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Meet the Team

Meet Audrey Kuang, MD, Internal Medicine Physician & Clinical Lead at ARCH/Mobile/Street

We recently met with Audrey Kuang, a physician and the clinical lead for CommUnity Care’s ARCH/Mobile/Street clinic. The clinic provides full-service primary care to patients at the Austin Resource Center for the Homeless (ARCH). They have a mobile team that provides on-site medical care at several community locations and a street medicine team that provides care to those staying at encampments, bridge underpasses, and anywhere that care is needed.

Audrey is also the Associate Director of Community Engagement and Health Equity at CommUnityCare and Assistant Professor in Department of Population Health and Internal Medicine at Dell Medical School.

 

What are your thoughts on the Housing First model? Why do you believe in it?

Without housing, you can’t do health. Housing is absolutely fundamental to a person’s wellbeing.

As a medical provider, so many medical problems we see are directly related to the absence of housing.

  • We see back problems that result from carrying a 50-pound backpack all day, which is exacerbated by sleeping on concrete.
  • We see foot ulcers from being on their feet all day that progress to leg amputations because these cannot heal on the streets.
  • We see poorly controlled diabetics who then develop kidney failure and blindness because of the difficulty in taking medications while living on the streets. As a doctor, we spend so much of our training learning about physiology, pathology of disease and the appropriate treatments and drugs needed. At the end of the day, housing is what my patients need most.

 

Tell us what guides your work providing primary health care to the homeless.

The healthcare system has many assumptions- that patients have a phone, transportation, access to food, a home and that they can advocate for themselves. For individuals suffering from homeless, every aspect of medical care is a challenge. Therefore my goal is to offer medical care that is easy to access with as few barriers as possible.

  • Our shelter clinic is a one stop shop where many needs can be addressed. Not only do we provide medical (acute, chronic and preventative) care, but also offer mental health services, assistance with things like transportation, medications, food stamps, vision vouchers and insurance.
  • We engage our patients where they are staying, rather than waiting for them to come to us through our mobile and street teams.
  • We strive to create a safe and welcoming environment where our patients feel respected, heard, and their priorities and preferences are incorporated into the treatment plan.
  • We believe in community collaboration and are fortunate to partner with Integral Care and Austin Travis County EMS Community Health Paramedics who bring healthcare for the homeless to a whole new level.

 

What’s your background that made you want to work with this population?

One of my first jobs was working as a hospitalist. I quickly started to see the revolving door of the hospital for my homeless patients who would come back to the hospital days to weeks later because they couldn’t take care of their wounds, they couldn’t afford the medications, and they were unable to make it to their follow up appointment. It was then that I helped start the Santa Clara County Medical Respite Program which gave homeless individuals a safe and clean place to heal after an acute hospitalization, while addressing mental health needs, substance abuse issues, and working on benefits and housing. Working alongside our social worker,  nurse, psychiatrist, community health worker and addiction specialists, affirmed my belief in the importance of integrated, team-based, holistic care. I am hoping to start a program like this in Austin someday.

I believe all lives are of equal worth, yet not everyone gets equal treatment. To me, this truth is unacceptable. As the wealth gap grows, so does the health gap. I make it my mission to change that.

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Meet the Team

Meet the Staff: Darilynn Cardona-Beiler

We recently met with Darilynn Cardona-Beiler, Director of Adult Behavioral Health Systems at Integral Care, to learn about her experience with and passion for Housing First.

 

Why are you passionate about Housing First?

It’s very simple – I’ve seen it work. Housing is at the core of health and well-being. Housing First is the solution to homelessness and it serves as a platform from which an individual can pursue personal goals and improve their quality of life. When you don’t have a home, there are very few opportunities to achieve a state of well-being. One of the things that makes me very passionate about Housing First is the philosophy of treating people with unconditional positive regard in contrast to traditional homeless programs that insist on preconditions such as sobriety or psychiatric care and moving through steps to have a home. Individuals don’t have to earn their housing. Once someone is housed and achieves stability, it creates a positive ripple effect that impacts their lives and the lives of those around them.

 

Can you tell us about your involvement with Housing First in Ohio?

I’ve been involved in the provision of homeless services since 1997 and have been involved with the development of Housing First since 2000. I was part of a team in Cleveland who was charged with the implementation of Housing First in Cleveland. While I was there, we built the first Housing First program that created the energy to bring stakeholders together to create more housing opportunities for people with disabilities. The Housing First Initiative has been successful. As it stands now, Housing First has implemented 518 apartments for singles and over 100 apartments for young adults and families with histories of long-term homelessness and disabilities.  While I was there, I was part of the development of 6 of those properties and the creation of 378 units of permanent supported housing.

 

What excites you most about bringing Housing First to Austin?

I am passionate about Housing First because this model is effective in changing people’s lives. Housing first is not housing only. It is housing with supports. There’s nothing I want to do more than ending homelessness in our community.  It’s unfortunate to see how many people in Austin don’t have a safe place to call home.  Integral Care’s Housing First Oak Springs project will stand as an example in our community to develop more housing opportunities for people with mental illness. In the same way that the first project in Cleveland created momentum, I’m excited to see how Housing First Oak Springs will stand as that building that will energize the community behind this initiative.

 

What else would you like readers to know?

I feel honored to be part of an amazing team that has embraced and supported the Housing First philosophy. Most importantly, I am really inspired by the strength of the people we serve. We currently have over 450 individuals in housing, but last year, Integral Care served 3,000 individuals experiencing homelessness, which means we have work to do!

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Meet the Team

Meet the Staff: Stephanie Dziuk

We recently met with Stephanie Dziuk, who works on the Assertive Community Treatment (ACT) team. This program provides treatment, rehabilitation and mental health support services to adults living with mental illness and substance use disorder who have experienced multiple hospitalizations. Some of these clients are formerly homeless individuals. Services include: 24-hour crisis support, counseling, medication management and fills, housing support, nursing services, help managing symptoms, social skills building, and community living and job skills training. Services can be provided in the community or at the client’s home.

Tell us about your role at Integral Care.

I work on the ACT team. I am pursuing my LPCI (Licensed Professional Counselor Internship) and have to collect 3,000 hours before I can become fully licensed. On Mondays, I hold individual counseling with four different people, which is mostly trauma counseling. I also facilitate the Social Skills Group with another one of my teammates. Every Wednesday, we alternate between serving clients in the community and practicing our skills as a group in the office. Clients come to me for individual counseling or I meet them in their homes.

What do you like most about your job?

The population of people served by ACT team are typically marginalized.  A genuine human connection can mean the world to them. I enjoy that I am able to help clients feel like they are important and that they matter.

What made you want to work with this population?

I felt drawn to this population early in life.  I was taking speech class through a community college and we had to do a group presentation.  I chose the topic of mental illness and fell in love with the idea of working with the types of individuals we serve.

Describe about an impactful experience you have had here.

A year ago, one of the individuals that I work with weekly was in distress. She required repeat hospitalization. She didn’t go in very often, but when she did, it was really challenging for her. We’ve been working together for about 7 months. She is going to be graduating from the ACT team to a less intensive level of care soon. She communicates with family members and other people whereas before, she would isolate in her apartment. But now she socializes. She wants to use her lived experience with depression to reach out and help others who are struggling. Seeing true success in this field is amazing.

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Meet the Team

Meet the Staff: Kristi Kaiser

We recently met with Kristi Kaiser, Program Manager II with the Healthy Community Collaborative.

Tell us about your role at Integral Care.

I am a Program Manager with the Healthy Community Collaborative team.  Our program works to expand services to individuals experiencing mental illness and homelessness.  I manage a team of nine at Community First! Village—a supportive housing community in East Austin with unique dwellings for the individuals who were chronically homeless.  I am responsible for overseeing operations at Integral Care’s on-site clinic, The Topfer Family Health Resource Center.  On a day to day basis, I coordinate the interested resident prioritization list, interface with community partners, and work with our mental health experts in our clinic. I also maintain a relationship with Mobile Loaves and Fishes, the ministry that developed the community and serves as Resident Care and Property Management.

What are some opportunities you see in your position?

I am fortunate enough to be part of a larger team that values and honors flexibility and thinking outside of the box in order to best meet the needs of our clients.  As the census grows at Community First! Village, my team has been able to expand and includes mental health case management, Peer Support services, as well as medical and administrative staff.  In the future, I can imagine growing our capacity for outreach as well as potentially bringing DBT, WRAP or skill building groups. We have been working to increase primary and specialty medical care, as well as develop a Health Risk Assessment that would allow us to track health outcomes for those transitioning from the streets into housing.

What do you enjoy most about your work?

I feel that one of my most fundamental functions is to build a team that likes each other and likes their job.  Because this was a new project, I was able to hire my team from the ground up, allowing me to be selective about bringing on staff who are dedicated to providing quality care to an otherwise underserved and often misunderstood population.  As a team, we have been able to play a part in transitioning 134 individuals into permanent housing from chronic homelessness.  It doesn’t get better than that!

Describe about an impactful experience you have had here.

Just recently, we were able to rehouse an individual at Community First! Village who had been evicted and incarcerated.  It was pretty rewarding to see how things came full circle for him, and how low-barrier entry allowed him to return to the community that he’s chosen as his permanent home.  He has since accessed residential substance use treatment, and is eager to continue taking advantage of the array of wrap around supports available to him at the Village.

Is there anything else you’d like people to know?

The Housing First model works! An individual is only able to start building stability once they have a safe place to call home.  People need this basic necessity before attending to things like getting a job, or managing their substance use.  This approach is universally appropriate for individuals or households experiencing any degree of service need—not to mention how cost effective this intervention is! Providing access to housing without pre-condition saves the community money, as housed people are less likely to utilize emergency services including hospitals and jails. Housing First is a win-win for all!

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Meet the Team

Meet the Staff: Lauren Dreyer

We recently met with Lauren Dreyer, Licensed Clinical Social Worker and Program Manager with the Healthy Community Collaborative.

Tell us about your role at Integral Care.

I am a Program Manager of the Collaborative Community Specialists (CCS) team within the Healthy Community Collaborative, and also manage a small team of housing specialists working with the Home Front permanent supportive housing partnership between Front Steps and Integral Care. The CCS team provides intake, counseling, peer support, SOAR, transition, and jail-based services to individuals with a history of homelessness, mental health issues, and co-occurring disorders. In addition, I teach Adult Mental Health First Aid and provide clinical supervision to social workers obtaining their clinical license.

What are some opportunities you see in your position?

Our team is innovative, and it is exciting to work with staff to further refine their roles in ways that best meet the needs of the team and the individuals with whom we work.

What do you enjoy most about your work?

I really enjoy the opportunities to work with different teams within Integral Care as well as other agencies throughout our community who have common goals of ending homelessness and helping people find their own path to recovery.

Tell us about an impactful experience you have had here.

It takes a team. I get motivated by how different team roles can work together to get fresh perspectives and new ideas to help people work towards their goals.

Is there anything else you’d like people to know?

I love to experiment with various baking methods and sharing these with my team when the creations turn out well (which happens less often than I would like)!

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Meet the Team

Meet the Staff: Ruth Ahearn

We recently met with Ruth Ahearn, LMFT at our Dove Springs Clinic, where she is Community Rehabilitation and Treatment Program Manager with the Healthy Community Collaborative.

Tell us about your role at Integral Care.

I am one of three Program Managers for the Healthy Community Collaborative. I manage the Rehabilitation Specialists on the Community Recovery Team – ten Rehabilitation Specialists, an LPHA (Licensed Practitioner of the Healing Arts) Team Lead, and a new site based case manager at the Oak Creek Apartments.

What does the Community Recovery Team do?

We work with people in their homes and in the community, visiting a minimum of once weekly. The people served by our team are individuals who were homeless and now live in permanent supportive housing. In addition to a home, we provide mental health care, supportive employment and training in living skills.

What are some opportunities you see in your position?

Although the Healthy Community Collaborative program has been around for a few years, it’s relatively young. We are always finding new ways to engage the community, the chronically homeless population, and to build new relationships with other homeless service providers – to really be innovative in providing services. For example, the Oak Creek position is a brand new relationship that we’re forging with the Ending Community Homelessness Coalition. We’ll have a Case Manager housed at that apartment complex to work with veterans and families that live there as well as a peer support specialist. It’s something we’ve never done before. It always keeps me engaged being in a program where we can come up with something new.

In the two and a half years that I’ve been in this program, I’ve enjoyed seeing how far the community really come together to make certain processes more effective, and to identify people that need our services.

What do you enjoy most about your work?

I’m fortunate to work in a unit where we have the flexibility to try new things – both with the positions on our staff and in the way we engage our clients, who can be wary of services. I enjoy building client relationships. Our team excels at that.

It’s amazing seeing people who have been chronically homeless get housed. We even enjoy doing things like going to Wal-Mart with a client to pick out bed sheets. It’s so exciting for them.

I also enjoy supervising people – getting to build a team and be creative. It helps that we have really supportive leadership.

What are some innovative moments you’ve had in your work?

My supervisor, Christine Laguna, the Practice Manager for the Healthy Community Collaborative, and I were recently discussing what to present at a conference. What work have we been doing that’s different? One thing that’s different is the wrap-around support we provide to our clients. We’re seeing more clients that might need more intensive services. We have been able to engage these clients in different ways. Across the Healthy Community Collaborative, we have three Peer Support Specialists. Being able to have a peer step in at times to meet with clients has been amazing. We have a Supportive Employment Specialist just for our team. We have a Jail Liaison, which has been instrumental when we need to advocate for a person who may have been picked up when they were trying to get basic needs met. If we can get a client housing, income and support, we can work to minimize their time in jail. We also have a therapist now that provides counseling. We have a nurse that’s able to go into people’s homes. So we provide all of these things, but through the lens of working with the chronically homeless – and asking ourselves, “What do they need that’s a little bit different?”

We have brought people into our program who have been on the street for 20 years, and we weren’t sure they would make it until they got their apartment. Now they’ve been housed for two years! They’re working on their sobriety, they’ve got an income, and maybe they have a peer that they see weekly. That’s life-changing.

Is there anything else you’d like people to know?

I would encourage people to continue to stay informed, ask questions and be aware of who is in your community. That will include folks experiencing homelessness, who tend to be marginalized. Try to see their faces and ask yourself what their story is. Ask yourself how you can learn more about them and the community resources that serve them. Individuals experiencing homelessness are our neighbors.

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Meet the Team

Meet the Staff: David West

We recently met with David West to learn more about his work and insights into the East 2nd Street Clinic, where he is Practice Manager.

 

What is your role at Integral Care?

I am the practice manager of our E. 2nd Street Clinic. At this location, we have about six teams of providers working to meet the needs of our clients. Each of those teams has a program manager. Together, we navigate concerns and advocate for resources and support to best meet the needs of our clients and our staff. I view my job as working for them. It’s really about providing direction and support.

 

What other roles have you had?

I’ve been in my current role for three years. I came to the agency in October of 2010. I was originally a social worker on the ACT Team, which is a community-based behavioral health treatment team. I loved that team – the work is kind of a lifestyle. There’s such a sense of dedication to the client population and also to the team, which was unbelievably rewarding due to the shared experience. With a shared caseload, everyone on the team worked with all of our clients, so there was a shared perspective and this kind of  joy to the work. I went on to manage the ACT Team for about two years before transitioning over to the clinic.

 

Is there a particular population that this clinic serves?

We are an adult integrated behavioral health clinic. Our primary focus at this location is providing services to adults. . Our homeless population is significantly higher at this clinic because we are closer to downtown and all of the homeless resources nearby. We also tend to serve more deaf clients here, in part because this used to be the only clinic. This is the oldest clinic in the agency, and there were some systems developed here that haven’t necessarily been fully replicated at other locations. We are unable to serve children at E. 2nd Street, but we have children’s services available at multiple locations throughout Travis County. Otherwise, the work we that we do here is very much in line with our other clinic locations. Our shared focus is to provide fully integrated behavioral health and primary care services. We have over 2,300 clients open to ongoing services at this clinic alone, and an average of about 20 people accessing services  through our intake department here per day. We have a staff of over 60 employees at E. 2nd Street alone in order to meet the needs of our growing population. We have recently been focusing a whole lot of our attention on increasing access to services. Our goal is to get those who are in need of services open and connected on the same day. We have come a very long way with this in a short period of time, and we are going to stay on it.

 

What are some opportunities you see in your particular role and for the clinic?

I’m leading Integral Care’s Trauma-Informed Care initiative, and that’s a wonderful opportunity because it involves systemic change that spans our agency as a whole. There’s no limit to the scope of that work; it touches every aspect of our work. Our vision is to create a community of compassionate, collaborative care. We have 7 workgroups going right now that report to our core implementation team. I have the opportunity to come together with my counterparts at the other clinics, other practice managers within adult behavioral health, and with leaders throughout our agency, and we focus on improving services across our agency.

 

What do you enjoy about your work?

Working with people is one of the things I enjoy the most. Being able to influence positive change is important. I enjoy identifying how to improve parts of our operation to create an ongoing dialogue about optimizing our clinic flow, atmosphere and system. It’s an ongoing process. One of the ways I try to foster that is to model an open and positive approach to change – if there’s a problem, let’s recognize it and if we can think of a better way to do it, we’ll do it. In the end, we all want to do good work.

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Meet the Team

Meet the Staff: Helen Eisert

As Integral Care’s Housing Services expands, the Housing team is growing as well. Helen Eisert joined the Supported Housing team as a lead and helps ensure streamlined and efficient access to housing for our clients. Helen evaluates and develops existing and emerging resources for individuals experiencing homelessness or that are at-risk of becoming homeless. Helen has worked with individuals experiencing homelessness for over two decades in multiple capacities. Previously, she led programming at the University of Texas Health Science Center that worked to transition individuals with serious mental illness from institutions into the community. She also directed programs at Saint Louise House. In these two positions, she developed programming guided by the belief in people’s unfailing capacity for change and the basic human right to have safe and decent housing.

 

Helen shared a little about her position, opportunities on the Supported Housing team, and what she enjoys most about working at Integral Care. Welcome to the team, Helen!

 

“Program development is an amazing opportunity to work both ends of the problem of homelessness and still stay hands-on with the day-to-day challenges people face in the transition out of homelessness.  I also have the opportunity to partner with passionate, creative staff at Integral Care and other agencies to work toward the common goal of ending homelessness in Austin.

 

Our local community is at a pivotal time in recognizing safe, decent housing as not only a basic human right, but essential to a healthy community.  We all suffer when one of us experiences homelessness.  Integral Care is on the frontlines with finding creative ways to support people in transitioning from homelessness to housing and prevent homelessness in the first place.  We have an amazing opportunity to leverage the wealth of expertise both staff and clients possess about how to best support people living with serious mental illness find and maintain housing and ultimately prevent and end homelessness.

 

The transition from homelessness to housing stability encompasses every aspect of a person’s life.  A person can move from a place of suffering and fear living on the streets to thriving in ways they never imagined once they have a safe, stable place to call home.   Witnessing that each day and supporting the staff walking with people on that journey is a remarkable experience.”

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Meet the Team

Meet The Team: Elizabeth Baker

“The ACT team assertively engages the chronically homeless population by providing community based services and innovative engagement strategies to build trusting and meaningful relationships.  From this foundation of trust, and a Housing First philosophy, the team helps consumers identify and work toward goals related to housing, employment, harm reduction and wellness. “

~Elizabeth Baker, LCSW


liz-bakerWhat is your role at Integral Care? I am a Practice Manager, focusing on developing and refining the practices of the ACT teams and Supported Housing services we offer to adults experiencing mental health issues and/or homelessness.

 

How does Assertive Community Treatment team work with Travis County’s homeless population?   The ACT team assertively engages the chronically homeless population by providing community based services and innovative engagement strategies to build trusting and meaningful relationships.  From this foundation of trust, and a Housing First philosophy, the team helps consumers identify and work toward goals related to housing, employment, harm reduction and wellness.  The team also connects consumers to subsidized housing resources, helps them transition from homelessness to housing and provides ongoing wrap around supports to ensure consumers maintain their housing.

 

What are the mobile services you  provide? Eighty percent of ACT services are provided in the community or client home.  The ACT team provides a wide variety of support services including nursing, psychiatric prescriptions, case management, supported housing, supported employment, SOAR (rapid social security application for homeless adults), Co-occurring Psychiatric and Substance Use Disorder treatment, and peer support services.

 

Once in a home, what’s the biggest change you see in your clients? Once in a home, consumers are able to lock the door behind them and feel safe.  Over time, they can begin to take pride in their space, their health and their successes, without fear of their progress being stripped from them by the brutality of the streets/shelter.  That is the biggest change I see—clients feeling safe and secure enough to succeed.

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Meet the Team

Meet the Team: David Gomez

“Being present when things fall into place, working together to accomplish goals using dignity, respect, an open heart and willingness to help is the reason I do what I do for as long as I’ve been doing it.”

~ David Gomez


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What is your role at Integral Care?

I am the Program Manager for Homeless Services and oversee the PATH/ACCESS and Safe Haven programs.

What part of your work is the most rewarding?

Having an opportunity to re-build hope with the staff and the people we serve. It is rewarding and affirming to see how interacting with individuals and accepting them as they are results in happy and successful outcomes.

Being present when things fall into place, working together to accomplish goals using dignity, respect, an open heart and willingness to help is the reason I do what I do for as long as I’ve been doing it.

I am lucky to work within programs that allow me to meet people where they are and see the world from their perspective. Both Safe Haven and PATH/ACCESS provide an opportunity to see the magic that happens when people trust each other and use their combined strengths to overcome life’s barriers and challenges.

What is the most challenging aspect of your job?

The barriers people face in getting what they need to reach their full potential.

If there was one thing you wanted people to know about Austin’s homeless, what would it be?

That they are our brothers, sisters, mothers, fathers, sons and daughters.

What is on your wish list for the next 5 years in terms of housing support for our homeless population?

That we, as a community, will focus our efforts to end homelessness and all the associated challenges it brings to our community.