Outreach, Education, Housing and Shelter
Goal: Engaging and connecting to health home and H2O Services
Locating and engaging referred members Connect and reconnnect to Health home and needed services Coordinate care with Health home including verifying homelessness Warm handoff to pre-tenancy or tenancy support services Community Assisting to enroll in mainstream benefits Complete SDOH assessment with Clients
Goal: Support member in getting into housing and sustaining it
- Screening and housing assessment
- Coordinate with member’s behavioral health provider
- Develop and execute housing plan
- Housing readiness: applications, documents needed for housing, attending briefings, etc.
Goal: Provide shelter services to eligible members for up to 6 months
- 24/7 accessible space
- Complete social determinants of health (SDOH) assessment on members
- Develop housing plan within 48 hours of admission
- Connect member to needed and appropriate services, including substance use treatment
- Assist member in applying for mainstream benefits

