Frequent Users Systems Engagement (FUSE)

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Catholic Social Services of Washtenaw County was selected as one of four subgrantees to take part in CSH’s Social Innovation Fund national initiative to address one of the most pressing policy problems currently facing states and the nation as a whole: rising public health care costs associated with fragmented and uncoordinated care that result in poor health outcomes. In nearly every state, a tragic “revolving door” of emergency room visits, in-patient hospitalizations, detox stays, and involvement in other costly crisis health services among a small subset of individuals contributes to rising Medicaid costs. The initiative will pilot innovative models of supportive housing linked to coordinated primary and behavioral health care in four different sites across the country (San Francisco, Los Angeles, Connecticut and Washtenaw County) that target homeless high utilizers of crisis health services.

The initiative is jointly funded by the Corporation for Supportive Housing (CSH) and the Corporation for National and Community Services (CNCS) and backed by a prestigious Social Innovations Fund. Catholic Social Services and the Washtenaw County team has been granted an award of $200,000 per year for two years with eligibility to renew the grant annually for three additional years based on performance and availability of funding. The grant must be matched on a dollar-for-dollar basis in cash with eligible non-federal matching funds. CSH will provide one-on-one technical assistance to Catholic Social Services of Washtenaw County focusing on strengthening local partnerships, aligning housing, care management, and health services, client identification and recruitment, raising matching funds and engaging with policy makers.


  • Lead Agency
    • Catholic Social Services of Washtenaw County
  • Non-profit Housing and Service Providers
    • Avalon Housing, Inc.
    • Ann Arbor Housing Commission (AAHC)
    • Plymouth Housing Commission (PHC)
    • Michigan Ability Partners (MAP)
    • Washtenaw Housing Alliance
    • Shelter Association of Washtenaw County
    • Washtenaw Prisoner Re-entry
  • Integrated Health
    • University of Michigan Hospital System
    • Saint Joseph Mercy Health System
    • Huron Valley Ambulance
    • Packard Health
    • Washtenaw Health Plan
  • Government
    • Washtenaw Community Health Organization
    • Project Outreach Team
  • Funding
    • CSH Social Innovation Fund grant and philanthropic partners
  • Evaluation
    • NYU

Washtenaw FUSE will integrate resources of area supportive housing providers and hospitals to provide housing and coordinated primary and behavioral health care to 100 homeless frequent users of crisis health services in the Washtenaw County, Michigan area. These individuals will be identified through the analysis of administrative data from hospitals, shelters and the Community Mental Health system. Health care services will be facilitated by an intensive case management team that coordinates with a group of psychiatrists, medical doctors, medical case managers, substance abuse providers, homeless outreach workers and shelter staff. The end result will be a patient-centered medical home for clients.


Men and women who meet all of the following criteria:

• Very low-income

• Have a diagnosed mental health condition or substance abuse disorder and/or one or more chronic physical health conditions

• Homeless or in persistent housing crisis High utilizers of crisis health services


Cross-System Partnerships: A comprehensive and diverse collaborative of hospitals, housing agencies, primary and behavioral health care providers, nonprofit social service organizations andgovernment agencies

Data-Driven Strategy: Administrative data matched across multiple systems to identify the specific target population

Outreach, Recruitment and Engagement: Assertive outreach into crisis service, institutional settings and homeless service settings

Housing Resources: 40 Housing Choice Vouchers provided by the Ann Arbor Housing Commission; 15 units of supportive housing provided by Avalon Housing; 5 Housing Choice Vouchers provided by the Plymouth Housing Commission; ongoing commitments from MAP, the Shelter Association of Washtenaw County and the Washtenaw Housing Alliance

Integrated Health and Housing Services: The combination of supportive housing with intensive case management and coordinated, client-centered primary and behavioral health care

Evidence-based Practices: Based on Housing First principles, the Critical Time Intervention case management model and a Harm Reduction approach to substance abuse


Participant Level

• Improve physical and mental health, decrease mortality rates and reduce substance abuse

• Reduce homelessness and increase housing stability

• Reduce emergency room utilization

• Reduce medical and psychiatric inpatient admissions and hospital days

• Reduce utilization of detox facilities, shelters, jails and other crisis service systems

Systems Level

• Increase visibility, awareness and understanding

• Reduce public and private health care costs

• Break down systemic barriers to coordinated primary and behavioral health care and enhance the quality of care delivered

• Integrate affordable housing resources with the health care system

• Build a solid base of evidence for supportive housing’s effectiveness as a health care solution

• Engage local and state level policymakers to stimulate system changes that work toward sustaining and disseminating the model of care


• Assertive outreach and engagement

• Intake and comprehensive needs assessment

• Connection to affordable housing and vouchers

• Intensive case management

• Coordinated primary and behavioral health care

• Medication management

• 24-hour crisis intervention

• Landlord-tenant mediation and eviction prevention

• Community living supports

• Legal advocacy

• Employment and education support

• Income and benefits maintenance supports