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MERCY MARICOPA INTEGRATED CARE. Connecting Young Adults with Behavioral Health Needs. Heather Williams, BS Transitional Youth Coordinator, Mercy Maricopa Integrated Care Jessica Woodruff, LCSW Clinical Manager, Transition to Adulthood Program, Jewish Family and Children’s Services.

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Connecting young adults with behavioral health needs


Connecting Young Adults with Behavioral Health Needs

Heather Williams, BS

Transitional Youth Coordinator, Mercy Maricopa Integrated Care

Jessica Woodruff, LCSW

Clinical Manager, Transition to Adulthood Program, Jewish Family and Children’s Services

C onnecting young adults with behavioral h ealth n eeds
Connecting Young Adults with Behavioral Health Needs

  • Objectives

    • Learn about Mercy Maricopa and it’s role in managing behavioral health services for transitioning youth in Maricopa County

    • Define system changes that contribute to successful transitions to adulthood

    • Define Mercy Maricopa’s role in collaborating with stakeholders and community partners

    • Identify challenges facing “disconnected youth” with behavioral health needs

    • Identify best practices for addressing behavioral health needs with “disconnected youth”

Who is mercy maricopa
Who is Mercy Maricopa?

  • Mercy Maricopa Integrated Care is a local not-for-profit health plan sponsored by Mercy Care Plan (MCP) and Maricopa Integrated Health System (MIHS)

  • Both of Mercy Maricopa’s sponsors have a long history of caring for Maricopa County residents

    • MCP is a 28-year-old Medicaid plan, also a not-for-profit, that is sponsored by Dignity Health and Carondelet Health Network, faith-based health care systems

    • MCP already serves nearly half the AHCCCS SMI population for their physical health care needs

    • MIHS is a public health care system, serving AHCCCS members, privately insured and uninsured citizens of Maricopa County for 135 years.

Values and principles
Values and Principles

  • Focus on members and the whole person

  • Collaboration with providers and stakeholders

  • Use of data and information in decision making and system improvements

  • Improve the member – provider interaction

  • Integration occurs at multiple levels: state, managed care, provider, member and family

  • Integration will include children and GMHSA

  • Ultimately about recovery and resiliency

How does mercy maricopa serve t ransition age y outh
How does Mercy Maricopa serve Transition-age Youth?

  • Children’s Services

    • Serve youth and young adults between the ages of 14 and 17

    • Responsible for coordinating the transition from the children’s service delivery system to the adult service delivery system

  • General Mental Health/ Substance Abuse (GMH/SA) Services

    • Serve young adults between the ages of 18-25 with general mental health needs (medication monitoring, therapy)

  • Seriously Mentally Ill (SMI) Services

    • Serve young adults between the ages of 18-25

    • Additional supportive services to meet complex needs of young persons diagnosed with a Serious Mental Illness

Establishing priorities
Establishing Priorities

Putting transition-age youth and families at the center

How will mercy maricopa improve the system for transition age youth
How will Mercy Maricopa improve the system for transition-age youth?

  • Mercy Maricopa will enhance service delivery to this population by:

    • Utilizing Mercy Maricopa’s Youth Leadership Council as advisors to system changes effecting transition-age youth

    • Encourage the use of recognized best /promising practices for working with Transition-age Youth (TAY) aged 16-21

    • Utilize data to influence system changes that may benefit transition-age youth

The value of collaboration
The Value of Collaboration transition-age youth?

  • Engaging system partners in transition to adulthood discussions will encourage:

  • Sharing of information on program successes and barriers

  • Sharing of community resources relevant to transition-age youth

  • Young adults to share their perspectives and provide leadership

  • Development of training opportunities for transition providers and community members

Who are the transitioning youth
Who transition-age youth?are the Transitioning Youth?

  • Young adults between the ages of 14 and 25 are considered to be within the transition period

  • Youth with mental health needs struggle to achieve the hallmarks of adulthood such as finishing their education, entering the labor force, establishing an independent household, forming close relationships, and potentially getting married and becoming parents.

Why is transition to adulthood so important to us
Why is transition to adulthood so important to us? transition-age youth?

  • Young adults with mental health concerns are at a higher risk of:

  • Dropping out of high school

  • Not finishing college

  • Abusing drugs or alcohol

  • Having unplanned pregnancies

  • Being unemployed

  • Arrests

  • Incarceration

Best practices
Best Practices transition-age youth?

Child and Family Team (CFT) Model

Arizona Vision

  • In collaboration with the child and family and others, Arizona will provide accessible behavioral health services designed to aid children to achieve success in school, live with their families, avoid delinquency, and become stable and productive adults.

  • Services will be tailored to the child and family and provided in the most appropriate setting, in a timely fashion and in accordance with best practices, while respecting the child’s family’s cultural heritage.

Best practices1
Best Practices transition-age youth?

Child and Family Team (CFT) Model

  • 12 Arizona Principles

    1. Collaboration with the child and family

    2. Functional outcomes

    3. Collaboration with others

    4. Accessible services

    5. Best practices

    6. Most appropriate setting

    7. Timeliness

    8. Services tailored to the child and family

    9. Stability

    10. Respect for the child and family’s unique cultural heritage

    11. Independence

    12. Connection to natural supports

Best practices2
Best Practices transition-age youth?

Child and Family Team (CFT) Model: Transition Planning

  • The CFT begins transition planning no later than 16

  • For youth who are age 16 and older at the time they enter the behavioral health system, planning begins immediately

  • At age 17, the team should begin to create the adult services plan and determine whether or not the youth meets criteria for Seriously Mentally Ill (SMI) services

  • Once a plan has been determined, the children’s provider begins outreach to the adult provider to ensure continuity of care

Best practices3
Best Practices transition-age youth?

Incorporating transition planning into the Individualized Service Plan includes an assessment of:

  • Self-care and independent living skills

  • Social skills

  • Work and education plans

  • Earning potential

  • Psychiatric stability

Best practices4
Best Practices transition-age youth?

  • Strengths, Needs, Cultural Discovery

  • A general approach rather than a specific intervention

  • Identifies possibilities and options vs. limitations

  • Enhances engagement and builds relationships

  • Focuses on identifying solutions

Best practices5
Best Practices transition-age youth?

Strengths, Needs Cultural Discovery

Supports exploring additional natural supports throughout transition process

Provides a way to show the youth and family’s strength and abilities.

Opens the door to the future, giving hope, which is a key component to transition planning

Assists in identifying cultural considerations, such as norms, values, health considerations, and sexual identity.

Best practices6
Best Practices transition-age youth?

  • Positive Behavioral Support

  • Decreases the need for more intrusive intervention

  • Considers both physiological and environmental factors that influence behavior

  • Community based support, focused on “meeting the young person where they’re at”

    • Implement multiple interventions in complex systems with many variables

Best practices7
Best Practices transition-age youth?

  • Peer Support

  • Helps individual develop a better understanding of their circumstances

  • Provides opportunity to engage with others who are in recovery

  • Occurs in both formal and informal contexts

  • Promotes youth involvement

Best practices8
Best Practices transition-age youth?

  • Transition to Independence Process (TIP)

  • Engage youth and young adults (14-29 years) in their own future’s planning process

  • Provide them with developmentally-appropriate services and supports

  • Involve the young adult, their families and other informal key players in a process that prepares and facilitates them in their movement toward:

    • greater self-sufficiency and

    • successful achievement of their goals

Best practices9
Best Practices transition-age youth?

  • Transition To Independence Process (TIP): SODAS

  • Situation

    • Who/What/When/Where/How

  • Options

    • Brainstorming

    • Judgment Free

  • Disadvantages/Advantages

  • Solutions

    • Young Persons Choice

  • Best practices10
    Best Practices transition-age youth?

    • Transition To Independence Process (TIP): Rationales

    • Bridges behavior and natural consequences that are likely to incur

    • Link likelihood of positive natural consequences for following appropriate behavior and likelihood of negative consequences for inappropriate behavior

    • Rationales will not change behavior immediately.

    • ‘In-Vivo’ Teaching – when you are showing, modeling, or educating something.

    Jewish family children s service
    Jewish Family transition-age youth?& Children’s Service

    • The Approach

    • Program began at the request of Department of Child Safety (DCS) to meet the needs of Transition Age Youth dually enrolled in DCS and Behavioral Health.

    • Focus on working with youth/young adults in areas of education, career/employment, stable living situation, community life functioning and personal effectiveness and wellbeing.

    • The teams are community-based: Transition facilitators have cell phones, laptops, wireless cards; Services are delivered where the youth/young adult lives.

    • Skills training is done with the youth/young adult in their environment through a combination of role playing, role modeling and coaching

    Jewish family children s services
    Jewish transition-age youth?Family & Children’s Services

    • Unique Needs

    • Understand that youth/young adult culture is a distinct and separate culture.

      • Unique population with special needs

  • Transition-age youth are not transitioning into adult services but are transitioning into adulthood.

    • Need for developmentally appropriate services specific to the distinct needs of a young person just entering adulthood

    • Effective behavioral health services must be mindful of the unique needs, interests and goals of young adults

  • Jewish family children s services1
    Jewish transition-age youth?Family & Children’s Services

    • Explore and determine barriers and inefficiencies in the quality and effectiveness of services in order to strengthen outcomes across (5) transition domains:

      • Employment/Career

      • Education

      • Living Situation

      • Personal Effectiveness/Wellbeing

      • Community-Life Functioning

    Jewish family children s services2
    Jewish transition-age youth?Family & Children’s Services

    • Staff Commitment

    • The Youth in Transition Facilitators are diverse racially and ethnically. Each one was recruited for a compilation of skills and talents which makes the entire program greater than the sum of its parts.

    • Transition Facilitators take youth to job interviews, college registrations, meetings with P.O.s, apartment hunting, help with homework, rush them to the emergency room, intervene in the middle of the night when someone is suicidal, take them to court (to list just a few of the activities).

    • Each interaction/activity is used to teach the life skills identified as necessary by the youth/young adult and their family and/or Child and Family Team.

    Jewish family children s services3
    Jewish Family & Children’s Services transition-age youth?

    • TIP Today

    • Over 210 youth and young adults currently active in the Program from the Department of Economic Security/Division of Children, Youth & Families, the Arizona Department of Juvenile Corrections, Partners in Recovery and from the community at large.

    • JFCS partners with state and community stakeholders to provide service and support for the youth/ young adults we serve.

    • Just as we partner with diverse agencies we recruit staff that reflect the diversity of the youth/young adults we serve; developing a strong racial and ethnic identity is crucial to the development of personal effectiveness and wellbeing.

    Jewish family children s services4
    Jewish Family & Children’s Services transition-age youth?

    • The Rewards

    • 25% of youth are employed.

    • 18% of youth are enrolled in post high school academic or trade program.

    • 70% of young adults have demonstrated a positive change in their interpersonal relationships.

    • 68% of youth have achieved improvement in their personal health.

    • 75% of young adults are using and developing the daily living skills they have learned.

    • 65% of youth are participating in the community.

    • 82% of young adults in a home-type permanent setting.

    Questions? transition-age youth?

    Thank you!