Community Psychiatric Rehabilitation Presented by Susan Blume, M.Ed. Certification Coordinator Department of Mental Health Division of Comprehensive Psychiatric Services

The goal of today’s presentation is to answer questions such as: What is the community psychiatric rehabilitation (CPR) program? What is the philosophy of this program? Who is eligible for services? What services are available through CPR? What is the funding stream for services?

Community Psychiatric Rehabilitation was established in Missouri in 1989 is funded by both the Missouri Department of Mental Health (DMH) and by Medicaid is part of the rehabilitation option to the Missouri State Medicaid Plan

Community Psychiatric Rehabilitation is administered jointly by the DMH Division of Comprehensive Psychiatric Services (CPS) and the Division of Medical Services, which is part of the Department of Social Services the development and implementation of the Community Psychiatric Rehabilitation program is an important component of the DMH community-based system of care

Community Psychiatric Rehabilitation CPR programs provide a range of mental health services to adults with serious and persistent mental illness and children and youth with serious emotional disturbances

Services are designed to: maximize independent functioning promote the recovery and self-determination process increase interagency coordination and collaboration in all aspects of the treatment planning process and reduce inpatient hospitalizations and out-of-home placements

The core services that must be provided in order for an agency to be certified by DMH as a CPR program are: Evaluation Community Support Crisis Intervention Medication Administration Medication Services Consultation and Psychosocial Rehabilitation

Evaluation Assessment and evaluation are crucial to the delivery of quality services since the findings of the assessment provide a foundation for determining service delivery needs and developing strategies for intervention and level of care Evaluation occurs at intake and annually after that

The intake evaluation focuses on: presenting problems history of treatment history in areas such as family, vocation, education and community current functional strengths and weaknesses physical and medical complaints and recommendations for treatment

Annual evaluations focus on: changes over the past year in all areas of assessment update of diagnostic formulation and recommendations for treatment

Treatment Planning Treatment plans and treatment plan reviews are part of the evaluation package Treatment plans are developed from the assessment and in partnership with the consumer in order to have goals that are individualized and realistic Treatment plan reviews summarize progress toward goals for a three month period

Community Support Services Many individuals with mental illness experience difficulty being included in the community and accessing community resources This is due in part to the segregation and isolation that they may have experienced, and in part to the disabilities associated with their mental illness

Community Support Services Is defined as those activities designed to ease an individual’s immediate and continued community adjustment

Community support activities include: teaching community living skills advocating for individuals and families coordinating delivery of mental health services with services provided by other agencies providing individualized guidance and support and monitoring progress in organized treatment programs

Community Support Services Community support workers (CSW) are responsible to assure that appropriate resources are available to individuals and to support them in attaining their highest level of functioning in their families and in the community

Community Support Services In order to be included in the community, individuals are assisted in filling legitimate, valued social roles such as worker, student, neighbor, voting citizen, church member, volunteer, spouse and parent

A typical day for a team of CSWs might include: helping a person with a medical or psychiatric appointment monitoring a person’s mental health developing or reviewing a treatment plan providing support to someone in the hospital and participating in hospital discharge planning

A typical day (continued) training/coaching in daily living skills such as housekeeping, cooking, grooming, budgeting training/coaching in community living skills such as paying bills, taking the city bus, shopping for groceries within a budget or within special dietary constraints helping someone with an appointment at DFS, the housing authority or vocational rehabilitation

A typical day (continued) For example, with vocational rehabilitation, CSW’s can help their client remember and keep appointments, complete paper work, and understand what is required when receiving services

Crisis Intervention Crisis intervention services include telephone access and face-to-face emergency response. Interventions are available to the consumer 24 hours a day, 7 days a week Services are provided by Access Crisis Intervention (ACI) providers regionally (see handout) with back-up by program staff locally

Crisis Intervention Crisis personnel have access to a physician for consultation purposes 24 hours a day Crisis personnel assist clients in utilizing natural supports or perhaps, if needed, in admission to an inpatient psychiatric facility

Crisis Intervention The goals of crisis service are to: Provide immediate response, intervention and referral for persons experiencing mental health crisis, whether in a rural, urban or metropolitan area Respond to crisis by providing community-based intervention in the least restrictive environment, e.g. home, school

Crisis Intervention Avert the need for hospitalization to the greatest extent possible Stabilize persons in crisis and refer them to appropriate services to regain an optimal level of functioning and To mobilize and link individuals with services, resources and supports needed for ongoing care following a crisis, including natural support networks

Medication Services Psychiatrists or Advanced Practice Nurses assess individuals in the need for medication as well as e ongoing management of the medication regimen. Services also include reviewing for side effects and providing education about medications

Medication Administration Medication administration services provide for: coordination with pharmacies and indigent drug programs setting up medication boxes monitoring of medication compliance consumer and family education therapeutic injection of medication

Consultation Services CPR personnel often consult with human service and other government agencies as well as natural and professional supports The goals of consultation services are to: provide direction to treatment promote effective working relationships heighten awareness of the characteristics and needs of the population advocate for an individual or group

Psychosocial Rehabilitation Services Psychosocial rehabilitation services (PSR) are defined as a combination of goal-oriented rehabilitative services provided in a group setting as outlined in the person’s treatment plan

Psychosocial Rehabilitation Services Services focus on development of behaviors and abilities that allow the person to: fully participate in community living maximize independence enhance interpersonal relationships develop support systems Participate in meaningful recreation and socialization activities that are appropriate to the age and interest of the person

Psychosocial Rehabilitation Services Some agencies may include pre-vocational services as part of PSR. These services are designed to assist a person in preparing for employment, including: interview and job application skills therapeutic work opportunities temporary employment opportunities referral to a community-based agency that specializes in the provision of vocational services

CPR Program Philosophy The CPR program is based on the following ten specific principles and values: Persons with mental illness should be active participants in program planning as well as individualized treatment planning, consistent with individual abilities. In the case of children, the child and parent(s) are an integral part of the treatment team and have ownership of the plan.

CPR Program Philosophy 2. To the extent possible, community integration, inclusion, recovery and self-determination shall be goals for service delivery. 3. Outreach, engagement and ease of service access are essential characteristics of successful programs serving adults with serious mental illness and children with serious emotional disturbance.

CPR Program Philosophy 4. Continuity and coordination of care are essential to the delivery of quality mental health services. 5. Services shall be available in varying levels of intensity based on the individual’s need. 6. An interdisciplinary and interagency team approach to service delivery is a model which best assures the quality and continuity of care.

CPR Program Philosophy 7. Services and programs shall be responsive to the needs of those it serves and sensitive to the individual’s community, ethnic and cultural context. 8. Natural supports existing within the community shall be utilized whenever possible.

CPR Program Philosophy 9. The focus of the CPR program is on the strengths of the individual. 10. Services are community-based.

Service Linkages Consistent with the principles of coordination and continuity of care, the CPR program must establish linkages with service/government agencies and natural supports that interact with individuals served by the program

Service Linkages Key service functions in brokering a range of services to individuals include developing working relationships with other service providers possessing knowledge of access to and operation of other service providers identifying interventions to support or enhance the quality of services received through other service providers

Service Linkages These types of activities must take place to assure that individuals are referred to other service providers as necessary to meet their needs and to maximize the benefit of those services

Standards for mental health programs further state that the CPR provider shall provide services and liaison activities to state and local public assistance/housing agencies and employment/training agencies in order to provide assistance to persons with serious mental illness in seeking public benefits work closely with the staff of state and local public assistance/housing and employment/ training agencies, within the limits of confidentiality, to expedite the application process and continuation of the client’s eligibility

Service Linkages Additionally, standards (also known as the code of state regulation) indicate that a key service function of the community support service is to assist the client in accessing and utilizing a variety of community agencies and resources to provide ongoing social, educational, vocational and recreational supports and activities

Service Linkages As a result, consultation with these agencies can significantly influence the quality and quantity of services provided to individuals Consultation and education by CPR program staff with criminal justice, juvenile courts, public assistance, housing and employment agencies, schools and DFS is critical

Department Oversight Community Mental Health programs that provide CPR services must be certified by the Department of Mental Health Each agency is reviewed on an annual basis to determine compliance with the code of state regulation as defined by the CPS division

Department Oversight Certification activities may consist of a team going to an agency for four or five days to review governing authority, environmental safety, policy and procedure guidelines, quality assurance systems, fiscal management, personnel qualifications/background/training, as well as, clinical review of client records for service provision and documentation

DMH Visions and Values In addition to being in compliance with the code of state regulation, agencies are expected to fall in line with the Department of Mental Health’s vision and values These values should be recognized and reflected in the operation of the CPR program

Eligibility To be eligible for CPR program services, individuals must be determined to be seriously and persistently mentally ill, or, for children, have a serious emotional disturbance, as measured against diagnostic, disability and duration criteria.

Disability There is clear evidence of serious and/or substantial impairment in the ability to function at an age or developmentally appropriate level in each of the following two areas of behavioral functioning:

Disability 1. Social role functioning/family life – the ability to sustain functionally the role of worker, student, homemaker, family member or a combination of these. For children, consider their play and leisure activities, ability to establish or maintain satisfactory relationships with peers and adults, capacity to live in a family or the equivalent of a family, learning ability, self expression or ability to communicate effectively with others, and their ability to function in school.

Disability 2. Daily living skills/self-care skills – the ability to engage in personal care (grooming, personal hygiene, etc.) and community living (handling individual finances, using community resources, performing household chores, interacting with peers, etc.), learning ability/self-direction and activities appropriate to the individual’s age and social role development.

Diagnosis A physician, advanced practice nurse, or licensed psychologist shall certify a primary diagnosis of any of the following, which may coexist with other psychiatric or medical diagnoses:

Diagnosis Schizophrenia (7 types) Delusional disorder Bipolar I disorders (4 types) Bipolar II disorders Psychotic disorders NOS Major Depressive disorder – recurrent Obsessive-Compulsive Disorder Post Traumatic Stress Disorder Borderline personality disorder Anxiety disorders (5 types)

Diagnosis (for children and youth only) Major depressive disorder, single episode Bipolar disorder, not otherwise specified Reactive attachment disorder of infancy or early childhood

Duration is evidenced by one or more of the following occurrences: Psychiatric treatment more intensive than outpatient and received more than once in a lifetime (crisis services, alternative home care, partial hospital, inpatient)

Duration Continuous residential care other than hospitalization, for a period long enough to disrupt the normal living situation Psychiatric disability has been present for one year or more and/or Treatment of a psychiatric disorder has been or will be required for longer than six months

Funding Stream CPR program services have multiple funding sources, including Medicaid for Medicaid eligible individuals, Division of Comprehensive Psychiatric Services general revenue Purchase of Service (POS) funds for those providers who have a POS contract, and individual fee for services

Funding Stream Because CPR is a Medicaid supported program, the federal government pays approximately 60 percent of the costs for clients with Medicaid eligibility The departments of Mental Health and Social Services assume responsibility and accountability for administration and reimbursement of service delivery consistent with requirements

Funding Stream The Department of Mental Health monitors each CPR provider through an annual billing audit, that coincides with the certification survey, to review for adequate service provision and compliance with Medicaid requirements

Any questions?