National Definitions of PATH Eligibility and Enrollment

Background

Historically, PATH enrollment has been conceptually, but not specifically defined on a national level. In the current environment of increased expectations of outcome data from national programs, it has become important that the data elements used in the PATH program have universally understood and applied definitions.

It is challenging to report on outcomes and service information and to guide the program into a more outcome based reporting system without consistent use of the core terms used by PATH. As PATH will undergo a review and revision of the PATH Annual Report and Data Collection Elements over the next year, the timing of this clarification is critical.

In 2005, the Administrative Workgroup completed and released their work of providing service definitions for PATH. The next task recommended was to define enrollment, and this document provides that next step. Legislative language and the interpretation of legislative intent is used to develop the majority of PATH documents that provide guidance to the field.

Legislative language states that PATH should provide services to individuals who:

1. (A) are suffering from serious mental illness; or (B) are suffering from serious mental illness and from substance abuse; and
2. are homeless or at imminent risk of becoming homeless.

This historically understood intent of PATH eligibility and PATH enrollment is:

1. PATH Eligibility: An individual is eligible for PATH enrollment if it is determined that they meet the following criteria:
   1. The individual is determined to be experiencing serious mental illness or co-occurring serious mental illness and substance abuse disorder", AND
   2. The individual is experiencing homelessness or is at imminent risk of homelessness.
2. PATH Enrollment: An individual may be enrolled in PATH when the above eligibility criteria are met and an individual record or file is developed for this individual.

In the Workgroup's review of the current use of the terms PATH eligibility and PATH enrollment, it was discovered that the application of these terms varied widely across states and programs. In order to come to a more universally understood and practiced use of PATH enrollment, the following guidance was developed.

Guidance for Determining PATH Eligibility and PATH Enrollment

PATH Eligible

The following guidelines are recommended for determining if an individual should be identified as "PATH Eligible." It is important to note that PATH outreach services prior to PATH enrollment should continue without the expectation or burden of the identification of PATH eligibility.

Once an individual is determined to meet the homeless or at risk of homelessness criteria AND the mental health or co-occurring criteria described below, they are determined to be PATH Eligible.

I. (a) PATH Eligibility under the status of "Experiencing Literal Homelessness":

• PATH legislation refers to the Public Health Service Act (PHA) definition of homelessness. The PHS language provides the following:
• "an individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and an individual who is a resident in transitional housing".
• Administrative Workgroup Recommendation: Continue to use the PHA definition as provided in the legislation.

I. (b) PATH Eligibility under the status of "imminent risk of homelessness":

• "Definitions of imminent risk for homelessness commonly include one or more of the following criteria: doubled-up living arrangement where the individual's name is not on the lease, living in a condemned building without a place to move, arrears in rent/utility payments, having received aneviction notice without a place to move, living in temporary or transitional housing that carries time limits, being discharged from a health care or criminal justice institution without a place to live."

Administrative Workgroup Recommendation:

• Imminent risk of homelessness is the expectation that homelessness will occur in the immediate future without intervention or assistance. In addition to the criteria above, persons who live in substandard conditions are, by definition at risk of homelessness, due to local code enforcement, police action, voluntary action by the person, or inducements by service providers to go to alternatives like short-term shelters whose residents are considered to be homeless.
• The Administrative Workgroup will not recommend a time-frame for imminence as individual state eviction laws vary in time and process. For example, a state/locality might require that the landlord provide notice of intent to evict and provide a window of time for intervention or correction to the tenancy violation. Without intervention in this window, the eviction may be difficult or impossible to prevent. Limitations such as 30 day or 10 day imminence rules could prevent the PATH provider from being effective in their efforts.
• PATH requirements do allowfor the provision of homelessness prevention services.PATH projects, however, should focus on people who are already homeless or almost certain to become homeless without immediate intervention. States and Territories are encouraged to maintain flexibility and support PATH workers to intervene with people at risk, especially imminent risk of homelessness. PATH grantees should exercise discretion and balance in prevention and intervention efforts in light of the need to prioritize first the people who already are experiencing literal homelessness.

II. PATH Eligibility under Serious Mental Illness or Co-Occurring Serious Mental Illness and Co-Occurring Substance Use Disorders

• There is no formal or historical written guidance for this determination to reference.
• PATH programs are legislatively directed to serve individuals with serious mental illness, but are not held at fault for serving those who were believed to be eligible but are later determined not eligible. The outreach component of PATH provides the opportunity to reach out to individuals in order to determine need, interest, and eligibility. The intention of the PATH program is to provide outreach and engagement to individuals who are not otherwise being served by the mental health services system. Prior to their formal enrollment in services in the mainstream system, it is critical that PATH have the capacity to make an informed determination of assumed eligibility without formal clinical supports and evaluations. The consumer peer provider movement has shown hownon-licensed providers can make a reasonable determination of a "mental health impression" of individuals.Several states noted that when they have allowed PATH Eligibility to be determined on the basis of a "mental health impression", those individuals are often determined clinically eligible by the formal mental health system.

Administrative Workgroup Recommendation

Serious Mental Illness

• PATH providers may determine individuals as meeting the Serious Mental Illness criteria if there is an informed presumption that the individual:
  • is experiencing or displaying symptoms of mental illness and is experiencing difficulty in functioning as a result of these symptoms that indicates severity, and
  • has shared or has a known history of engagement with mental health services OR has symptoms and functioning that indicates there is a history of or expected tenure of significant mental health concerns, and
  • is of appropriate age to be diagnosed with a Serious Mental Illness, where transition-age youth may be eligible. This determination should reflect and be consistent with the state's definition of Serious Mental Illness.

Co-Occurring Substance Use Disorders

• Individuals experiencing substance use disorders only are not eligible for PATH services. However, PATH providers are expected to serve individuals with co-occurring substance use disorders and provide documentation of this in the PATH Annual Report.
• The designation of a co-occurring disorder would occur when the worker, and in some cases the consumer, believes that the consumer is in a period of active use that affects his/her functioning OR recovery from substance use and continues to require support.
  • This definition does not require the consumer to be in treatment.
  • Providers are encouraged to engage in a dialogue with the consumer to gain consensus on this determination.

Youth

• Transition age youth who are homeless or at-risk of homelessness, have serious mental illness, and who are otherwise considered adults, e.g. emancipated youth,may be PATH Enrolled. Youth who are still eligible for other protective or human services may be served by PATH in the outreach setting, and when appropriate enrolled, for the sole purpose of engaging the human services agencies, mental health services, or the education system to serve them. The goal of PATH enrollment is to advocate for the youth in accessing the services available to them and prevent them from falling through the cracks. Serving youth who are minors solely in PATH without the purpose of rapidly, safely, and effectively connecting them to the mainstream child services system is not recommended for PATH programs.

Training, Reporting, Application in Practice, and Programming

• Individuals are not expected nor required to provide documentation of their mental illness. PATH programs are not expected, encouraged, or required to acquire a formal diagnostic assessment in order for an individual to be determined eligible for PATH services.
• The Administrative Workgroup recommends that the PATH TA Center provide training materials and tools to the PATH provider community to assist all providers, regardless of clinical background, to make the necessary determinations and to establish consistency across programs. The Administrative Workgroup recommends that once this training is available, that State PATH Contacts use the provider monitoring process to ensure that:

• • It is also recommended that when the revised PATH Annual Report is developed, that providers will not be required to report under specific diagnostic categories of mental illness. However individual states will be provided with the option to collect this data from their providers.

PATH Enrollment

• There is no formal guidance available for when PATH Enrollment should occur, other than the following informal recommendation:
  • An individual may be enrolled in PATH when the PATH eligibility criteria are met and an individual record or file is developed for this individual.

Administrative Workgroup Recommendation

• PATH Enrollment implies that there is the intent to provide services for an individual other than those provided in the outreach setting. The term enrolled means that there is a mutual intent for the services to begin. Therefore, the Administrative Workgroup recommends the following standard for PATH Enrollment:

1. The individual has been determined to be "PATH Eligible",
2. The individual and the PATH provider have reached a point of engagement where there is a mutual agreement that"services" will be provided, and
3. The PATH provider has started an individual file or record for the individual that includes at a minimum:
   1. Basic demographic information needed for reporting,
   2. Documentation by the provider of the determination of PATH Eligibility,
   3. Documentation by the provider of the mutual agreement for the provision of services, and
   4. Documentation of services provided.

• Although the goal of the PATH program is to assist individuals in accessing mental health services and housing, services that begin the PATH Enrolled relationship can be any service, assistance, or provision of resources that the individual is willing to accept or any mutual work that the individual identifies as important. PATH does not require that a service plan be developed unless case management services are part of the services provided to the individual. PATH providers are expected to document all services and the outcomes in an individual file.