CHD Program Provides Outreach and Engagement to Individuals with Behavioral Health and Housing Needs

Housing and Recovery Support Program Director Heather Pietras-Gladu

For individuals in recovery, experiencing housing instability will often contribute to substance use problems. Indeed, addiction can be both a cause and a result of homelessness. However, CHD, under a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA)—$400,000 a year for five years—aims to help put the brakes on this vicious cycle among people we serve at five of our outpatient clinics by providing comprehensive case management, nursing, outreach, and supported referrals.

CHD’s Pioneer Valley Housing and Recovery Support Program works with individuals with a range of substance use and housing concerns that may impact their behavioral health. The grant has enabled the program to hire personnel, including Community Support Program staff, to help stabilize the lives of clients by providing them with wraparound services to treat the symptoms that contribute to them being unhoused. They also link these individuals with housing and other necessary services.

This program is in place in CHD’s outpatient behavioral health clinics in Orange, Greenfield, Holyoke, and two clinics in Springfield: on State Street and on Pine Street.

“Being unhomed—or even having the possibility of losing your home—is such a lonely place to be, and can increase substance use and mental health symptoms,” said Heather Pietras-Gladu, who directs the Housing and Recovery Support Program, as well as CHD’s Stimulant Use Disorder Treatment Program at our Pine Street Outpatient Behavioral Health Clinic. “We’re working on strategies to get the people we serve stabilized by providing care coordination, and helping them navigate community resources.”

One of the hallmarks of CHD has always been addressing the social determinants of health by using a fully integrated system of care to treat the whole person. Because substance use and mental health problems are often tied in with other factors, these issues are often inextricably linked together with homelessness. And with affordable housing being scarce in Massachusetts—waiting lists can sometimes be measured in years—so many of those seeking recovery and mental health treatment lack basic necessities—especially shelter—which adds to feelings of fear, vulnerability, and trauma, exacerbating their conditions.

“Many shelters in the area are at capacity,” said Pietras-Gladu. “Some transitional housing requires a six months or year of documented clean time for an applicant. So we’re working with people to find such places as sober living homes and other types of temporary housing.”

SUD Nurse Case Manager Jennifer Barr

When it comes to housing insecurity, the numbers are indeed daunting: according to the Springfield-Hampden County Continuum of Care, in January of 2024, 2,091 people were identified as homeless in Hampden County, up 8.1 percent from January of 2023. The data also shows that people of color are disproportionally impacted, with Hispanic residents in Hampden County making up 41 percent of the homeless population and Black residents comprising 36 percent of people unhoused.

Veterans, who are 50 percent more likely to become homeless than other Americans, are another vulnerable population that CHD’s Housing and Recovery Support Program works with. “Our Greenfield Outpatient Clinic, especially, helps veterans because of its proximity to the Greenfield VA Clinic, but Scott Brennan, one of our Community Support Program staff, works with veterans in Springfield to help them get their maximum benefits—he has helped them receive their medical care for free through the VA, and he has gotten them into shelters,” she said. “Many veterans don’t know which benefits are available at their fingertips,” and researching and applying for them can be overwhelming.

Pietras-Gladu has high praise for Brennan, recalling his work with one unhoused person in his 40s— in recovery from alcohol use disorder—who he had gotten placed into a temporary shelter. Then he was able to guide the individual into applying for emergency help for housing costs through the Massachusetts Residential Assistance for Families in Transition program. “Now, he has his own apartment, and he has reconnected with his family, and is still receiving other services from CHD,” she said.

Another success story from the program is a woman from India who was diagnosed with schizophrenia and was unhoused when she came to the Pine Street Clinic. “She had been rescued from a human trafficking ring and had been receiving no services, so we worked closely with the state Department of Mental Health and she was able to be placed in a group home setting,” said Pietras-Gladu.

Community Support Program (CSP) Caseworker Scott Brennan, SUD Nurse Case Manager Jenny Barr, and CSP Caseworker Britney Parke at the Tapestry mobile health van

The Housing and Recovery Support Program also refers individuals to additional CHD services and other providers for a continuum of substance use disorder treatment, Medication Assisted Treatment, primary care at CHD’s Park Street Outpatient Behavioral Health Clinic (and by working with partner community health centers), and recovery coaching. “We’ve referred many clients to our Park Street Clinic,” said Pietras-Gladu.

Some clients in the program have received services from a mobile health van operated by Tapestry, a community health nonprofit. The van visits the Pine Street Clinic every third Wednesday and provides STI and hepatitis C testing and treatment, birth control, pap smears, wound care, vaccines, and harm reduction supplies. “Many of our clients don’t have a primary care doctor or insurance, but they can get a full medical checkup at the Tapestry van, even without insurance,” said Brennan.

SUD Nurse Case Manager Jennifer Barr likens the program’s collaborative, team-based approach as “one-stop shopping” for clients’ behavioral health needs. “We’re combining all those resources under one umbrella, and we’re also helping knock down some of the barriers that keep these individuals from finding a home,” she said.

Barr pointed out that the program’s Community Support Program staff help clients find housing by being a point of contact, reaching out to landlords, and even providing clients transportation to look at apartments.

“For people who are trying to manage their recovery or their mental health—if you just give them all these phone numbers to call, and all these hoops to jump through to get housing, they’re not going to be able to do all this,” said Barr. “At this point, they’re just trying to manage their daily lives—their self-care. So they really need that handhold and that guidance to get through a lot of it. This grant provides us with an opportunity to provide them with more cohesive care and to achieve better outcomes.”