InvisALERT Solutions – ObservSMART

Safe Options Support: Charting a Path to Stability for Homeless Individuals through Coordinated Care

A transformative shift is underway for New York City programs focused on helping homeless individuals. Instead of relying on a singular approach to homeless outreach, new initiatives and adaptations are reshaping and diversifying the community-based services available. This remodeled, multidimensional approach is harnessing the power of a centralized and streamlined access to care hub, a cross-system collaboration, a learning community framework, and enhanced resource accessibility to address the unique needs and challenges of those experiencing homelessness, particularly those with serious mental illness.

Young happy woman holds key while moving into new home.

In April 2022, Coordinated Behavioral Care (CBC) and the New York State Office of Mental Health (OMH) launched Safe Options Support (SOS). This new initiative aims to help individuals living on the streets by transitioning them into stable housing. Over the course of 12 months, SOS employs focused engagement, identification and provision of immediate needs, and service linkages. SOS teams consisting of licensed mental health practitioners, nurses, peer specialists, and care managers work together to rapidly connect individuals with housing and establish strong connections to social, medical, mental health, and substance use care. In collaboration with emergency shelters, outreach providers, and permanent and supportive housing agencies, SOS flexibly provides the person-centered care needed during this crucial transition period with the goal of sustained housing placement.

Individuals experiencing street homelessness cite several barriers to housing, including services that feel unreliable, unsafe shelter options due to fear of theft, violence, and unsanitary conditions, and the general public’s resistance to helping with even basic needs like food and public transportation. For service providers working tirelessly to support the homeless, their experiences include systemic barriers like well-intended policies with counterintuitive effects, complex systems failing to work together and communicate efficiently, ongoing discriminatory practices, and the absence of key stakeholders at the decision-making table, such as managed care organizations.

CBC has adopted a comprehensive model designed to tackle each aspect of the challenge directly.

CBC Hub: Centralized and Streamlined Access to Care

CBC plays a crucial role in the SOS program by serving as a centralized administrative Hub. This Hub manages contracting, maintains a single point of access for referrals, enhances coordination among behavioral health agencies, facilitates collaboration across different sectors, handles logistics, maintains a centralized care management electronic record, conducts data analysis and reporting, and oversees quality improvement through program evaluation and an active learning community. Moreover, CBC offers 24/7 on-call access to address urgent needs for individuals and their support network.

Within CBC, a dedicated housing specialist possesses extensive knowledge and experience in navigating the complex landscape of housing resources. They provide invaluable support to the SOS team and its members, facilitating connections to a variety of housing opportunities.

By serving as a centralized hub, CBC streamlines the process, making it easier for individuals experiencing homelessness to access the care and services they need. Through close collaboration with SOS teams and other stakeholders, CBC ensures seamless coordination and communication. The Hub’s comprehensive resources, including clinical expertise, integrated technology, data analysis, and evidence-based practices, further enhance the effectiveness and efficiency of the SOS program, ultimately maximizing its positive impact on the lives of those it serves.

CBC’s Model Development Across Systems and Agencies

SOS operates as a collaborative effort, involving a network of providers including ACMH, BronxWorks, Federation of Organizations, Services for the Underserved (S:US), and The Bridge. These agencies have extensive expertise in working successfully with people experiencing homelessness and operate temporary and supportive housing to provide expedited access in addition to behavioral health care. CBC assumes a critical role in the operation of SOS, overseeing program implementation, coordinating services, and ensuring that providers adhere to best practices and evidence-based treatment approaches. At CBC, concerted efforts are underway to integrate diverse perspectives and develop a unified theory of change and care delivery, encompassing immediate needs, workforce development, and systemic transformation across multiple levels.

The community of homeless service providers has been seeking an approach that accommodates the nuances of individual needs while allowing for flexibility, scalability, and program fidelity. In line with CBC’s “we are one network” approach, a team of thought leaders in the field meets weekly to continuously improve on the model focused on lasting change and adaptability for diverse populations while never losing focus on meeting the homeless community’s needs. It is recognized that there are multiple paths to achieving the same goal, and each agency and its staff utilize their unique strengths to achieve the desired outcome.

Cross System Collaboration

The SOS Program stands as an exceptional example of how a large city’s traditionally fragmented service system can come together to provide a powerful intervention for a stigmatized, marginalized, and discriminated-against population. CBC has established an inclusive ecosystem that involves coordination between behavioral health community-based organizations, multiple government agencies at the state and city levels, public and voluntary hospitals, the public transit system, emergency medical services, law enforcement agencies, food pantries, supportive and private housing providers, harm reduction providers, social care providers, and others.

CBC’s active formation and participation in cross-system collaboration meetings present a valuable opportunity for SOS staff to engage with a diverse range of stakeholders and foster cooperation. These meetings serve as a platform for sharing ideas, receiving feedback, and forming partnerships with like-minded professionals who share common goals. By actively engaging in these collaborative efforts, CBC remains informed and shares knowledge about emerging projects, new initiatives, and innovative approaches in the field of homeless services. Additionally, these meetings provide a forum for discussing challenges, sharing successes, and exchanging best practices. This exchange of information informs decision-making processes and contributes to improved outcomes for members served.

Cross System Collaboration approach has had a positive impact on administrative, supervisory, and frontline SOS staff by cultivating a sense of community, promoting motivation, fostering connections, facilitating shared learning, nurturing productive working relationships, and enhancing overall engagement in the mission of homeless outreach initiatives.

Learning Community and Collaborative

Collaborative work and learning present an invaluable opportunity to leverage collective expertise, share innovative approaches, and foster collaboration, thereby resulting in enhanced services and outcomes.

In partnership with OMH and SOS Agencies, CBC developed a comprehensive training curriculum for SOS staff to enhance their clinical skills and knowledge. Moreover, the implementation of a Learning Management System through the Center for Practice Innovations at New York State Psychiatric Institute ensures convenient tracking of staff progress toward meeting training requirements. The CBC Hub offers interactive trainings, encompassing informative sessions, webinars, and opportunities for learners to engage through live presentations and experiential exercises. The learning curriculum encompasses a range of training sessions and workshops designed to deepen staff understanding of the unique challenges involved in serving individuals experiencing homelessness. Topics covered include effective outreach strategies, engagement techniques, safety and de-escalation and the latest evidence-based practices in the treatment of serious mental illness.

A Learning Collaborative was initiated to create a dynamic platform for providers in the homeless outreach sector to exchange knowledge and enhance their practices. The role of CBC is to gather a network from various parts of the city healthcare ecosystem and meet and dialog with the aim to improve and evaluate the system of care efficacy of current and new models. With a focus on improving the quality of services for homeless individuals, fostering collaboration and communication, and sharing best practices, the collaboration is poised to drive significant positive change in NYC’s homeless outreach efforts.

The collaboration consists of regular meetings involving representatives from SOS, homeless outreach providers, and other local health and human services. Through these meetings, participants engage in discussions, brainstorming sessions, and review real-life care narratives to learn from each other’s experiences. Anticipated outcomes include increased collaboration, improved service quality, and shared best practices. The SOS Learning Collaborative holds great promise in enhancing homeless outreach efforts and fostering a more effective and impactful approach to serving individuals experiencing homelessness.

Initial data from the first year showcases the positive impact made already. With 7,690 canvassing encounters conducted, SOS has demonstrated a proactive approach in reaching out to those in need. As a result, over 140 members have been successfully placed in permanent housing, providing them with stability and a place to call home, and over 600 members placed into emergency/temporary housing from the street. The program’s commitment to comprehensive care is evident in the 1,253 referrals received, with an impressive enrollment rate of 903 members (72%). The demographics of those served reflect the diversity of the community, with 78% of the members being male, 73% identifying as black, 27% falling between the ages of 51 and 60, and 23% between the ages of 31 and 40.

CBC’s centralized Hub and streamlined access to care, engagement in cross-system collaboration, and commitment to continuous learning position the SOS program at the forefront of innovative homeless outreach and care. By actively facilitating a learning collaborative and leveraging the valuable insights gained from stakeholders, CBC remains adaptable and open to refining its model to enhance access and improve care. The collaborative spirit fostered through these initiatives ensures that CBC can respond effectively to emerging challenges and incorporate new approaches into the SOS care model.

Pamela Mattel, LCSW, is President and CEO, Gerardo Ramos, MPA, MSW, is Senior Vice President, and Barry Granek, LMHC, is Vice President, at Coordinate Behavioral Care, Inc.

For more information about Safe Options Support, visit or call the 24-hour toll-free information line 1-866-SOS-4NYC.

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