2024 Consolidated Annual Performance and Evaluation Report (CAPER)

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facilities, mental health facilities, foster care and other youth facilities, and corrections programs and institutions); and, receiving assistance from public or private agencies that address housing, health, social services, employment, education, or youth needs Discharge planning within the community remains challenging, with hospitals and community mental health centers coordinating plans with emergency shelter facilities but still falling short of ideal conditions for individuals released from their care. The RPC developed the following for foster care, health care, mental health systems of care, and re- entry from corrections facilities care and are working with appropriate agencies and providers to improve the coordination of discharge policies. Foster Care: The Division of Child Services' (DCS) written protocol, partners with community providers to avoid youth exiting foster care to be discharged into the streets. DCS case managers create individualized plans for each youth and are responsible for case planning and reunification conferences with providers. Health Care: RPC leadership works with area hospitals, clinics, and agencies to serve the needs of individuals that are homeless or are at risk of homelessness. By meeting with key hospital staff, they can discuss opportunities to maximize coordination of services. Conversations are ongoing to focus on partnerships with RPC agencies to close the housing gap for those who are homeless and have substance use disorders. Discussions are progressing about mobile clinic deployment to provide preventative care, reduce trauma, decrease ED expenses, and improve the quality of life for those unhoused. Beacon Health System and St.Joseph Regional Medical Center, major medical hospitals in the community, have accredited Clinical Social Workers assigned to all inpatient and outpatient areas who provide discharge planning services to all patients.Trained social workers and/or case managers follow protocols to assess needs upon admission and develop a plan of care which includes the healthcare team, patient, and family.They are responsible to coordinate the plan of care incorporating services, resources, and other providers appropriate to their needs prior to discharge. Mental Health: Beacon Health System operates 4 inpatient psychiatric care units located at Epworth Hospital and follows regulatory standards and protocols to ensure appropriate discharge and follow-up care. Oaklawn Psychiatric Center is the community's designated Community Mental Health Center and is a Certified Community Behavioral Health Clinic. Oaklawn provides outpatient services including placement into permanent housing for patients who are homeless or at risk of homelessness. Oaklawn has both a PATH team, funded by FSSA, and City Outreach Team, funded by the City of South Bend,to support the efforts to help individuals gain or maintain stable housing. Both PATH and the City Outreach Team consistently assess individual housing needs and refer to Coordinated Entry or appropriate housing resources. Oaklawn has been awarded funding to bolster services to tenants at Oliver and Hope Avenue Homes, both permanent supportive housing communities in South Bend. Oaklawn patients are CAPER 29 OMB Control No:2506-0117(exp.09/30/2021)