Coming Home of Middlesex County

Coordinated Entry & Assessment - In collaboration with homeless service providers, Coming Home created a system of standardized assessment and coordinated referral of people experiencing a housing crisis. The goals of the system are to minimize the time anyone in the county experiences a crisis and to prioritize available assistance, based on vulnerability and severity of service needs. A coordinated entry & assessment (CEA) system also provides information about social and health service needs and gaps to help our broader community better plan its assistance and identify the resources needed. The chronological waiting lists of the past have become instead prioritization lists, making sure that we rehouse, as quickly as possible, the persons most in need.Pursuant to the CEA process, all persons enter the system through calling NJ 211, the homeless hotline, or visiting a few physical access sites in the community where a triage is conducted using a concise, standard assessment tool and standard protocols. A person can be immediately placed into service programs, e.g., a shelter bed, the board of social services. The service programs will conduct a full assessment, using a more expansive tool to determine needs, strengths and barriers to housing. They forward their assessments to the CEA team, housed in coming home, which maintains an inventory of available housing options, reviews the assessments done by the agencies and prioritizes placement based on appropriateness, vulnerability and severity of service needs.

Social And Healthcare Integration (SHI)- Coming Home convened a collaborative of social service providers, health care providers and professional school representatives in 2016 to respond to an RFP from the center for Medicare and Medicaid services asking communities to build a bridge between the healthcare and social systems in the community in order to effectively address the "social determinants of health" of the high utilizers of the hospitals' emergency rooms, we were not awarded the CMS grant, but used our work to institute the SHI program whereby RWJUH (part of Barnabas Health) and Saint Peter's University Hospital fund the cost of two social service navigators on a 2-year term basis to address the social determinants of health of their high utilizers of their ed. Coming Home obtained, permanent supportive housing vouchers from the state department of community affairs to house persons from this population who are homelessness. The goal of SHI is to improve the health outcomes of the clients and to reduce unnecessary, and often unreimbursed, costs to the health care system due to inappropriate use of the hospitals ERs. SHI fully launched in January 2019 and has been renewed on a 2 year term basis for 4 terms.