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Homeless, Physical, and Behavioral Health

Accessing Coordinated Care and Empowering Self Sufficiency (ACCESS) Harris County is an integrated care-coordination model that works to improve outcomes for vulnerable individuals through a multi-interdepartmental disciplinary team called a Care Coordination Team. The team focuses on supporting clients holistically by addressing multiple needs to achieve well-being and self-sufficiency.

ACCESS Harris County works with community members experiencing hardships, including health challenges (physical and/or mental), financial and housing needs, substance abuse, and social inequity by providing intensive, wraparound support across Harris County’s safety net system.

The ACCESS Harris County Homeless, Physical & Behavioral Health Cohort aims to improve the health, well-being, sustained recovery, and self-sufficiency of Harris County’s most vulnerable residents impacted by homelessness.

How the program works

  • Eligible individuals from the community work with a case manager on a one-on-one basis.
  • Participants undergo screening and assessments to help develop a personalized care plan.
  • A team of subject matter experts across multiple agencies work with a case manager to provide coordinated care to help participants follow their treatment plan and achieve their goals.

Who Qualifies for ACCESS Harris County Homeless Support Services

  • Harris County community members who are homeless and have a physical and or mental health condition
  • Be at least 16 years and are experiencing social vulnerability
  • Must consent to participate in the Interdepartmental Multi-Disciplinary Team (IMDT) for care
  • Be eligible for long-term case management to address the social determinants of health (SDOH)
  • Live within Harris County

What is the ACCESS Homeless, Physical and Behavioral Health (PBH) Cohort?

Under the auspices of ACCESS Harris County, the Homeless PBH Cohort focuses on supporting the needs of one of the most vulnerable populations in Harris County, the homeless population, through the provision of coordinated care services inclusive of housing.

Who will be served?

Harris County residents who are experiencing homelessness and who have a physical and/or behavioral health condition.

Clients will be referred through the Coordinated Access (CA) System; following the community prioritization of serving the most vulnerable first and those who are eligible for Permanent Supportive Housing. CA is a powerful tool designed to ensure that people experiencing homelessness and people at risk of homelessness are matched, as quickly as possible, with the intervention that will most efficiently and effectively end their homelessness.

What is the goal of the Homeless PBH Cohort?

This pilot program is a new and unique coordinated care program in Harris County that will pilot a direct partnership between Harris County Public Health, a variety of additional County departments, the homeless response system, and community services with the goal of improving Harris County homeless population outcomes through providing Permanent Supportive Housing, Coordinated Care Management, Enabling Technology (WCM), comprehensive service portfolio (e.g., medical, mental health, housing, etc.), and braided funding.

This cohort will operate as a Permanent Supportive Housing (PSH) program in connection with the Coalition for the Homeless. This program will serve people experiencing homelessness who are eligible for PSH which will provide long-term housing with supportive services to persons who are chronically homeless and have a documented disability or people who are literally homeless with a documented disability if there is no one on the waitlist who qualifies as chronically homeless.

Goal: To house 150 individuals experiencing homelessness who have a physical and/or behavioral health condition.