Idaho Health and Welfare: Treatment and Transitions Program Evaluation 2021 Annual Report

Report Authors

• Vanessa Fry, PhD, Interim Director
•  Lantz McGinnis-Brown, Research Associate
• Benjamin Larsen, PhD, Research Associate

This report was prepared by Idaho Policy Institute at Boise State University and commissioned by Idaho Department of Health and Welfare.

Recommended citation: Crossgrove Fry, V., McGinnis-Brown, L., & Larsen, B. (2022). Idaho Health and Welfare: Treatment and Transitions Program Evaluation 2021 Annual Report. Idaho Policy Institute. Boise, ID: Boise State University.

Download a printable pdf of this report

Year 3 Quarter 4 Report

The Idaho Department of Health and Welfare’s (IDHW) Treatment and Transitions (TNT) Program serves individuals with severe mental illness and/or a co-occurring disorder who are experiencing homelessness or housing instability. The project is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services. As the Project Evaluator, Idaho Policy Institute (IPI) oversees all evaluation activities and works closely with IDHW program staff to design data collection strategies, monitoring, and reporting for this program with the objectives to:

1. Measure the program’s ability to meet its stated goals and objectives, and
2. Inform IDHW’s decisions for program improvement.

This report serves as the third annual evaluation of the program.

Key achievements in this year include admitting 85 Idahoans experiencing severe mental illness and/or co-occurring disorders into the TNT Program. To date, the program has launched four enhanced safe and sober houses and directly provided 181 Idahoans with stable housing and supportive services.

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Idaho’s population is medically under-served and there is a shortage of mental health professionals in the state. Lack of coordinated services and housing instability often result in readmission to state psychiatric hospitals among Idaho’s most vulnerable residents. When discharged from psychiatric hospitals, some patients have difficulty accessing community and housing resources.

As a result of receiving a Substance Abuse and Mental Health Services Administration (SAMHSA) grant from the U.S. Department of Health and Human Services, the Idaho Department of Health and Welfare (IDHW) initiated the Treatment and Transitions (TNT) Program to improve local infrastructure, ensuring individuals experiencing housing insecurity who are discharged from psychiatric hospitals have continued access to behavioral health treatment as well as housing support services. Participants in the program have a serious mental illness (SMI) and/or a co-occurring disorder (COD), were discharged from a state or community hospital in the previous 12 months, and are experiencing or at-risk of homelessness.

The TNT Program supports transition homes that provide recently hospitalized patients with a place to live for up to six months after discharge. The program provides participants with stable housing while they continue their recovery and attain permanent supportive housing. Participants are also provided with coordinated care services which eases potential difficulty managing the use of services on their own. The TNT Program aids participants by providing recovery coaches, continued behavioral health services, a supportive environment in transitional housing upon discharge, and entry into permanent supportive housing. The program relies on the combination of four types of evidence-based health service practices in order to better serve Idahoans with SMI/COD: permanent supportive housing, integrated treatment for co-occurring disorders, health navigators, and SSI/SSDI Outreach, Access, and Recovery (SOAR) case management.

This report serves as the third annual evaluation of the TNT Program (Y3). It provides an analysis of participant data from December 1, 2018 to November 30, 2021. This report reviews the results of the program’s goals, including ongoing collection of participant data, services provided, and program completion rates.

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Idaho Policy Institute (IPI) worked with IDHW to develop a data collection plan that meets the requirements of the federal SAMHSA grant. The following report contains the data agreed upon and made available to the evaluators. IPI obtained data from SPARS¹ which was supplemented with Idaho WITS² data provided to the evaluators by IDHW personnel.

The TNT Program has four main goals with underlying objectives.

Goal 1: Reduce state and community hospital readmissions for individuals with an SMI and/or COD who experience unstable housing.

Goal 2: Increase project participant access to health services and retention of safe, suitable, and affordable housing.

Goal 3: Promote recovery, resilience, and independence in the community of choice.

Goal 4: Develop a collaborative approach to providing services and supports.

Key accomplishments and challenges from the program’s third year are articulated below followed by a discussion of participant demographics. The report ends with an evaluation of the program’s ability to meet its goals and objectives.

2021 Accomplishments

Four enhanced safe and sober houses (ESSH) were operating during Y3. Two houses serve more urban populations. Two houses are located in Boise and with one serving female participants and the other serving male participants. One house is in Idaho Falls and serves male participants. The fourth house, in Caldwell, provides access to a more rural population and male participants. Throughout the year, all houses operated at or near capacity with a total of 74 participants housed at the end of the year.

The majority of participants currently enrolled are on track to finish the full length of the program and graduate successfully. Since the beginning of the program, 126 participants have been discharged. Of these, 62 successfully graduated from the program. By closing housing gaps for program participants, ESSHs are expected to perform better than their traditional counterparts that do not offer transition into long-term supportive housing. As outlined by this report, the TNT Program is meeting these expectations. The program has enabled a high level of success among its program participants and has met nearly all of its objectives.

Program providers noted a number of accomplishments during this year including:

• Increased self-advocacy with providers, medication managers, family, and peers.
• Increased learning coping skills and application of those skills when experiencing an increase in mental health symptoms.
• Increased learning of life skills including cooking, cleaning, laundry, etc.
• Increased application for employment opportunities, more clients securing employment, and more clients maintaining employment.
• Increased engagement in counseling, trauma counseling, and medication compliance.
• Increased number of clients remaining clean and sober.

2021 Challenges

The COVID-19 pandemic continues to influence the TNT Program. As such, each ESSH continues to operate under sanitation, distancing, and isolation protocols to protect TNT participants as well as staff. Some clients stayed in ESSH longer than the 180 day standard so as to not transfer them or expose them to the virus. However, despite the challenges of the pandemic, the program is still able to report no positive COVID-19 cases in any of the houses.

The TNT Program’s largest challenge of accessing housing vouchers for program participants in the Boise ESSH continued throughout Y3. Population growth in the state will continue to put pressure on the voucher system. Despite this challenge, all participants graduating from the program have moved into stable housing and continue accessing supportive services.

Program providers noted a number of challenges during this quarter including:

• Hospital capacity is overwhelmed for medical and mental health. Residents have been turned away for psychiatric assistance due to the hospitals not being able to place them. When they are turned away, they are encouraged to continue on the same medications, to go see their medication manager, and/or to utilize the crisis centers. This has caused an increase in emergency room visits on multiple occasions until they are able to be placed in a psychiatric placement.
• Due to the increase in people needing housing, there are minimal housing options. All of the safe and sober housing agencies have large waiting lists. Therefore when the residents in the ESSH are due to graduate, they are not always able to be placed in a traditional safe and sober houses. This causes the residents to have to apply for other housing options. Many are placed on waiting lists for other agencies’ housing; however, there are times that they have to go to the shelters as there are no housing options.
• Some residents procrastinate addressing issues as they tend to have the mindset that the program is six months long and they have a “long time” to figure things out.
• COVID has made a HUGE impact in the programs including an increase in sanitizing the houses to decrease people getting sick, loss of employment, decrease in community outings, in-person groups, meetings, court sessions, and decrease in ability to spend time with family and friends.
• In order to retain staff, organizations running the ESSH’s reported having to increase the salaries due to the increased cost of living. Programs are concerned with their ability to continue operating unless daily rates are increased.

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IDHW recognizes that minority groups in the state are particularly vulnerable to behavioral health disparities. To identify a target population to serve, the TNT Program takes into consideration subpopulations that are more susceptible to health disparities Table 1 demonstrates both the proposed number of enrollees from the program’s disparity statement as well as the demographic makeup of the participants enrolled since the program’s beginning.

^{*These calculations are for unique program participants as some participants have enrolled more than once.}

^{**The race/ethnicity categories utilized are non-exclusive; participants could identify as more than one race/ethnicity. This results in the total count in the chart above being larger than the number of total participants.}

^{***The TNT Program enables clients to identify with the gender of their choice, and clients are placed in houses according to their self-identified gender.}

^{****Age was not included in the grant’s diversity statement, but IDHW personnel requested that this data be included with demographic data in this report.}

Based on enrollment in the TNT Program, the distribution of participants by race and ethnicity continues to nearly match the long-term goals of the program. Gender distribution within the program also aligns closely with the proposed enrollment numbers, but because two houses serve men there is a greater percentage of male participants. Rural Idaho remains overrepresented when compared to projections based on the locale residence prior to program entry. This is due to two of the ESSH homes being located outside Ada County.

The program’s current population should be considered when recruiting future participants so the population continues to align closely with the numbers proposed in the disparity statement.

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IDHW established four main goals for the TNT Program. This section outlines the program’s ability to attain the objectives associated with these goals. For this portion of the analysis we use all program entries (n=174), rather than unique clients (n=163).

Goal 1: Reduce state and community hospital readmissions for individuals with an SMI and/or COD who experience unstable housing.

Objective 1: Idaho will deliver mental health and/or substance abuse disorder services to 28 individuals during the first year and 37 individuals each year for years 2-5.

During the TNT Program’s first year, 27 participants were enrolled in the program, while 80 participants were actively enrolled in year two, exceeding the year two requirements. In the first three quarters of year three, the program served 111 participants, already exceeding the year three goal.

Objective 2: At least 60% of project participants will avoid readmission to psychiatric hospital settings within twelve months of entry into the project.

Of the participants in the program, 73 were enrolled less than 12 months. Of these participants, nine were readmitted to psychiatric hospital settings, as indicated in Table 2.

Objective 3: Idaho will provide recovery coaches to at least 80% of eligible participants within two business days of entry into the project.³

Recovery coaches are employed at each ESSH and provided service to all participants within two days of entering into the program, as indicated in Table 3.

Goal 2: Increase project participant access to health services and retention of safe, suitable, and affordable housing.

Objective 1: SOAR case management services will be provided to at least 80% of eligible project participants within six months of entry into the project.

^{*One participant denied the case management services offered and another application is in the appeals process}

Of the eligible participants in the program for at least six months, 64% were provided SOAR case management, which is below the 80% threshold set by the objective. Totals will continued to be updated as missing data is received.

Objective 2: At least 80% of project participants without insurance will apply for Medicaid and other eligible benefits within three months of admission to the project.

Out of the 85 participants who have been in the program at least three months and are eligible for Medicaid without prior coverage, 94% of participants applied after admission into the project. Staff have been able to update missing data from past reporting periods which allows for a fuller picture of the rate of meeting this objective.

Objective 3: 80% of eligible participants will be connected to their local HUD Coordinated Entry within six months of entry into the project.

Table 6 indicates the number of participants referred to housing voucher programs within the state’s two Continuums of Care (n=43). The program refers participants to the Coordinated Entry system within each Continuum of Care to ensure participants are prioritized into housing opportunities when they become available. However, the waitlist is closed for the Boise City/Ada County Continuum of Care (Our Path Home). This prevents applications from being submitted and therefore referred, although applications have been filled out for program participants that would qualify for the Boise City/Ada County voucher program. The voucher program is working effectively in the Balance of State Continuum of Care as long as there are housing vouchers available. One program participant went into an assisted living facility. Those participants graduating from the program and unable to access housing vouchers have moved into regular safe and sober housing.

126 participants have been discharged from the TNT Program, shown in Table 7. 119 of those participants received housing services, despite the challenges faced accessing vouchers. Two withdrew from the program and refused treatment, and three who graduated did not receive housing services. There were no services available for two other participants who graduated from the program.

Goal 3: Promote recovery, resilience, and independence in the community of choice.

Objective 1: At least 45% of project participants will report continued involvement with local supportive services and resources after six months of admission to the project.

Since the TNT Program launched, 152 individuals were in the program for at least six months. Of those, 59 successfully graduated the program and were referred for supportive services and resources. One was clinically referred to another program. Twenty-three participants left the program and are no longer receiving services. Fourteen were discharged for non-compliance with rules while eight were incarcerated. Eight left due to becoming stable and mutually agreeing with program staff to cease treatment. Three additional participants were discharged due to no longer qualifying for the program and one is temporarily at Intermountain Hospital. The 35 participants remaining in the program continue to have access to supportive services and resources.

Objective 2: At least 70% of participants will report no arrests in the past 30 days after six months of entry into the project.

152 individuals have been in the TNT Program for at least six months. Of those, 12 individuals have been arrested. Of these, 11 were due to mental health court sanctions and one was due to a probation violation. No arrests were due to new offenses.

Goal 4: Develop a collaborative approach to providing services and support.

Objective 1: A Steering Committee will be established within four months of project award.

Objective 2: The Steering Committee will be composed of consumers and other stakeholders and will meet quarterly to review project outcomes, consult, and review evaluation results.

Objective 3: In years 3-5, the Steering Committee will be expected to actively assist with efforts to identify collaborating partnerships and funding to ensure project sustainability after the grant period ends.

IDHW intended to establish the Steering Committee for the TNT Program within the program’s second year. However, challenges presented from the COVID-19 pandemic further delayed the committee’s launch. This Committee was not able to be established in the program’s third year due to some staff turnover. In the first quarter of the program’s fourth year, IDHW will begin to identify and recruit members for the committee with a goal of having it established by the completion of the second quarter of the fourth year. Despite no formal committee formation, IDHW has conferred with subject matter experts throughout the first three years of the program.

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The TNT Program was designed to address the lack of behavioral and mental health services in Idaho, particularly for those experiencing homelessness or housing instability. This report indicates the TNT Program is meeting nearly all its target goals.

Within the first three years of the program, four enhanced safe and sober houses operated at full or near capacity with consistent participation rates. The program exceeded the goal of serving 37 participants in year two with 80 participants enrolled throughout the year. In year three, the program served 85 participants. In total, the program has now served 181 Idahoans. Graduation rates from the houses continue to be consistent and referral rates are steady overall.

The program continues to face one major challenge – accessing housing vouchers for program participants in the Boise ESSH. However, voucher applications continued to be filled out for participants and will be submitted once the current waiting list for vouchers opens or if IDHW is able to work with project partners, including the Ada County/City of Boise Continuum of Care, to remedy this issue. In some instances, program participants who cannot access housing vouchers moved into regular safe and sober houses while maintaining program support. IDHW could also explore the possibility of accessing American Rescue Plan Act (ARPA) funding from the federal government.

The TNT Program continues thriving despite the COVID-19 pandemic. The safety and security of project participants were the program’s first priority. As such, the program allowed participants to remain housed after the six month mark of the program. This effort enabled this very vulnerable population to remain safe and healthy during the pandemic.

In its third year, the TNT Program continues to enhance the safety and well-being of program participants. Entering into its fourth year, the program should work toward establishing a steering committee. In addition, the program team should explore accessing ARPA funding or other funding sources to ensure program participants are able to access safe an secure housing after leaving the ESSH.

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1SAMHSA’s Performance Accountability and Reporting System (SPARS)

2Web Infrastructure for Treatment Services (WITS)

3 In the first year, the TNT Program shifted from providing navigation services to recovery coaches. Objective 3 originally read “Idaho will provide navigation services to at least 80% of eligible participants within two business days of entry into the project.”