Comprehensive Community Support Services Competency & CSA Training

1. Comprehensive Community Support Services Competency & CSA Training Heather A. Clark MS, CPRP, LPCC Presbyterian Medical Services

2. Purpose of the Training To provide participants with a strong knowledge base and necessary skills required for successful delivery of Comprehensive Community Support Services (CCSS) consistent with Core Service Agency (CSA) Values

3. Outline • H2015 Service Definition as CCSS overview • CSA Criteria • Wraparound Approach • Key Concepts for CSW’s and CPS’s • Research • CSA Standards • Crisis Planning

4. Comprehensive Community Support Services Revised 7.30.2010 HCPCS Service Definition: The purpose of Community Support Services is to surround individuals/families with the services and resources necessary to promote recovery, rehabilitation and resiliency. Community support activities address goals specifically in the following areas: independent living; learning; working; socializing and recreation. Community Support Services consist of a variety of interventions, primarily face-to-face and in community locations, that address barriers that impede the development of skills necessary for independent functioning in the community.

5. Comprehensive Community Support Services Revised 7.30.2010 HCPCS • Community Support Services also include assistance with identifying and coordinating services and supports identified in an individual’s service plan; supporting an individual and family in crisis situations; and providing individual interventions to develop

6. H2015 Revised 7.30.2010 HCPCS Individuals having problems accessing services and/or receiving multiple services from a single or multiple providers and/or systems and • Individuals needing support in functional living • Individuals transitioning from institutional or highly restrictive settings to community-based settings or • Children at risk of/or experiencing Serious Emotional/Neurobiological/Behavioral Disorders or • Adults with severe mental illness (SMI) or • Individuals with Chronic Substance Abuse or • Individuals with a co-occurring disorder (mental illness/substance abuse) and/or dually diagnosed with a primary diagnosis of mental illness

7. H2015 Revised 7.30.2010 HCPCS Designated agency Individuals that meet the target population criteria for community support services must have one designated agency that will have the primary responsibility of assisting the recipient and family with implementing the service plan.

8. H2015 Revised 7.30.2010 HCPCS Designated community support worker The designated community support worker will coordinate and may facilitate family team meetings/treatment team meetings.

9. H2015 Revised 7.30.2010 HCPCS- Activities • Assistance to the individual in the development and coordination of the individual’s service plan including a recovery a management plan and a crisis management plan; • Assessment support and intervention in crisis situations including the development and use of crisis plans which recognize the early signs of crisis/relapse, use of natural supports, use of alternatives to emergency departments and inpatient services, • Assistance to the individual in the development of advanced directives related to his/her behavioral healthcare; and • Individualized interventions, with the following objectives: • Identification, with individual, of barriers that impede the development of skills necessary for independent functioning in the community; as well as strengths, which may aid the individual in recover; • Services and resources coordination to assist the individual in gaining access to necessary rehabilitative, medical and other services; • Support to facilitate recovery and resiliency;

10. H2015 Revised 7.30.2010 HCPCS- Activities Continued… • Assistance in the development of interpersonal, community coping and functional skills (including adaptation to home, school and work environments); • Encouraging the development and eventual succession of natural supports in workplace and school environments; • Assistance in learning symptom monitoring and illness self-management skills (e.g. symptom management, behavioral management, relapse prevention skills, knowledge of medication and side effects and motivational/skill development in taking medication as prescribed) in order to identify and minimize the negative effects of symptoms which interfere with the individual’s daily living; • Assistance with financial management and skill development; • Assistance with personal development and school/work performance; • Assistance in enhancing social and coping skills that ameliorate life stresses resulting from the individual’s disability; • Assistance to individuals with illness self-management as it relates to maintaining employment and school tenure; • Assisting the individual to obtain and maintain stable housing; • Any necessary monitoring and follow-up to determine if the services accessed

11. H2015 Revised 7.30.2010 HCPCS The majority (60% or more) of non facility-based community support services provided must be face-to-face and in vivo (where the client is). The community support worker must monitor and follow-up to determine if the services accessed have adequately met the individual’s treatment needs.

12. H2015 Revised 7.30.2010 HCPCS For individuals and/or their families: The community support worker will make every effort to engage the client in achieving treatment/recovery goals.

13. H2015 Revised 7.30.2010 HCPCS When the service is provided by a Certified Peer Specialist, the above functions/interventions should be performed with a special emphasis on recovery values and processes such as: • Empowering the individual to have hope for and participate in his or her own recovery; • Helping the individual identify strengths and needs related to attainment of independence in terms of skills, resources, and supports, and to use available strengths, resources and supports to achieve independence; • Helping the individual to identify and achieve their personalized recovery goals (which should include attainment of meaningful employment if desired b the individual); and • Promoting an individual’s responsibility related to illness self-management.

14. H2015 Revised 7.30.2010 HCPCS • Only one provider organization at a time can serve as an individual’s clinical home. This does not preclude that other organizations provide community support activities. These community support activities and providers must be clearly identified in the service plan, be coordinated by the primary community support worker and not duplicate community support services provided by the primary community support worker

15. Core Service Agency What is a Core Service Agency (CSA)? A Core Service Agency (CSA) coordinates care and provides essential services to children, youth and adults who have a serious mental illness, severe emotional disturbance, or dependence on alcohol or drugs. For those eligible to receive services, the CSAs provide or coordinate: 1. psychiatric services (medication management) 2. everyday crisis services, and 3. comprehensive community support services (CCSS) that support an individual’s self‐identified recovery goals, and other clinical services.

16. CSA Criteria- Adult Target Populations • Severe Mental Illness (SMI) • Chronic Substance Dependence (CSD) • Co-Occurring Disorders (COD) *SMI with substance disorder *SMI with developmental disability AND Symptom severity causing functional impairment in activities of daily living, interferes with functioning by inhibiting recovery and resiliency goals. OR Transition concerns *from inpatient treatment *from residential treatment *from prison

17. CSA -Target Populations- Youth Child/Youth Consumer is documented with * diagnosis of Severe Emotional Disturbance (SED) AND Symptom severity causing functional impairment in activities of daily living interferes with functioning by inhibiting recovery and resiliency goals OR Transition concerns *from inpatient treatment *from residential treatment *from a juvenile justice facility

18. CSA – Special Populations If Adult CSA: *persons who are homeless *persons with DD/MI If Youth CSA: *0-5 year olds; AND, *persons who are homeless; AND, *persons with DD/MI

19. Wraparound Approach

20. Wraparound Principles 1. Individual Voice & Choice: The Individual has ownership over their plan and represents their own perspective, choices reflect their culture and preferences. Cultural Competence, sensitivity, instills hope

21. Wraparound Principles 2. Team Based A collaborative team based process that consists of formal, informal, family/natural and community supports chosen by the individual. Be engaging with the individual, family and team build a strong therapeutic alliance.

22. Wraparound Principles 3. Natural Supports Encouragement of community and interpersonal supports that are key in providing necessary intervention. Natural supports help in managing crisis and risk – connectedness.

23. Wraparound Principles 4. Collaboration The team collaborates and guides a plan that guides each team members work. Team helps individual to identify strengths/needs.

24. Wraparound Principles 5. Community Based Inclusive, accessible, least restrictive settings

25. Wraparound Principles 6. Culturally Competent Respects and builds on value, beliefs and culture

26. Wraparound Principles 7. Individualized Plan/Team is uniquely tailored to fit the individual

27. Wraparound Principles 8. Strengths-Based Validate, expand and build on assets

28. Wraparound Principles 9. Persistence Despite challenges and a limited system the team continues to work towards stated goals.

29. Wraparound Principles 10. Outcome Based The Team is accountable for achieving the goals laid out in the plan. Ongoing monitoring and assessing is the plan is required.

30. Key CCSS Concepts Life Domains • Independent and community living • Work • Learn • Socializing • Recreation

31. Key CCSS Concepts *CSW’s and CPSW’s address the functional limitations created by the illness that interfere with the person reaching their recovery and resiliency goals. We do this by focusing on individual strengths that will help them overcome the limitations. This must be reflected in all documentation.

32. Key CCSS Concepts • Resiliency – being able to rebound from adversity and challenges. • Recovery – the process by which people are able to live, work, learn and participate fully in their communities.

33. Key CCSS Concepts Recovery Components: www.samhsa.gov (SAMHSA, 2004) • Self Direction • Individualized & Community focused • Empowerment • Holistic- Medical/Behavioral Health Wellness • Non-linear- Stages of Change • Strengths-based • Peer Support • Respect • Responsibility • Hope & Optimism

35. Key CCSS Concepts • Self – Directed Individuals & families lead, control, choose, and determine their own path. Individual/Family centered, sensitive to culture, instills hope, understandable language

36. Key CCSS Concepts • Self-Determination- Personal decision to do something and think in a certain way

37. Key CCSS Concepts CSW’s have a responsibility to adopt language that conveys respect & that is person centered. “Person with Schizophrenia” Vs. “Schizophrenic”

38. Key CCSS Concepts Doing With not Doing For: Doing With- Teaching, Coaching, Sharing, Modeling, Developing, Designing, Coordinating, Linking, Promoting, Evaluating, Crisis Planning, Safety Planning Doing For- Telling people what to do, making appointments for them, calling, shopping for.

39. Key CCSS Concepts Personal Safety • Differentiate between self/others- your personal issues vs. individual’s issues- be self aware, take responsibility, don’t use the helper relationship to meet personal needs (to be liked, do well, be needed) • Practice de-escalation techniques- be smart, carry phone, let supervisor know where you are, go with someone on first home visit, scan surroundings • Protect yourself against burnout.

40. Key CCSS Concepts Manage Crisis/Risk • Complete Detailed CCSS Crisis plan that detect warning signs/triggers to things breaking down with appropriate action plans and steps for the individual to manage crisis- UPDATE THEM!!! • Listen and report abuse, neglect, exploitation & danger to self/others. • Focus on Behavior Changes that might indicate concern.

41. Key CCSS Concepts • Remember face-to-face visit must occur within 48 hours after a crisis. • Adult Crisis Plans should include Advance Directives, risk factors and development of interventions developed from knowledge of past crisis situations • Indicate escalating risk and levels of crisis support-

42. Research:Patricia E. Deegan, Ph.D. Institute for the Study of Human Resilience“Offer support like you offer a cup of tea.”http://www.bu.edu/resilience/staff/pdeegan.html

43. Research:Recovery After an Initial Schizophrenia Episode (RAISE): A Research Project of the NIMH • Patricia Deegan is currently a member of the executive and intervention committees of a study funded by the National Institute of Mental Health called R.A.I.S.E (Recovery After Initial Schizophrenia Episode). This is a multi-year study of an intervention aimed at young folks who have a first psychotic episode. The intervention includes a team of professionals who work in a coordinated fashion to outreach and engage people in recovery-oriented services including supported employment and supported education. Active linkage to peer support, natural supports, substance abuse services and trauma services (if indicated) are part of the study protocol. 

44. Psychosocial Rehabilitation (PSR) Psychiatric Rehabilitationpromotes recovery—full community integration and improved quality of life for persons who have been diagnosed with any mental health condition that seriously impairs functioning. Psychiatric rehabilitation services are collaborative, person-directed, and individualized, an essential element of the human services spectrum, and should be evidence-based. They focus on helping individuals develop skills and access resources needed to increase their capacity to be successful and satisfied in the living, working, learning and social environments of their choice. www.USPRA.org

45. Research:12 PSR Principles of Recovery • PSR practitioners convey hope and respect, and believe that all individuals have the capacity to learn and grow. • PSR practitioners recognize that culture is central to recovery, and strive to ensure that all services are culturally relevant to individuals receiving services. • PSR practitioners engage in the processes of informed and shared decision-making and facilitate partnerships with other persons identified by the individual receiving services. • PSR practices build on the strengths and capabilities of individuals. • PSR practices are person-centered; they are designed to address the unique needs of individuals, consistent with their values, hopes and aspirations. • PSR practices support full integration of people in recovery into their communities where they can exercise their rights of citizenship, as well as to accept the responsibilities and explore the opportunities that come with being a member of a community and larger society. www.USPRA.org

46. Research:12 PSR Principles of Recovery • PSR practices promote self-determination and empowerment. All individuals have the right to make their own decisions, including decisions about the types of services and supports they receive. • PSR practices facilitate the development of personal support networks by utilizing natural supports within communities, peer support initiatives, and self-and mutual-help groups. • PSR practices strive to help individuals improve the quality of all aspects of their lives; including social, occupational, educational, residential, intellectual, spiritual and financial. • PSR practices promote health and wellness, encouraging individuals to develop and pursue individualized wellness plans. • PSR services emphasize evidence-based, promising and emerging best practices that produce outcomes congruent with personal recovery. Programs include structured program evaluation and quality improvement mechanisms that actively involve persons receiving services. • PSR services must be readily accessible to all individuals whenever they need them. These services also should be well coordinated and integrated with other psychiatric, medical and holistic treatments and practices. www.USPRA.org

47. Research:Courtenay M. Harding, Ph.D. The American Psychological Foundation awarded Dr. Harding its 2004-2005 Alexander Gralnick Research Investigator Award. This prestigious prize "recognizes exceptional contributions to the study of schizophrenia and other serious mental illness and for mentoring a new generation of researchers." She was appointed Professor of Psychiatry at the Boston University School of Medicine in 2007. www.bu.edu

48. Service Planning Stages of Change • Pre-contemplation = Engagement • Contemplation & Preparation= roll with resistance listen for “change talk” • Action= identify goals/strengths/coping strategies to avoid crisis/relapse • Maintenance= ongoing movement towards goals & objectives

49. Service Planning • Assessment- minimally documents diagnosis/illness & impact on functioning • Baseline Functional Assessment- further documents functional limitations and barriers to recovery • Service Plan- address Life domains, goals in person’s own words, steps to restore functioning in frequency/duration (objectives) • Activities/Interventions relate to Plan/Medically Necessary • Progress Notes- demonstrate progress • Enhanced Assessment • Review Revise

50. Service Planning Enhanced Assessment If Adult CSA, use HOO31 U8 for consumer who meets one of the following: _____Significant current danger to self or others _____Has 3 or more emergency room visits or psychiatric hospitalizations w/in last year _____Meets ASAM Placement Criteria for Level III or IV services and must have a high score on the following dimensions: intoxicated/withdrawal potential, biomedical condition, emotional/behavioral/cognitive conditions _____Person is experiencing trauma symptoms related to traumatic event _____Severe impairment in at least one Axis IV functional domain _____Moderate functional impairment in multiple domains _____Substance Dependency diagnosis and any mental illness that affects functionality _____SMI or Substance Dependence and potentially life-threatening medical condition _____SMI or Substance Dependency and Developmental Disability Assessment Adult