the name of the
agencies):
When deemed eligible, individuals are referred to Permanent Supportive Housing
programs. Such programs include:
Tampa Housing Authority.
Various Permanent Supportive Housing programs operated by ACTS and
Gracepoint
Friendship Palms operated by Project Return
Volunteers of America
Metropolitan Ministries
HOME 3 with the Tampa Hillsborough Homeless Initiative
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Plant City Housing Authority
Catholic Charities
DACCO
St. Vincent de Paul
8. Staff Information:
a. Describe the demographics of the staff serving the consumers:
Demographics of the staff serving the population
Veterans 0%
Gender
Male 43%
Female 57%
Race
American Indian/Alaskan Native 0%
Asian 0%
Black/African American 14%
Caucasian 86%
Native Hawaiian/Pacific Islander 0%
Two or More Races 0%
Ethnicity
Hispanic/Latino 43%
b. Describe 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 consumers; 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).
Gracepoint ensures that staff members are sensitive to the diverse needs of the
population it serves, evidenced by demonstrated competency, including awareness of
stereotypes and projection. Recognizing diversity in age, gender, race, culture,
spiritual preferences and beliefs, sexual preferences, and gender orientation, staff
work closely with individuals to ensure interventions are individualized and applied
in a person-centered manner. Intervention plans are developed based on the
individuals’ expressed desires and strengths.
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Staff receive training in cultural diversity at new hire orientation and through the use
of videos, handouts, and web-based programs in order to remain aware of personal
attitudes, beliefs, biases, and behaviors that may influence their assessments and
actions.
9. Client Information: Describe the following:
a. The demographics of the PATH client population
Demographics of the population to be served:
Gender
Male 28%
Female 72%
Race
American Indian/Alaskan Native 1%
Asian 0%
Black/African American 50%
Caucasian 44%
Native Hawaiian/Pacific Islander 0%
Two or More Races 5%
Ethnicity
Hispanic/Latino 16%
Age
18-23 years 3%
24-30 years 10%
31-50 years 47%
51-61 years 33%
62 years and older 7%
b. The projected number of adult consumers to be contacted and PATH enrolled and rationale for
these numbers: The number of projected adult consumers to be contacted and PATH enrolled
was derived from combining previous year’s numbers of individuals contacted and PATH
enrolled. By combining results from previous years and taking into consideration program
changes, we were able to come up with an approximate number of individuals we project to
serve in FY 17-18.
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Grant year 2016-2017 number or percentage of:
# of individuals contacted through outreach: 814
# of individuals enrolled: 288
% of individuals enrolled that were literally homeless:73%
% of individuals enrolled that were veterans: 6%
Grant year 2017-2018 projected number or percentage of:
# of individuals to be contacted through outreach: 500
# of individuals to be enrolled: 200
% of individuals enrolled that are literally homeless: 85%
% of individuals enrolled that are veterans: 5%
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.
Each individual enrolled in the PATH Program is encouraged to complete the satisfaction survey
that is used throughout the Agency. Participant input is also received through community
meetings with individuals at the homeless drop-in center operated by Gracepoint.
11. Budget: a. Provide a detailed budget that includes the agency’s use of PATH funds.
Gracepoint - 2017-2018 PATH Grant Budget
Personnel
Annual
Salary*
(total
number)
PATH-
funded
FTE
(%)
PATH-
funded
Salary
Matched
Dollars
Total
Dollars Comments
Administrative Assistant
$27,435 0.65 $ 17,833 $ 4,161 $ 21,994
Case Manager
$30,000 3.7 $111,000 $25,891 $136,891
Program Supervisor
$45,000 0.8 $ 36,000 $ 8,400 $ 44,400
Subtotal
$164,833 $38,452 $203,285
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* Indicate "annualized salary for
positons."
Fringe Benefits (Max of 27%) $ 29,835 $ 6,960 $ 36,795
Subtotal
$ 29,835 $ 6,960 $36,795
Travel
Training -
Annual Conference or Meetings $ 500 $ 117 $ 617
SOAR,
UNITY,
Outreach
Committee,
etc.
Subtotal $ 500 $ 117 $ 617
Equipment
Vehicle repairs $ 1,000 $ 233 $1,233
Four
company
vehicles are
used to
perform
outreach
and to
transport
program
participants.
Equipment repairs $ 1,000 $ 233 $ 1,233
Computers,
telephones,
printers.
Subtotal $ 2,000 $ 466 $ 2,466
Supplies
Office supplies $ 1,750 $ 408 $ 2,158
Pens, paper,
binders,
dividers,
staples,
cleaning
supplies,
calendars,
etc.
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Outreach Supplies/ Hygiene kits/Misc. $ 1,500 $ 350 $ 1,850
Hygiene
products
and survival
items
provided to
program
participants.
Software $ 500 $ 117 $ 617
AVATAR,
UNITY
Network
(HMIS);
KRONOS
to manage
employees'
information.
Subtotal $ 3,750 $ 875 $ 4,625
Contractual
Legal/contractual $ 500 $ 117 $ 617
Subtotal $ 500 $ 117 $ 617
Other
Insurance (property, vehicle,
malpractice, etc.) $ 4,600 $ 1,073 $ 5,673
Vehicle
insurance;
employee
health
insurance;
liability
insurance.
Office: Misc. (Copying, Courier,
Postage, etc.) $ 2,700 $ 630 $ 3,330
Printers,
postage.
Office: Security, Janitorial, Grounds
Maintenance $ 4,500 $ 1,050 $ 5,550
Jnaitorial
services.
Office: Utilities/Telephone/ Internet $ 7,500 $ 1,750 $ 9,250
Water,
electricity,
telephone
lines, and
wifi.
Office: rent $ 18,601 $ 4,340 $22,941 Rent.
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Office: building maintenance $ 1,151 $ 280 $ 1,431
On call
maintenance
team.
Subtotal $39,152 $ 9,123 $48,175
Total Direct Charges (Sum of each
section) $240,470 $56,110 $296,580
Indirect Costs (Max of 10%)
(Administrative Costs) $24,047 $ 24,047
Grand Total (Total of "total direct" and
"indirect costs") 240,470 $80,157 $320,627
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C. Local Provider Intended Use Plan:
1. Local Provider Description: Provide a brief description of the provider organization
receiving PATH funds:
Name of the Organization: Guidance Care Center, Inc.
Type of Organization: Community Mental Health Center
Address of Provider: 1205 4th Street, Key West, FL 33040
Local Continuum of Care Lead Agency: Monroe County Homeless Services Continuum
of Care (CoC)
PATH Contact Name/E-Mail/Phone #: Maureen Dunleavy, MA, NCC, LMHC
[email protected] / 305-434-7660 extension 31221
Region Served: Southern Region (Monroe County)
Indicate the amount of federal, state and local PATH funds the organization will
receive.
Federal: $ 90,000
Match: $ 30,000
Total: $120,000
2. Collaboration with HUD Continuum of Care Program: Describe the organization’s
participation in the HUD Continuum of Care and any other local planning, coordinating or
assessing activities:
The Guidance Care Center (GCC) is a participating member of the Monroe County Homeless
Services Continuum of Care (MCHSCOC) which serves as the lead agency for Monroe
County. GCC’s PATH Director serves on the Board of Directors and attends monthly
meetings to analyze housing utilization and other issues affecting homelessness. GCC served
as the lead agency in developing the Coordinated Assessment process for Monroe County
which was implemented in December 2013. GCC continues to be actively involved in
monitoring and revising the Coordinated Assessment process through monthly committee
meetings with feedback from implementing agencies. The agency also participates in the
annual Point in Time count.
3. Collaboration with Local Community Organizations: Provide a brief description of
partnerships and activities with local community organizations that provide key services (i.e.,
outreach teams, primary health, mental health, substance abuse, housing, employment, etc.)
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to PATH eligible clients and describe coordination of activities with each of these
organizations (describe all that apply):
The MCHSCOC meetings include input from the majority of homeless services providers
who make up its membership. Meetings are monthly and focus on improving services and
cooperation between agencies to decrease homelessness risks. GCC partners with all
housing programs and shelters in Monroe County to offer coordinated assessment and
behavioral health consumer services designed to help participants attain or maintain housing.
Homeless populations and those in housing programs are given priority for services. GCC
staff assists in referrals to other agencies and community partners and are responsible for
service coordination and follow up. The agency is a receiving center for local and county
law enforcement for individuals brought in through Crisis Intervention Teams. Often
homeless, these individuals receive immediate intervention instead of jail placement. An
agreement with Rural Health Network strengthens the referral process and improves
communication on persons served between both agencies. Agency staff are available on a
walk-in basis to help individuals complete the application for the Loaves and Fishes food
pantry.
GCC maintains active partnerships with the following entities to offer services indicated:
Rural Health Network - medical services (Federally Qualified Health Center)
Florida Keys Outreach Coalition - housing and food
Key West Police Department Crises Intervention Team - receiving center
Monroe County Sheriff’s Crisis Intervention Team - receiving center
Lower Keys Medical Center - medical care
Womankind - screening and treatment of women’s health issues
Samuel’s House - transitional housing services
Peacock House - supportive living services
Robert Neese Center - transitional housing services
AIDS Help Inc. - transitional housing and Ryan White Services
Loaves and Fishes Food Pantry - application site for required forms
Salvation Army - clothing
Catholic Charities - rental assistance and soup kitchen
Southernmost Homeless Assistance League - shelter services for adults
Heron House - GCC affiliate that provides assisted living with a Limited Mental
Health License
4. Service Provision: Describe the organization’s plan to provide coordinated and
comprehensive services to eligible PATH clients, including:
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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:
Outreach services target such areas as homeless shelters, detention centers, and other
agencies. Additional outreach opportunities will be used as they are identified. Housing
partners and other agencies will receive training on PATH services and will be
encouraged to refer any resident or applicant with behavioral health needs to GCC.
Coordinated assessment for housing will be conducted on a walk-in basis regardless of
whether the individual enrolls in PATH. Coordinated assessment and monthly homeless
coalition meetings are the vehicle for coordination of housing services. Case management
is used to identify persons experiencing homelessness who are admitted to detox and
crisis stabilization units for PATH services including housing application and discharge
placement. Case management assists enrolled participants in accessing additional support
to improve housing readiness and housing retention. Eligible participants are assisted
with social security applications through SOAR. Referrals for primary care, dental care,
clothing, food, and other needs include follow-up. GCC will screen all adult persons
served for PATH eligibility.
b. Provide specific examples of how the agency maximizes use of PATH funds by
leveraging use of other available funds for PATH client services:
Monroe County provides match for PATH and other state-funded services. It is Monroe
County funds which provide the Adult Mental Health Medical and Therapy services for
PATH consumers.
c. Describe any gaps that exist in the current service systems:
According to the 2016 Point in Time (PIT) survey results, there are 741 homeless
individuals in Monroe County. 236 of these individuals are considered "unsheltered,”
with 118 in the Lower Keys, 67 in the Middle Keys, and 51 in the Upper Keys. 394 are
considered “sheltered” and 84 homeless individuals were incarcerated at the PIT date. 20
individuals experiencing homelessness refused the survey or responded “don’t know” to
most questions and 7 were hospitalized. Identified needs from the survey are as follows:
Available services differ in each region of the Keys
Need for additional housing opportunities
Lack of affordable housing
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Restrictions on housing for those with battery charges, sex offenses, substance use,
mental health issues, etc.
Restrictive program rules for available housing, such as curfews, employment
requirements, and restrictions, drug testing, etc.
Limited housing options for families and children.
d. Provide a brief description of the current services available to clients who have both a
serious mental illness and a substance use disorder:
As a community behavioral health provider, GCC offers comprehensive services for
participants experiencing co-occurring disorders. These services include assessment,
counseling, case management, crisis stabilization (CSU), detoxification, and psychiatric
services based on current treatment needs of the participant. Among GCC physicians are
psychiatrists who have attained advanced training and credentialing in evaluating and
treating substance use disorders. All staff receive annual training on co-occurring issues.
e. Describe how the local provider agency pays for providers or otherwise supports
evidence-based practices, trainings for local PATH-funded staff, and trainings and
activities to support collection of PATH data in HMIS:
All GCC staff are continually trained and monitored through supervision in Trauma
Informed Care which is practiced in all aspects of the agency’s services. Outpatient
therapy services utilize Seeking Safety for trauma treatment and Relapse Prevention for
Substance Abuse. In addition, Wellness Recovery Action Plans are utilized to plan care
and monitor progress of persons served. All GCC staff are also trained in Motivational
Interviewing as the primary method of engagement with all persons served.
f. 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).
Guidance/Care Center has a Forensic Case Manager located at the jail who assists
consumers with housing, benefits, or ancillary services needed. The Forensic Case
Manager is SOAR trained and has access to HMIS to complete coordinated assessments
for housing.
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Please check all services to be provided using PATH funds:
Outreach Services
Screening and diagnostic treatment services
Habilitation and rehabilitation services
Recovery Support Services such as Peer Support/Recovery Coaching
Community Mental Health services
Alcohol and drug treatment services
Assisting individuals to connect with Community Mental Health Services and
alcohol or other drug treatment services
Staff training (including training of individuals who work in shelters, mental
health clinics and substance abuse programs and other sites where homeless
individuals require services)
Case management services (see PATH eligible services document)
Supportive and supervisory services in residential settings
Referral for Primary healthcare
Referral for job training
Referral for educational services
Referral for housing services
5. Data:
a) Describe the provider’s status on the HMIS transition plan, with accompanying
timeline, to collect PATH data by fiscal year 2017:
PATH data is tracked using an HMIS Data Entry system. Service Activity logs that
record staff service provision are also used. Special modifiers have been developed to
identify PATH eligible individuals and services provided within the clinical database
system.
b) If providers are fully utilizing HMIS for PATH services, please describe plans for
continued training and how providers will support new staff.
The MCHSCOC provides ongoing training and support through the HMIS
Administrator to HMIS users and agencies. These trainings are mandatory. The
agency is also active in the HMIS user meetings held monthly.
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6. SSI/SSDI Outreach, Access, and Recovery (SOAR):
a. Describe the agencies plan to train PATH staff in SOAR:
All case managers and care coordinators are trained in SOAR. The on-line training is
accessed during the first 90 days to complete the required training and obtain
certification. In addition, SOAR is also covered in the targeted case management
training as required by Medicaid for all new hires. All Case Managers are trained and
required to use SOAR where applicable as part of their case management job.
b. Indicate the number of PATH staff trained in SOAR during the grant year ending in
2016 (2015- 2016):
Currently, there are nine trained GCC employees, and the agency expects to train
another seven in FY 17-18.
c. Indicate the number of PATH funded consumers assisted through SOAR (include all
distinct consumers whether approved, denied, or initiated on appeals):
During the 15/16 FY there were 26 PATH funded consumers assisted through SOAR.
d. Indicate the number of PATH enrolled consumers your program proposes to assist
with SOAR applications in FY 16/17:
e.
GCC proposes to assist 15 enrolled PATH consumers in FY 16/17.
f. Does the agency PATH program have a SOAR specialist who does all PATH SOAR
cases or does each PATH staff handle their own SOAR cases? Please describe the
rationale for this decision:
SOAR is used to help expedite disability benefits for anyone who is homeless or at
risk of homeless. All outcome measures are entered into the Online Tracking System
(OAT). GCC does have a dedicated PATH case manager and discharge planner
providing PATH services, but all case managers are trained and required to use
SOAR where applicable as part of their case management job.
g. If the provider does not use SOAR, describe the system used to improve accurate,
timely completion of mainstream benefit applications and timely determination of
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eligibility. Also, describe efforts used to train staff on this system. Indicate the
number of staff trained, the number of PATH funded consumers assisted through this
process, and application eligibility results:
GCC uses SOAR and OAT so this question is not applicable.
h. Application eligibility results (i.e., approval rate on initial application, average time to
approve the application).
Currently there is a 20% approval rate on applications with approval within 120 days.
i. Describe how the providers plan to ensure that PATH staff have completed the SOAR
online course.
All Case Management staff complete SOAR on-line training and certificates are kept
in personnel files.
j. Describe which staff plan to assist consumers with SSI/SSDI application using the
SOAR model.
All case managers and care coordinators are PATH specific case managers assist who
consumers with SSI/SSDI application using the SOAR model.
k. Describe which staff plan to track the outcomes of those applications in the SOAR
Online Applications (OAT) system.
All SOAR-trained staff enter data into the OAT system and track the applications.
l. The number of staff dedicated to implementing SOAR, Is SOAR their part-time or
full-time job duty?
All 12 case management/care coordination staff include the SOAR model as part of
the case management/care coordination duties. All are full-time staff, but SOAR is
only conducted part-time.
m. 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.)
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N/A
n. 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.
N/A
7. Housing:
a. Indicate what strategies are used for making suitable housing available for PATH
clients (i.e., indicate the type(s) of housing provided and the name of the agencies):
GCC is the only coordinated assessment site currently available for those applying for
housing in the Middle and Upper Keys. Coordinated assessment is a countywide one-
stop process to apply for housing and is designed to simplify and maximize housing
placement. Provider agencies include:
•Florida Keys Outreach Coalition (permanent and supportive housing, transitional
housing)
•Samuel’s House and Kathy’s Hope (permanent supportive housing for women
and their children)
•Robert Neese Center- Peacock House Apartments (supported living)
•Heron House (Assisted Living Facility- Limited Mental Health Living)
•AIDS Help (permanent supportive housing)
•MARC House (permanent supportive housing for those with developmental
disabilities)
•Keys Overnight Temporary Shelter (basic shelter)
•Catholic Charities (permanent supportive housing)
•Domestic Abuse Shelter (emergency shelter)
•Florida Keys Children’s Shelter (emergency shelter)
8. Staff Information:
a. Describe the demographics of the staff serving the consumers:
Demographics of the staff serving the population
Veterans 3%
Gender
Male 18%
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Female 82%
Race
American Indian/Alaskan Native 0%
Asian 0%
Black/African American 15%
Caucasian 61%
Native Hawaiian/Pacific Islander 0%
Two or More Races 3%
Ethnicity
Hispanic/Latino 21%
b. Describe 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).
GCC staff receive training in cultural competency at hire and through multiple web
based applications such as NetSmart. Staff are trained in the use of a telephone
interpreter’s service capable of interpretation of over 200 languages through Pacific
Interpreters. For individuals who communicate through the use of sign language,
interpretation services using video conferencing is available. Assistive
communication devices are available as required. A civil rights presentation is a
mandatory part of New Employee Orientation. The agency embraces the concept of
“One Human Family” with staff and persons served. GCC leadership promotes
cultural diversity in all aspects of its daily operations, as demonstrated through
supervision, diverse training, and personnel policies. Cultural diversity training is
required by the agency.
9. Client Information: Describe the following:
a. The demographics of the PATH client population
Demographics of the population to be served:
Gender
Male 72%
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Female 28%
Race
American Indian/Alaskan Native 1%
Asian 1%
Black/African American 6%
Caucasian 89%
Native Hawaiian/Pacific Islander 1%
Two or More Races 2%
Ethnicity
Hispanic/Latino 9%
Age
18-23 years 3%
24-30 years 14%
31-50 years 23%
51-61 years 52%
62 years and older 8%
b. The projected number of adult clients to be contacted and PATH enrolled and
rationale for these numbers:
Grant year 2016-2017 number or percentage of:
# of individuals contacted through outreach: 46
# of individuals enrolled: 264
% of individuals enrolled that were literally homeless: 23%
% of individuals enrolled that were veterans: 6%
Grant year 2017-2018 projected number or percentage of:
# of individuals to be contacted through outreach: 200
# of individuals to be enrolled: 312
% of individuals enrolled that are literally homeless: 40%
% of individuals enrolled that are veterans: 6%
Performance will be tracked through data entered into HMIS and GCC IT systems. The
above information will be captured on the GCC PATH Data Entry form and entered into
the HMIS system Client Track.
Screening and diagnostic services and outreach will improve identification of those who
are literally or chronically homeless. Mental health and substance abuse services address
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significant factors contributing to homelessness. Case management provides continued
support, including physician appointments, and linkage to additional services designed to
increase wellbeing and decrease risk of homelessness. Supportive services in residential
settings such as crisis stabilization or detoxification units present an opportunity to apply
for housing before discharge.
10. Consumer Involvement:
a. 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 PATH participant identifies and prioritizes service needs and is empowered to
explore, select, and implement strategies to address those needs. Services are
completely voluntary, with individuals served being in control. The Discharge
Planner and Outreach Specialist also provide supportive services. Family members
are welcome to participate, at the discretion of the person served. GCC uses consumer
satisfaction surveys to encourage participants to evaluate services provided under
PATH.
11. Budget: a. Provide a detailed budget that includes the agency’s use of PATH funds.
Guidance Care Center - 2017-2018 PATH Grant Budget
Personnel
Annual
Salary*
(total
number)
PATH-
funded FTE
(%)
PATH-
funded
Salary
Matched
Dollars
Total
Dollars Comments
Project Director $ 60,000 0.05 $ 3,000 $ 3,000 $ 6,000
Outreach Specialist $ 37,502 1.00 $37,502 - $37,502
Discharge Planner $ 37,502 0.40 $ 15,001 $ 15,001
Case Manager $ 37,502 0.42 $ 15,751 $ 15,751
Other (describe)
Other (describe)
Subtotal $ 172,507 2 $ 71,254 $3,000 $74,254
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* Indicate "annualized salary
for positons."
Fringe Benefits (21%)
Subtotal $ 14,963 $ 613 $15,576
Travel
Training
Annual Conference or
Meetings
Rental Car
Per Diem
Local Travel 30 miles per month X 12 months $160 $ 23 $ 183
Other (describe)
Subtotal $ 160 $ 23 $ 183
Equipment
Subtotal
Supplies
Office supplies ($20/month X 12 months) $ 124 $ 116 $ 240
Program supplies ($20/month X 12 months) $ 124 $116 $ 240
software
Other (describe)
Other (describe)
Subtotal $ 248 $ 232 $ 480
Contractual
MD Contract Hours (3.75 hours per month @
$484.75/Hour) $ 21,814 $21,814
OP Therapy Hours (3.00 hours per month @ $88.69/Hour) $ 3,193 $ 3,193
Subtotal $25,007 $ 25,007
Other
One-time housing rental
assistance
Insurance (property, vehicle,
malpractice, etc.)
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Office: Misc. (Copying,
Courier, Postage, etc.)
Office: Security, Janitorial,
Grounds Maintenance
Office occupancy costs PATH staff @ Key West Site $ 1,500 $ 500 $ 2,000
Office occupancy costs PATH staff @ Marathon Site $ 1,125 $ 375 $ 1,500
Office occupancy costs PATH staff @ Key Largo Site $ 750 $ 250 $ 1,000
Staffing (Not Salary or
Benefits):
Training/Education/Conference
Fees
Staffing (Not Salary or
Benefits): Other (describe)
Audit
Subtotal $ 3,375 $ 1,125 $ 4,500
Total Direct Charges (Sum of
each section) $ 90,000 $ 30,000
$
120,000
Indirect Costs (Max of 10%)
(Administrative Costs)
Grand Total (Total of "total
direct" and "indirect costs") $ 90,000 $ 30,000 $120,000
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C. Local Provider Intended Use Plan:
1. Local Provider Description: Provide a brief description of the provider organization
receiving PATH funds:
Name of the Organization: Henderson Behavioral Health, Inc.
Type of Organization: Not-for-profit community behavioral healthcare organization
Address of Provider: 4740 N. State Rd. 7, Lauderdale Lakes, FL 33319
Local Continuum of Care Lead Agency: Broward County Homeless Initiative Partnership
PATH Contact Name/E-Mail/Phone #: Debbie Perry
[email protected] (954)735-4331
Region Served: Southeast Region/Broward County
Indicate the amount of federal, state and local PATH funds the organization will
receive.
Federal: $248,110
Match: $ 83,113
Total: $331,223
2. Collaboration with HUD Continuum of Care Program: Describe the organization’s
participation in the HUD Continuum of Care and any other local planning, coordinating or
assessing activities:
Broward County’s Homeless Initiative Partnership is the lead organization for the community’s
Continuum of Care. The County has developed a Continuum of Care designed to address the
needs of persons experiencing homelessness in the community. The Continuum takes advantage
of every funding opportunity to enhance, improve, strengthen, augment, and increase the
availability of safe and affordable permanent housing.
Through funding provided by Broward County’s Homeless Initiative Partnership, Henderson
Behavioral Health (Henderson) operates a mental health Emergency Shelter Safe Haven, the
HHOPE project, serving individuals experiencing chronic homelessness; and the COURT project
for individuals who are homeless and recently incarcerated or involved with the Mental Health
Court. Henderson operates a 40-unit permanent housing program, Chalet Apartments, funded by
the U.S. Department of Housing and Urban Development. Chalet provides Section 8 assistance
to eligible tenants, as well as supportive services including on-site staff support and case
management. This project targets individuals who are homeless and diagnosed with a serious
mental illness, and those with co-occurring disorders. It is the first and only Single Room
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Occupancy (SRO) project in Broward County. These services are an integral part of the local
Continuum of Care. In order to strengthen this continuum in Broward County, Henderson
continuously seeks to enhance and expand partnerships through project and service
collaborations with other providers of services for individuals who are homeless. Henderson
maintains strong partnerships with Broward Health, the Salvation Army, Broward Outreach,
Broward Partnership for the Homeless, Inc. (BPHI), Broward Housing Solutions, and HOPE
South Florida.
Henderson’s Housing Administrator chairs the Homeless Providers and Stakeholders Committee,
and sits on Broward County’s Homeless Continuum of Care Advisory Board. Henderson staff
participates on the HMIS Data committee, the Performance & Outcomes & Needs & Gaps
(PONG) committee, and the Coordinated Entry and Assessment committee. All Henderson
supervisors managing programs that offer services to individuals experiencing homelessness
participate on at least one Continuum of Care committee.
3. Collaboration with Local Community Organizations: Provide a brief description of
partnerships and activities with local community organizations that provide key services (i.e.,
outreach teams, primary health, mental health, substance abuse, housing, employment, etc.)
to PATH eligible individuals and describe coordination of activities with each of these
organizations (describe all that apply):
Henderson works closely with the Broward County Housing Authority (BCHA) and Broward
Housing Solutions in developing temporary subsidy programs, as well as long-term rental and
lease-to-purchase options. Project-based vouchers for Henderson’s SRO project are managed by
the Hollywood Housing Authority, and the organizations work closely together to provide
excellent service to Chalet tenants.
Henderson has assisted PATH participants in becoming self-sufficient, productive members of
the community for over 20 years. Henderson is a front-door service provider through the Mobile
and Walk-In Crisis Center. The organization works closely with other organizations and local
entities to strengthen the system of care for individuals experiencing homelessness and who may
also have diagnoses of serious mental illnesses. These organizations include:
Broward Health – Healthcare for the Homeless
Broward County Homeless Initiative Partnership
Broward County Housing Authority
Broward County Housing Finance and Community Development
Hollywood Housing Authority
TaskForce Fore Ending Homelessness, Inc.
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First Call For Help
Broward Housing Solutions
Hope South Florida
4. Service Provision: Describe the organization’s plan to provide coordinated and
comprehensive services to eligible PATH persons, 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:
In Broward County, PATH-funded outreach services are provided by the TaskForce Fore Ending
Homelessness (TFEH). TFEH refers individuals to Henderson for psychiatric and case
management services. The organizations have worked closely together for many years to serve
individuals who are homeless. All persons experiencing homelessness served by Henderson’s
Housing Services receive services from a case manager who plays a critical role in the person’s
transition to permanent housing. The organization assesses the needs of the person served,
coordinates the delivery of services and ensures that services are delivered in accordance with
the person’s service plan. Henderson also provides assistance in obtaining mainstream resources
such as Social Security Administration benefits, food stamps, and Medicaid. All Henderson case
managers are SOAR (SSI/SSDI Outreach, Access, and Recovery) trained in order to help
persons served correctly complete their initial SSI/SSDI benefits applications. Henderson also
coordinates transportation and arranges for healthcare and other necessary services. Most
importantly, staff assists in the transition to permanent supportive housing and the retention of
that housing.
b. Provide specific examples of how the agency maximizes use of PATH funds by
leveraging use of other available funds for PATH participant services:
Henderson maximizes the use of PATH funds with a variety of leverage sources. These include
the Safe Haven Homeless Emergency Shelter, where many individuals are first connected with
PATH case management services. While in shelter, linkage to psychiatric services and the
securing of medication is provided through services funded by Broward Behavioral Health
Coalition. Henderson assists persons transitioning out of the shelter into permanent supportive
housing with security and utility deposits, moving costs, and furniture purchase through the
Simple Dream Endowment fund.
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c. Describe any gaps that exist in the current service systems:
In 2013 Broward County hired the National Alliance to End Homelessness (the Alliance) to
assess the current Continuum of Care (CoC) system, and make recommendations to enhance
its efficiency and capacity, as well as prepare the CoC to implement the new HEARTH Act.
The subsequent report recommended reducing the amount of transitional housing,
establishing a Coordinated Entry and Assessment process, and increasing the amount of
available permanent housing.
The CoC has made significant progress in many areas, including implementation of a
Coordinated Entry and Assessment process, prioritization process for services, and expansion
of permanent supportive housing opportunities. The Continuum’s Performance & Outcomes
& Needs & Gaps (PONG) committee identified permanent supportive housing opportunities
for individuals who are homeless as a need in the community.
Although the 2015 Point-In-Time (PIT) Count reported that there were 2,615 individuals
experiencing homelessness in Broward County, the TaskForce outreach team touched 4,441
unduplicated individuals experiencing homelessness between July 1, 2015-June 30, 2016.
The discrepancy between the PIT Count versus the number documented in HMIS by the
TaskForce may be due to the decrease of PIT Count volunteers throughout the years, the time
of year the PIT Count takes place, and the fact that many individuals receive their tax returns
by the end of January. As an example, this year’s PIT Count (January 2017) totaled 123
volunteers, while last year’s PIT Count (January 2016) registered 180 volunteers. Being as
that funding is distributed according to the need verified by assessments like the PIT Count,
Broward County’s funding needs far exceed the funding actually being received. Of the
4,441 identified outreached individuals, only 353 (8%) are enrolled in PATH services with
TaskForce, and only 159 (4%) individuals receive HBH PATH case management services.
The limited dollars allocated toward PATH are restricting the number of people that can be
served in this program.
d. Provide a brief description of the current services available to clients who have both a
serious mental illness and a substance use disorder:
At first contact, most PATH recipients are living in Henderson’s Safe Haven emergency
shelter. The Program connects recipients with behavioral health services, both mental
health and substance use. Psychiatric services are provided at the Housing Services
administrative location. The Safe Haven offers two tiers of recovery support groups run
by a PATH-funded licensed clinician. The tiers are based on length of recovery time.
The clinician also provides onsite individual and group therapy. HBH operates a co-
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occurring disorder outpatient program at its New Vistas location. Services are available
to PATH recipients.
e. Describe how the local provider agency pays for providers or otherwise supports
evidence-based practices, trainings for local PATH-funded staff, and trainings and
activities to support collection of PATH data in HMIS:
All direct service staff are trained in the theory and techniques of Motivational
Interviewing, an evidence-based practice. Ongoing trainings are provided to train new
staff and support the knowledge and skill of staff already trained.
Henderson provides training throughout the year on topics relevant to different
disciplines. Some of the topics PATH staff participate in may include Working with
Service Resistant Individuals, Treatment of Co-occurring Disorders, Trauma Informed
Care, and Psychopharmacology. Trainings are provided by both in-house staff and
experts in the community.
HMIS data is entered by administrative support staff at Henderson. They received
training from the Continuum of Care HMIS training staff.
f. Specific examples of how the agency serves to better link consumers 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 consumers with a criminal history
(e.g. jail diversion, active involvement in reentry).
Henderson recognizes that homelessness contributes to the risk of incarceration, and
incarceration contributes to higher risks of homelessness. Those who are homeless and
have behavioral health disorders are overrepresented in the criminal justice system.
Henderson offers housing and supportive services to support this high-risk population.
Henderson offers programs and housing options to participants involved with Broward
County’s Mental Health Court. Upon admission to the residential facility, a case manager
works with the individual to identify needs in areas such as employment, health care,
needed mainstream resources, and identification of future housing options. The case
manager provides progress updates to the Court and attends hearings with the individual.
The objective is to keep the person in compliance with Court requirements and provide
the necessary support services to lessen the chance of reoffending.
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Please check all services to be provided using PATH funds:
Outreach Services
Screening and diagnostic treatment services
Habilitation and rehabilitation services
Recovery Support Services such as Peer Support/Recovery Coaching
Community Mental Health services
Alcohol and drug treatment services
Assisting individuals to connect with Community Mental Health Services and
alcohol or other drug treatment services
Staff training (including training of individuals who work in shelters, mental
health clinics and substance abuse programs and other sites where homeless
individuals require services)
Case management services (see PATH eligible services document)
Supportive and supervisory services in residential settings
Referral for Primary healthcare
Referral for job training
Referral for educational services
Referral for housing services
5. Data: a) Describe the provider’s status on the HMIS transition plan, with accompanying
timeline, to collect PATH data by fiscal year 2017:
Data on all PATH participants is entered into the HMIS system.
b) If providers are fully utilizing HMIS for PATH services, please describe plans for
continued training and how providers will support new staff:
HMIS data is entered by administrative support staff at Henderson. They received training
from the Continuum of Care HMIS training staff.
6. SSI/SSDI Outreach, Access, and Recovery (SOAR):
a) Describe the agencies plan to train PATH staff in SOAR:
Henderson has SOAR trainers on staff and all PATH case managers are trained on SOAR
techniques. BBHC is working with Henderson to identify SOAR case managers for the
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PATH program, and to ensuring that they are fully trained through the on-line SOAR
training.
b) Indicate the number of PATH staff trained in SOAR during the grant year ending in
2016 (2015- 2016):
Two.
*Numbers are provided by PATH program, but are not verifiable through OAT system.
c) Indicate the number of PATH funded consumers assisted through SOAR (include all
distinct consumers whether approved, denied, or initiated on appeals):
Seventy-four.
*Numbers are provided by PATH program, but are not verifiable through OAT system.
d) Indicate the number of PATH enrolled consumers your program proposes to assist
with SOAR applications in FY 16/17:
Seventy.
*Numbers are provided by PATH program, but are not verifiable through OAT system.
e) Does the agency PATH program have a SOAR specialist who does all PATH SOAR
cases or does each PATH staff handle their own SOAR cases? Please describe the
rationale for this decision:
Henderson employs one SOAR dedicated staff for the agency who assists several PATH
recipients living in Henderson’s Homeless Safe Haven shelter. Otherwise, PATH case
managers manage their own SOAR cases, as able. The rationale for this decision is
financial. The organization would need to secure funding to hire a fully dedicated SOAR
specialist for PATH. If PATH funds were expanded, Henderson would be interested in
hiring a case manager to work solely on SOAR applications.
f) If the provider does not use SOAR, describe the system used to improve accurate,
timely completion of mainstream benefit applications and timely determination of
eligibility. Also, describe efforts used to train staff on this system. Indicate the
number of staff trained, the number of PATH funded consumers assisted through this
process, and application eligibility results:
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FY 2017-2018
Local Provider Henderson Behavioral Health Page 8 of 20
Intended Use Plan
N/A
g) Application eligibility results (i.e., approval rate on initial application, average time to
approve the application).
Many of the applications received by Henderson’s PATH case managers are on
appeal or reconsideration. Henderson employs the SOAR method when working on
these pending cases, as the denials are often a result of a previously submitted
incomplete applications prior to PATH engagement. The initial applications are
handled collaboratively by Henderson’s SOAR Designated Representative and PATH
case managers. The current approval rate is 96%, with an average of 39 days to a
decision. There is a total of 26 decisions; 25 approvals and one denial. There is a
100% approval rate for reconsiderations.
h) Describe how the providers plan to ensure that PATH staff has completed the SOAR
online course.
All newly hired PATH and non-PATH Henderson case managers are required to
complete the SOAR online course. Upon completion, staff must submit the required
training sample application to the SOAR TA Center within 180 days from date of
hire. All certificates related to this, in addition to all other required case management
trainings, are tracked by Henderson Behavioral Health’s Quality Improvement
Coordinator. Staff are also offered training and technical assistance from BBHC’s
SOAR/Entitlements Coordinator.
i) Describe which staff plan to assist consumers with SSI/SSDI application using the
SOAR model.
PATH-funded case managers assist individuals with SSI/SSDI applications using the
SOAR model. Henderson also has a designated SOAR Representative that is
available to assist agency-wide case managers with processing, completing, and
tracking applications in the OAT system. Henderson also utilizes the services of
Legal Aid Homeless Assistance Attorney to assist consumers who have previously
submitted applications, have been denied, or have pending applications.
j) Describe which staff plan to track the outcomes of those applications in the SOAR
Online Applications (OAT) system.
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FY 2017-2018
Local Provider Henderson Behavioral Health Page 9 of 20
Intended Use Plan
The Henderson SOAR Designated Representative is the primary point of contact and
is responsible for is tracking outcomes of applications in the OAT system. The
SOAR Representative coordinates with all the agencies adult case management
supervisors to obtain the necessary information for input into the OAT system.
k) The number of staff dedicated to implementing SOAR, Is SOAR their part-time or
full-time job duty?
BBHC has one full-time SOAR Designated Representative for the agency who is
solely responsible for overseeing SOAR. Additionally, Henderson has two PATH-
funded case managers, both of whom are trained in the SOAR process. As an agency,
all Henderson’s adult case managers are trained in the SOAR approach and utilize
said method for the individuals assigned to their caseloads.
l) 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.)
N/A
m) 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.
N/A
7. Housing:
a. Indicate what strategies are used for making suitable housing available for PATH
clients (i.e., indicate the type(s) of housing provided and the name of the agencies):
Henderson provides a variety of housing options for PATH recipients. Most connect with PATH
services while in Henderson’s Homeless Safe Haven shelter. The program prepares individuals
for permanent housing through the provision of services such as skills teaching, medication
management, and case management. Permanent housing options available for PATH recipients
include Henderson’s Chalet Apartments, a 40-unit apartment complex with onsite supportive
services, and Henderson’s HHOPE team, a multi-disciplinary team assisting individuals who are
homeless. Other options include a voucher-based program operated by Broward Housing
Florida PATH Intended Use Plan
FY 2017-2018
Local Provider Henderson Behavioral Health Page 10 of 20
Intended Use Plan
Solutions. In all options, ongoing case management services are provided for the duration of and
at the intensity needed by the recipient.
8. Staff Information:
a. Describe the demographics of the staff serving the consumers:
Demographics of the staff serving the population
Veterans 0%
Gender
Male 40%
Female 60%
Race
American Indian/Alaskan Native 0%
Asian 0%
Black/African American 20%
Caucasian 60%
Native Hawaiian/Pacific Islander 0%
Two or More Races 20%
Ethnicity
Hispanic/Latino 40%
b. Describe 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).
Henderson Behavioral Health has developed and implemented a formal cultural competency
plan. This plan designates cultural competence as an essential characteristic and defining quality
that is embedded in all aspects of its service system. Since its implementation, Henderson has
been committed to providing a culturally competent system of care that responds effectively to
the needs and differences of all individuals, based on their race, gender, age, physical or mental
status, sexual orientation, and ethnic or cultural heritage. In keeping with this commitment,
Henderson’s plan clearly addresses the importance of culturally sensitive outreach efforts and
human resource development. Henderson accepts and respects differences among and within
Florida PATH Intended Use Plan
FY 2017-2018
Local Provider Henderson Behavioral Health Page 11 of 20
Intended Use Plan
different groups; continually assesses policies and practices regarding culture, and adapts
services in order to better meet the needs of different racial and/or ethnic groups. Throughout the
years, it has expanded its outreach/off-site efforts to ensure that benefits and services are
available to individuals who may have difficulty seeking out these resources on their own.
Henderson takes pride and places emphasis on hiring staff who are unbiased, and those who
represent the racial and ethnic communities being served. Henderson seeks the advice and
counsel from individuals and families it serves.
Henderson Behavioral Health works on the guiding principle that every individual served will
have access to a clinician that is knowledgeable and sensitive to his/her customs, beliefs, values
and language. Hence, staff is representative of the population served, coming from a diversity of
cultures and speaking over fifteen different dialects or languages.
Cultural Competency is a major focus for Henderson Behavioral Health. There is ongoing
training throughout the year ensuring that staff are culturally aware and competent. Training
begins at New Employee Orientation, where new staff are introduced to Henderson's policies.
One segment of Orientation specifically covers Cultural Competency. It outlines differences and
how staff respect and embrace them at Henderson. Through the provision of culturally and
linguistically appropriate services, the quality of services provided can be improved, ultimately
helping to reduce health disparities and achieve health equity.
The training department also provides an annual mandatory Cultural Competency training at all
of its branches. During this training, staff discuss diversity and how to effectively serve
individuals. Henderson supervisors must attend the Clinical Supervision Training, which
prepares them to supervise others. This training has a section on Contextual Variables that
explores diversity and the importance of being sensitive these differences. Henderson staff
members also participate in cultural diversity workshops in the community that focus on training
the clinician to be aware of the impact of various cultures on the therapeutic relationship.
Broward Behavioral Health Coalition, the Managing Entity, has reviewed Henderson’s CLC plan
to ensure adherence to national CLAS standards. Henderson is in process of updating the plan to
meet competency standards and accessibility to the diverse populations served
Florida PATH Intended Use Plan
FY 2017-2018
Local Provider Henderson Behavioral Health Page 12 of 20
Intended Use Plan
9. Client Information: Describe the following:
a. The demographics of the PATH client population
Demographics of the population to be served:
Gender
Male 56%
Female 44%
Race
American Indian/Alaskan Native 0%
Asian 0%
Black/African American 44%
Caucasian 56%
Native Hawaiian/Pacific Islander 0%
Two or More Races 0%
Ethnicity
Hispanic/Latino 2%
Age
18-23 years 1%
24-30 years 9%
31-50 years 40%
51-61 years 43%
62 years and older 7%
b. The projected number of adult clients to be contacted and PATH enrolled and
rationale for these numbers:
Grant year 2016-2017 number or percentage of:
# of individuals contacted through outreach: 0%
# of individuals enrolled: 132
% of individuals enrolled that were literally homeless: 100%
% of individuals enrolled that were veterans: 3%
Grant year 2017-2018 projected number or percentage of:
# of individuals to be contacted through outreach: 0%
# of individuals to be enrolled: 135
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FY 2017-2018
Local Provider Henderson Behavioral Health Page 13 of 20
Intended Use Plan
% of individuals enrolled that are literally homeless: 100%
% of individuals enrolled that are veterans: 3%
Because the majority of PATH funding is allocated to case management and there is a caseload
capacity of approximately 25 participants, Henderson is unable to increase the anticipated
number of persons served.
10. Consumer Involvement:
a. 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.
PATH participants residing in Henderson’s Homeless Safe Haven program are encouraged to
attend weekly Community Meetings. During these meetings, individuals are encouraged to
provide and give input regarding program policies, both existing and proposed. Residents assist
in the running of this weekly activity.
For evaluation purposes, Henderson uses the following three types of consumer satisfaction
surveys to obtain input from persons served or parents/guardians of persons served: 1) a
consumer report card for adult consumers and parent/guardians of children served; 2) a
children’s report card; and 3) a satisfaction survey for persons who receive Walk-In or Inpatient
Crisis services. The results from these surveys provide the framework for improving service
delivery. Recommendations pertaining to any area of concern are reviewed by Henderson’s
Leadership Team and are assigned to the appropriate personnel and/or improvement team for the
development of corrective actions.
11. Budget: a. Provide a detailed budget that includes the agency’s use of PATH funds.
Henderson Behavioral Health - 2017-2018 PATH Grant Budget
Personnel Annual
Salary*
(total
number)
PATH-
funded
FTE
(%)
PATH-
funded
Salary
Matched
Dollars
Total
Dollars
Comments
Entitlement Specialist $32,300 1 $32,300 $32,300
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FY 2017-2018
Local Provider Henderson Behavioral Health Page 14 of 20
Intended Use Plan
Housing Services Coordinator $53,000 0.35 $18,550 $11,000 $29,550 Dollars to
offset the costs
of Matching
Funds are
derived from
Donations,
Fund Raising,
Interest
Income, and
Investment
Income.
Case Manager $36,000 1 $36,000 $36,000
Case Manager $36,000 1 $36,000 $36,000
Case Manager $36,000 1 $36,000 $36,000
Therapist $41,600 0.5 $20,800 $20,800
Administrative Support $26,000 $26,000 Dollars to
offset the costs
of Matching
Funds are
derived from
Donations,
Fund Raising,
Interest
Income, and
Investment
Income.
Subtotal $234,900 4.85 $179,650 $37,000 $216,650 Dollars to
offset the costs
of Matching
Funds are
derived from
Donations,
Fund Raising,
Interest
Income, and
Investment
Income.
Florida PATH Intended Use Plan
FY 2017-2018
Local Provider Henderson Behavioral Health Page 15 of 20
Intended Use Plan
* Indicate "annualized salary
for positons."
Fringe Benefits (Max of 27%) $63,243 $48,505 $9,990 $58,495
Subtotal $298,143 $228,155 $46,990 $275,145
Travel
Training $7,231 $7,231 Provide
ongoing
trainings to
PATH staff on
relevant topics
including
Crisis
Intervention,
Trauma
Informed Care,
Motivational
Interviewing,
Medication
Education,
PSY, and other
applicable
trainings
regarding
service
provision to
persons
experiencing
homelessness.
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FY 2017-2018
Local Provider Henderson Behavioral Health Page 16 of 20
Intended Use Plan
Other: $5,000 $5,000 Mileage-local
travel to
support PATH
eligible
individuals and
other
supportive
services. The
figure is
calculated
based on
approximately
11,364 miles
driven annually
by 3 case
managers,
reimbursed at
$.445/mile.
Other: $2,724 $3,704 $6,428 Vehicle gas.
Match:
Donations,
Fund Raising,
Interest
Income, and
Investment
Income.
Other: $2,000 $2,000 Vehicle repair
and
maintenance.
Match:
Donations,
Fund Raising,
Interest
Income, and
Investment
Income.
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FY 2017-2018
Local Provider Henderson Behavioral Health Page 17 of 20
Intended Use Plan
Subtotal $14,955 $5,704 $20,659
Equipment
Subtotal
Supplies
Office supplies $2,000 $1,863 $3,863 Copy paper,
business cards,
pens and
pencils,
binders and
clips, misc
items. Match:
Donations,
Fund Raising,
Interest Income
and Investment
Income.
Client: Outreach Supplies/
Hygiene kits/Misc.
software
Other (describe)
Other (describe)
Subtotal $2,000 $1,863 $3,863
Contractual
Subtotal
Other
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FY 2017-2018
Local Provider Henderson Behavioral Health Page 18 of 20
Intended Use Plan
One-time housing rental
assistance
$3,000 $3,000 Dollars to
offset the costs
of Matching
Funds are
derived from
Donations,
Fund Raising,
Interest
Income, and
Investment
Income.
Insurance (property, vehicle,
malpractice, etc.)
Office: Misc. (Copying,
Courier, Postage, etc.)
Office: Security, Janitorial,
Grounds Maintenance
Office: Utilities/Telephone/
Internet.
$3,000 $3,000 Projected
annual costs,
based on
historical data.
Utilities
(electric, water,
etc.) used by
PATH-funded
staff. $100 per
month X 12
months=$1200.
Cell phone
service for case
managers: $50
per month x 12
months=$1800.
Match:
Donations,
Fund Raising,
Interest
Income, and
Florida PATH Intended Use Plan
FY 2017-2018
Local Provider Henderson Behavioral Health Page 19 of 20
Intended Use Plan
Investment
Income.
Office: $18,000 $18,000 Office space
cost. Match:
Donations,
Fund Raising,
Interest
Income, and
Investment
Income.
Office: Other (describe)
Staffing (Not Salary or
Benefits):
Training/Education/Conference
Fees
Staffing (Not Salary or
Benefits): Other (describe)
Audit
Subtotal $3,000 $21,000 $24,000
Florida PATH Intended Use Plan
FY 2017-2018
Local Provider Henderson Behavioral Health Page 20 of 20
Intended Use Plan
Total Direct Charges (Sum of
each section)
$298,143 $248,110 $75,557 $323,667
Indirect Costs (Max of 10%)
(Administrative Costs)
0 $7,556 $7,556
Grand Total (Total of "total
direct" and "indirect costs")
$298,143 $248,110 $83,113 $331,223
Jerome Golden Center for Behavioral Health, Inc.
PATH Intended Use Plan
FY 2017-2018
Local Provider Jerome Golden Center Page 1 of 20
Intended Use Plan
C. Local Provider Intended Use Plan:
1. Local Provider Description: Provide a brief description of the provider organization
receiving PATH funds:
Name of the Organization: Jerome Golden Center for Behavioral Health, Inc. (JGC)
Type of Organization: Private, Not-for-Profit, Community Mental Health Center
Address of Provider: 1041 45th Street, West Palm Beach, FL 33407-2415
Local Continuum of Care Lead Agency: Division of Human Services of Palm Beach
County
PATH Contact Name/E-Mail/Phone #: Renan Steele, LMHC. / [email protected];
(561) 993-8058
Region Served: Southeast/Palm Beach County
Indicate the amount of federal, state and local PATH funds the organization will
receive.
Federal: $180,000
Match: $ 60,000
Total: $240,000
2. Collaboration with HUD Continuum of Care Program: Describe the organization’s
participation in the HUD Continuum of Care and any other local planning, coordinating or
assessing activities:
PATH providers at the Jerome Golden Center (JGC) assist in the community coordination of
homeless services through active participation in the Palm Beach County Continuum of Care
(CoC) and through partnerships with other agencies within the CoC, as well as in the private
sector. The Agency is also a recipient of U.S. Department of Housing and Urban
Development (HUD) funds, supervises fifty-six apartments under the Housing First Model,
and contributes to projects related to homelessness. As members with full voting rights, PATH staff attend monthly CoC planning meetings, take part in a variety of its sub-
committees, and contribute to the CoC’s annual grant writing to develop the HUD Super
NOFA application. Staff are directly involved with performance measures, discharge
planning, Homeless Management Information System (HMIS), the Homeless Coalition of
Palm Beach County, and the Ten Year Plan to End Homelessness directive. PATH staff also
contribute to the planning of and participate in the local Point-in-Time Counts.
Jerome Golden Center for Behavioral Health, Inc.
PATH Intended Use Plan
FY 2017-2018
Local Provider Jerome Golden Center Page 2 of 20
Intended Use Plan
3. Collaboration with Local Community Organizations: Provide a brief description of
partnerships and activities with local community organizations that provide key services (i.e.,
outreach teams, primary health, mental health, substance abuse, housing, employment, etc.)
to PATH eligible consumers and describe coordination of activities with each of these
organizations (describe all that apply):
JGC collaborates with many agencies in Palm Beach County to provide comprehensive
services and supports that enable PATH participants to access mainstream resources.
Partner organizations include:
The Drug Abuse Foundation of Palm Beach County, Inc. (DAF) – provides services
for substance abuse issues
The Salvation Army – provider agency of the Center of Hope Residential Program;
also provides housing placement assistance
The Lord’s Place – provides employment training and residential substance abuse
housing programs
St. Ann Place – outreach center for men and women who are homeless; provides
hygiene and laundry assistance; a food program; health care advocacy; a job support
program; and various other forms of special assistance and services
Local food pantries and soup kitchens – distribute free meals to individuals in need
o St. George’s Center
o The Caring Kitchen
o Boca Helping Hands
o First Baptist Church of Lake Worth
Peer Place Support Center – connects individuals to relevant community resources
and support services; offers mental health and peer mentoring services
Palm Tran Public Transportation – offers discounted public transportation services for
active PATH participants
The Lewis Center Homeless Resource Center – single point of access for all homeless
services in Palm Beach County, including coordination of housing placements
Department of Education Division of Vocational Rehabilitation – offers employment
services, including supported employment, to individuals who have significant mental
and/or physical disabilities
Jerome Golden Center for Behavioral Health, Inc.
PATH Intended Use Plan
FY 2017-2018
Local Provider Jerome Golden Center Page 3 of 20
Intended Use Plan
4. Service Provision: Describe the organization’s plan to provide coordinated and
comprehensive services to eligible PATH consumers, 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:
JGC’s PATH-funded outreach and case management services will continue to be
conducted with a focus on serving adults in the community who are literally and
chronically homeless or at risk of homelessness. These individuals also have diagnosed
severe mental illnesses and may also be diagnosed with a co-occurring disorder. As such,
eighty percent of the outreach time that the Agency’s PATH staff members conduct will
be geared toward identifying and working with these individuals within the community
setting. To maximize serving literally and chronically individuals who are experiencing
homelessness, PATH outreach staff will drive by parks, homeless encampments, and
traffic intersections to identify individuals that may be experiencing homelessness,
engage them, and meet them at designated in-reach sites. According to Agency staff, the
utilization of peer counselors has been the most successful outreach and engagement
strategy; thus peer counselors will continue to work alongside PATH case managers to
provide in-reach at community programs within Palm Beach County that are frequented
by individuals who are experiencing homelessness, such as shelters, soup kitchens, food
banks, homeless camps, and other service providers.
Once an individual experiencing homelessness is enrolled in PATH as a participant,
he/she will be linked to case management services through a two-step process:
1. Each PATH participant will be assessed by an outreach worker;
2. If the outreach worker determines that case management is needed, they will
refer the PATH participant to a Case Manager who will then contact the
participant to arrange a meeting to organize the provision of needed services.
b. Provide specific examples of how the agency maximizes use of PATH funds by
leveraging use of other available funds for PATH client services:
The PATH Program has a HUD-funded Housing First permanent residential program that
provides housing. The PATH Program is linked with the local emergency shelter
program, which is the single point of entry for housing. Full case management services
are provided. Additionally, mental health technicians and peer counselors assist with
Jerome Golden Center for Behavioral Health, Inc.
PATH Intended Use Plan
FY 2017-2018
Local Provider Jerome Golden Center Page 4 of 20
Intended Use Plan
wrap around services to reduce episodes of homelessness. A dedicated psychiatrist, who
is familiar with challenges faced by people experiencing homelessness provides
medication management, psychiatric evaluation, and in-patient and out-patient treatment
services is on staff.
PATH outreach staff dedicate six hours a day to outreach services, visiting designated
sites to assist individuals experiencing homelessness. The team provides up-to-date
referrals and transportation to the referral sources when needed. To encourage the
individual to use treatment services, PATH outreach staff also attend intake appointments
with outreach clients.
c. Describe any gaps that exist in the current service systems:
Gaps in Palm Beach County’s homeless services system currently exist in the following
areas, many of which were originally identified in the County’s Ten-Year Plan to End
Homelessness:
Inadequate number of beds in locations designated for housing individuals
experiencing homelessness, as indicated by current waitlists and the most recent
Point-In-Time Count reports
Insufficient housing for couples and married persons experiencing homelessness
Insufficient housing for individuals who do not have disabilities
Lack of specialized services for individuals who do not have health insurance
Need for twenty-four-hour medical respite and recuperative care programs for
medical and mental health recovery
Lack of damp shelters where intoxicated individuals experiencing homelessness who
have been turned away from other emergency shelters can temporarily take refuge for
a night while “sobering up”
Lack of counseling services for individuals who do not have health insurance
Lack of services for specific underserved sub-populations of individuals who are
homeless and at-risk, as identified by the Plan, including:
o Seniors
o Prisoners exiting jail
o Persons with disabilities
o Pregnant women
o Single women who do not have children
o Veterans
o Undocumented individuals
o People with co-occurring or dual needs
Jerome Golden Center for Behavioral Health, Inc.
PATH Intended Use Plan
FY 2017-2018
Local Provider Jerome Golden Center Page 5 of 20
Intended Use Plan
Lack of supportive services specifically designed to address the challenges that face
individuals who are homeless as they attempt to live independently in housing
settings that are integrated into the community
d. Provide a brief description of the current services available to clients who have both a
serious mental illness and a substance use disorder:
JGC provides mental health and substance abuse services though the following programs:
Synergy Modified Intensive Community Treatment Team – outpatient intensive case
management and substance abuse counseling services indicated for individuals
identified as having co-occurring mental health and substance abuse disorders
Detox Unit – substance abuse detoxification services are offered in a safe, secure, and
structured environment at the Center’s Belle Glade location.
PANDA – residential substance abuse treatment facility that specifically serves
women who meet the criteria for substance abuse or dependence and are pregnant or
have children between the ages of 0-5.
Outpatient Psychiatric Services: these services are also available specifically for
individuals who are dually-diagnosed.
Supportive Housing – programs that provide housing services to individuals who are
actively using alcohol or other drugs
Residential Integrated Treatment for Co-occurring Disorders – this evidence-based
program takes on the complex task of addressing co-occurring psychiatric and
substance abuse concerns simultaneously in a 16-bed Residential Treatment Facility.
e. Describe how the local provider agency pays for providers or otherwise supports
evidence-based practices, trainings for local PATH-funded staff, and trainings and
activities to support collection of PATH data in HMIS:
f.
JGC’s PATH Program employs several evidence-based practices originating from the
person-centered and flexible design of the Assertive Community Treatment (ACT)
model. Such evidence-based practices are a key component of the Agency’s PATH
outreach process, and are implemented as follows:
Peer Counselors who have personal experience related to homelessness, substance
use, and mental health diagnosis are employed to provide outreach. Due to this first-
hand experience, peer counselors effectively interact with and advocate for PATH-
served participants.
Jerome Golden Center for Behavioral Health, Inc.
PATH Intended Use Plan
FY 2017-2018
Local Provider Jerome Golden Center Page 6 of 20
Intended Use Plan
PATH case managers offer flexible schedules and options for meeting places to
accommodate PATH participants’ needs in locations where they feel comfortable,
with most appointments taking place in community settings. Such mobility is applied
to all aspects of the Agency’s outreach process, and staff members are trained to be
accommodating and non-threatening in order to develop healthy working
relationships with PATH participants.
Front-line PATH staff members are trained to develop adequate assessment skills for
identifying mental health issues and recognizing patterns of behavior requiring
clinical intervention. These skills are particularly useful during the outreach
interview and referral processes.
Nonviolent crisis prevention and intervention techniques based upon current Crisis
Prevention Institute (CPI) standards are utilized when necessary to de-escalate a
crisis- situation. These CPI-based interventions are used to stabilize an environment
to ensure the health and physical safety of individuals living in that environment.
Motivational Interviewing techniques are used by PATH staff members when
interacting with PATH participants and engaging them during the PATH Program
application process. These methods assist participants in developing a plan of action
that are suitable, effective, and based on their unique needs.
Therapeutic groups for co-occurring disorders with evidence-based curriculum for
Integrated Combined Therapies (ICT), which includes aspects of Motivational
Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT), and Twelve
Step Facilitation (TSF)
Data Collection: PATH staff members currently manually collect and tabulate PATH
data, which are recorded in monthly reports, HMIS, and Excel spreadsheets accessible to all staff members, to ensure consistency of reports and prevent
accidental duplication of demographic information. The PATH Program has developed a system of submitting data to HMIS, (Client Management Information
System) and reports can now be generated to address the data needed for the PATH
Annual Report.
g. 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 consumers often have criminal histories which can pose additional challenges for
support. JGC has added a corporate strategic goal to its five-year plan to further develop
Jerome Golden Center for Behavioral Health, Inc.
PATH Intended Use Plan
FY 2017-2018
Local Provider Jerome Golden Center Page 7 of 20
Intended Use Plan
services for individuals with mental health diagnoses who are in the criminal justice
system. The goal is to explore opportunities to intervene at multiple points of criminal
justice service involvement to assist consumers with criminal history in accessing
housing programs, health services, jail diversion, and community reintegration. The Path
program is a key point of entry, as this is often one of the first points of contact with
consumers who have these challenges. Path staff often coordinate with the legal system
on behalf of consumers.
Please check all services to be provided using PATH funds:
Outreach Services
Screening and diagnostic treatment services
Habilitation and rehabilitation services
Recovery Support Services such as Peer Support/Recovery Coaching
Community Mental Health services
Alcohol and drug treatment services
Assisting individuals to connect with Community Mental Health Services and
alcohol or other drug treatment services
Staff training (including training of individuals who work in shelters, mental
health clinics and substance abuse programs and other sites where homeless
individuals require services)
Case management services (see PATH eligible services document)
Supportive and supervisory services in residential settings
Referral for Primary healthcare
Referral for job training
Referral for educational services
Referral for housing services
5. Data:
a) Describe the provider’s status on the HMIS transition plan, with accompanying
timeline, to collect PATH data by fiscal year 2017:
JGC’s PATH Program has assigned one PATH case manager and one additional
PATH staff member to submit data to CMIS. Staff designate one day per week to
complete entries for the entire week, and full implementation of the HMIS data
system has been implemented. As a system of checks and balances, logs and
spreadsheets are also generated and can be made available for monthly review.
Jerome Golden Center for Behavioral Health, Inc.
PATH Intended Use Plan
FY 2017-2018
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b) If providers are fully utilizing HMIS for PATH services, please describe plans for
continued training and how providers will support new staff:
Palm Beach County utilizes the CMIS as HMIS. CMIS is a locally administered,
HUD-required electronic data collection system. Palm Beach County’s CoC
designated staff to provide technical support, system performance, outcome reporting,
intensive training, and data quality monitoring.
6. SSI/SSDI Outreach, Access, and Recovery (SOAR):
a. Describe the agencies plan to train PATH staff in SOAR:
Trainings will be coordinated with South East Florida Behavioral Health Network
(SEFBHN) to train new staff as needed.
b. Indicate the number of PATH staff trained in SOAR during the grant year ending in
2016 (2015- 2016):
One PATH case manager, one Residential/PATH case manager and two outreach
staff were trained in the SOAR process in 2015-2016.
c. Indicate the number of PATH funded consumers assisted through SOAR (include all
distinct consumers whether approved, denied, or initiated on appeals):
Nine SOAR applications were completed during the 2015-2016 reporting year. Four
applications are pending for 2016-2017.
d. Indicate the number of PATH enrolled consumers your program proposes to assist
with SOAR applications in FY 16/17:
JGC’s Path Program proposes to assist 12 consumers with SOAR applications in FY
16/17.
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e. Does the agency PATH program have a SOAR specialist who does all PATH SOAR
cases or does each PATH staff handle their own SOAR cases? Please describe the
rationale for this decision:
Each PATH staff is trained and able to handle his/her own SOAR cases. Cases are
assigned to another team member only if necessary due to urgency or availability of
staff.
f. If the provider does not use SOAR, describe the system used to improve accurate,
timely completion of mainstream benefit applications and timely determination of
eligibility. Also describe efforts used to train staff on this system. Indicate the number
of staff trained, the number of PATH funded consumers assisted through this process,
and application eligibility results:
g.
SOAR is used to assist eligible PATH participants who are in need of assistance in
completing SSI/SSDI applications.
h. Application eligibility results (i.e., approval rate on initial application, average time to
approve the application).
The Path program currently has an approval rate of 50% with an average of 183 days
to approval. There were five submitted applications, one approved, one denial, two
pending, and one archived to date. Training and monitoring to improve both
efficiency and quality are being implemented. A new supervisor of Homeless
Services will provide ongoing supervision.
i. Describe how the providers plan to ensure that PATH staff have completed the SOAR
online course.
The Path staff have been SOAR trained via face-to-face training. Any new Path staff
will have to complete the SOAR online training course. Verification of training will
be monitored by the program supervisor.
j. Describe which staff plan to assist consumers with SSI/SSDI application using the
SOAR model.
Path staff consisting of two outreach workers and one path case manager are trained
to assist consumers using the SOAR model.
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k. Additional targeted case managers across the organization are also SOAR-trained to
assist consumers.
l. Describe which staff plan to track the outcomes of those applications in the SOAR
Online Applications (OAT) system.
The Path staff and supervisor of Homeless Services will track the outcome of
applications in OAT.
m. The number of staff dedicated to implementing SOAR, Is SOAR their part-time or
full-time job duty?
The supervisor of Homeless Services spends time planning, training, scheduling, and
providing support for and supervision of case management and peer counselor staff.
SOAR monitoring is part of those duties. The Path team of two outreach workers and
one Path case manager provide ongoing services to Path consumers. Outreach staff
dedicate 20% of their time for SOAR and 80% providing outreach services. The Path
case manager provides SOAR services as needed.
n. 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.)
N/A
o. 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.
N/A
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7. Housing:
a) Indicate what strategies are used for making suitable housing available for PATH clients
(i.e., indicate the type(s) of housing provided and the name of the agencies)
The following strategies are used to ensure that suitable housing is available:
The Lewis Center Homeless Resource Center – single point of access for all homeless
services in Palm Beach County, including emergency housing services and
coordination of transitional housing services
The Lord’s Place – directs individuals experiencing homelessness to housing
resources; also offers training programs and case managers who provide advocacy
and social service linkage
Joshua House – HUD-funded residential substance abuse treatment program for
males
JGC’s Homeless Assertive Community Treatment Team – works with individuals
experiencing homelessness who have severe mental illnesses and/or co-occurring
disorders, connecting them to relevant community services, including housing
programs
JGC’s HUD-funded housing programs – the Center’s Supported Housing programs
provide housing and supportive services for individuals with disabilities experiencing
homelessness, on a long-term basis
Project Home IV – supportive housing for individuals with mental health issues
requiring staff supervision
Emergency Shelters – overnight sleeping accommodations and safe, short-term
shelter as an alternative to living on the streets:
o Casa Vegso (Aid to Victims of Domestic Abuse (AVDA))
o Families First’s
o Family Interim Program’s (The Lord’s Place, Inc.)
o Family Promise of North Central Palm Beach County’s
o Florida Resource Center for Women and Children’s emergency shelter
o Harmony House (YWCA of Palm Beach County)
o J.A.Y. Outreach Ministries, Inc.’s Emergency Housing for Men
o Palm Beach County Human Services’
o Safe Harbor (Children’s Home Society of Florida, Inc.)
o Senator Philip D. Lewis Center’s transitional and residential beds (Gulfstream
Goodwill Industries, Inc.)
o Stand Down House
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Transitional Housing facilities – provide temporary housing linked with supportive
services to help individuals develop the necessary skills for successful independent
living:
o Casa Vegso Transitional Housing (AVDA)
o Center of Hope (Salvation Army)
o Florida Resource Center for Women and Children’s transitional housing
o Family Interim Program (The Lord’s Place, Inc.)
o Harmony House West (YWCA of Palm Beach County)
o First Stop Housing
o J.A.Y. Outreach Ministries, Inc.’s Transitional Housing for Men
o Project Success (Gulfstream Goodwill’s Homeless Residential Programs)
o Recovery Center (The Lord’s Place, Inc.)
o Stand Down House
o Transitions Home (Children’s Home Society of Florida, Inc.)
o Villages of Hope (Christ Fellowship Church)
o Vita Nova Village transitional housing (Vita Nova, Inc.)
Permanent Supportive Housing facilities –long-term, community-based housing, for
those who have first completed supportive services programs in preparation for
permanent housing placement:
o Flagler Project (Jerome Golden Center for Behavioral Health, Inc.)
o Project Home IV (Jerome Golden Center for Behavioral Health, Inc.)
o Section 8 Housing Choice Voucher Program (HUD VA Supportive Housing
(HUD-VASH))
o Joshua House (The Lord’s Place, Inc.)
o New Avenues (Gulfstream Goodwill Industries, Inc.)
o Phoenix, UMI Village, and scattered-site housing options (Jerome Golden Center
for Behavioral Health, Inc.)
o Project Family Care (The Lord’s Place, Inc.)
o Project Home III (Jerome Golden Center for Behavioral Health, Inc.)
o Project Northside (Jerome Golden Center for Behavioral Health, Inc.)
o Project Safe (Adopt-A-Family of the Palm Beaches, Inc.)
o Project Succeed I (Gulfstream Goodwill Industries, Inc.)
o Project Succeed II (Gulfstream Goodwill Industries, Inc.)
o Project Succeed III (Gulfstream Goodwill Industries, Inc.)
o Project Succeed IV (Gulfstream Goodwill Industries, Inc.)
o Vita Nova Village (Vita Nova, Inc.)
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8. Staff Information:
a. Describe the demographics of the staff serving the consumers:
Demographics of the staff serving the population
Veterans 0%
Gender
Male 17%
Female 83%
Race
American Indian/Alaskan Native 0%
Asian 0%
Black/African American 50%
Caucasian 50%
Native Hawaiian/Pacific Islander 0%
Two or More Races 0%
Ethnicity
Hispanic/Latino 0%
b. Describe 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).
JGC recognizes that cultural competence is an important goal when delivering mental
health services, and thus strives to remain current by providing several training
opportunities. The Behavioral Health Learning Center operated by the JGC is
designed to meet the training needs of all employees and volunteers, and frequently
hosts relevant trainings. Many of these trainings are specifically developed to
enhance and strengthen Center staff members’ understanding of behavioral health
treatment and issues as they pertain to the various cultures represented in Palm Beach
County. PATH staff members attend trainings from other local agencies, as well as
State of Florida mandated trainings, to enhance staff effectiveness in serving
particular populations, and in assisting these individuals in accessing appropriate
support services. All services are purposefully provided in an appropriate cultural
context and without discrimination to race, culture, national origin, language, income
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level, physical disability, religion, gender, sexual preferences, gender orientation, or
age. The Agency constantly adapts its choices of intervention and treatment to best
accommodate the needs, values, and customs expressed by PATH participants and
their families. Pertinent cases and scenarios are reviewed during weekly center staff
meetings, ensuring that cultural competence is also reviewed. The Center strives to maintain a staff population that is representative of the various
populations it serves in the areas of age, gender, and racial/ethnic characteristics, as
well as sensitive to the diverse needs of the population being served, especially
concerns such as the unique challenges homelessness presents. This sensitivity is
always considered when staffing programs and has been a priority within the PATH
program since the onset of its funding. The PATH Homeless Community Treatment
Team Program staff reflect the population JGC serves, with regard to in age, gender,
and racial/ethnic background. In fact, some current PATH staff members are or have
been homeless and/or served by the PATH program. To address issues related to
language barriers, JGC has developed a roster of staff members who speak other
languages. This roster can easily be accessed by other staff members in order to
readily assist any participants in the PATH Program who have identified English as
their second language This staff foreign language roster currently includes members
who speak Spanish, Hindi/Gujarati, Urdu, French/Creole, and Vietnamese.
9. Client Information: Describe the following:
a. The demographics of the PATH client population
Demographics of the population to be served:
Gender
Male 60%
Female 40%
Race
American Indian/Alaskan Native 2%
Asian 1%
Black/African American 41%
Caucasian 54%
Native Hawaiian/Pacific Islander 1%
Two or More Races 1%
Ethnicity
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Hispanic/Latino 4%
Age
18-23 years 1%
24-30 years 29%
31-50 years 35%
51-61 years 30%
62 years and older 5%
b. The projected number of adult clients to be contacted and PATH enrolled and
rationale for these numbers:
Grant year 2015-2016 number or percentage of:
# of individuals contacted through outreach: 500
# of individuals enrolled: 206
% of individuals enrolled that were literally homeless:88%
% of individuals enrolled that were veterans: .08%
Grant year 2017-2018 projected number or percentage of:
# of individuals to be contacted through outreach: 500
# of individuals to be enrolled: 250
% of individuals enrolled that are literally homeless: 80%
% of individuals enrolled that are veterans: 5%
10. Consumer Involvement:
a. 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.
JGC continually strives to involve participants in the PATH Program at different levels of
involvement such as advisory committees for the various group therapy programs,
residential programs, and monthly group meetings. Family members are also an integral
part of these advisory boards. PATH-eligible individuals are encouraged to participate
on several boards at the state and local level, including the CoC, the Homeless Advisory
Board, and the Jerome Golden Center Advisory Board. JGC has PATH participants
actively involved in committees such as the Committee on Rights, Responsibilities, and
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Ethics, and the JGC Board/Staff Committee, which includes representatives who have
family members in treatment, and are an integral part of the Agency’s program reviews.
The Consumer Advisory Board is comprised of individuals from throughout the Agency,
and provides feedback regarding how to improve Agency services and supports. JGC
also continuously looks for opportunities for betterment through its quality improvement
teams, and administers quality satisfaction surveys to participants in the PATH Program
Recommendations received from the Consumer Advisory Board and satisfaction surveys
are submitted to the Performance Improvement Council for review. The Agency hires a significant number of peer counselors to work in the PATH Program. These individuals
who help shape and guide the program from the perspective of lived experience.
11. Budget:
a. Provide a detailed budget that includes the agency’s use of PATH funds.
Jerome Golden Center - 2017-2018 PATH Grant Budget
Personnel
Annual
Salary*
(total
number)
PATH-
funded
FTE
(%)
PATH-
funded
Salary
Matched
Dollars
Total
Dollars Comments
Supervisor $45,445 0.7 $31,812 $
31,812
Provides program
oversight of grant
compliance, planning,
training, and support to
staff and participants.
Case Manager $32,523 1 $32,523 $32,523
Provides screening and
needs assessments;
psycho-social
evaluations; treatment
plans; advocacy; case
management services;
counseling; home
visits; food/park site
visits; and referrals to
appropriate agencies
based on PATH
participants’ individual
needs
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Outreach Worker $19,282 2 $38,564 $38,564
Provides outreach and
assessment services, as
well as advocacy and
emotional support, for
individuals who are
homeless and need
assistance.
Licensed Practical Nurse $35,350 0.2 $7,070 $ 7,070
Monitors PATH
participants’
medication and vital
signs ; reviews doctors’
orders and
prescriptions.
Psychiatrist/Nurse Practitioner $77,250 0.1 $7,725 $ 7,725
Oversees
psychopharmacological
and medical treatment.
Secretary $30,900 0.1 $ 3,090 $ 3,090
Assists with phone
messages; schedules
initial psychiatric
evaluations and
monthly visits.
MATCH (2) FTE outreach
peer /(.5) Case manager $60,000 $60,000
Engaging and
educating homeless
individuals about
mental health,
substance abuse, and
social services
available locally as
well as advocacy and
emotional support for
homeless individuals.
Subtotal $120,784 $180,784
* Indicate "annualized salary
for positons."
Fringe Benefits (Max of 27%) $ 32,612 $ 32,612
Subtotal $ 32,612 $32,612
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Travel $ 1,492 $ 1,492
($124.33 per month x
12 months). Staff
mileage to food sites,
parks, medical/social
service appointments,
home visits, and
trainings.
Training $ 1,000 $ 1,000
Participation in
trainings in relevant
evidence-based
practices such as
Motivational
Interviewing, Trauma
Informed Care, SOAR,
Housing First, and
Conflict Resolution.
Annual Conference or
Meetings
Rental Car
Per Diem
Other (describe)
Other (describe)
Subtotal $ 2,492 $ 2,492
Equipment
Subtotal
Supplies
Office supplies $ 877 $ 877
Pens, pads, calendars,
printer cartridges,
staples, and related
materials.
Client: Outreach Supplies/
Hygiene kits/Misc.
software
Air Card (2) computers $ 1,860 $ 1,860 Internet Access for 2
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computers.
Other (describe)
Subtotal $ 2,737 $ 2,737
Contractual
Subtotal
Other
One-time housing rental
assistance
Insurance (property, vehicle,
malpractice, etc.) $ 6,355 $ 6,355
Liability Insurance
provides coverage for
staff.
Office: Misc. (Copying,
Courier, Postage, etc.)
Office: Security, Janitorial,
Grounds Maintenance
Office: Utilities/Telephone/
Internet incl. Cell Phone $4,000 $ 4,000
Projected annual cost
of utility services for
the two offices for Path
staff; cell phones used
to make appointments
and referrals for PATH
participants while on-
site in community.
Contingency Fund $1,020 $1,020
Bus passes,
replacement
identification cards,
replacement birth
certificates, gift cards
for PATH participants
enrolled in case
management services.
Center Vehicle $ 5,000 $ 5,000
Vehicle lease,
insurance, registration,
tag, maintenance, and
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gasoline.
Office: Space Rental $ 5,000 $ 5,000
Office space for
Supervisor, Case
Manager, and Peer
Counselors.
Staffing (Not Salary or
Benefits):
Training/Education/Conference
Fees
Audit
Subtotal $ 21,375 $ 21,375
Total Direct Charges (Sum of
each section) $180,000 $60,000 $240,000
Indirect Costs (Max of 10%)
(Administrative Costs)
Grand Total (Total of "total
direct" and "indirect costs") $180,000 $60,000 $240,000
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C. Local Provider Intended Use Plan:
1. Local Provider Description: Provide a brief description of the provider organization
receiving PATH funds:
Name of the Organization: Mental Health Resource Center, Inc. (MHRC)
Type of Organization: Private, not-for-profit 501(c)(3) community mental health center
Address of Provider: 10550 Deerwood Park Boulevard, Suite 600, Jacksonville, FL 32256
Local Continuum of Care Lead Agency: Changing Homelessness Inc.
PATH Contact Name/E-Mail/Phone #: Robert Sommers, Ph.D./ [email protected]/ (904)743-1883 Ext. 7103 or Jill Speiser, Executive Office
Manager/[email protected]/(904)743-1883 Ext. 7103
Region Served: Northeast/Duval County
Indicate the amount of federal, state and local PATH funds the organization will
receive.
Federal: $243,091
Match: $218,772
Total: $461,863
2. Collaboration with HUD Continuum of Care Program: Describe the organization’s
participation in the HUD Continuum of Care and any other local planning, coordinating or
assessing activities:
Since 1988, MHRC has been a participating member in the Continuum of Care (CoC)in
Duval County. MHRC LINK staff attend monthly CoC meetings to explore ways to better
advocate for and serve those who are homeless and provide MHRC LINK with ongoing
networking opportunities. MHRC LINK staff participate on several standing and ad hoc
committees. Mental Health Resource Center’s Program Manager-Homeless Services, serves
as a member of the CoC Data Committee local SOAR Steering Committee, and
Universal/Coordinated Intake Board. Staff assist with past data collection and writing of the
Continuum of Care; participate in the annual memorial service for people experiencing
homelessness who pass away every year, and continually work with the local drop-in center
on McDuff Avenue that serves PATH eligible individuals. The MHRC LINK Team Leader
participates as a member of Jacksonville Area Discharge Enhancement (JADE), which assists
ex-offenders in their process of reintegrating into the community. Staff participate in the
collection of data for the Homeless Coalition's Annual Census and Survey, which is an
invaluable measurement tool for the homeless community and area service providers. Each
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year, MHRC LINK sends representatives to the Florida Coalition for the Homeless' Annual
Conference.
3. Collaboration with Local Community Organizations: Provide a brief description of
partnerships and activities with local community organizations that provide key services (i.e.,
outreach teams, primary health, mental health, substance abuse, housing, employment, etc.)
to PATH eligible clients and describe coordination of activities with each of these
organizations (describe all that apply):
MHRC LINK staff work closely with several non-PATH funded housing and service
providers and other community organizations to ensure that individuals receive all the
services for which they are eligible, including referrals and linkage to services and
coordination with local clinics to determine risk for chronic medical conditions, infectious
diseases, and/or life-threatening illnesses. Through coordination with psychiatric hospitals,
substance abuse centers, crisis stabilization units, homeless shelters, and anyone who calls to
report an individual who appears to be homeless and may have a mental illness or substance
abuse disorder, MHRC LINK staff provide individuals who are reluctant to seek help with
outreach, screening, and engagement into services. MHRC LINK also conducts outreach to
screen individuals in local correctional facilities who will become homeless after their
release. The Veterans Administration (VA) provides weekly services to all PATH eligible
veterans at the MHRC LINK service center. Staff also participate in the Annual Point-In-
Time Count.
The MHRC LINK program works closely with the following organizations:
Ability Housing
Baptist Hospital
Catholic Charities
Changing Homelessness (Formerly: Jacksonville Emergency Services Homeless
Coalition)
Clara White Mission
City of Jacksonville, Behavioral and Human Services Division
City Rescue Mission
Trinity Rescue Mission
Department of Corrections
Downtown Ecumenical Services
Duval County Public Health Department
First Call/United Way
Gateway Community Services
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Jacksonville Area Legal Aid
Jacksonville Re-Entry Center
Jacksonville Sheriff’s Office
Liberty Center Single Room Occupancy facility
Memorial Hospital
Mental Health Court
New Outlook, Inc. and New Outlook II, Inc. apartments
River Region Human Services
Salvation Army
State Licensed Assisted Living Facilities
The Sulzbacher Center
UF-Health, Shands Jacksonville Medical Center
Veterans Administration
Victim’s Services
Volunteers of American of Northeast Florida, Inc.
We Care Clinics
4. 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:
The MHRC LINK program will align with PATH goals by coordinating screening and outreach
dates to assess those hard to reach individuals in the community. Staff also coordinate and
communicate with organizations like psychiatric hospitals, substance abuse centers, crisis
stabilization units, homeless shelters, local businesses, and anyone who calls to report an
individual who appears to be homeless and may have a mental illness or substance abuse
disorder. MHRC LINK staff will provide individuals help through outreach, screening, and
engagement into services. Outreach is provided to screen individuals in local correctional
facilities, crisis stabilization units, local hospitals, and other facilities that serve individuals who
are homeless. In addition, outreach is also conducted in areas around homeless shelters and on
the streets. Staff will provide case management services to the individuals seeking assistance
until they are able to meet their goals and are connected to long-term services.
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b. Provide specific examples of how the agency maximizes use of PATH funds by
leveraging use of other available funds for PATH client services:
The MHRC LINK Program maximizes the use of PATH funds by leveraging resources from
multiple sources. For example, the program receives donated bus tickets, with an approximate
value of $4,800 from the local transportation authority. In addition, prescribed psychotropic
medication is available to eligible participants through MHRC's participation in the Department
of Children and Families’ (DCF) Indigent Drug Program. The estimated value of the medication
available to PATH-funded program participants in FY 16-17 is $64,000. Finally, due to funder
limits for indirect cost reimbursement, agency-provided resources will fund approximately
$25,000 of the administrative cost during FY 16-17.
c. Describe any gaps that exist in the current service systems:
Many individuals MHRC LINK screens and assists are reluctant to seek help and do
not formally enroll. Counting only enrolled individuals discounts the importance of
the outreach effort and those services provided on an informal, as-needed, basis.
Availability of affordable permanent housing options are very limited for PATH-
eligible individuals.
Many individuals with chronic mental illnesses or histories of substance abuse lack
the income needed to obtain housing. Due to a lack of needed treatment history,
often times, the application process for entitlement benefits can be lengthy and leave
the individual without needed income for a substantial amount of time.
Many individuals who are homeless do not have legal identification (e.g. driver’s
license, birth certification, immigration papers, etc.) or the resources to obtain
identification.
Duval County’s case management services to individuals who have serious mental
illnesses or substance abuse disorder are structurally fragmented. Due to the large
number of individuals requiring services, along with high caseload sizes, DCF has
implemented more restrictive guidelines based on regional funding capabilities.
Many individuals who are homeless and have mental illnesses or experiencing
substance abuse disorders do not meet the restricted criteria.
Local case management agencies are unable to devote the intensive services needed
to meet the special and varied needs of the individuals who are homeless and have
mental illnesses or co-occurring disorders.
Medication management services continue to be extremely difficult to access for
individuals who are homeless and have mental health diagnoses. Many of these
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individuals may not have current psychiatric diagnoses or documented histories, lack
insurance, and they are not able to provide sufficient information to be considered a
priority individual. When medication management services are able to be accessed,
often times due to their diagnoses, individuals are unable to maintain scheduled
appointments required to maintain ongoing services.
d. Provide a brief description of the current services available to clients who have both a
serious mental illness and a substance use disorder:
MHRC LINK’s PATH-funded program provides mental health and substance abuse
services for individuals who have serious mental illnesses and may have co-occurring
substance abuse disorders:
• Homeless Specialists, in consultation with the ARNP and Medical Case Manager,
identify individuals who are experiencing co-occurring disorders.
• Upon identification as having a co-occurring disorder, the staff works with local
substance abuse providers to ensure continuity of care for individuals.
• Close monitoring is provided to ensure the appropriate treatment modality can be
identified and adjusted to meet the individual’s need.
• Staff screen individuals at local treatment centers and make recommendations for
services upon discharge.
• Staff collaborates with detoxification facilities, correctional institutions, inpatient
and outpatient substance abuse treatment facilities, and area halfway houses.
• Individuals are linked with recovery groups such as Alcoholics Anonymous and
Narcotics Anonymous.
e. Describe how the local provider agency pays for providers or otherwise supports
evidence-based practices, trainings for local PATH-funded staff, and trainings and
activities to support collection of PATH data in HMIS:
MHRC has a System of Care Committee that meets on a monthly basis and includes
discussion of Evidence-Based Practices. The MHRC Program Manager-Homeless
Services is an active member on this committee. MHRC LINK staff receives training
and provide services using evidence-based practices such as Outreach and Engagement,
Housing with Appropriate Supports, and Income Support and Entitlement Assistance.
Staff also participate in Motivational Interviewing workshops to assist its individuals in
various situations.
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f. 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).
Meridian has received several grants and other funding to provide services to those
individuals who are involved with the criminal justice system. The criminal justice
diversion department at Meridian has developed jail diversion programs and mental
health courts in the state of Florida by providing mentoring, advocacy, training, and
education. These programs support PATH initiatives and are used as referral mechanism
for PATH participants. Because of its robust criminal justice program, the Agency can
assist PATH consumers with reentry through its specialized reentry program, and use jail
diversion services to assist PATH participants.
Meridian was awarded the Criminal Justice Mental Health and Substance Abuse grant
through the Department of Children and Families and Alachua County. The funds are
used to plan, implement, and expand initiatives that improve the accessibility and
effectiveness of treatment services for adults and juveniles who might be homeless and
have a mental illness, a substance use disorder, or a combination thereof, with a focus on
those who are in, or at risk of entering, the criminal or juvenile justice systems.
Meridian was awarded the Substance Abuse and Mental Health Services Administration
(SAMHSA), Center for Substance Abuse Treatment (CSAT) Offender Reentry Program
(ORP) grant. The funds are used to provide treatment and wraparound reentry services to
individuals with substance abuse disorders or co-occurring substance abuse/mental health
disorders who are re-entering the community from local jails.
For health issues, The Agency links PATH served consumers to Meridian’s Primary Care
unit. Many times the participants do not have transportation to get to the clinic. When this
occurs, the agency provides bus passes to use for transportation. It also refers these
consumers to the mobile outreach clinic that travels around the community providing
health services. The county health department is also a place to refer PATH program
participants.
Currently, Meridian has 72 permanent supportive housing (PSH) units designated
specifically for the use of individuals with chronic behavioral health disorders, and an
additional five rental homes for very low income persons or households. In addition,
Meridian is an active participant in both the FL-508 and FL-518 Continuums of Care
(CoC). Meridian was awarded PSH funding for victims of domestic violence through the
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CoC. Meridian was also awarded the PSH bonus through the CoC. Additionally, in
partnership with LSF and the CoC, Meridian offers housing stipends using PATH funds.
These funds link all enrolled individuals/families to permanent housing as appropriate
and available, or use the local HUD Coordinated Entry Process to assist with securing
permanent housing. The CoC has decided to use the Vulnerability Index Service
Prioritization Decision Assistance Tool (VI-SPDAT) as the triage tool. This evidence-
based survey tool provides a base number predicating vulnerability and is the basis for
beginning the prioritization process for permanent housing. In addition to the VI-SPDAT,
the prioritization process also includes the score from a SPDAT assessment, which is
completed prior to a housing offer, and any other factors to determine priority housing
needs. The process also promotes a Housing First philosophy with the aim of focusing on
and removing the barriers to immediate permanent housing.
Meridian is an active participant the local CoCs. The CoC Lead Agency operates the
one-stop homeless assistance center (HAC). At the HAC, they regularly provide
assistance with resume building, how to complete job applications online, provide job
listings, and provide space for community groups to offer classes. Staff are developing an
education center and curriculum where Meridian will be able to provide not only hard job
skills but also training in soft skills and entrepreneurship training. The HAC regularly
works with Action Labor, a local labor pool, to provide employment to persons
experiencing homelessness while they seek more permanent employment. Meridian
refers consumers to CareerSource, the one-stop workforce center. In addition,
community job listings (compiled and distributed by the CoC weekly) are displayed and
distributed to consumers in outpatient counseling areas.
Please check all services to be provided using PATH funds:
Outreach Services
Screening and diagnostic treatment services
Habilitation and rehabilitation services
Recovery Support Services such as Peer Support/Recovery Coaching
Community Mental Health services
Alcohol and drug treatment services
Assisting individuals to connect with Community Mental Health Services and
alcohol or other drug treatment services
Staff training (including training of individuals who work in shelters, mental
health clinics and substance abuse programs and other sites where homeless
individuals require services)
Case management services (see PATH eligible services document)
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Supportive and supervisory services in residential settings
Referral for Primary healthcare
Referral for job training
Referral for educational services
Referral for housing services
5. Data: a) Describe the provider’s status on the HMIS transition plan, with accompanying
timeline, to collect PATH data by fiscal year 2017:
MHRC enters PATH data into HMIS.
b) If providers are fully utilizing HMIS for PATH services, please describe plans for
continued training and how providers will support new staff:
The local HMIS administrator distributes monthly report cards to participating service agencies
in an effort to improve data quality. MHRC uses the report card to identify staff training needs.
MHRC’s Homeless Services Program Manager participates on the Data Committee facilitated by
the local HMIS administrator. The Data Committee is used to disseminate HMIS information
and plan local HMIS strategies.
6. SSI/SSDI Outreach, Access, and Recovery (SOAR):
a. Describe the agencies plan to train PATH staff in SOAR:
• The MHRC LINK Team Leader participates in the Train the Trainer training
by SAMHSA to be able to train staff and local organizations in the
community about the SOAR process. The staff participate in SOAR training
and are currently assisting PATH participants in the process of obtaining their
disability benefits. All case managers are currently trained in SOAR.
• MHRC LINK staff collaborate and regularly refer individuals to dedicated
SOAR processors who work in the local community.
• MHRC LINK staff participate in a local SOAR steering committee that works
to expand SOAR resources in the community.
b. Indicate the number of PATH staff trained in SOAR during the grant year ending in
2016 (2015- 2016):
MHRC PATH had two new staff members trained in SOAR during the 2015-2016
fiscal year.
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Seven MHRC PATH direct care staff are currently trained in SOAR.
c. Indicate the number of PATH funded consumers assisted through SOAR (include all
distinct consumers whether approved, denied, or initiated on appeals):
MHRC provided SOAR application assistance to three consumers during the 2015-
2016 fiscal year.
d. Indicate the number of PATH enrolled consumers your program proposes to assist
with SOAR applications in FY 16/17:
MHRC proposes to assist eight PATH consumers with SOAR applications in the
2016-2017 fiscal year.
e. Does the agency PATH program have a SOAR specialist who does all PATH SOAR
cases or does each PATH staff handle their own SOAR cases? Please describe the
rationale for this decision:
The Program doesn’t have a SOAR specialist. Each PATH staff handles his/her own
SOAR cases. The PATH staff have caseloads assigned that they work with. Eligible
SOAR consumers are assisted individually by the PATH staff.
f. If the provider does not use SOAR, describe the system used to improve accurate,
timely completion of mainstream benefit applications and timely determination of
eligibility. Also describe efforts used to train staff on this system. Indicate the number
of staff trained, the number of PATH funded consumers assisted through this process,
and application eligibility results:
The Program utilizes the SOAR process to assist eligible consumers.
The Agency does not fund a PATH Dedicated SOAR Processor. The agency refers
individuals in need to the nearest providers who have dedicated SOAR processors.
g. Application eligibility results (i.e., approval rate on initial application, average time to
approve the application).
N/A
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h. Describe how the providers plan to ensure that PATH staff have completed the SOAR
online course.
N/A
i. Describe which staff plan to assist consumers with SSI/SSDI application using the
SOAR model.
N/A
j. Describe which staff plan to track the outcomes of those applications in the SOAR
Online Applications (OAT) system.
N/A
k. The number of staff dedicated to implementing SOAR, Is SOAR their part-time or
full-time job duty?
N/A
l. 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.)
N/A
m. 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.
N/A
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7. Housing:
a. Indicate what strategies are used for making suitable housing available for PATH
clients (i.e., indicate the type(s) of housing provided and the name of the agencies):
The MHRC PATH program works with the local Coordinated Intake Program to refer consumers
to housing programs. Coordinated Intake connects consumers to permanent supportive housing,
rapid rehousing, transitional housing, and other low income permanent housing options. Some
agencies Coordinated Intake often refers consumers to are; Ability Housing, Sulzbacher Center,
Presbyterian Social Ministries, Catholic Charities, and Salvation Army. The MHRC PATH
program also utilizes PATH funding to assist with deposits and first month rent payments, as
necessary.
8. Staff Information:
a. Describe the demographics of the staff serving the consumers:
Demographics of the staff serving the population
Veterans 29%
Gender
Male 86%
Female 14%
Race
American Indian/Alaskan Native 0%
Asian 0%
Black/African American 43%
Caucasian 43%
Native Hawaiian/Pacific Islander 0%
Two or More Races 0%
Ethnicity
Hispanic/Latino 14%
b. Describe 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
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is use of the recently revised national Culturally and Linguistically Appropriate
Services (CLAS) standards: (http://www.ThinkCulturalHealth.hhs.gov).
MHRC is committed to cultural competency and sensitivity to age, gender, and racial/ethnic
differences of individuals and adopts a written plan for Cultural Diversity and an
Organization Commitment to Accessibility Plan. Mandatory orientation training for new
employees and annual training for current employees include modules addressing cultural
diversity, gender and age, equal employment opportunity, civil rights, the Americans with
Disabilities Act and the Rehabilitation Act, of 1973 policy and practice. Office of Civil
Rights FACT Sheets, notices regarding Interpreter Services for the Hearing-Impaired and
Limited English Proficient, and a Non-Discrimination Policy are reviewed with staff and
posters are visible within staff areas at all MHRC facilities.
9. Client Information: Describe the following:
a. The demographics of the PATH client population
Demographics of the population to be served:
Gender
Male 60%
Female 40%
Race
American Indian/Alaskan Native 0%
Asian 1%
Black/African American 57%
Caucasian 40%
Native Hawaiian/Pacific Islander 1%
Two or More Races 1%
Ethnicity
Hispanic/Latino 1%
Age
18-23 years 21%
24-30 years 37%
31-50 years 40%
51-61 years 1%
62 years and older 1%
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b. The projected number of adult clients to be contacted and PATH enrolled and
rationale for these numbers:
Grant year 2016-2017 number or percentage of:
# of individuals contacted through outreach: 406
# of individuals enrolled: 195
% of individuals enrolled that were literally homeless: 89%
% of individuals enrolled that were veterans: 1%
Grant year 2017-2018 projected number or percentage of:
# of individuals to be contacted through outreach: 400
# of individuals to be enrolled: 150
% of individuals enrolled that are literally homeless: 75%
% of individuals enrolled that are veterans: 1%
10. Consumer Involvement:
a. 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.
Each individual collaborates in the planning and implementation of services provided
and also is given the opportunity for ongoing evaluation of the services received. At
both intake and on an ongoing basis individuals served and, if applicable, their
family, are asked to provide input regarding their care and services. An annual
assessment of the MHRC LINK program is completed using individual comments
and satisfaction surveys to determine areas for improvement.
A comment box is prominently placed in the office lobby to solicit suggestions,
concerns or complaints, which are reviewed by the Program Manager-Homeless
Services, who is responsible for follow-up in a timely manner.
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11. Budget:
a. Provide a detailed budget that includes the agency’s use of PATH funds.
Mental Health Resource Center, Inc. - 2017-2018 PATH Grant Budget
Personnel
Annual Salary* (total
number)
PATH-funded
FTE (%)
PATH-funded Salary
Matched Dollars
Total Dollars
Comments
Dept. Secretary/Security $ 23,340 0.35 $ 8,169 $ 1,866 $10,035 Match Source - LSF General Revenue
Case Manager $ 28,450 0.68 $ 19,346 $ 9,104 $28,450 Match Source - Local Government
Case Manager $ 29,000 0.68 $ 19,720 $ 9,280 $29,000 Match Source - Local Government
Case Manager $ 26,000 0.68 $ 17,680 $ 8,320 $26,000 Match Source - Local Government
Case Manager $ 26,500 0.68 $ 18,020 $ 8,480 $26,500 Match Source - Local Government
Medical Case Manager $ 38,950 0.7 $ 27,265 $ 11,685 $38,950 Match Source - Local Government
LINK Program Manager $ 40,140 0.7 $ 28,098 $ 12,042 $40,140 Match Source - Local Government
Homeless Program Manager $ 53,060 0.45 $ 23,877 $ 531 $24,408 Match Source - LSF General Revenue
ARNP $104,000 0.1 $ 10,400
$10,400
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Subtotal $369,440 5.02 $172,575 $ 61,308 $233,883
* Indicate "annualized salary for positons."
Fringe Benefits (Max of 27%)
Subtotal $ 41,418 $ 50,156 $ 91,574 Match Source - LSF General Revenue and Local Government
Travel
Training
Annual Conference or Meetings
Rental Car
Per Diem
Local Mileage Reimbursement $ 1,300 $ 60 $ 1,360 3,400 miles @ .40 per mile. Match Source - LSF General Revenue
Subtotal $ 1,300 $ 60 $ 1,360
Equipment
Vehicle Lease $ 2,954 $ 2,954
Vehicle used for participant transportation. Match Source - LSF General Revenue
Vehicle Operating Expenses $ 1,875 $ 1,875
Vehicle gas and oil; maintenance; repair. Match Source - LSF General Revenue
Equipment Rental and Lease $ 600 $ 600 Copier Rental Match Source - LSF General Revenue
Equipment Repairs and Maintenance
$ 850 $ 850
Copier Maintenance/Use Agreement Match Source - LSF General
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Revenue
Depreciation $ 1,166 $ 1,166
Vehicle and Computer Depreciation Match Source - LSF General Revenue
Subtotal - $ 7,445 $ 7,445
Supplies
Office supplies $ 1,220 $ 1,220
General Supplies, such as paper, pens, and medical record folders. Match Source - LSF General Revenue
Client: Outreach Supplies/ Hygiene kits/Misc.
$ 5,455 $ 5,455 Clothing and hygiene kits. Match Source - LSF General Revenue
Software $ 402 $ 402 EHR Expense Match Source - LSF General Revenue
Emergency food for participants
$ 675 $ 675 Match Source - LSF General Revenue
Other (describe)
Subtotal
$ 7,752 $ 7,752
Contractual
Transcription Expense $ 367 $ 1,803 $ 2,170 For ARNP Services. Match Source - LSF General Revenue
Subtotal $ 367 $ 1,803 $ 2,170
Other
One-time housing rental assistance
$ 36,325 $ 36,325 Match Source - Local Government
Pharmacy and lab fees $ 2,743 $ 2,743
Fees charged for prescriptions written by ARNP. Match Source - LSF General Revenue
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Insurance (property, vehicle, malpractice, etc.)
$ 5,724 $ 5,724 Insurance as required by contract. Match Source - LSF General Revenue
Office: Misc. (Copying, Courier, Postage, etc.)
$ 153 $ 153 Forms, brochures, and postage. Match Source - LSF General Revenue
Office: Security, Janitorial, Grounds Maintenance
$ 1,900 $ 2,056 $ 3,956 Janitorial for Office. Match Source - LSF General Revenue
Office: Utilities/Telephone/ Internet
$ 3,300 $ 5,765 $ 9,065
Electricity, Water, Telephone, Refuse Service, Pest Control, and Maintenance. Match Source - LSF General Revenue
Office: Other (Rent) $ 16,254 $16,254 Office Rent. Match Source - LSF General Revenue
Bus Tickets/Taxi for Participants
$ 1,300 $ 1,300
Transportation assistance for participants. Match Source - LSF General Revenue
Staffing (Not Salary or Benefits): Training/Education/Conference Fees
$ 140
$ 140
CPR Training 4 sessions @ $35.00 each. Match Source - LSF General Revenue
Staffing (Not Salary or Benefits): Other (Screening)
$ 40 $ 40
Annual Background Screening. Match Source - LSF General Revenue
Audit
Subtotal $ 5,340 $ 70,360 $ 75,700
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Total Direct Charges (Sum of each section)
$221,000 $198,884 $419,884
This budget is prepared to support the program as presented in the LIUP. In the event that Mental Health Resource Center, Inc.'s general revenue allocation from LSF Health Systems does not include the approximately $100,000 necessary to operate the program as designed, the program will be modified accordingly.
Indirect Costs (Max of 10%) (Administrative Costs)
$22,091 $19,888 $ 41,979
Match Source - Local Government, LSF General Revenue, and agency-provided funding
Grand Total (Total of "total direct" and "indirect costs")
$243,091 $218,772 $461,863
The Match column includes all non-PATH funding used to support the program. The budgeted amounts from the other sources are $100,000 of General Revenue from LSF Health Systems; $113,819 from the City of Jacksonville; and $4,953 of agency-provided funding.
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C. Local Provider Intended Use Plan:
1. Local Provider Description:
Name of the Organization: Meridian Behavioral Healthcare, Inc.
Type of Organization: Community Behavioral Health, non-profit 501(c)(3)
Address of Provider: 4300 SW 13th St., Gainesville, FL 32608
Local Continuum of Care Lead Agency: Alachua County Coalition for the Homeless
Hungry (ACCHH), (FL-508) and the Suwannee Valley Homeless Coalition (FL-518)
PATH Contact Name/E-Mail/Phone #: Richard V. Anderson/[email protected]/352-283-
1566
Region Served: Northeast/Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton,
Lafayette, Levy, Suwannee, and Union Counties
Indicate the amount of federal, state and local PATH funds the organization will
receive.
Federal: $116,972
Match: $ 38,993
Total: $155,965
2. Collaboration with HUD Continuum of Care Program: Describe the organization’s
participation in the HUD Continuum of Care and any other local planning, coordinating or
assessing activities:
Meridian is an active participant in the North Central Florida Alliance Continuum of Care
(CoC) and the Homeless Services Network of Suwannee Valley CoC. These are the lead
agencies for the local continuums. Meridian staff participates in all aspects of the CoC
planning process including the annual Point-In-Time census, inventory of current services,
gap analysis, coordination of local services, and short and long-term planning. Meridian’s
president/CEO (or her designee) serves on the steering committee of the Alachua/Gainesville
10-Year Plan to End Homelessness. Meridian staff are also active in regional events that seek
to raise community awareness about homelessness such as the “Annual Breakfast on the
Plaza” and the “Stand Down for Homeless Veterans.”
3. Collaboration with Local Community Organizations: Provide a brief description of
partnerships and activities with local community organizations that provide key services (i.e.,
outreach teams, primary health, mental health, substance abuse, housing, employment, etc.)
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to PATH eligible clients and describe coordination of activities with each of these
organizations (describe all that apply):
Meridian has strong working relationships with area providers to ensure that PATH
participants receive person-focused assistance. Partnerships with community providers assist
care managers and outreach staff in accessing services and providing a referral system for
PATH participants. Meridian staff provides services in many of these venues and have
written agreements for vouchers where immediate services to participants can be provided.
Meridian works with the North Central Florida Alliance and other community partners to
secure funding and a location for an 80-bed homeless facility in Gainesville, FL. Meridian
partners with the Gainesville Housing Authority and Alachua County Housing Authority to
implement Shelter Plus Care and permanent housing for individuals experiencing
homelessness with mental illnesses. Meridian has a direct allocation of funding for over 18
placements for PATH-eligible participants. Other partnership organizations at which
Meridian provides outreach and referrals services for PATH participants include: Malcolm
Randall VA Medical Center for healthcare for Homeless Veterans; St. Francis House and
Salvation Army for Emergency Homeless Shelter; Bread of the Mighty Food Bank, Catholic
Charities and Gainesville Community Ministry for food, financial assistance and budgeting;
Peaceful Paths Network for domestic abuse services; Shands Hospital, Mobile Outreach
Clinic, Shands Eastside Health Clinic, Palms Medical, Helping Hands Clinic, County Health
Departments for primary healthcare; Alachua County Community Support Services for
various benefit services; and FloridaWorks for employment and employability skill
development.
4. 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:
Meridian’s outreach and case management efforts concentrate on serving individuals
experiencing chronic homelessness. Meridian’s staff provide outreach services to homeless
individuals living on the street, in homeless camps, and/or in shelters. These outreach efforts are
provided throughout Meridian’s service area in an attempt to engage individuals experiencing
homelessness into services by repeated contact. Outreach staff maintain lists of homeless camp
locations and other areas throughout the counties it serves where there are concentrations of
persons experiencing homelessness. Outreach services are targeted in the areas that have the
highest rates of literal persons experiencing homelessness, such as shelters, outreach service
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centers, food banks, and homeless camps. Case management services are provided to participants
that move into housing to help them maintain their housing.
b. Provide specific examples of how the agency maximizes use of PATH funds by
leveraging use of other available funds for PATH client services:
Meridian’s core PATH funding is utilized to provide case management and outreach
services. Staff will provide ongoing outreach services in camps, Gainesville Downtown
Plaza, Empowerment Center (Grace Marketplace), meal sites, and other places where the
homeless congregate. This will be essential in engaging individuals who have experienced
long-term homelessness. When PATH staff are able to engage this targeted population, they
will then help participants navigate the system of care (mental health treatment, economic
assistance, SOAR, primary care, etc.) with the goal of getting enrollees into safe, appropriate
housing. Staff will also provide continual case management services to participants that are
placed into housing to help them maintain their housing.
c. Describe any gaps that exist in the current service systems:
Gaps in Meridian’s current service system have been identified through the Continuum of Care
(CoC), homeless coalitions, planning councils, city and county government, and the 10-year plan
to end homelessness committees. Without these needs being addressed in the service area, people
experiencing homelessness can be expected to remain in a revolving door cycle between the
street, jails, meal sites, and emergency shelters. These gaps include:
Emergency and Transitional Housing (identified through homeless planning council)
Permanent Housing for individuals and families (identified through the 10-year plan to
end homeless committees)
Permanent supportive housing with a Housing First approach (identified through the CoC
gap analysis)
Long-term case management to prevent homelessness (identified through the homeless
planning council)
Homeless One-Stop Center with coordinated intake system (identified through city and
county government)
Jail diversion and reentry services (not enough services to meet the needs) identified
through the Criminal Justice Planning Council).
These were all identified as high priority needs in the community. The Alachua County Board of
County Commission and the Board of City of Gainesville Commission continues to fund a
homeless one-stop center and seek funding to expand service and housing capacity.
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d. Provide a brief description of the current services available to clients who have both a
serious mental illness and a substance use disorder:
Meridian is a CARF accredited licensed provider of both mental health and substance use
disorders services. Meridian provides a full continuum of behavioral health services for
individuals who have serious mental illnesses and co-occurring substance use disorders.
Meridian provides detoxification facilities, inpatient and outpatient mental health and
substance use disorders treatment facilities, group homes, and transitional living
facilities. Meridian’s PATH staff have been trained to identify the needs of PATH
participants and make referrals for assessment and treatment when it is determined to be
necessary. PATH staff can make direct referrals for PATH participants to programs and
services of their choice and for which they meet criteria within Meridian. Meridian
maintains a clinical best practice for the treatment of people with co-occurring disorders
that embodies the Comprehensive, Continuous, Integrated System of Care (CCISC)
model. All services provided by Meridian staff meet the criteria as co-occurring
enhanced based on the commitment to continuous training and practice of the CCISC
model.
e. Describe how the local provider agency pays for providers or otherwise supports
evidence-based practices, trainings for local PATH-funded staff, and trainings and
activities to support collection of PATH data in HMIS:
The Vice President of Forensics at Meridian is a trainer for SSI/SSDI Outreach, Access
and Recovery (SOAR). She will continue to provide trainings to community stakeholders
at least twice annually. Meridian has already implemented this practice with all PATH
staff as they have all been trained in SOAR. Meridian staff continues to provide refresher
courses and monitoring through staff supervision to ensure that fidelity is maintained.
Meridian uses Motivational Interviewing (MI) to increase treatment readiness and
motivation to change. Motivational Interviewing is one of the most frequently used
strategies for enhancing motivation. The operational assumption in MI is that ambivalent
attitudes or lack of resolve is the primary obstacle to behavioral change. Establishing the
PATH participant’s motivation to change is an essential first step in fostering program
continuation from outreach to follow-up and completion. All PATH staff have been
trained in this model. This is documented in their Human Resource records. Oversight
to ensure continuous fidelity of the model is achieved through supervision,
documentation, and re-training.
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f. 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).
Meridian has received several grants and other funding to provide services to those
individuals who are involved with the criminal justice system. The criminal justice
diversion department at Meridian has developed jail diversion programs and mental
health courts in the state of Florida by providing mentoring, advocacy, training, and
education. These programs support PATH initiatives and are used as referral mechanism
for PATH participants. Because of its robust criminal justice program, the Agency can
assist PATH consumers with reentry through its specialized reentry program, and use jail
diversion services to assist PATH participants.
Meridian was awarded the Criminal Justice Mental Health and Substance Abuse grant
through the Department of Children and Families and Alachua County. The funds are
used to plan, implement, and expand initiatives that improve the accessibility and
effectiveness of treatment services for adults and juveniles who might be homeless and
have a mental illness, a substance use disorder, or a combination thereof, with a focus on
those who are in, or at risk of entering, the criminal or juvenile justice systems.
Meridian was awarded the Substance Abuse and Mental Health Services Administration
(SAMHSA), Center for Substance Abuse Treatment (CSAT) Offender Reentry Program
(ORP) grant. The funds are used to provide treatment and wraparound reentry services to
individuals with substance abuse disorders or co-occurring substance abuse/mental health
disorders who are re-entering the community from local jails.
For health issues, The Agency links PATH served consumers to Meridian’s Primary Care
unit. Many times the participants do not have transportation to get to the clinic. When this
occurs, the agency provides bus passes to use for transportation. It also refers these
consumers to the mobile outreach clinic that travels around the community providing
health services. The county health department is also a place to refer PATH program
participants.
Currently, Meridian has 72 permanent supportive housing (PSH) units designated
specifically for the use of individuals with chronic behavioral health disorders, and an
additional five rental homes for very low income persons or households. In addition,
Meridian is an active participant in both the FL-508 and FL-518 CoC. Meridian was
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awarded PSH funding for victims of domestic violence through the CoC. Meridian was
also awarded the PSH bonus through the CoC. Additionally, in partnership with LSF and
the CoC, Meridian offers housing stipends using PATH funds. These funds link all
enrolled individuals/families to permanent housing as appropriate and available, or use
the local HUD Coordinated Entry Process to assist with securing permanent housing.
The CoC has decided to use the Vulnerability Index Service Prioritization Decision
Assistance Tool (VI-SPDAT) as the triage tool. This evidence-based survey tool provides
a base number predicating vulnerability and is the basis for beginning the prioritization
process for permanent housing. In addition to the VI-SPDAT, the prioritization process
also includes the score from a SPDAT assessment, which is completed prior to a housing
offer, and any other factors to determine priority housing needs. The process also
promotes a Housing First philosophy with the aim of focusing on and removing the
barriers to immediate permanent housing.
Meridian is an active participant the local CoCs. The CoC Lead Agency operates the
one-stop homeless assistance center (HAC). At the HAC, they regularly provide
assistance with resume building, how to complete job applications online, provide job
listings, and provide space for community groups to offer classes. Staff are developing an
education center and curriculum where Meridian will be able to provide not only hard job
skills but also training in soft skills and entrepreneurship training. The HAC regularly
works with Action Labor, a local labor pool, to provide employment to persons
experiencing homelessness while they seek more permanent employment. Meridian
refers consumers to CareerSource, the one-stop workforce center. In addition,
community job listings (compiled and distributed by the CoC weekly) are displayed and
distributed to consumers in outpatient counseling areas.
Please check all services to be provided using PATH funds:
Outreach Services
Screening and diagnostic treatment services
Habilitation and rehabilitation services
Recovery Support Services such as Peer Support/Recovery Coaching
Community Mental Health services
Alcohol and drug treatment services
Assisting individuals to connect with Community Mental Health Services and
alcohol or other drug treatment services
Staff training (including training of individuals who work in shelters, mental
health clinics and substance abuse programs and other sites where homeless
individuals require services)
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Case management services (see PATH eligible services document)
Supportive and supervisory services in residential settings
Referral for Primary healthcare
Referral for job training
Referral for educational services
Referral for housing services
5. Data: a) Describe the provider’s status on the HMIS transition plan, with accompanying
timeline, to collect PATH data by fiscal year 2017:
Meridian is currently using HMIS (Servicepoint) to collect information for
participants in the Continuum of Care transitional and supportive housing programs.
Full implementation of HMIS utilization has been ongoing. Care Managers enter
basic demographics and service data into the HMIS.
b) If providers are fully utilizing HMIS for PATH services, please describe plans for
continued training and how providers will support new staff:
The Program Manager and HMIS /CoC Coordinator work to develop and provide
training to staff, oversee data quality, and develop protocols for monthly transmission
of HMIS data. The HMIS lead agency has scheduled basic Servicepoint trainings on
an on-going basis. Meridian’s HMIS staff and the COC liaison have developed HMIS
procedures for PATH staff providers.
6. SSI/SSDI Outreach, Access, and Recovery (SOAR):
a. Describe the agencies plan to train PATH staff in SOAR:
Meridian completes an evaluation on all PATH participants including their eligibility
and status of benefits when they enter the program. Meridian partners with Three
Rivers Legal Services attorney/advocate who assisted thirty-five homeless individuals
seeking SSI/SSDI benefits to navigate the denial process when necessary.
Consumer SOAR SSI/SSDI applications and supporting documents are maintained in
individual consumer files. The information includes initial or subsequent applications,
appeals, medical records, correspondence with the Social Security Administration,
consumer communication logs and any other relevant information. SOAR Online
Application Tracking System Language needed. Summary data is collected annually
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and includes the number of initial applications, progress towards determination, and
final determination notices.
b. Indicate the number of PATH staff trained in SOAR during the grant year ending in
2016 (2015- 2016):
Zero.
c. Indicate the number of PATH funded consumers assisted through SOAR (include all
distinct consumers whether approved, denied, or initiated on appeals):
Sixty.
d. Indicate the number of PATH enrolled consumers your program proposes to assist
with SOAR applications in FY 16/17:
Seventy.
e. Does the agency PATH program have a SOAR specialist who does all PATH SOAR
cases or does each PATH staff handle their own SOAR cases? Please describe the
rationale for this decision:
Yes. Forensics program has its own SOAR specialist as does the PATH program.
f. If the provider does not use SOAR, describe the system used to improve accurate,
timely completion of mainstream benefit applications and timely determination of
eligibility. Also describe efforts used to train staff on this system. Indicate the number
of staff trained, the number of PATH funded consumers assisted through this process,
and application eligibility results:
N/A
The Agency does not fund a PATH Dedicated SOAR Processor. The agency refers
individuals in need to the nearest providers who have dedicated SOAR processors.
g. Application eligibility results (i.e., approval rate on initial application, average time to
approve the application).
N/A
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h. Describe how the providers plan to ensure that PATH staff have completed the SOAR
online course.
N/A
i. Describe which staff plan to assist consumers with SSI/SSDI application using the
SOAR model.
N/A
j. Describe which staff plan to track the outcomes of those applications in the SOAR
Online Applications (OAT) system.
N/A
k. The number of staff dedicated to implementing SOAR, Is SOAR their part-time or
full-time job duty?
N/A
l. 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.)
N/A
m. 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.
N/A
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7. Housing:
a. Indicate what strategies are used for making suitable housing available for PATH
clients (i.e., indicate the type(s) of housing provided and the name of the agencies):
• Alachua County Housing Authority – subsidized low-income housing
• Gainesville Housing Authority – Section 8 housing vouchers (waiting list)
• Habitat for Humanity – home ownership
• CHOICE – HUD permanent supportive housing
• Satellite Apartments – HUD permanent supportive housing
• Neighborhood Stabilization Project – permanent supportive housing
• Joyce House – permanent supportive housing for mental health/co-occurring women
• Meridian CoC – permanent supportive housing allocation for ten individuals and
families experiencing homelessness with mental illnesses or co-occurring disorders
• St. Francis House and Salvation Army – emergency shelters
• Honor Center – transitional housing for veterans
• HELP – Shelter Plus Care for permanent supportive housing
• Arbor House – domestic violence shelter
8. Staff Information:
a. Describe the demographics of the staff serving the consumers:
Demographics of the staff serving the population
Veterans 0%
Gender
Male 43%
Female 57%
Race
American Indian/Alaskan Native 0%
Asian 0%
Black/African American 58%
Caucasian 42%
Native Hawaiian/Pacific Islander 0%
Two or More Races 0%
Ethnicity
Hispanic/Latino 0%
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b. Describe 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).
Meridian is committed to cultural competency. Staff receive training in cultural
diversity at the new hire orientation and through the use of videos, handouts, and
web-based programs in order to remain aware of personal attitudes, beliefs, biases,
and behaviors that may influence their assessments and actions. Meridian ensures
that staff is sensitive to the diverse needs of the population served, specifically the
unique challenges that accompany homelessness. Recognizing diversity in age,
gender, race, culture, spiritual preferences and beliefs, sexual preferences, and gender
orientation, staff works closely with the individual to ensure interventions are
individualized and applied in a person-centered manner. Service plans are developed
based on the PATH participants’ expressed desires and strengths. The agency
maintains a cultural competence plan that is reviewed annually to address staff
competency, as well as the organizational framework.
9. Client Information: Describe the following:
a. The demographics of the PATH client population
Demographics of the population to be served:
Gender
Male 45%
Female 55%
Race
American Indian/Alaskan Native 0%
Asian 1%
Black/African American 65%
Caucasian 33%
Native Hawaiian/Pacific Islander 0%
Two or More Races 0%
Ethnicity
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Hispanic/Latino 1%
Age
18-23 years 14%
24-30 years 22%
31-50 years 51%
51-61 years 13%
62 years and older 1%
b. The projected number of adult clients to be contacted and PATH enrolled and
rationale for these numbers:
Grant year 2016-2017 number or percentage of:
# of individuals contacted through outreach: 958
# of individuals enrolled: 247
% of individuals enrolled that were literally homeless: 100%
% of individuals enrolled that were veterans: 0%
Grant year 2017-2018 projected number or percentage of:
# of individuals to be contacted through outreach: 850
# of individuals to be enrolled: 200
% of individuals enrolled that are literally homeless: 80%
% of individuals enrolled that are veterans: 4%
10. Consumer Involvement:
a. 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.
PATH staff provide opportunities for participants and family involvement in planning
for the services they receive. The participants are the primary focus of Meridian’s
PATH program. Staff seek directions from participants on services and community
needs. Meridian surveys program participants on an annual basis (more frequently
for some programs) to determine participant satisfaction. Survey results are used in
evaluating services and making programmatic changes where necessary.
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11. Budget: a. Provide a detailed budget that includes the agency’s use of PATH funds.
Meridian Behavioral Healthcare, Inc. - 2017-2018 PATH Grant Budget
Personnel
Annual
Salary*
(total
number)
PATH-
funded
FTE
(%)
PATH-
funded
Salary
Matched
Dollars
Total
Dollars Comments
Executive Assistant $ 27,500 0.15 $ 4,125 $ 1,375 $ 5,500
Cash match
through county
funds
Case Manager/Outreach
Specialist $ 36,400 0.75 $ 27,300 $ 9,100 $ 36,400
Cash match
through county
funds
Outreach Specialist $ 32,100 0.37 $ 12,037 $ 4,013 $ 16,050
Cash match
through county
funds
Vice President Housing $ 70,000 0.15 $ 10,500 $ 3,500 $ 14,000
Cash match
through county
funds
Other (describe)
Other (describe)
Subtotal $166,000 1.43 $ 53,962 $ 17,988 $ 71,950
* Indicate "annualized salary
for positons."
Fringe Benefits (Max of 27%)
Meridian (22.00)
Subtotal $ 11,872 $ 3,957 $ 15,829
Cash match
through county
funds
Travel
Training
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Annual Conference or
Meetings $ 2,363 $788
$
3,150
Expenses for
Outreach
Specialists to
attend Florida
Housing
conference;
Expenses for
Outreach
Specialists to
attend Florida
Supportive
Housing;
Expenses for
Outreach
Specialists to
attend Florida
Institute for
Homeless -
Cash match
through county
funds
Rental Car
Per Diem $ 354 $ 118 $
472
Meals for staff
while attending
conferences -
Cash match
through county
funds
Other (local travel): $ 794 $ 265 $
1,059
2,379 miles at
$0.445 per mile
- Cash match
through county
funds
Other (describe)
Subtotal $ 3,511 $ 1,171 $
4,681
Equipment
$ - $
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-
Subtotal - $
-
Supplies
Office supplies $ 330 $ 110 $
440
Supplies:
Folders, pens,
staples, etc. -
Cash match
through county
funds
Outreach Supplies/ Hygiene
kits/Misc. $ 5,250 $ 1,750
$
7,000
Hygiene
supplies and
other
miscellaneous
items for
participants -
Cash match
through county
funds
software $
-
Other (Brochures) $ 120 $ 40 $
160
Brochures
describing
PATH services
- Cash match
through county
funds
Other (Educational Supplies) $ 90 $ 30 $
120
Educational
Supplies for
PATH
participants -
Cash match
through county
funds
Subtotal $ 5,790 $ 1,930 $
7,720
Contractual
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-
Subtotal
-
Other
One-time housing rental
assistance $ 9,829 $ 3,276 $ 13,105
Provides for
needed housing
assistance such
as deposits and
first month rent
- Cash match
through county
funds
Insurance (property, vehicle,
malpractice, etc.) $ 5,337 $ 1,779 $ 7116
Property,
Professional
Liability - Cash
match through
county funds
Office: Misc. (Copying,
Courier, Postage, etc.)
Office: Security, Janitorial,
Grounds Maintenance $ 2,399 $ 800 $ 3,199
Facility
Allocation for
PATH staff -
Cash match
through county
funds
Office: Utilities/Telephone/
Internet $ 9,044 $ 3,015 $ 12,059
Telephone,
utilities,
internet and
other IT and
Information
services
functions -
Cash match
through county
funds
Office: Other (describe) -
Office: Other (describe) -
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Staffing (Not Salary or
Benefits):
Training/Education/Conference
Fees
$ 2,006 $ 669 $ 2,675
MBH Related
training
expenses for
SOAR, Mental
Health First
AID, etc. -
Cash match
through county
funds
Staffing (Not Salary or
Benefits): Other (describe) $ -
Audit $ 2,588 $ 863 $ 3,450
Analysis of data
and expenses
for PATH
related services
- Cash match
through county
funds
Subtotal $ 31,203 $ 10,402 $ 41,604
Total Direct Charges (Sum of
each section) $106,338 $ 35,448 $141,787
Indirect Costs (Max of 10%)
(Administrative Costs) $ 10,634 $3,545 $ 14,179
Grand Total (Total of "total
direct" and "indirect costs") $116,972 $38,993 $155,965
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C. Local Provider Intended Use Plan:
1. Local Provider Description: Provide a brief description of the provider organization
receiving PATH funds:
Name of the Organization: Mid Florida Homeless Coalition, Inc.
Type of Organization: Not-for-Profit
Address of Provider: 104 E Dampier Street, Inverness, FL 34452
Local Continuum of Care Lead Agency: Mid Florida Homeless Coalition, Inc.
PATH Contact Name/E-Mail/Phone #: Barbara Wheeler/[email protected] /352-860-
2308
Region Served: Northeast/Citrus, Hernando, Lake and Sumter Counties
Indicate the amount of federal, state and local PATH funds the organization will
receive.
Federal: $113,475
Match: $ 37,825
Total: $151,300
2. Collaboration with HUD Continuum of Care Program: Describe the organization’s
participation in the HUD Continuum of Care and any other local planning, coordinating or
assessing activities:
Mid Florida Homeless Coalition, Inc. (MFHC) is the designated lead agency for the homeless
continuum of care for a four-county service area. After the initiation of the local homeless
coalition by Mid Florida Homeless Coalition, the agency continues to execute the homeless
coalition responsibilities as set forth in the HEARTH Act and Florida Statutes. MFHC became
incorporated in 2000, was established as a 501(c)(3) in 2001, and became the local homeless
coalition. In 2004, MFHC became recognized by the U.S. Department of Housing and Urban
Development (HUD) and by the State of Florida Office on Homelessness as the Continuum of
Care (CoC) upon applying for its first HUD CoC grant. As a result of the recognition of the
organization as the homeless coalition lead agency, MFHC benefits from the coalition staffing
grant through the Department of Children and Families.
In 2005, Mid Florida Homeless Coalition received funds to start the Homeless Management
Information System (HMIS). MFHC became the Lead Agency for the HMIS and continues to
administer the system throughout the CoC.
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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 (i.e.,
outreach teams, primary health, mental health, substance abuse, housing, employment, etc.)
to PATH eligible clients and describe coordination of activities with each of these
organizations (describe all that apply):
MFHC, due to its roles as the homeless coalition lead agency and as the HMIS lead agency,
maintains partnerships with each of the provider agencies who are members of the local
homeless coalition. This relationship extends to agency staff who are responsible for the entry of
HMIS data, as HMIS training is made available as needed by homeless coalition staff member
who also has coalition staffing responsibilities. Our four staff members assume responsibility for
facilitating meetings of the HMIS Users Group and HMIS Data Quality Committee, Coordinated
Entry and meetings in all four counties.
MFHC interacts significantly with those coalition agencies which receive coalition-related
funding, but also works with organizations throughout the CoC. All but two shelters enter data
into HMIS, funded and non-funded organizations participate in meetings and the Governing
Board in growing in its diversity. MFHC is part of two Public Safety Committee Boards that
have oversight over Criminal Justice Mental Health and Substance Abuse Reinvestment
(CJMHSR) Grants as well as serving on Affordable Housing Advisory Committee in Citrus
County.
4. 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:
The intent of the PATH funded services is to conduct street outreach and case management.
Adults who are literally and chronically homeless may be hard to reach and may not access
services on their own; therefore, these individuals will be assisted through these services.
b. Provide specific examples of how the agency maximizes use of PATH funds by
leveraging use of other available funds for PATH client services:
MFHC currently has a three-year Emergency Solutions Grant (ESG) contract. MFHC can
leverage 40% of these funds as they are currently targeted to outreach. MFHC is currently under
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contract for $200,000 for Challenge Grant funds. These funds are used for Rapid Re-housing.
MFHC submitted a Letter of Intent to the Citrus County Community Charitable Foundation for
funds to provide medical services to the Citrus population. MFHC has a $30,000 3-year contract
for TANF funds which are being used in Lake and Citrus Counties to keep people from losing
their housing. MFHC’s current HUD HMIS grant of $75,000, plus its 25% match, can be
leveraged for the services needed via HMIS.
In addition, MFHC will be applying for funds through other foundations to support this and other
services that are being identified as gaps in the CoC.
c. Describe any gaps that exist in the current service systems:
Gaps in the current service system include the absence of effective street outreach throughout the
four counties serviced. Knowing those who are homeless, their conditions, and needs will help
MFHC better plan for those needs.
While the CoC has improved its funding towards Rapid Re-housing, it recognizes that there is
still not information known about those on the street to be able to identify the funding needed for
long-term, short-term, or prevention services. Obtaining that information can help the Agency
speak to local County government, as well as the State, regarding newly identified gaps or better
expounding on current gaps; e.g., medical needs, mental health needs, and affordable housing.
d. Provide a brief description of the current services available to clients who have both a
serious mental illness and a substance use disorder:
The local homeless coalition includes agencies through which services are available to
individuals with co-occurring mental health and substance use disorders. These include:
Mid Florida Homeless Coalition (MFHC) which is currently the recipient of ESG funds of which
some are being used for outreach. Mid Florida Homeless Coalition’s plan is to use the PATH
funds to provide targeted outreach and case management to those who are identified through
current outreach services as having mental health and/or substance abuse disorders. As the
CoC’s Lead Agency for the Centralized Intake, MFHC conducts the VI-SPDAT and SPDAT for
all people experiencing homelessness who are seeing housing. Thus, the Agency maintains not
only the CoC’s Homeless By Name List, it monitors who is most vulnerable and works with
local organizations to get them into housing. With limited Case Management services in the
CoC, the PATH funds will provide needed services to those most vulnerable to meet their needs;
e.g., connection to SOAR, Housing Locator, medication, and a plethora of other needs.
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LifeStream Behavioral Center, The Centers, and Baycare Behavioral Health all have contracts
for services for those with mental health, substance abuse and co-occurring disorders. These
services include operating a CSU, in patient, outpatient, groups, case management, and more.
LifeStream operates a HUD CoC permanent supportive housing program for chronically
homeless, as well as providing case management for a HUD CoC permanent supportive housing
program that is operated by Lake County. LifeStream is also working with those who are
experiencing homelessness and have interactions with the local jail through the CJMHSA grant.
While all three organizations are serving some people who are homeless, all of these
organizations have waiting lists due to the need in the community versus funding available. Two
of the three organizations provide SOAR services to people within the CoC.
e. Describe how the local provider agency pays for providers or otherwise supports
evidence-based practices, trainings for local PATH-funded staff, and trainings and
activities to support collection of PATH data in HMIS:
Mid Florida Homeless Coalition, in its role as the lead agency for the local homeless coalition,
seeks to implement evidence-based best practices including the implementation of a coordinated
assessment and entry process. MFHC is helping to steer its CoC in the direction of serving
individuals who are most vulnerable, and using the Housing First model to do so.
f. 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).
Citrus County – MFHC has a relationship with the Citrus County Jail staff. If an individual
identifies as homeless and is interesting in a housing assessment, the Agency is contacted and the
Coordinated Entry Navigator who will go to the jail to conduct the assessment.
Lake County – MFHC has operated a CJMHSA Grant for several years, and Mid Florida
Homeless Coalition’s Executive Director serves on Lake County’s Public Safety Council as the
Homelessness representative. The Agency has developed relationships with the Correctional
Facilities in the Lake County to ensure the steps outlined in the grant are accomplished. In
addition, Mid Florida Homeless Coalition (MFHC) collaborates with LifeStream, which runs the
program under this grant.
Sumter County – The Refuge at Jumper Creek, the organization that receives funds through
MFHC to conduct outreach in all four counties, has developed a relationship with the local jail,
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and those who identify themselves as being homeless will soon be able to request to have the
Coordinated Entry staff come to the jail to complete housing assessments.
Hernando County – Career Source of Pasco/Hernando has been awarded a grant from which it
will provide training to people while they are in the county jail. MFHC has been asked to go to
the jail to conduct housing assessments on some of the people participating in this program. The
County has recently been awarded a CJMHSA Grant. MFHC’s Executive Director serves on the
Hernando County Public Safety Council.
The Coordinated Entry Navigator learns about all possible needs of the individuals incarcerated,
provides a Quick Resource Card pointing out potential resources, and assists the participant in
understanding how to connect to services.
Please check all services to be provided using PATH funds:
Outreach Services
Screening and diagnostic treatment services
Habilitation and rehabilitation services
Recovery Support Services such as Peer Support/Recovery Coaching
Community Mental Health services
Alcohol and drug treatment services
Assisting individuals to connect with Community Mental Health Services and
alcohol or other drug treatment services
Staff training (including training of individuals who work in shelters, mental
health clinics and substance abuse programs and other sites where homeless
individuals require services)
Case management services (see PATH eligible services document)
Supportive and supervisory services in residential settings
Referral for Primary healthcare
Referral for job training
Referral for educational services
Referral for housing services
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5. Data:
a) Describe the provider’s status on the HMIS transition plan, with accompanying
timeline, to collect PATH data by fiscal year 2017:
The PATH program has been fully implemented into the CoC HMIS system, and all training
and monitoring of data quality and performance will continue to be done by the HMIS
Administrator.
b) If providers are fully utilizing HMIS for PATH services, please describe plans for
continued training and how providers will support new staff:
MFHC not only utilizes HMIS, but is the HMIS lead agency. MFHC staff already has the
responsibility to train those utilizing the PATH funding, as well as monitoring this program.
As changes are made to this or any other program required to be entered into HMIS, the
vendor providing the database system makes all necessary updates to the software.
6. SSI/SSDI Outreach, Access, and Recovery (SOAR):
a. Describe the agencies plan to train PATH staff in SOAR:
Mid Florida Homeless Coalition has one staff member previously trained in SOAR and all
staff has a general knowledge of SOAR. MFHC currently funds some outreach through ESG,
which includes funding a position to complete SOAR applications.
b. Indicate the number of PATH staff trained in SOAR during the grant year ending in
2016 (2015- 2016):
Two.
c. Indicate the number of PATH funded consumers assisted through SOAR (include all
distinct consumers whether approved, denied, or initiated on appeals):
None.
d. Indicate the number of PATH enrolled consumers your program proposes to assist
with SOAR applications in FY 16/17:
Thirteen
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e. Does the agency PATH program have a SOAR specialist who does all PATH SOAR
cases or does each PATH staff handle their own SOAR cases? Please describe the
rationale for this decision:
The agency has a SOAR specialist who does all PATH SOAR cases.
f. If the provider does not use SOAR, describe the system used to improve accurate,
timely completion of mainstream benefit applications and timely determination of
eligibility. Also, describe efforts used to train staff on this system. Indicate the
number of staff trained, the number of PATH funded consumers assisted through this
process, and application eligibility results:
N/A
The Agency does not fund a PATH Dedicated SOAR Processor.
The agency refers individuals in need to the nearest providers who have dedicated SOAR
processors.
g. Application eligibility results (i.e., approval rate on initial application, average time to
approve the application).
N/A
h. Describe how the providers plan to ensure that PATH staff have completed the SOAR
online course.
N/A
i. Describe which staff plan to assist consumers with SSI/SSDI application using the
SOAR model.
N/A
j. Describe which staff plan to track the outcomes of those applications in the SOAR
Online Applications (OAT) system.
N/A
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k. The number of staff dedicated to implementing SOAR, Is SOAR their part-time or
full-time job duty?
N/A
l. 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.)
N/A
m. 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.
N/A
7. Housing:
a. Indicate what strategies are used for making suitable housing available for PATH
clients (i.e., indicate the type(s) of housing provided and the name of the agencies):
Through the coordinated entry process, a housing assessment will determine the type of
housing needed.
Rapid Rehousing – Refuge at Jumper Creek, Lake Community Action Agency, and
Catholic Charities
Permanent Supportive Housing – LifeStream, Citrus County Housing, and Lake
County Housing
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8. Staff Information:
a. Describe the demographics of the staff serving the consumers:
Demographics of the staff serving the population
Veterans 1%
Gender
Male 0%
Female 100%
Race
American Indian/Alaskan Native 0%
Asian 0%
Black/African American 0%
Caucasian 100%
Native Hawaiian/Pacific Islander 0%
Two or More Races 0%
Ethnicity
Hispanic/Latino 0%
b. Describe 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).
MFHC sends its staff to trainings that are held throughout the CoC service area to be kept up-
to-date on cultural competence, as well as mental health first aid. Current staff has been
working in the homeless system for a period of years, and are advocates regardless of age,
gender, disability, sexual orientation and racial/ethnicity.
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9. Client Information: Describe the following:
a. The demographics of the PATH client population
Demographics of the population to be served:
Gender
Male 61%
Female 39%
Race
American Indian/Alaskan Native 2%
Asian 0%
Black/African American 16%
Caucasian 80%
Native Hawaiian/Pacific Islander 0%
Two or More Races 2%
Ethnicity
Hispanic/Latino 8%
Age
18-23 years 8%
24-30 years 26%
31-50 years 20%
51-61 years 44%
62 years and older 2%
b. The projected number of adult clients to be contacted and PATH enrolled and
rationale for these numbers:
Grant year 2016-2017 number or percentage of:
● # of individuals contacted through outreach: 0
● # of individuals enrolled: 0
● % of individuals enrolled that were literally homeless: N/A
● % of individuals enrolled that were veterans: N/A
Grant year 2017-2018 projected number or percentage of:
● # of individuals to be contacted through outreach: 180
● # of individuals to be enrolled: 110
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● % of individuals enrolled that are literally homeless: 97%
● % of individuals enrolled that are veterans: 7%
10. Consumer Involvement:
a. 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.
With the current ESG-funded outreach, which these funds will expand upon, those who are
being served are encouraged to volunteer to help the outreach team. Through this involvement,
those individuals can help identify and locate other individuals who are homeless. Those who
volunteer is usually forthcoming about what they feel is working effectively and what can be
changed to help themselves or others. A person formerly experiencing homelessness currently
sits on the Mid Florida Homeless Coalition’s Governing Board. These practices will continue
with the expansion allowed by the addition of PATH funds.
11. Budget: a. Provide a detailed budget that includes the agency’s use of PATH funds.
Mid-Florida Homeless Coalition - 2017-2018 PATH Grant Budget
Personnel
Annual
Salary*
(total
number)
PATH-
funded
FTE
(%)
PATH-
funded
Salary
Matched
Dollars
Total
Dollars Comments
Administrative Assistant $
-
Case Manager $35,360 1 $ 35,360 $ 35,360
Outreach Worker $35,360 1 $ 35,360 $ 35,360
Other (Data Entry) $10,400 0.79 $ 8,216 $ 2,184 $ 10,400 Cash match
Other (describe) -
Other (describe) -
Subtotal $81,120 2.79 $ 78,936 $ 2,184 $ 81,120 Cash match
* Indicate "annualized salary
for positons."
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Fringe Benefits (Max of 27%)
Subtotal $5,337 $ 869 $ 6,206 Cash match
Travel
Training -
Annual Conference or
Meetings -
Rental Car -
Per Diem -
Other (mileage) $ 6,500 $ 6,500
Travel
reimbursement
for outreach &
case
management -
Cash match
Other (describe) -
Subtotal $ 6,500 $ - $ 6,500
Equipment
Laptop computers $1,500
$ 1,500 2 laptop
computers
-
Subtotal $1,500 - $ 1,500
Supplies
Office supplies $ 200 $ 200
Folders, pens,
etc. - Cash
match
Client: Outreach Supplies/
Hygiene kits/Misc. $ 686 $ 4,000 $ 4,686
Hygiene &
food items -
In-Kind match
software - $ 1,606 $ 1,606
2 copies of
Microsoft
Office - Cash
match
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Other (HMIS user access) $ 1,032 $ 1,032 HMIS 2 users
- Cash match
Other (Prescription costs) - $ 1,163 $ 1,163
Cost of
prescriptions -
Cash match
Subtotal $ 686 $ 8,001 $ 8,687
Contractual
-
-
Subtotal - - -
Other
One-time housing rental
assistance -
Insurance (property, vehicle,
malpractice, etc.) $ 732 $732
Liability,
worker's comp
& non-owned
auto - Cash
match
Office: Misc. (Copying,
Courier, Postage, etc.) $ 1,000 $ 1,000
Copying &
Postage - Cash
match
Office: Security, Janitorial,
Grounds Maintenance $ 500 $ 500
Security -
Cash match
Office: Utilities/Telephone/
Internet $ 4,200 $ 4,200 $8,400
Mobile Phone
& Internet -
Cash match
Office: Other (Rent) $10,200 $10,200
Office: Other (describe) -
Staffing (Not Salary or
Benefits):
Training/Education/Conference
Fees
- $ 700 $ 700 FCH Institute
- Cash match
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Staffing (Not Salary or
Benefits): Other (describe)
Audit $ 6,000 $ 6,000 $ 12,000 Cash match
Subtotal $10,200 $23,332 $ 33,532
Total Direct Charges (Sum of
each section) $103,159 $34,386 $137,545
Indirect Costs (Max of 10%)
(Administrative Costs) $10,316 $ 3,439 $13,755
Grand Total (Total of "total
direct" and "indirect costs") $113,475 $37,825 $151,300
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C. Local Provider Intended Use Plan:
1. Local Provider Description: Provide a brief description of the provider organization
receiving PATH funds:
Name of the Organization: New Horizons Community Mental Health Center, Inc.
(NHCMHC)
Type of Organization: Community Mental Health Center
Address of Provider: 1469 NW Northwest 36th Street, Miami, FL 33142
Local Continuum of Care Lead Agency: Miami-Dade County Homeless Trust
PATH Contact Name/E-Mail/Phone #: Jean Eveillard / [email protected] /
(305) 759-5262
Region Served: Southern Region (Miami-Dade County)
Indicate the amount of federal, state and local PATH funds the organization will
receive.
Federal: $465,000
Match: $155,000
Total: $620,000
2. Collaboration with HUD Continuum of Care Program: Describe the organization’s
participation in the HUD Continuum of Care and any other local planning, coordinating or
assessing activities:
NHCMHC is a participating member of the Miami-Dade County Homeless Trust Continuum
of Care. The local homeless continuum of care and its providers exist as a formal countywide
partnership for service providers, consumers, and stakeholders. This working group is
responsible for developing standards of care, shaping public policy, distribution of funding,
monitoring, and quality improvement efforts in the homeless service delivery system for
individuals and families experiencing homelessness in Miami-Dade County. NHCMHC staff
attends monthly Homeless Trust Board meetings, participate in standing committees, and
assist in writing the Continuum of Care HUD grant applications. Staff also participates in the
Point-in-Time (PIT) census count, which is a measure of individuals experiencing
homelessness on a specific day. The PIT Count is one of the best methods of determining
progress towards eradicating homelessness.
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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 (i.e.,
outreach teams, primary health, mental health, substance use, housing, employment, etc.) to
PATH eligible consumers and describe coordination of activities with each of these
organizations (describe all that apply):
New Horizons is a provider partner to the Miami-Dade County Continuum of Care (CoC); as
such, the Agency has collaborative work relationships with its provider members New
Horizons’ PATH staff work closely with the CoC coordinated outreach team for assessment
and placement process. Individuals and families experiencing homelessness are placed based
on level of vulnerability, availability of beds, and/or housing. In turn, the coordinated
outreach team may refer individuals that have mental health conditions and who are
experiencing homelessness to New Horizons for mental health services and/or co-occurring
services.
New Horizons has a Memorandum of Understanding (MOU) with Jessie Trice Community
Health Center and collaborative relationships with Camillus Health Concern and Jackson
Memorial Hospital for the provision of primary health care and medical services.
In addition to collaborative efforts in increasing the County’s housing inventory for
individuals and families experiencing homelessness, the Agency is part of a community
partnership designed to improve the delivery of services to persons experiencing
homelessness who are involved in multiple systems. These organizations include:
Miami-Dade County Homeless Trust
Miami-Dade County Public Housing and Development
Miami Dade Community Action and Human Services
City of Miami
City of Miami Beach
Social Security Administration
DCF Southern Region SAMH Program Office
South Florida Behavioral Health Network (SFBHN)
Miami-Dade County Public Transportation
South Florida Workforce Chapman Partnership
Miami-Dade Safe Space
Jackson Behavioral Health Hospital
Veterans Administration Hospital
Jessie Trice Family Health Center
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Miami Rescue Mission
Salvation Army
New Hope Corps.
Camillus House/Camillus Health Concern
Citrus Health Network, Inc.
Douglas Gardens CMHC
Banyan Health Systems
Catholic Charities of the Archdiocese of Miami, Inc.
Carrfour Supportive Housing
Fellowship House
Lotus House
Lutheran Services
Legal Services of Greater Miami
Betterway of Miami, Inc.
New Hope Drop-In Center
Jewish Community Services of South Florida, Inc.
Goodwill Industries
Volunteers of America
Fresh Start Consumer Network
Agape
4. 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:
The focus of PATH services is on outreach and case management services to persons
who are chronically and literally homeless in need of mental health or co-occurring
mental health and substance abuse services and who do not receive such services from
mainstream mental health or substance use programs. Outreach services occur in the
street, homeless shelters, and other target areas where individuals experiencing
homelessness may congregate. “In-Reach”, contact within the agency initiated by an
individual who is homeless, is also conducted by PATH staff. Outreach staff is trained in
the engagement process including the use of reflective listening, brief and consistent
interactions, as well as allowing the participant to exercise control in the interaction.
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These strategies are guided towards building relationships so acceptance of and
connection with services is maximized. Case management services are designed to assist
PATH participants to access health care, income through employment or social security
utilizing the SOAR model, and mental health services or co-occurring services. In
addition, case managers provide linkage and referral services to other community
resources and supportive services and help PATH participants in the acquisition and
maintenance of adequate and stable housing.
b. Provide specific examples of how the agency maximizes use of PATH funds by
leveraging use of other available funds for PATH client services:
In addition to working relationships with the CoC member organizations to create
housing and implement needed services for individuals experiencing homelessness, the
Agency has formal Memorandum of Agreement(s) with Jessie Trice Family Health
Center and collaborative relationships with other community organization such as
Jackson Memorial Hospital and Camillus Health Concern for primary care and medical
services; Miami-Dade County Public Transportation for free bus passes for individuals
experiencing homelessness; Miami-Dade County Meals Program; Camillus House and
the Miami Rescue Mission for hot meals and showers; South Florida Workforce; and
Elder Affairs meals program to ensure maximization of resources and to reduce
overlapping and duplication of services.
c. Describe any gaps that exist in the current service systems:
The Miami-Dade County Homeless Trust’s gaps analysis reveals a continued need for the
creation of new permanent housing for individuals experiencing chronic homelessness
(preferably Housing First models) and veterans experiencing homelessness. On January
21, 2016, as revealed by the PIT Homeless count, there were 982 unsheltered persons and
3,253 sheltered individuals. On this date, 1,306 persons experiencing homelessness were
surveyed. The data collected suggests the following needs:
Housing
Transportation
Employment
Case management
Health Care
Food
Mental Health Services
Rapid Rehousing
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Vocational Training
Substance Abuse Counseling
d. Provide a brief description of the current services available to clients who have both a
serious mental illness and a substance use disorder:
Outreach - identification and engagement of persons who are chronically and literally
homeless in need of mental health or co-occurring mental health and substance use
services and who do not receive such services from mainstream mental health or
substance abuse programs.
Psychiatric services - psychiatric evaluation, follow-up, and medication
management.
Crisis support - this service aims at reducing stress and helps the individual’s
ability to cope with the current situation.
Case management - these services include assessment, planning, referral,
consumer and program related record keeping; assisting those consumers
engaged through outreach services into linkage with mainstream resources,
including community mental health services, housing options, and income
support services.
Psychosocial rehabilitation services - services designed to enable consumers
to function in the community in the least restrictive environment and restore
or enhance social and prevocational life management services. Help
consumers assume responsibility over their lives and improve general well-
being.
Mental health services - include assessment, diagnosis, and treatment or counseling to
assist a consumer in alleviating or recovering from mental illness.
Outpatient substance use counseling—this service includes education,
prevention, drug screening, treatment, and counseling for individuals at
different stages of recovery.
Permanent Supportive Housing—tenant-based rental assistance with
supportive services for individuals experiencing homelessness and chronic
homelessness and who have been impacted by mental illnesses.
SSI/SSDI Outreach, Access and Recovery (SOAR)—this service is designed
to increase access to SSI/SSDI for eligible individuals experiencing
homelessness or at risk of homelessness and having mental illnesses.
Transitional housing—Temporary housing with supportive services.
Screening and diagnostic services.
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e. Describe how the local provider agency pays for providers or otherwise supports
evidence-based practices, trainings for local PATH-funded staff, and trainings and
activities to support collection of PATH data in HMIS:
Miami-Dade County Homeless Trust and South Florida Behavioral Health Network
(SFBHN) provide ongoing trainings and support. New Horizons’ HMIS administrator,
together with homeless service providers within the Continuum of Care, attend
mandatory monthly group meetings scheduled by the lead Agency, Miami-Dade County
Homeless Trust. Technical assistance is provided as needed.
f. 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).
New Horizons has collaborative relationships with Jessie Trice, Camillus Health
Concern, and Jackson Memorial Hospital. All consumers in need of health services are
referred to the aforementioned entities. The Agency has 120 units of permanent
supportive housing using the Housing First model for homeless and chronically homeless
persons with mental illnesses. There are no preconditions such as sobriety, participation
in treatment, or minimum income threshold for program entry. Criminal background is
not a disqualifying criterion for admission. Other housing arrangements are explored for
consumers, including reunification with family members or placement in transitional
housing programs. In addition, the Agency is involved in housing and employment
initiatives with South Florida Behavioral Health Network, the Managing Entity, with the
goal of improving housing and employment outcomes for consumers.
The Agency provides an array of supportive services including: outreach, medication
management, residential services, case management, psychosocial rehabilitation, mental
health, substance abuse counseling and other services designed to help consumers
transition from the criminal justice system into the community.
Please check all services to be provided using PATH funds:
Outreach Services
Screening and diagnostic treatment services
Habilitation and rehabilitation services
Recovery Support Services such as Peer Support/Recovery Coaching
Community Mental Health services
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Alcohol and drug treatment services
Assisting individuals to connect with Community Mental Health Services and
alcohol or other drug treatment services
Staff training (including training of individuals who work in shelters, mental
health clinics and substance abuse programs and other sites where homeless
individuals require services)
Case management services (see PATH eligible services document)
Supportive and supervisory services in residential settings
Referral for Primary healthcare
Referral for job training
Referral for educational services
Referral for housing services
5. Data: a) Describe the provider’s status on the HMIS transition plan, with accompanying
timeline, to collect PATH data by fiscal year 2017:
The HMIS transition plan is fully completed. PATH data for fiscal year 2017 is
collected accordingly.
b) If providers are fully utilizing HMIS for PATH services, please describe plans for
continued training and how providers will support new staff:
Miami-Dade County Homeless Trust and SFBHN provide ongoing trainings and
support. Presently, the Agency’s PATH program has three (3) HMIS administrators.
New Horizons’ HMIS administrators, together with homeless service providers
within the Continuum of Care, attend mandatory monthly group meetings scheduled
by the lead Agency, Miami-Dade County Homeless Trust. Technical assistance is
provided as needed.
6. SSI/SSDI Outreach, Access, and Recovery (SOAR):
a. Describe the agencies plan to train PATH staff in SOAR.
The Agency presently has a certified SOAR trainer, two SOAR trained case
managers, and one dedicated SOAR specialist. During this fiscal year the Agency
plans to add one more dedicated SOAR specialist. SOAR training are conducted
online and are supervised by the Agency’s SOAR trainer.
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b. Indicate the number of PATH staff trained in SOAR during the grant year ending in
2016 (2015- 2016):
During the grant year ending in 2016 one PATH staff was trained in SOAR.
c. Indicate the number of PATH funded consumers assisted through SOAR (include all
distinct consumers whether approved, denied, or initiated on appeals):
During the FY 15/16 one consumer was assisted through SOAR.
d. Indicate the number of PATH enrolled consumers your program proposes to assist
with SOAR applications in FY 16/17:
The PATH program intends to assists a minimum of thirty-five consumers with
SOAR applications in FY 16/17.
e. Does the agency PATH program have a SOAR specialist who does all PATH SOAR
cases or does each PATH staff handle their own SOAR cases? Please describe the
rationale for this decision:
The PATH program has a full time dedicated SOAR specialist. Without access to
benefits PATH enrolled consumers find it difficult to access housing, medical
services, and related services. Therefore, it makes sense that the Agency and the
Managing Entity allocate its funds where it makes the greater impact as expeditiously
as possible.
f. If the provider does not use SOAR, describe the system used to improve accurate,
timely completion of mainstream benefit applications and timely determination of
eligibility. Also describe efforts used to train staff on this system. Indicate the number
of staff trained, the number of PATH funded consumers assisted through this process,
and application eligibility results:
The PATH program uses the SOAR process to improve timely completion of
mainstream benefit applications and timely determination of eligibility.
g. Application eligibility results (i.e., approval rate on initial application, average time to
approve the application).
The approval rate is 57% and average time for approval is 51 days.
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h. Describe how the providers plan to ensure that PATH staff have completed the SOAR
online course.
All identified SOAR staff complete the online training and submit a copy of the
SAMHSA certificate of completion to the Agency’s Human Resources Department.
i. Describe which staff plan to assist consumers with SSI/SSDI application using the
SOAR model.
Presently, the Agency has two full-time SOAR dedicated staff that assist consumers
with SSI/SSDI applications using the SOAR model.
j. Describe which staff plan to track the outcomes of those applications in the SOAR
Online Applications (OAT) system.
The program director is responsible for tracking the outcomes of applications in the
online Applications (OAT) system.
k. The number of staff dedicated to implementing SOAR, Is SOAR their part-time or
full-time job duty?
Presently, the Agency has two full-time SOAR dedicated staff.
l. 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.)
N/A
m. 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.
N/A
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7. Housing:
a. Indicate what strategies are used for making suitable housing available for PATH
clients (i.e., indicate the type(s) of housing provided and the name of the agencies):
New Horizons has been successfully operating tenant-based, scattered site housing
for over twenty years. The Agency is a current sponsor of the following projects: two
supportive services only programs to individuals and families formerly experiencing
homelessness who also are diagnosed with disabilities residing in permanent
supportive housing and four Permanent Supportive Housing (PSH) programs to
provide 120 units of rental assistance for individuals and families experiencing
homelessness with serious mental illness, substance abuse, and/or co-occurring
disorders and HIV-related illnesses. The PSH programs provide housing to
approximately 230 persons. During the most recent CoC NOFA cycle New Horizons
applied and was awarded a new tenant-based PSH program with 20 units of rental
assistance. This will add 20 more housing units to the 120 units, increasing the
agency’s inventory to 140 PSH rental assistance housing units. The following is a list
of resources utilized to connect PATH participants with Permanent Housing:
Active partner of the local Homeless Miami-Dade County Continuum of Care.
Active participant in Homeless Trust sub-committees (Homeless Providers Forum,
Services Development Committee) and assist in writing Continuum of Care HUD
grant applications.
Active partner in the coordination of Homeless services through the Management
Information Systems (HMIS).
Provider of Homeless Outreach and Wrap-Around Supported Services.
Provider of transitional housing beds for individuals experiencing homelessness and
mental illness.
Active participation in training and follow-up in the implementation of Permanent
Supportive Housing, one of SAMHSA’s Evidence-Based Practices, and the use of
that Tool Kit.
Miami-Dade County Public Housing and Development- Section 8.
Active participant in SFBHN Housing and Employment Initiatives.
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8. Staff Information:
a. Describe the demographics of the staff serving the consumers:
Demographics of the staff serving the population
Veterans 0%
Gender
Male 53%
Female 47%
Race
American Indian/Alaskan Native 0%
Asian 0%
Black/African American 65%
Caucasian 35%
Native Hawaiian/Pacific Islander 0%
Two or More Races 0%
Ethnicity
Hispanic/Latino 35%
b. Describe 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 consumers; 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).
New Horizons employs PATH staff with ethnic and racial backgrounds that correlate
to that of the target population it serves. New Horizons’ staff receive training in
cultural competence through scheduled in-service trainings. In addition to in-house
trainings the CoC and SFBHN schedule cultural, gender sensitivity, and other
relevant trainings throughout the fiscal year. These trainings are ongoing and allow
for staffs’ identification of their own culture, bias, and values as well as the cultures
of those the Agency serves. This process prepares staff to adequately assess and
respond to the unique needs of the population they serve and ensures sensitivity in
responding to factors that influence the consumer’s response to treatment outcomes
including family, ethnicity, language, belief system, age, gender, and sexual
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preference. Similarly, it allows for the creation of interventions that are strength-
based and person-centered.
9. Client Information: Describe the following:
a. The demographics of the PATH client population
Demographics of the population to be served:
Gender
Male 62%
Female 38%
Race
American Indian/Alaskan Native 0.3%
Asian
Black/African American 60.2%
Caucasian 39.3%
Native Hawaiian/Pacific Islander 0.2%
Two or More Races
Ethnicity
Hispanic/Latino 33%
Age
18-23 years 7%
24-30 years 15%
31-50 years 46%
51-61 years 28%
62 years and older 4%
b. The projected number of adult clients to be contacted and PATH enrolled and
rationale for these numbers:
Grant year 2016-2017 number or percentage of:
# of individuals contacted through outreach: 608
# of individuals enrolled: 452
% of individuals enrolled that were literally homeless: 65%
% of individuals enrolled that were veterans: 2.9%
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Grant year 2017-2018 projected number or percentage of:
# of individuals to be contacted through outreach: 600
# of individuals to be enrolled: 400
% of individuals enrolled that are literally homeless: 80%
% of individuals enrolled that are veterans: 2%
10. Consumer Involvement:
a. 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.
PATH consumers are actively involved in their recovery process from admission to
discharge. Consumers are encouraged to define their own goals and exercise control
over their path to recovery. PATH staff encourage family involvement and, at the
discretion and consumer’s request, may reconnect with the family of origin. New
Horizons consumers are involved in evaluating PATH-funded services through
consumer evaluation surveys, which are completed on a quarterly basis. New
Horizons’ Quality Improvement Committee reviews the surveys and makes
recommendations for continual improvement of services, service delivery approaches,
staff skills, competencies, and clinical treatment approaches. Ongoing consumer input
is a valuable contribution to the continued work of improving services and program
outcomes within New Horizons CMHC. In addition, New Horizons will reassemble
its consumer advisory group. This group of current and former consumers has
experiential knowledge that is instrumental in the planning, implementation, and
evaluation of program services.
Florida PATH Intended Use Plan
FY 2017-2018
Local Provider New Horizons CMHC Page 14 of 18
Intended Use Plan
11. Budget: a. Provide a detailed budget that includes the agency’s use of PATH funds.
New Horizons Community Mental Health Center, Inc. - 2017-2018 PATH Grant Budget
Personnel
Annual
Salary*
(total
number)
PATH-funded
FTE (%)
PATH-
funded
Salary
Matched
Dollars
Total
Dollars Comments
Program Director $ 52,000 0.50 $ 26,000 $ 26,000
Outreach Worker $ 20,800 1 $ 20,800 $ 20,800
Psychosocial Rehab
Technician $ 31,200 1 $ 31,200 $31,200
Case Manager Director $ 65,000 0.20 $ 13,000 $13,000
SOAR Case Manager $ 42,807 1 $ 42,807 $ 42,807
Case Manager $ 42,807 1 $ 42,807 $ 42,807
Case Manager $ 42,807 1 $ 42,807 $ 42,807
Case Manager $ 42,807 0.50 $ 21,404 $ 21,404
Therapist $ 48,700 0.50 $ 24,350 $ 24,350
Psychiatrist $ 225,000 0.1 $ 22,500 $22,500
Registered Nurse $ 41,600 0.23 $ 9,568 $ 9,568
Administrative
Assistant $ 24,960 1 $ 24,960 $ 24,960
Driver $ 19,240 0.20 $ 3,848 $ 3,848
Psychosocial Rehab
Technician $ 24,960 0.40 $ 9,984 $ 9,984
Patient Care
Coordinator $ 35,152 0.10 $ 3,515 $ 3,515
Clinical Director $80,000 0.05 $ 4,000 $ 4,000
Medical Record Clerk $ 21,840 0.30 $ 6,552 $ 6,552
Data Entry Assistant $ 24,960 0.40 $ 9,984 $ 9,984
Quality/Compliance $ 72,000 0.05 $ 3,600 $ 3,600
Therapist $ 48,700 0.40 $ 19,480 $ 19,480
Cost of Custodian $ 16,203 0.20 $ 3,241 $ 3,241
Florida PATH Intended Use Plan
FY 2017-2018
Local Provider New Horizons CMHC Page 15 of 18
Intended Use Plan
Psychiatrist $ 176,800 0.15 $ 26,520 $ 26,520
Subtotal $
1,200,343 10.28 $ 326,051 $ 86,876
$412,927
Fringe Benefits (16%) $ 52,168 $13,900 $ 66,068
Subtotal $ 52,168 $ 13,900 $ 66,068
Travel
Annual Conference or
Meetings $ 1,000
$ 1,000
Registration
fee, hotel
expenses
for Program
Director
Travel Expenses $ 600 $ 600
Rental
Car@500,
Per diem @
$100 for
two staff
Field Trips $ 2,462 $ 2,462
Field trips
for
consumers
to various
educational
sites
Subtotal $ 4,062 $ 4,062
Equipment
Subtotal
Supplies
Office supplies $ 2,160 $ 2,160
Folders,
markers,
papers,
notebooks,
etc., for
Therapist
and Case
Managers
Florida PATH Intended Use Plan
FY 2017-2018
Local Provider New Horizons CMHC Page 16 of 18
Intended Use Plan
Program Participants:
Outreach Supplies $ 2,800 $ 2,800
Hygiene
kits/Misc.
Program Supplies $2,600 $ 2,600
Educational
recreational
and first aid
kits
Subtotal $ 7,560 $ 7,560
Contractual
Subtotal
Other
One-time housing rental
assistance $ 10,000 $10,000
One time
rental and
security
deposits for
program
participants
Insurance (property,
vehicle, malpractice,
etc.)
$ 1,750 $ 7,767 $ 9,517
Expenses
for liability
and
property
insurance
Office: Misc. (Copying,
Courier, Postage, etc.) $ 4,200 $ 900 $ 5,100
Leasing
expense for
copier,
cartridge
etc.
Office: Security,
Grounds Maintenance/
Repairs
$ 5,476 $ 3,400 $ 8,876
Security,
repairs for
the program
building.
Florida PATH Intended Use Plan
FY 2017-2018
Local Provider New Horizons CMHC Page 17 of 18
Intended Use Plan
Office: Telephone/
Internet $ 5,160 $ 5,160
Telephone,
Internet
monthly
allocation
$430
Lab tests $ 6,788 $ 6,788
Monthly
allocation
for lab
works
@$565
Utilities $ 5,211 $ 5,211
Electricity
and Water
monthly
@$434
Networks/EHR/IT $ 9,456 $ 11,705 $ 21,161
Allocated
on the basis
of number
of users
Transportation $ 4,818 $ 2,000 $ 6,818 Van leasing
Gas for motor vehicle $ 1,800 $ 2,452 $ 4,252
Monthly
gas
expenses
for van
@$351
Subtotal $ 54,659 $28,224 $82,883
Total Direct Charges
(Sum of each section) $444,500 $129,000 $573,500
Indirect Costs (Max of
10%) (Administrative
Costs)
$20,500 $26,000 $46,500
4.4%
allocated as
indirect
cost