An outcome from the OSU Task-Force on Community Safety and Well-Being came a need for a social worker within the University District.
August 2021, UDO hired a full-time clinician via Southeast Healthcare to provide direct outreach for our most vulnerable residents.
I N T R O D U C T I O N
Morgan Weininger, LISW-S
"Bachelor’s & Master’s from The Ohio State University.
Connection for residents via Southeast for primary care, mental health, substance use disorder needs and PATH housing program
Provide immediate recovery supports (food, clothing, hygiene, transportation assistance)
Connect with community partners for more linkage opportunities
Build empathy for residents in the University District
MSW ASAP Program from The Ohio State University
Observe, learn, and work with UDO Social Worker to provide extra support to Outreach Initiative
Propose and write thesis on subject related to outreach while in this placement
Connect with community partners for more linkage opportunities
Build empathy for residents in the University District
During her placement, Taylor conducted research on how education and awareness would build empathy of residents
UDO Outreach engages with clients in the University District who need assistance with mental health, substance use, housing, or any other basic needs.
Our outreach team addresses a variety of needs through four areas of work to create lasting impact for our residents.
Many of the unhoused residents we work with are skeptical of support systems due to negative experiences Thus, our top priority is to establish genuine connections with our clients that can pave the way for linking them to traditional resources.
As trust builds and as clients get their paperwork in order we start to connect them with various support resources such as assessments for mental health, substance use disorder, and long term housing options This linkage creates a long term impact to assist the individual to continue to help them in their journey
Our light case management work begins by addressing fundamental client needs so that they may be better prepared for accessing additional resources. For instance, we help clients obtain vital documents such as their ID, birth certificate, or social security card. These documents are crucial in enabling them to apply for housing, Medicare, and food stamps
We provide our unhoused residents with immediate supports to assist them with being able to get to doctor's appointments, job interviews, get nutrition, continue their treatment. These resources include hygiene products, clothes, bus passes, food, identification documents, phones, tents, and other basic needs
We meet clients where they are at through direct on the ground street outreach, through in-person office hours, and direct access to resources.
Going to hot spots in the UD to check-in with residents for specific needs bus passes, sacked lunches, water, etc
Monday - Wednesday - Friday
Office Hours 9am-12pm
When someone is ready to go straight to treatment we connect them with immediate care
The demographics of the University District match national statistics regarding homelessness The reason why we primarily see unsheltered men is that women, children, and individuals with physical disabilities are given priority for housing, leaving able-bodied men as the last group to be sheltered.
To be considered chronically homeless you must meet at least one of the following:
•continuously for at least 12 months
•four separate occasions of homelessness in the last 3 years, with combined occasions total a time of at least 12 months
Encounters are moments of connection
Immediate recovery support provided, but individual is not an engaged client
Engagements are supports provided to clients
Areas of need identified, and work started on long term recovery supports
Linkage is treatment and active client recovery
This includes PATH applications for housing, residents engaged in Mental Health (MH) and Substance Use Disorder (SUD) treatment
Building trust and community through immediate recovery supports
Direct outreach is all about engaging with the community and meeting their needs on their own terms. This approach is based on Maslow’s hierarchy of needs, where satisfying one level opens the door to progress towards the next.
Top Immediate Recovery Supports Provided
36 21 9 120
The numbers here reflect the average time and level of engagement required by our outreach team to support individuals towards active recovery Our team achieves this through building trust, providing immediate recovery support, and assisting with documentation
To help visualize progress and impact, let’s use an analogy of a cell phone battery. Even when it’s low, you can still utilize it. As it continues to charge up, you become more confident about its ability to assist you in your everyday cell phone needs
Engagement with our unhoused individuals starts with identifying basic needs. Our team works to help them take small steps towards positive change and feeling empowered It’s like the process of charging a cell phone battery - even though it starts off low, we can see progress as the client becomes more independent and takes charge of their own life.
Although many more than 36 of our clients most likely have SUD, this can only be determined through an official assessment, which requires time, an appointment, and agreement to the assessment On average it takes our outreach team 21 engagements for someone to be ready to be assessed and then ready for treatment.
Example of an unhoused client who engaged with our outreach team and successfully linked into treatment
I met Jay at a bus stop in the University District
After several encounters, Jay and I built a trusted relationship. He disclosed his long-time battle with substance use disorder which led to his homelessness. We discussed the treatment process at length and what his best options would be and how he could access them. After more continued engagements he shared he recently reconnected with his child and told me,
“I can’t be a role model to my child while I’m still using and on the streets. They are growing up now and he told me his child was worried about him staying outside and I can’t do that to them”
With this motivation, he agreed to treatment and was linked to an out of town (away from familiar triggers) detox and treatment program through Southeast. This increased his chances for success. He is now in sober living working towards employment, permanent housing and building a relationship with his child.
For Jay, this process started in the end of October 2021 and was actively in treatment by January of 2022
Names and identifying factors have been removed from this story to protect the client
Example of an unhoused client who engaged with our outreach team and successfully linked into treatment
Jane was one of the first clients I met in the University District and immediately expressed to me how she ‘knows she is better than the life she is living but needs help to get there.’ After many continued engagements she attended my office hours asking for support about treatment for substance use disorder. Over the next few weeks, I provided transportation assistance (bus passes) so she could collect the necessary documentation for medical insurance required by a substance use disorder treatment center
After obtaining medical insurance I did not hear from Jane for a few months and thought she had changed his mind But one day, she reached out to thank me and let me know she had gone to detox and a treatment outside of Columbus to be away from familiar triggers and was now in sober living. Jane later reached out again to share an update that she moved up a level in her program and spends a few hours on her own each day
Jane asked if she could come back to my office hours to collect copies of her documents to use for obtaining a full-time job. She arrived at my office hours a very different person than the last time I remembered seeing her. She spoke with so much passion about her sobriety and how she reconnected with his family. She expressed her gratitude and shared how her family is proud of her recovery. Her newfound pride and enthusiasm for life is wonderful to see.
For Jane, her process started in October of 2021 and took many engagements and steps to get into treatment by July of 2022.
Names and identifying factors have been removed from this story to protect the client
27 15 10 93
Residents
Mental Health
Identified
Avg. Continued Engagements/ Encounters
These numbers reflect the length of time and engagement it takes for a client on average to get linked into treatment for an area of their mental health.
Comorbidities is when a client presents more than 1 disease This could mean they have more than one serious mental illness or they also have a substance use disorder along with a mental illness.
The University District demographics align with the following national statistics:
●SUD: 35% about 1 in 3 clients
●SMI: 26% about 1 in 4 clients
●More than 75% of individuals with SMI have more than one mental illness, or a mental illness and a substance use or misuse condition.
Actively in Treatment
Avg. Days From Moment of Engagement - Linkage
SMI: mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.
SMI includes:
major depression schizophrenia bipolar disorder obsessive compulsive disorder (OCD) panic disorder
post traumatic stress (PTSD) borderline personality disorder
A client can also be assessed with having SMI with various other factors such as continuous treatment of 6 or more moths, and/or 2 or more admissions within 12 month period
For more information: Mental Health Fact Sheet – Serious Mental Illness (va.gov)
I met an individual at a homeless encampment during the winter. They expressed interest in mental health treatment and substance use disorder recovery throughout the times I visited the camp. Their perseverance and patience is their best asset on their path to housing and treatment. After a few continued engagements they successfully connected to mental health, primary care and dental services. This individual is a leader and cares for others immensely They encourage their friends at the homeless encampment to get connected with services as well
They are also a very positive person. It is extremely humbling to speak with them and experience their positivity despite experiencing homelessness and the way they feel they are viewed by society on a daily basis. This individual had to move to a new location at the end of winter and we lost contact but they eventually reached out again stating their phone was lost in the move, but they had saved my number.
After reconnecting they were able to finish their housing application, get a new ID and glasses They are now on a waitlist for a housing voucher and they contact me once a week for basic supplies like water and food or to refer friends for assistance. During our most recent encounter they shared, ‘I have been doing good, staying out of trouble and have been staying away from drugs. It feels good.’
This Individual experiences both MH and SUD. Their journey started in December 2021 and are now in active treatment as of march 2022
Names and identifying factors have been removed from this story to protect the client
103
442 14 + Engaged Clients
Total Encounters/ Continued Engagements Recovery Support Areas Identified
In the first year, our outreach team established client-provider relationships with 103 individuals who continue to engage as clients. We have conducted MH and SUD assessments for almost half of our clients, identifying both immediate and long-term recovery support needs. Our approach continues to be successful through ongoing engagement and consistent support for both immediate and long-term recovery measures.
PermanentHousing(318)
Food/ClothingAssistance(285) Documents(114)
PrimaryHealth/DentalCare(77)
EmploymentAssistance(36)
Benefits/phoneapplication(31)
IncomeAssistance(20)
MedicalInsurance(10)
Benefitsapplication(8)
Legalassistance(7)
TemporaryHousing(5)
CrisisIntervention(3)
EmergencyServices(1)
Top Basic Need Areas
The most frequently requested long-term support is for permanent housing. We assist clients in finding housing by providing access to PATH applications PATH, or Projects for Assistance in Transition from Homelessness, is a federal grant program that supports individuals holistically as they transition into permanent housing. Our social work provider, Southeast, is a PATH provider and works with us to provide this resource to our clients
This data showcases the basic needs identified by our clients.
Food and clothing are consistently requested as basic needs. Community partners, like Jordan’s Crossings, help to provide lunches, and Neighborhood Services Inc is a food pantry resource that we use to connect our clients with We also receive clothing donations and provide clean shirts and pants when available to those in need. The most frequently requested items are new socks and underwear
It is common for many of our homeless residents to have lost, had stolen, or destroyed their documents while living outside We assist our clients in obtaining new official copies of crucial documents such as social security cards, birth certificates, and state IDs These documents are necessary for applying for other assistance programs, housing, and jobs. This is an integral part of obtaining many basic needs
BusPass(310)
Lunch(198)
Clothes(100)
McDonald'sgiftcard(69)
Hygiene/Resourcebag(57)
Other[notspecified](54)
Sleepingbag(36)
Tent(19)
Food(15)
BC(6)
ID(6)
SScard(6)
Phone(5)
This data showcases the immediate recovery supports provided specifically to our engaged clients.
Need Areas are common barriers -- by providing these supports clients are able to improve their quality of life
The most in-demand immediate support item are bus passes. These are used to get to daily appointments as many clients need to get treatments for their SUD
Food insecurity is a large issue due to many barriers such as not having the documentation to apply for food stamps or access to be able to make their own food. This is why lunches and McDonald's gift cards are in high demand
Our clients request clothes and hygiene items due to lack of laundry. Men's underwear and socks are the most asked for items.
As a way to demonstrate the progress of our outreach, we keep track of our clients’ needs throughout their journey. The following graph illustrates when support is requested or needed. Ideally, as one recovery support is obtained, the client can concentrate on securing others until all needs are met.
Housing is the hardest support to achieve due to the lack of housing and housing affordability in the city
This client was able to secure documents, but then hit a setback and needed to request documents again This is common and also the reason why the process can take longer than expected
In our first year of outreach, we connected with over 20 community partners, enabling us to collaborate effectively and provide additional resources to our unhoused residents.
Downtown SID C O M M U N I T Y C O N N E C T I O N S
Southeast Health Care
Neighborhood Services Inc (NSI food pantry)
St. Stephens Episcopal Church
OSU College of Social Work
OSU Student Life
Gateway Security
Mount Carmel Street Medicine
City of Columbus Dept of Neighborhoods
Clintonville Resource Center
Jordan’s Crossing
Columbus Metropolitan Library
St Sophia’s Church
Buckeye Food Alliance
OSUPD
CPD (Community Liaison Officers)
University Interfaith Council
Community Clothing Outreach
Columbus Free Clinic
STAR House
We are dedicated to strengthening our program through collaboration and connection with University District community partners and residents
01
Expand Community Partnerships
We believe we can strengthen community partnerships already in place as well as work with ones we have yet to connect with.
03
We will continue. toincrease the number of linkages between clients and resources for sustain supportive impact. Continue Linkages
Building Empathy
02 We plan to create educational opportunities to build understanding of the reality of homelessness in the University District.
04
Continue Safety Partnerships
We will continue to communicate with our safety partners and collaborate on ways to best engage residents with mental health needs.
Thank you to our partners at Ohio State and Southeast Healthcare for funding and supporting the creation of this program.
Thanks to Dr. Kristina Johnson, President of the Ohio State University and Jay Kasey, Senior Vice President of Administration & Planning at Ohio State for providing the funding of this initiative.
Thank you to Ohio State Department of Social Work for your support and student placement work. Special thanks to Dean Tom Gregoiore and Anna Stewart, LISW-S Assistant Director of Field Research for helping to start this initiative. Thank you to our first MSW student, Taylor Jobe, for their research and work.
Thank you also to Southeast Health Care as our outreach provider. Special thanks to Sandy Stephenson, LISW-S, LPCC-S Executive Director of Southeast, and Christina Bournique, LPCCS University District PATH lead.
Thank you to our Social Worker, Morgan Weininger, LISW-S, who built this program as the only social work provider for this initiative. Morgan is an integral part of our team and this program's success. Her impact is already felt by the community we serve.
Contact
University District Organization
2231 N. High Street., Columbus, OH 43202 614-610-4546
www.universitydistrict.org info@universitydistrict.org @universitydistrict
A C K N O W L E D G E M E N T S