Transforming Care: RS EDEN's Innovative Integrated Care Model

At RS EDEN we are proud to offer an innovative Integrated Care Model designed to eliminate barriers and ensure access to services for people navigating the complexities of the criminal justice, housing, human services, substance use, and mental health sectors. We recognize that these paths are intertwined: no recovery is secure without stable housing, no housing can be stable without addressing recovery, and mental health cannot thrive if substance use is left unaddressed.

Years ago, RS EDEN's substance use, housing, and criminal justice services were distinct. Participants could receive one type of service but had to seek additional support elsewhere. Recognizing this gap, we restructured our operations to integrate services. This transformation allows us to address critical components of health, including mental health and medical services, all within the same organization. We have reoriented our teams, programs, funding sources, structures, and physical locations to create hubs for integrated care—easy access points for individuals who often lack transportation, childcare, financial resources, and social support. 

As shown below, our model places the unique individual at the center, offering a range of tailored services based on each participant's needs. Our approach is simple yet profound: “Hello, human being. how can we help you?” From this starting point, we create a personalized care plan that encompasses all necessary services, reflecting the reality that each person’s journey is different.

We provide a wide range of services, including:

• Substance Use Treatment: Outpatient, residential, and withdrawal management
• Mental Health Services: Comprehensive support for all mental health needs
• Permanent and Supportive Housing: Over 600 units across the metro area
• Services for People Exiting Incarceration: Tailored support for community reentry

To support our participants effectively, we also offer:

• Certified Peer Support Specialists: Individuals with lived experience who provide guidance and understanding
• Case Managers: Professionals dedicated to helping participants navigate their care
• In-House Medical and Psychiatric Services: Comprehensive health support within our facilities
• Access Points for All Services: Participants can access any service from different entry points, ensuring a seamless experience

We all want integrated care. Just as you expect your primary care physician to connect you seamlessly with specialists—sharing records and coordinating treatment—our model aims to achieve the same for our participants. However, systemic barriers often prevent individuals with limited resources or criminal backgrounds from accessing this seamless care.

For many, including myself, the healthcare system is navigable due to resources such as insurance, reliable transportation, before- and after-school childcare, sufficient funds to cover deductibles, social support from friends and family, and more. But for those who come to RS EDEN, we become their primary resource. Whether they seek permanent supportive housing, substance use treatment, or other services, we assume the role of their “primary care provider”—not in the traditional sense, but as a comprehensive support system that meets their diverse needs.

Our approach flips traditional nonprofit models on their head. Many programs are driven by funding constraints, creating barriers that complicate access for participants. This “program-driven” model places the burden of navigating multiple services squarely on the individual, often resulting in stigmatizing experiences and overwhelming processes that can do more harm than good. We frequently encounter individuals who arrive at RS EDEN in worse condition due to negative experiences with other providers.

As their primary care provider, it is our responsibility to clear the hurdles that obstruct their path to care. While this requires complex administrative coordination and blurred lines of organizational structure, it is essential to our mission-driven, values-first approach. Our framework centers on the person in need, not the organization, prioritizing impact over administrative ease.

Integrated Care at RS EDEN is not just a service delivery system; it is a commitment to reshaping how care is provided to those who need it most. By focusing on holistic support and seamless coordination, we can help our participants navigate their paths to recovery and stability.