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Specialized Services for High-Acuity Populations

Tailored support for veterans, individuals with medical complexities, behavioral health challenges, and those experiencing chronic homelessness

22%
Veterans Served
82%
Telehealth Access
1:18
Caseload Ratio
97%
Retention Rate
Veterans Services

Serving Those Who Served

Specialized coordination with VA, HUD-VASH, SSVF, and GPD programs to ensure veterans receive the housing, benefits, and support they've earned

22% of Our Clients Are Veterans

We understand the unique challenges veterans face and provide specialized pathways to housing stability and wellness.

Housing Stability Rate
92-97%
HUD-VASH Placement Time
≤ 14 Days

Comprehensive Veteran Support

Peer Veteran Stability Coaches

Veterans with lived experience provide mentorship, accountability, and peer support throughout the housing journey. They understand military culture and the unique transition challenges.

HUD-VASH Rapid Placement

Expedited processing for HUD-VA Supportive Housing vouchers with placement completed within 14 days or less. We coordinate directly with VA case managers and housing authorities.

Average placement: 14 days vs. national average 45+ days

VA Benefits Discovery & Upgrading

Complete review of VA benefit eligibility, assistance with claims filing, and support for service connection upgrades. We help veterans access all benefits they've earned including disability compensation, pension, and healthcare.

VA Healthcare Integration

Direct coordination with VA Medical Centers, Vet Centers, and community-based outpatient clinics. We facilitate enrollment in VA healthcare and ensure continuity of care for physical and mental health needs.

Veterans Court & Justice System Coordination

Liaison with Veterans Treatment Courts and legal advocacy for veterans in the justice system. Housing placement can be part of successful court program completion.

Partnering With Leading Veterans Organizations

VA Medical Centers
Healthcare coordination
HUD-VASH
Voucher program
SSVF Programs
Supportive services
GPD Programs
Transitional housing
Medical & Healthcare Services

Comprehensive Medical Care Integration

Connecting clients to primary care, telehealth platforms, dental services, and specialized medical support within 30 days of housing placement

Primary Care Physician (PCP) Linkage

Every client connected to a primary care provider within 30 days of housing. We coordinate appointments, transportation, and ensure follow-up care.

  • Annual physicals and preventative care
  • Chronic disease management (diabetes, hypertension)
  • Prescription medication coordination
82% ATTENDANCE RATE

24/7 Telehealth Access

Removing transportation barriers through virtual medical, psychiatric, and therapy appointments. Clients can access care from their homes.

  • Medical consultations and follow-ups
  • Psychiatric medication management
  • Individual therapy sessions

Dental Health Services

Connections to community dental clinics and dental schools for essential oral health care, often a barrier to employment and social integration.

  • Emergency dental care
  • Cleanings and preventative services
  • Dentures and prosthetics

Specialty Medical Referrals

Coordinated access to specialists for complex medical needs including cardiology, endocrinology, oncology, and infectious disease treatment.

  • Specialist appointment coordination
  • Transportation assistance to appointments
  • Medical record transfer support

Medication Management & Adherence

Support for prescription access, medication adherence monitoring, and pharmacy coordination to ensure consistent treatment compliance.

  • Prescription assistance programs
  • Medication counts and pill organizers
  • 31% improvement in adherence

Insurance Enrollment & Benefits

Assistance enrolling in Medicaid, Medicare, ACA marketplace plans, and understanding coverage options to ensure continuous healthcare access.

  • Medicaid/Medicare enrollment assistance
  • ACA marketplace navigation
  • Benefits advocacy and appeals

Measurable Health Outcomes

55-70%
Reduction in ER Visits
Among housed clients with PCP connection
48%
Fewer Psychiatric Emergencies
Through integrated care model
82%
Telehealth Attendance
Eliminating transportation barriers
Behavioral Health & Recovery

Integrated Mental Health & Substance Use Support

Evidence-based treatment pathways for co-occurring disorders, substance use recovery, and mental health stabilization

Substance Use Disorder Treatment

Intensive Outpatient Programs (IOP)

Seamless referral pipeline to evidence-based IOPs for substance use and co-occurring disorders. Programs typically include 9-12 hours per week of group therapy, individual counseling, and skills training.

Group Therapy Individual Counseling Family Support

Medication-Assisted Treatment (MAT)

Connection to MAT providers for opioid and alcohol use disorders. Medications like buprenorphine, naltrexone, and methadone combined with counseling for comprehensive treatment.

Evidence shows MAT reduces overdose deaths by 50% and increases treatment retention

Peer Recovery Coaches

Certified peer specialists with lived experience provide hope, accountability, and mentorship. They understand the recovery journey and offer non-judgmental support during challenging times.

  • Weekly check-ins and accountability
  • Recovery community connections
  • Relapse prevention support

12-Step & Alternative Recovery Pathways

Transportation and support for AA, NA, SMART Recovery, Celebrate Recovery, and other peer support meetings. We respect each individual's choice of recovery pathway.

Mental Health Services

Psychiatric Care & Medication Management

Access to psychiatrists for diagnosis, medication evaluation, and ongoing medication management for conditions including depression, anxiety, bipolar disorder, schizophrenia, and PTSD.

Via Telehealth
Monthly psychiatric appointments available from home

Individual Therapy & Counseling

Licensed therapists providing trauma-informed therapy using evidence-based approaches including CBT, DBT, motivational interviewing, and trauma-focused interventions.

CBT DBT Trauma-Focused Motivational

Crisis Intervention & Safety Planning

24/7 crisis response protocols, safety planning for suicidal ideation, and immediate connection to psychiatric emergency services when needed.

Crisis Line Available
48% reduction in psychiatric emergencies through proactive support

Structured Living & Group Homes

Tiered housing options including group homes and structured sober living environments for clients not yet ready for independent leases. Provides additional supervision and community support.

Compassionate Accountability Standards

We believe in supporting recovery through clear expectations and tiered accountability measures that respect individual journeys while promoting stability

Tiered Goals

Individualized milestones based on client needs, readiness, and recovery stage

Supportive Testing

Random drug testing when appropriate, always within a framework of support not punishment

Medication Counts

Adherence monitoring for psychiatric and medical prescriptions with 31% improvement rate

Case Management

Critical Time Intervention (CTI) Model

Evidence-based intensive case management that reduces returns to homelessness by 32% through targeted support during critical transition periods

Three-Phase CTI Approach

1

Transition Phase

Days 1-30

Intensive daily-to-weekly contact establishing trust, connecting to resources, and addressing immediate crises. Focus on housing stability and basic needs.

  • Daily check-ins during move-in week
  • Crisis intervention as needed
  • Resource connection (food, benefits, healthcare)
2

Try-Out Phase

Days 31-120

Gradual reduction to weekly contacts as client builds skills and natural supports. Testing independence while maintaining safety net.

  • Weekly scheduled contacts
  • Skill-building and goal-setting
  • Natural support system development
3

Transfer of Care

Days 121-365+

Transition to light-touch follow-up or ongoing community supports. Client operates independently with resources in place for future needs.

  • Monthly check-ins
  • Connection to ongoing community supports
  • 12-month stability assessment

Caseload Standards

Standard Acuity 1:18

Typical caseload for stable clients

High Acuity 1:12

Intensive support for complex cases

Lower caseloads ensure case managers have time for meaningful engagement and crisis response

Service Coordination

Housing Stability Monitoring

Regular landlord communication, lease compliance support, and conflict resolution

Benefits Advocacy

SNAP, TANF, SSI/SSDI application assistance and appeals representation

Healthcare Coordination

Appointment scheduling, transportation, and follow-up with medical providers

Employment & Education Support

Job training referrals, resume building, and GED/vocational education connections

Legal Aid & Documentation

Legal clinic referrals, expungement support, and vital records recovery

Family Reunification

Support for rebuilding family relationships and child custody matters when appropriate

SBAR Communication Protocol

Standardized Situation-Background-Assessment-Recommendation reporting ensures critical incidents are escalated quickly and professionally to healthcare providers, emergency services, and team leadership.

Why It Matters: Clear, concise communication protocols reduce response time during crises and improve coordination with medical and emergency personnel.

Situation

What is happening right now?

Background

Context, history, relevant information

Assessment

What do you think the problem is?

Recommendation

What action should be taken?

Additional Support Services

Wraparound Services & Community Integration

Beyond housing and clinical care, we provide comprehensive support for every aspect of successful community reintegration

Transportation Assistance

Bus passes, rideshare vouchers, and coordinated transportation to medical appointments, job interviews, and essential services.

Food & Nutrition Support

SNAP enrollment, food bank connections, meal programs, and nutrition education to ensure food security.

Communication Access

Cell phone provision and activation for maintaining contact with case managers, employers, and healthcare providers.

Clothing & Personal Items

Professional clothing for job interviews, seasonal clothing, and personal care items for dignity and self-confidence.

Employment Services

Job training referrals, resume building, interview preparation, and connections to employment programs and workforce development.

Education & Skills Training

GED preparation, vocational training programs, community college connections, and continuing education opportunities.

Legal Support Services

Referrals to legal aid clinics, expungement support for criminal records, and assistance with civil legal matters.

Financial Capability

Budgeting education, banking access, credit rebuilding, and financial planning for long-term stability and independence.

Social & Recreation

Community engagement activities, support groups, recreational opportunities, and social skill-building for healthy integration.

Comprehensive Support. Lasting Results.

Our holistic approach addresses every barrier to housing stability, giving clients the tools and support they need to thrive

97%
Client Retention Rate
32%
Reduction in Returns to Homelessness
500+
Lives Transformed