JENNIFER ALFREDSON Updated 121919 Milwaukee County BHD Community Access to Recovery Services CARS The Service Array 2 hours Jen A Forward Health Update Go through all 14 services on the array ID: 782248
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Slide1
CCS – The Service Array
JENNIFER ALFREDSON
*Updated 12/19/19
Milwaukee County BHD
Community Access to Recovery Services (CARS)
Slide2The Service Array 2 hours - Jen A. Forward Health Update
Go through all 14 services on the array
Demonstrate the correlation between Positions and Services on the array.
Slide3The CCS Service Array
Can be found in the Forward Health Update, June 2014, no. 2014-42
Attachment 1
https://www.forwardhealth.wi.gov/kw/pdf/2014-42.pdf
Milwaukee County CARS CCS website:
https://county.milwaukee.gov/EN/DHHS/Provider-Portal/BHD-Providers#carsproviderforms
A link to the Forward Health update is on the CARS website and the CCS SharePoint.
Slide4PARTNERING WITH CONSUMERS IN THE RECOVERY PROCESS
Slide5“Psychosocial Rehabilitation Services”
Per DHS 36:
Namely the medical and remedial services and supportive activities provided to or arranged for a consumer by a comprehensive community services program authorized by a mental health professional to assist individuals with mental disorders or substance use disorders to achieve the individual’s highest possible level of independent functioning, stability and independence and to facilitate recovery.
*All services must be Rehabilitative in nature. That means that you are working with the consumer to set goals and make progress, not doing things for them.
Slide6“Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime” -old Chinese proverb
Slide7Service Array 1Screening and Assessment
Done first in the CCS process
Includes the MH/AODA Functional Screen (staff must be certified)
Also includes a written Assessment and Assessment Summary
This would include sending for, receiving, and reading medical records
S&A can be re-visited as needed, but must be done at a minimum yearly (MH/AODA FS)
Slide8Service Array 2Service Planning
Includes Developing a written Recovery Plan of Care (RPOC)
Development of the plan should occur in the context of a Recovery Team Meeting.
Minimum membership to the team includes the consumer, care coordinator, mental health professional, and substance abuse professional if applicable.
Other formal supports and natural supports are encouraged to be a part of the Recovery Team.
The first RPOC must be completed within 30 days of the consumer signing the CCS application/admission agreement.
RPOC’s should be living documents, updated any time there is a change.
At minimum, it needs to be a new scheduled RPOC every 6 months.
Slide9Service Array 3Service Facilitation
Milwaukee is calling the staff “Care Coordinators”. (i.e. Service Facilitation = Care Coordination)
The CC oversees the RPOC process, the Recovery Team, and all services listed on the RPOC.
The CC can also be a direct service provider as laid out on the RPOC, but this practice is discouraged. If the CC must provide a direct service, it must be listed as an intervention on the RPOC.
Slide10Service Array 4Diagnostic Evaluations
Includes specialized evaluations such as neuropsychological,
gero
-psychiatric, specialized trauma, and eating disorder evaluations.
Providers must be listed in the Program Directory on the SharePoint and be practicing within their scope.
Slide11Service Array 5Medication Management
Split into 2 categories: Prescribers and Non-Prescribers
Psychiatrists / APNP’s may bill through CCS instead of Medicaid or HMO’s for Medicaid.
If consumers have doctors that are not in the CCS network, the doctors may bill Medicaid/HMO’s directly.
Slide12Service Array 5 Medication Management – con’t
Services for non-prescribers:
Can monitor meds at a level that the provider and consumer agree upon, taking many factors into consideration. The Care Coordinator can do the service, but this practice is discouraged. CC should broker out the servicer to a different worker or even a different worker at a different agency.
Can also spend time assisting the consumer to understand their meds, benefits, and symptoms that they are treating.
Also covers the monitoring of symptoms and tolerability of side effects
Slide13Service Array 6Physical Health Monitoring
The Care Coordinator can do the service, but this practice is discouraged. CC should broker out the servicer to a different worker or even a different worker at a different agency.
Staff must work within the scope of their training (always)
For physical health, there are some things that staff can do after demonstrating competence, such as diabetes testing.
Assisting, training, monitoring for both the consumer and their family.
There are nurses in the network. Consult the provider directory on the SharePoint.
Slide14Service Array 7Peer Support
Can
only
be done by a
Certified Peer Specialist
(CPS) so unless your CC is a CPS, you will be hiring out this service to someone at your agency or perhaps a different agency.
CPS can assist the consumer AND their family.
Slide15Service Array 8Individual Skill Development and Enhancement
The Care Coordinator can do the service, but this practice is discouraged. CC should broker out the servicer to a different worker or even a different worker at a different agency.
There may be more than one staff hired to do this service at the same agency or different.
Will cover things such as grocery shopping, banking,
payeeship
, ADL’s, transportation – as long as it is in the RPOC and it is demonstrated that teaching will occur and progress made.
Connecting to community resources and services could mean helping a consumer find housing, apply for housing, yearly T19 and
Foodshare
renewals, etc.
Slide16Service Array 9Employment Related Skill Training
Emphasizes use of evidenced-based Practice
Primary model-Individualized Placement and Supports
(IPS)
Supported Employment Model
Slide17INDIVIDUALIZED PLACEMENT AND SUPPORT (IPS)- SUPPORTED EMPLOYMENT
Evidenced-based practice
Highly researched and proven to be effective
Model designed to offer ongoing employment related supports for adults coping with SPMI and/or substance use disorders
(currently being further researched with youth/young adult populations)
Supportive research, fidelity scale and related information
http://sites.dartmouth.edu/ips/
Slide18IPS PRINCIPLES
Work can promote recovery and wellness
IPS supported employment practitioners focus on client strengths and meet the client where they are at
Practitioners work in collaboration with state vocational rehabilitation
IPS uses a multidisciplinary team approach
(employment specialists are built into MH/AODA treatment teams)
Employment specialist (ES) focuses on employment related services
ONLY,
(does not take individuals grocery shopping, perform medication drops, etc.)
Employment Specialist may work on symptom management and reducing substance use as these are areas that may impact work related function
Services are individualized and long-lasting
Slide19IPS PRINCIPLES (CONTD.)
The IPS approach changes the way mental health services are delivered (philosophical shift), emphasis of recovery and positive outcomes
Emphasis on finding competitive employment (no sheltered employment)
Forming direct relationships with employers in the community through face to face contact and marketing
Job choice is based on consumer choice and preferences,
NOT
provider judgment
Can include supported education to desired build skill sets
Zero exclusion philosophy (includes mental health stability and active substance use)
Rapid Job Search- initial job assessment and first contact with employer (either with client or on behalf of them within 30 days of referral)
Slide20IPS IN MILWAUKEE COUNTY
IPS is embedded into CCS some teams as of December 2019:
APC
Bell Therapy
Guest House
Justice Point
MMHA
Project Access
PSG
WSC coming in January 2020
Whole Health
Slide21Service Array 10Individual and/or Family
Psychoeducation
Skills training, problem solving, social and emotional support
Can be done with the consumer and/or their family.
Can be provided individually or in a group
Slide22Service Array 11Wellness Management and Recovery / Recovery Support Services
Mental Health Services:
Empowering consumers, helping them to develop their own goals.
Teaching knowledge and skills necessary to make good decisions.
Can be individual or group setting.
Is often utilized for our more non-traditional therapies such as yoga, medication, tai chai, equine, music, float, etc.
Slide23Service Array 11Wellness Management and Recovery / Recovery Support Services
Substance Abuse Services:
Assisting the consumer to increase engagement with treatment.
Developing coping skills
Relapse prevention and follow ups
Slide24Service Array 12Psychotherapy
Would generally never be provided by the CC, unless the CC is licensed to provide therapy.
Can refer within the CC’s same agency, or a different agency listed in the Program Directory.
Can be individual or group setting
If a consumer is in CCS, they must received their psychotherapy by a CCS provider. Psychotherapists
cannot
bill T19/HMO’s directly.
Slide25Service Array 13Substance Abuse Treatment
Would typically not be served by the CC
Can be individual or group setting
CCS does not pay for Residential Treatment or Detox. Some of those services may still be covered by Medicaid/HMO’s.
Slide26What happens next?
Consumer can choose a CCS agency at time of their call to the CCS line or the branch presentation.
CCS Intake Coordinator will contact the consumer. They will meet to thoroughly discuss the program and if the consumer is still interested, sign the Admission Agreement / Application.
30 day
time clock starts ticking: Screen, Assessment, Summary, & RPOC must all be done within 30 days of the AA/A.
CSP, TCM, RSC’s – continue to work with their consumer until the RPOC is complete and services begin.