Community Access to Recovery Services (CARS) CCS – The Service Array JENNIFER ALFREDSON Milwaukee County BHD Community Access to Recovery Services (CARS)

The CCS Service Array Can be found in the Forward Health Update, June 2014, no. 2014-42 Attachment 1 https://www.forwardhealth.wi.gov/kw/pdf/2014-42.pdf Milwaukee County CARS CCS website: http://county.milwaukee.gov/CCS.htm A link to the Forward Health update is on the CARS website.

PARTNERING WITH CONSUMERS IN THE RECOVERY PROCESS

“Psychosocial Rehabilitation Services” Per DHS 36: Namely the medical and remedial services and supportive activities provided to or arranged for a consumer by a comprehensive community services program authorized by a mental health professional to assist individuals with mental disorders or substance use disorders to achieve the individual’s highest possible level of independent functioning, stability and independence and to facilitate recovery. *All services must be Rehabilitative in nature. That means that you are working with the consumer to set goals and make progress, not doing things for them.

“Give a man a fish and you feed him for a day “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime” -old Chinese proverb

Service Array 1 Screening and Assessment Normally done first in the CCS admission process Agency can do an abbreviated assessment, perform services first, and return to the assessment process within 3 months. Includes the MH/AODA Functional Screen (staff must be certified) Also includes a written Assessment and Assessment Summary This would include sending for, receiving, and reading medical records S&A can be re-visited as needed, but must be done at a minimum yearly (MH/AODA FS) Beyond Intake, S&A can be a service. Some examples include an AODA screen or a Social Security assessment.

Service Array 1 - example For CCS clients that are not engaged in Substance Use (SU) treatment services, follow the CARS/CCS SU referral process which includes comprehensive screening by IMPACT. SU needs are reflected on the IRP A screen or mobile screen, based on the needs of the client, is scheduled with IMPACT IMPACT completes the screen and forwards results to CCS CC, IRP updated, sent to CARS CARS enters/authorizes CCS SU services

Service Array 2 Service Planning Includes Developing a written Individualized Recovery Plan (IRP) Development of the plan should occur in the context of a Recovery Team Meeting. Minimum membership to the team includes the consumer, care coordinator, mental health professional, and substance abuse professional if applicable. Other formal supports and natural supports are encouraged to be a part of the Recovery Team. The first IRP must be completed within 30 days of the consumer signing the CCS application/admission agreement. IRP’s should be living documents, updated any time there is a change. Even if it’s been updated in the middle, the IRP again needs to be updated every 6 months.

Service Array 3 Service Facilitation Milwaukee is calling the staff “Care Coordinators”. (i.e. Service Facilitation = Care Coordination) The CC oversees the IRP process, the Recovery Team, and all services listed on the IRP. The CC can also be a direct service provider as laid out on the IRP.

Service Array 4 Diagnostic Evaluations Includes specialized evaluations such as neuropsychological, gero-psychiatric, specialized trauma, and eating disorder evaluations. Providers must be listed in the Program Directory on the website and be practicing within their scope.

Service Array 5 Medication Management Split into 2 categories: Prescribers and Non-Prescribers Psychiatrists / APNP’s may bill through CCS instead of Medicaid or HMO’s for Medicaid. If consumers have doctors that are not in the CCS network, the doctors may bill Medicaid/HMO’s directly. In order for a psychiatrist / APNP to become a CCS provider, they must get the 20 hours of orientation/training.

Service Array 5 Medication Management – con’t Services for non-prescribers: Can monitor meds at a level that the consumer chooses. The Care Coordinator can do the service, or hire a different worker or even a different worker at a different agency. Can also spend time assisting the consumer to understand their meds, benefits, and symptoms that they are treating. Also covers the monitoring of symptoms and tolerability of side effects

Service Array 6 Physical Health Monitoring Again – this can be done by the CC or by a different staff within your agency or by a different agency altogether. Staff must work within the scope of their training (always) For physical health, there are some things that staff can do after demonstrating competence, such as diabetes testing. Assisting, training, monitoring for both the consumer and their family.

Service Array 7 Peer Support Can only be done by a Certified Peer Specialist (CPS) so unless your CC is a CPS, you will be hiring out this service to someone at your agency or perhaps a different agency. CPS can assist the consumer AND their family. Even if the Care Coordination agency does not have a Peer Support Specialist on staff, they must offer this service to all CCS consumers.

Service Array 8 Individual Skill Development and Enhancement Again, services can be done by CC or a different staff at same agency or different agency. There may be more than one staff hired to do this service at the same agency or different. Will cover things such as grocery shopping, banking, payeeship, ADL’s, transportation – as long as it is in the IRP and it is demonstrated that teaching will occur and progress made. Connecting to community resources and services could mean helping a consumer find housing, apply for housing, My Home recertifications, yearly T19 and Foodshare renewals, apply for Social Security, etc.

Service Array 9 Employment Related Skill Training Emphasizes use of evidenced-based Practice Primary model-Individualized Placement and Supports (IPS) Supported Employment Model

INDIVIDUALIZED PLACEMENT AND SUPPORT (IPS)- SUPPORTED EMPLOYMENT Evidenced-based practice Highly researched and proven to be effective Model designed to offer ongoing employment related supports for adults coping with SPMI and/or substance use disorders (currently being further researched with youth/young adult populations) Supportive research, fidelity scale and related information http://sites.dartmouth.edu/ips/

IPS PRINCIPLES Work can promote recovery and wellness IPS supported employment practitioners focus on client strengths and meet the client where they are at Practitioners work in collaboration with state vocational rehabilitation IPS uses a multidisciplinary team approach (employment specialists are built into MH/AODA treatment teams) Employment specialist (ES) focuses on employment related services ONLY, (does not take individuals grocery shopping, perform medication drops, etc.) Employment Specialist may work on symptom management and reducing substance use as these are areas that may impact work related function Services are individualized and long-lasting

IPS PRINCIPLES (CONTD.)  The IPS approach changes the way mental health services are delivered (philosophical shift), emphasis of recovery and positive outcomes Emphasis on finding competitive employment (no sheltered employment) Forming direct relationships with employers in the community through face to face contact and marketing Job choice is based on consumer choice and preferences, NOT provider judgment Can include supported education to desired build skill sets Zero exclusion philosophy (includes mental health stability and active substance use) Rapid Job Search- initial job assessment and first contact with employer (either with client or on behalf of them within 30 days of referral)

IPS IN MILWAUKEE COUNTY Currently being piloted in one CSP and two CCS teams Plans for expansion 2015

Service Array 10 Individual and/or Family Psychoeducation Skills training, problem solving, social and emotional support Can be done with the consumer and/or their family. Can be provided individually or in a group Can be done by the CC or by someone else, possibly a Peer Specialist (certified or not)

Service Array 11 Wellness Management and Recovery / Recovery Support Services Mental Health Services: Empowering consumers, helping them to develop their own goals. Teaching knowledge and skills necessary to make good decisions. Can be the CC or someone else, can be individual or group setting. Possibly a Peer Specialist (certified or not)

Service Array 11 Wellness Management and Recovery / Recovery Support Services Substance Abuse Services: Assisting the consumer to increase engagement with treatment. Developing coping skills Relapse prevention and follow ups

Service Array 12 Psychotherapy Would generally not be provided by the CC, unless the CC is licensed to provide therapy. Can refer within the CC’s same agency, or a different agency listed in the Program Directory. Can be individual or group setting If a consumer is in CCS, they must received their psychotherapy by a CCS provider. Psychotherapists cannot bill T19/HMO’s directly.

Service Array 13 Substance Abuse Treatment Would typically not be served by the CC Can be individual or group setting CCS does not pay for Residential Treatment or Detox. Some of those services may still be covered by Medicaid/HMO’s. Residential Treatment providers that are CCS providers can provide CCS services for services on the array.

Service Array 14 Non-Traditional or Other Approved Services The service must have a psychosocial rehabilitative purpose. It cannot be merely recreational It would not otherwise be available to the consumer. Gym membership/exercise, yoga, acupuncture, massage, art therapy, etc. The only service that needs a prior authorization.

DHS 36.17 (4) Service Delivery (a) Psychosocial rehabilitation and treatment services shall be provided in the most natural and least restrictive manner and most integrated settings practicable consistent with current legal standards, be delivered with reasonable promptness, and build upon the natural supports available in the community. (b) Services shall be provided with sufficient frequency to support achievement of goals identified in the service plan. (c) Documentation of the services shall be included in the service record of the consumer under the requirements in s. DHS 36.18

“Rosters” Each agency will have a Roster. Staff need to be approved as a provider, for specific services on the array. An agency can add a staff by utilizing the form on the CCS website titled “Direct Service Staff Add Form”. You can also add a new service for an existing approved staff. You can also remove staff from your roster utilizing the “Provider Staff Drop Form”

“Rosters” Look at an example of a Roster and demonstrate the correlation between the positions and the services on the array. For Care Coordination agencies, all rosters need: Screen and Assessment, Service Planning, Service Facilitation, Mental Health Professional, and Substance Use Professional.

At least one Care Coordinator is necessary, but a second back up (perhaps a supervisor) is encouraged due to vacations, sick time, etc. All Mental Health/Substance Use Professionals should be approved for Screen and Assessment and Service Planning because the MHP and/or SUP will be involved in both of those two processes. The Care Coordinator can usually do several more services on the array.

For Service Array #7, the provider must be certified. The Certified Peer Support Specialist can also be approved to provide many other services on the array. A Peer Support Specialist who is not yet certified can also provide many services on the array, but not #7.