The Community Navigator

1. The Community Navigator “Finding A Way”

2. Community Mental Healthcare Inc. Dover, Ohio Serving Tuscarawas and Carroll County • JJ Boroski, Executive Director • Michelle Coon, Community Navigator • Gwen Malcuit, Program Supervisor, Manager of Crisis Services, Forensic Monitor

3. The Community Navigator Program at Community Mental Healthcare was made possible by a grant from the Margaret Clark Morgan Foundation in September of 2012. The grant was written by JJ Boroski, Executive Director at CMH Inc. The purpose of the program was to provide intensive, needs based, individualized support and assistance to high risk mentally ill or addicted individuals experiencing repeated hospitalizations, incarcerations, or are at risk of such. The program was designed to be holistic in its approach to the recovery process. Typically, these individuals have not been successful in traditional services or have been unable to access them.

4. The Community Navigator in Tuscarawas and Carroll County • The identified need and the target population • The projected goals • One year outcomes

5. The Identified Population • High level of vulnerability and risk in the community due to homelessness, symptom instability, substance abuse, lack of access to medical care, lack of access to healthy diet, lack of healthy supports, involvement with legal system • Experiencing high rates of recidivism or incarceration or at risk of such • Inability to navigate benefits and resources • Case complexity • Inability to access traditional services or past failure in traditional services • High risk of harm to self or others

6. The Identified Community Problems • Rural area with limited resources • No public transportation • Poor follow up rates post hospital discharge • Lack of effective communication across systems, between organizations • Traditional CPST struggle to provide level of intensity needed • Available resources and benefits not widely known or difficult to navigate • Lack of community awareness regarding SPMI individuals and substance abusing individuals

7. Goals • Decrease bed day use and recidivism rates • Decrease length of stay • Develop improved methods of communication between organizations and within our own organization • Increase compliance and post discharge follow up rates • Increase access to basic needs • Develop and foster healthy and supportive relationships • Provide advocacy and promote self advocacy • Increase reliance on natural supports • Provide support and education to community • Provide guidance in accessing benefits and resources • Develop means of identifying at risk individuals in other community systems • Provide leadership in the development of new resources

8. Activities of the Community Navigatorat Heartland Behavioral Healthcare • Engages at least weekly with clients at HBH • Contacts assigned social worker within one business day of admission • Point person for all follow up scheduling • Takes part in treatment team meetings • Provides support and assistance in level movement process • Conducts Needs Assessment, begins linkage to benefits and resources on site • Determines need for Navigator services versus traditional services • Develops rapport and provides the client a link to post hospital environment • Involves family/ involved others per client’s wishes • Facilitates step down to CSU • Provides support, guidance and contact following discharge and up to first post discharge appointment • Facilitates referral to Community Treatment Team if appropriate • Provides continuity of care from time of admission into the community

9. Activities of the Community Navigatorat Community Mental Healthcare • Communicates back to existing providers • Refers to appropriate services and assures services are accessed in a timely manner • Works in tandem with existing CPST to provide additional support, needed intensity, or when transferring to CPST • Collects needed records • Liaison to community providers • Works in tandem with the Forensic Monitor as needed • Communicates with Pharmacological Services to assure timeliness of appointments, availability of medication • Provides support and assistance to clients in CSU, including Needs Assessment, referrals, linkage to benefits and resources

10. Activities of the Community Navigatorin the Community • Assisted in the development of and participates in bi-weekly Community Treatment Team • Monthly team meetings with Probation and Courts • Is present in court at Judge request and conducts Needs Assessment on site at court • Engages with clients in jail at jail request • Improved communication with local guardians and attendance at guardianship hearings • Works closely with local group homes, facilitates training as needed • Developed a close working relationship with local homeless shelter • Gathers records to improve timeliness of access to benefits • Develops reports requested by Probation for PSI

11. What Have We Achieved? • Over 100 clients served over the past year • Show rate for post hospital discharge went from 64% to 95% • Individual client readmissions (Navigator clients) decreased by ? • Only two 30 day readmissions in past year • LOS remained fairly stable, however early linkage and engagement with Community Navigator improved compliance and outcomes post discharge • Of clients not previously linked to services, 100% were linked, with 83% still active in services • 76% of Navigator clients successfully “stepped down” to more traditional services

12. Communication, Communication, Communication… • Community Treatment Team • Community Corrections collaborative • Municipal Court and Municipal Court Probation collaborative • Homeless Shelter • Guardians • Tuscarawas County Jail • Northview Group Home • Risk Team • HBH

13. The Community Navigator From Community to Community • No two communities are the same • Systems of care are different from county to county • Resources differ • Existing services differ • Each community has its own unique strengths and weaknesses • The Community Navigator looks different from community to community but the goal of helping our most vulnerable citizens is the SAME

14. Our Navigator “Mission” • If there’s a GAP… BRIDGE it • If there’s a BARRIER… FIND another way • If there’s a STRENGTH…USE it • If there’s NOTHING… ENVISION it, BELIEVE in it, BUILD it!!

15. “The true beauty of this position is that we have an individual free from the constraints and demands of billing and productivity, free from the rigid limitations of more traditional services, who can not only guide those with mental health or substance abuse issues around the gaps in the system that people often fall into, but also has the ability to address the reasons those gaps are there in the first place and work across multiple systems of care, with multiple providers, and in multiple venues to close them for good. In this sense the Community Navigator is not just an advocate for the clients he or she serves, but an advocate for communities, organizations, families, and all who may in the future be touched by mental illness or substance abuse issues.”

16. Questions?

17. Much gratitude and Many thanks to… • The Margaret Clark Morgan Foundation • JJ Boroski MA, LPCC-S, Executive Director, CMH Inc. • The ADAMHS Board of Tuscarawas and Carroll Counties • The staff and administration of Heartland Behavioral Healthcare, especially Linda Ellis and Jeff Sims • Nicole Cooperider and Linda Blum • ODMHAS • And of course MICHELLE COON, COMMUNITY NAVIGATOR!