Duffy Health Center’s Opportunities project based in Hyannis, Massachusetts, was awarded a SAMHSA Treatment for Homeless Persons grant on September 30, 2008 to study the Intensive Case Management evidence-based model with returning veterans and chronic public serial inebriates. Opportunities provides services to individuals who are homeless and at-risk of homelessness who also have substance abuse, mental health, or co-occurring disorders.

Cape Cod is the perfect storm for homelessness; the peninsula has among the highest housing costs and lowest wages in Massachusetts. Homelessness is hidden, people live in camps, in cars, and in low-cost motels, but business owners on main street and community members focus on the few who inhabit the public spaces. Outreach workers and community partners refer individuals to Opportunities, which pairs intensive case management services with housing subsidies and health care. Mental health and substance abuse treatment is offered by Duffy’s Health Care for the Homeless program.  Clients receive these services at the Duffy Health Center, at the clients' homes, or other community locations. There is no wrong door approach at Opportunities. Case managers may complete a housing application, find ways a client can access transportation to AA meetings, or help build the confidence to walk into a business and apply for a job for the first time in years.

Duffy Health Center’s array of services starts with an all-encompassing intake, assessment, and then a discussion with clients about which services they would like to access. When we asked Heidi Nelson, Chief Executive Officer of Duffy, what other providers would find most interesting about this program, she said, “We provide services to people who many others have given up on. We are often the place of 'last resort' and once clients understand how much our staff will support them, they begin to feel empowered. At the same time, staff are careful to reinforce resiliency and recovery, not enabling.”

Opportunities staff (left to right): Jennifer Perloff, Brandeis University evaluator; Allison Fennell, Administrative Assistant; Jeffrey McHugh, Case Manager; Angela Ayre, Case Manager; Arlene Crosby, Program Coordinator and Director of Case Management; and Janet Mott, Case Manager

Opportunities has led to significant milestones for Duffy Health Center. “We finally had the resources to train and promote SAMHSA evidence-based practices with our staff and those who work at partner human service agencies in our community,” said Nelson. “These include Motivational Interviewing, Housing First, harm reduction and trauma-informed care. Our success with intensive case management and ending homelessness spurred us on to institutionalize our integrated model. Today, more than 80 percent of our patients who come in for medical care are also assessed for mental health and substance abuse treatment services.”

Nelson said, “We don't give up on our clients.” Case in point: 

From left to right: Janet Mott, William and Alberta - William had been living in the woods by himself for years. After consistent outreach by Duffy’s Opportunities Case Manager Janet Mott, and because of poor health exposure to the weather, he finally agreed to come in from the cold and accepted first a room in a motel secured by Duffy. William was concerned about his dog, Alberta, and would not come in from his camp until Opportunities found a motel that would accept his faithful companion. After becoming accustomed to living inside again, he agreed to live in an apartment. Duffy secured a housing voucher for him through Duffy’s HUD permanent housing program (for chronically homeless individuals). William continues to see his Opportunities case manager, and receives care at Duffy for ongoing medical and behavioral health needs. He loves to write -- and now will be able to write stories about his life.

Opportunities works with an array of community partners who not only cross-refer clients, but also develop and improve systems to reduce homelessness (and improve the health) of the most vulnerable persons on Cape Cod. Duffy Health Center is an active regional leader in partnerships including the Regional Network to End Homelessness as well as an initiative to reach out to persons who are experiencing homelessness on Main Street in Hyannis. Ultimately, the interdisciplinary team and entire mission-driven staff are the people who make the difference in supporting Duffy’s clients and building upon its strengths and resiliency.