2012-2015 DADS, AUSSLC, ATCIC, BBT, HC Pilot program 2012-2015 DADS, AUSSLC, ATCIC, BBT, HC

4 main objectives were developed for the Pilot program 1) Enhanced Community Exploration (in addition to CLOIP) 2) Community Planning and Preparation Support (Enhanced Continuity) 3) Intensive Service Coordination for day of move and post move (in addition to TCM) 4) Identifying Pre move and Post Move SC Response to Major Crisis/ Persistent Challenges

Enhanced Community Exploration (in addition to CLOIP) Accomplished through developing increased and more frequent contact with providers to have a current knowledge of capacity and barriers Communicating to individuals, family members/LARs, and team members about places that may be a good fit and are available to be toured for informational purposes Assisting with on campus Provider Fairs Interviewing Direct Care Staff and Professionals to better understand a person’s preferences, services, and supports

Continued: Enhanced Community Exploration In June of 2014 a downsizing of AuSSLC occurred with 7 homes closing, and 72 individuals identified to move to the community or transfer to another SSLC. The COC Coordinators working with AuSSLC Admissions and Placement attended approximately 72 living options meetings in two months, detailing what community living options can offer and addressing questions and concerns of individuals, family members, LARs, and IDT teams. After that an abundance of community living option tours were scheduled and attended by Coordinators and Admissions and Placement for individuals and LARs. Many of whom had never considered community in the past. We provided intensive support in the forms of tours and discussion of supports and services available.

Community Planning and Preparation Support (Enhanced Continuity) Once a person is referred to live in the community, COC Coordinators: attend all post referral meetings (14 day, 180 day, provider interviews etc) Continue assisting individuals and LARs with the discovery process of homes and the community living options discussion Identify pre supports to be in place to assist the person before they move Attend bi monthly meetings with Admissions and Placement to update and assist with community placement

Intensive Service Coordination for day of move and post move (in addition to TCM) COC Coordinators: Visit the person on the day of move and again within the first five days of the move Visit the person 4 times a month for a minimum of 3 months (up to a year, depending on the transition) Attend bi monthly meetings with Admissions and Placement to discuss post move monitoring and problem solve any issues or concerns

Intensive Service Coordination for day of move and post move (in addition to TCM) Monitor the CLDP supports and services agreed upon Provide a continuity of care link from AuSSLC to the community Provide post move monitoring for people who moved outside of Austin area and communicated with the receiving LA

Identifying Pre move and Post Move SC Response to Major Crisis/ Persistent Challenges COC Coordinators make referrals to put supports in place for crisis prevention services, such as START, HC Behavioral Supports and Crisis Center, and BBT Crisis Support Team, if appropriate Refer people to be a part of Person Centered Planning meetings conducted by START and as part of developing the PDP Connect a person to activities and supports in the community before moving

Identifying Pre move and Post Move SC Response to Major Crisis/ Persistent Challenges Begin transition planning before move By being present during all transition planning meetings, Coordinators are able to identify and set supports before a person moves, as well as, monitor to prevent psychiatric hospitalization, incarceration, or re institutionalization Part of the Pilot Program involved meeting with DADS regularly to discuss the program and to problem solve barriers to placement for individuals seeking community homes

From the beginning of the Pilot to the end.. 72 people have moved to the community since 2012, with only one person returning to an SSLC. …..and we learned a few things along the way

Things that worked well: Continuity of Care piece of being a part of transition planning An outside/ community based perspective De identified case studies to locate providers Person Centered Planning to develop the PDP and Cross Systems Crisis Planning with the individual, LAR, SSLC team, Provider, and Community Service Coordination

Things that worked well: Provider Direct Care Staff getting to know the person and shadowing the SSLC staff before moving was really helpful in creating repertoire and to be able to learn from the SSLC staff that knows the person well More frequent Post Move Monitoring to make sure the transition is going smoothly Communication with AuSSLC Post Move Monitors

How this relates to Enhanced Community Coordination 

Enhanced Community Coordination Providing enhanced information about available community living options, services, and supports in addition to the information provided during the community living options process Providing opportunities to visit community resources Providing an individual intensive and flexible support to achieve success in a community setting the individual is provided enhanced pre- and post-transition services

Enhanced Community Coordination monitoring an individual for one year after relocation * Providing intensive support to ensure an individual’s successful transition to the community to prevent admission or re-admission to an institution (enhanced coordination able to visit more frequently and to focus on assisting people who have moved from institutions) providing increased coordination and interaction with an institution’s interdisciplinary team (continuity of care)

Enhanced Community Coordination Being able to monitor and be apart of the transition planning process and CLDP Quarterly SPT meetings to insure continuity of care and discussion of services are addressed Being able to access one time emergency assistance funds Being able to identify and report barriers to placement

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