In Home Outreach

Team North (IHOT)

Description of IHOT North

• Short-term intervention designed to provide in-home outreach

and engagement services to individuals with behavioral health

challenges and their family members.

• Link participants with outpatient mental health services,

community resources, avoid unnecessary hospitalizations

and/or interaction with the criminal justice system and reduce

the effects of untreated mental illness.

Relationship building is the “key”

to successful linkage.

IHOT Composition

• Three agency collaboration made up of:

– Mental Health Systems (MHS)

– National Alliance of Mental Illness (NAMI)

– Union of Pan Asian Communities (UPAC)

• Teams consists of:

– Peer Support Specialist

– Family Specialist

– Case Manager

• Support Staff:

– Lead Clinician

– Consulting Psychiatrist

Eligibility Criteria for IHOT

Eligibility Criteria

• Adult individuals, 18 years and older, residing in San Diego

County. Family may live out of region.

• Identified person has serious mental health symptoms that

contribute to functional impairment in activities of daily living,

social relations and/or ability to sustain housing.

• Declines mental health services, may have sporadic contact

with an outpatient mental health program, but has discontinued

recommended treatment.

Eligibility Criteria Cont…

• Identified person had one, or more, of the following events in the

past year:

– Psychiatric hospitalization

– Psychiatric Emergency Room visit

– Police/PERT involvement

– Incarceration

IHOT North Coverage Area

IHOT North Coverage Areas

North Central

92037 La Jolla/Torrey Pines

92093 La Jolla East

92106 Point Loma

92107 Ocean Beach

92108 Mission Valley

92109 Pacific Beach

92110 Midway District/Linda Vista

92111 Linda Vista

92117 Clairemont

92119 San Carlos/Navajo

92120 Grantville/Del Cerro

92121 Sorrento Valley

92122 University City

92123 Serra Mesa

92124 Tierrasanta

92126 Mira Mesa

92130 Carmel Valley

92131 Scripps Ranch

92140 Marine Corp Recruit Depot

92145 MCAS Miramar

92161 UCSD/La Jolla

North Inland

92003 Bonsall

92004 Borrego Springs

92025 Escondido South

92026 Escondido North

92027 Escondido East

92028 Fallbrook/Rainbow

92029 Escondido West

92036 Julian

92059 Pala

92060 Palomar

92061 Pauma Valley

92064 Poway

92065 Ramona

92066 Ranchita

92069 San Marcos

92078 San Marcos

92096 San Marcos

92070 Santa Ysabel

92082 Valley Center

92086 Warner Springs

92127 Rancho Bernardo West

92128 Rancho Bernardo

92129 Rancho Penasquitos

92259 Ocotillo

92536 Agunda

North Coastal

92007 Cardiff by the Sea

92008 Carlsbad North

92009 La Costa

92010 Carlsbad East

92011 Carlsbad South/La Costa

92014 Del Mar

92024 Encinitas

92054 Oceanside

92055 Camp Pendleton

92056 Oceanside

92057 Oceanside

92058Oceanside/Camp Pendleton

South

92067 Rancho Santa Fe

92091 Rancho Santa Fe

92075 Solana Beach

92081 Vista South

92083 Vista Central

92084 Vista North

92672 San Clemente

Stages

• Referral

• Accepted into the IHOT program

• Outreach

• Engagement

• Short term intensive case management

– Needs assessment

– Service planning and coordination

– Individual and family goal planning

– Referrals and linkage to community resources, benefits and entitlements

Referrals

• This is the entry

point into the

program, the referral

is received, further

information gathered

and referred

individual is

assessed for

eligibility.

• Family member or loved ones

• Law Enforcement

• Jail System

• Las Colinas Detention Center

• Behavioral Health Units

• Hospital Emergency Departments

• Mental Health Programs

• Adult Protective Services / Senior

Teams

• NAMI or other advocacy agencies

• Optum Access and Crisis Line

Accepted & Outreach

• Accepted – Individual has been determined

to meet eligibility criteria.

• Outreach - Services begin to family (if

involved) and initial attempts are made to

engage individual.

Engagement

• Individual agrees to participate in IHOT services

– Successful outcomes of IHOT participants and their families include:

• Accessing and maintaining behavioral health treatment

• Obtaining safe and stable housing

• Obtaining employment assistance, medical care and benefits

• Enhanced boundary and limit setting

• Reconnecting with family or social supports

• Improved family communication skills

• Connecting to family support services (i.e. NAMI)

• Enhanced knowledge and ability to access emergency services

Whole Person Approach

• IHOT is based on a whole person approach which

recognizes that physical, mental and spiritual health

are interconnected, and recovery involves the whole

person.

• Alongside the participant, the team coordinates

participant’s care, including a primary care provider.

Whole Person Cont…

• IHOT teams also assist in identifying alternative

treatment options, if medication is not the chosen

method of treatment.

– Acupuncture

– Natural healing

– Spiritual healing

– Art therapies

– Other options dependent on beliefs and desires of the

participant

Psycho-education

• Clinical staff will lead medication groups and provide self-care

education.

– psychiatric symptoms

– treatment interventions

– techniques for relaxation and management of symptoms

– medication management strategies.

• Case Managers will lead resource groups.

• Upcoming… “Meet the Dr.” group that will meet monthly and be

at different locations throughout the county.

Psycho-education

• Peer Specialist facilitate monthly Peer lead support groups.

• Family Specialist run a bi-weekly family support group in English

and Spanish.

• Upcoming… Peer Specialist will be trained to provide weekly

WRAP classes for participants.

Goals of Service Delivery

• Participants and family members receive education about

mental illness, recovery, and accessing services and resources.

• Participants receive a substance abuse assessment during in-

home outreach.

• Participants receive an assessment of domestic violence issues

during in-home outreach.

• Participants shall be screened to determine the need for referral

to a primary care physician and referred for services when

appropriate.

Goals of Service Delivery

• 50% of family members will be linked the NAMI F2F class.

• 80% of family members will be able to identify one or more

coping mechanisms learned through the education provided.

• 75% of participants who complete enrollment phase will

experience greater satisfaction with life than at the beginning of

services.

Contact Information

Phone: 760-591-0100

Fax: 760-591-0101

Location: 365 Rancho Santa Fe,

San Marcos 92078

Office Hours 7am-7pm (everyday)

24 hour phone line