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Through the HCII Targeted Cost Challenge Investment (TCCI) Program, www.av¸£ÀûÓ°ÊÓ Health Network’s (BHN) Families in Transitions (“Project FIT”) initiative supported families affected by substance use disorder and/or mental illness who were experiencing homelessness or were at risk for homelessness. Project FIT provided families with high-touch care coordination for behavioral health, primary care, housing support, and vocational services.

One family enrolled in Project FIT included a mother with behavioral health needs and her two young children living in a shelter. While at a pediatrician visit for her children, the mother began experiencing acute pain and was transported, then admitted to the hospital. The mother was admitted for several days with her children. 

Since her children were not in the shelter during her hospital stay, the mother lost custody of her children and lost her space at the shelter. The mother was referred to Project FIT, and the team connected the mother to medical and behavioral health treatment, and worked with her to stabilize her medical and behavioral health needs. The team also helped her to be an advocate for her family in discussions with DCF and the shelter system so that she could be reunited with her children in a shelter placement.