Transcript Rule 132 New Services Clinical Models

Rule 132
New Services
Clinical Overview
April 2007
Introduction &
Overview
Objectives for the Day
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Understand the history and process of development
for the new services
Understand the role of new services in supporting
Recovery/Resiliency
Understand the clinical framework of new services
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Community Support
Psychosocial Rehabilitation
Assertive Community Treatment
Non-Medicaid Vocational & Outreach
History and Development Process
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System Restructuring Initiative (SRI)
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SRI Workgroups
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Statewide advisory task group (consumer chaired, included
consumers, providers, trade associations, advocates, state)
Services
Financial
Access and Eligibility
Services Workgroup
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Approx. 130 individuals counting all
Individuals with mental illnesses, providers, trade
associations, hospitals, state departments, consultants
History and Development Process
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Services Workgroup Objectives
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Review service array and Rule 132 with focus on:
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Supportive of recovery/resiliency
Accessible to individuals with mental illnesses
Compliance with Medicaid State Plan and other guidance
Identify gaps
Findings
Current service definitions did not fully promote
recovery/resiliency
 Medicaid State Plan and Rule should be updated
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History and Development Process
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Workgroup established service priorities
Community Support
 Psychosocial Rehabilitation
 Assertive Community Treatment
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Subgroups formed for each of the above:
Researched Evidence-Based Practices (EBP)/Best
Practices
 Reviewed other states’ definitions
 Reviewed recent federal CMS/OIG audits/actions
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History and Development Process
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Services Workgroup Results
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Developed new definitions which
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promote recovery/resiliency
support Evidence Based Practices/Best Practices
Minimize audit compliance risk
New non-Medicaid services
 Recommended improvements to current definitions
 New definitions and recommendations were used to
develop revised Rule 132 and Medicaid State Plan
Amendment
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New Taxonomy – Rule 132 Services
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Assertive Community Treatment
Case Management – MH
Case Management – Transition
Linkage, Aftercare
Client Centered Consultation
Community Support – Individual
Community Support – Group
Community Support – Team
Community Support – Residential
Comprehensive Mental Health
Services*
Crisis Intervention
*Sunset 6-30-08
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Mental Health Assessment
Mental Health Intensive
Outpatient
Psychological Evaluation
Psychosocial Rehabilitation
Psychotropic Medication
Administration
Psychotropic Medication
Monitoring
Psychotropic Medication Training
Therapy/Counseling
Treatment Plan Development,
review and modification
New Taxonomy – DHS/DMH NonMedicaid Services
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Vocational Assessment
Vocational Engagement
Job Finding Supports
Job Retention Supports
Job Leaving/Termination Supports
Oral Interpretation and Sign Language
Outreach & Engagement
Stakeholder Education
Primary Changes to Medicaid
Taxonomy
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Service labels deleted and activities subsumed under
new definitions
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Skills Training & Development
Therapeutic Behavioral Services
Activity Therapy
Day Treatment
New/expanded services
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Community Support (Indiv., Group, Team, Residential)
Psychosocial Rehabilitation
Assertive Community Treatment
Status of Approval &
Implementation
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Medicaid State Plan Amendment (SPA)
Accepted proposed language
 Alignment between SPA and Rule
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Revised Rule 132
Recovery and
Resilience
The Goal of Services in a
Transformed Mental Health System
Recovery
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Refers to a process
The outcome of the process of recovery is that
individuals are able to live, work, learn and
participate fully in their communities
The life picture of recovery is unique for each
individual
According to research, hope is an essential
element in recovery
Facilitating Recovery: Ten
Fundamental Components
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Hope
Self-Direction
Individual and Person-Centered
Empowerment
Holistic
Facilitating Recovery: Ten
Fundamental Components
(cont.)
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Non-Linear
Strengths-Based
Peer Support
Respect
Responsibility
Recovery Components: Hope
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The catalyst to the recovery process
Provides the essential and motivating message
of a better future
People can and do overcome the barriers and
obstacles that confront them
Hope is internalized, but it can be fostered by
peers, families, friends, providers and others
Recovery Components: SelfDirection
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By definition, the recovery process must be selfdirected by the individual
The individual defines his or her own life goals
and designs a unique path towards those goals
Examples of Self-Direction in
Mental Health Services
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Strengthening ACT service planning to be a
participatory process
Community Support: promote active
participation in decision-making
Psychosocial Rehabilitation: participating in
curriculum/strategy choices and selection
Recovery Components:
Individualized and PersonCentered
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There are multiple pathways to recovery
Services take into consideration: an individuals’
unique strengths and resiliencies; his/her needs,
preferences and experiences; past trauma;
cultural background
Examples of Individualized and
Person-Centered Mental Health
Services
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Community Support: point out strengths and
suggest ways to use them; consider barriers and
suggest ways to overcome them
Community Support: include the development
of such examples as crisis contingency and
Wellness Recovery Action Plans (WRAP)
Recovery Components:
Empowerment
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Individuals with mental illnesses have the
authority to choose from a range of options
Individuals with mental illnesses have the
authority to participate in all decisions that will
affect their lives, and are educated and
supported in so doing
Recovery Components:
Empowerment (cont.)
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Individuals with mental illnesses have the ability
and opportunity to join with one another to
collectively and effectively speak for themselves
about their needs, wants, desires and aspirations
Through empowerment, an individual gains
control of his or her own destiny
Examples of Empowerment in
Mental Health Services
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ACT: person-centered service planning as
evidenced by person’s participation in service
planning meetings with the team
PSR: inclusion of individuals with mental
illnesses in program design, development,
planning, implementation, evaluation
Recovery Components: Holistic
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Encompasses an individual’s whole life,
including
 Mind
 Body
 Spirit
 Community
Recovery Components: Holistic
(cont.)
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Embraces all aspects of life, including
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Housing
Employment
Education
Mental Health and Healthcare Treatment Services
Complementary and Naturalistic Services
Addictions Treatment
Spirituality, Creativity, Social Networks, Community
Participation, and Family Supports as determined by the
person
Examples of Holistic Strategies
in Mental Health Services
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Community Support: Encourage identification
and enhancement of the existing natural
supports in the individual’s social system
Community Support: Assist the individual to
maximize the degree to which natural supports
can be used
Recovery Components:
Non-Linear
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Not a step-by-step process
Based on continual growth, occasional setbacks,
and learning from experience
Begins with an initial stage of awareness in
which a person recognizes that positive change
is possible
Examples of Non-Linear
Components of Mental Health
Services
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If a person is receiving Community Support and
has a temporary increased need:
Add PSR for a period of time
 Intensify Community Support
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When increased need has resolved or changed,
the person can elect discontinuance of PSR
and/or reduction in Community Support
Recovery Components:
Strengths-Based
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Focuses on valuing and building on the multiple
capacities, resiliencies, talents, coping abilities,
and inherent worth of individuals
By building on strengths, individuals with mental
illnesses leave stymied life roles behind and
engage in new life roles
Examples of Strengths-Based
Focus in Mental Health Services
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Designing ACT interventions to build on the
strengths of the persons served
PSR: identifying, using and promoting strengths
Recovery Components: Peer
Support
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Mutual support, including the sharing of
experiential knowledge and skills and social
learning
Individuals with mental illnesses encourage one
another and engage each other in recovery
Individuals with mental illnesses provide each
other with a sense of belonging, supportive
relationships, valued roles and community
Examples of Peer Support in
Mental Health Services
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Strengthening ACT teams to have solid peer
support opportunities for all persons served
Peer support is encouraged throughout the
taxonomy via the RSA credential
Recovery Components: Respect
Includes respecting persons’ rights and
eliminating discrimination and stigma
 Ensures the inclusion and full participation of
persons in all aspects of their lives
 Self-acceptance and regaining belief in oneself
are particularly vital
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Recovery Components:
Responsibility
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Individuals have a personal responsibility for
their own self-care and journeys of recovery
Taking steps toward one’s own personal goals
may require great courage
Identifying coping strategies and healing
processes to promote one’s own wellness
Examples of Responsibility in
Mental Health Services
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Community Support: Teaches “how,” does not
“do for”
Community Support: Assists the individual to
do for self rather than doing for the person
Resilience
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Refers to the ability to harness inner strengths
and rebound from setbacks or challenges
People who are less resilient may dwell on
problems, feel victimized, become overwhelmed
and turn to unhealthy coping mechanisms
Allows individuals to go on with life with a
sense of mastery, competence and hope
If you aren't as resilient as you'd like, you can
teach yourself to become more resilient.
Building Resilience: Eleven
Essential Skills
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Getting Connected
Using Humor and Laughter
Learning From Your Experiences
Remaining Hopeful and Optimistic
Taking Care of Yourself
Building Resilience: Eleven
Essential Skills
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Accepting and Anticipating Change
Working Toward Goals
Taking Action
Learning New Things About Yourself
Thinking Better of Yourself
Maintaining Perspective
Fundamentals of Effective
Community Support (CS)
Pop Quiz
Of persons in the U.S. who have been diagnosed
with Schizophrenia, how many function well
with no or minimal professional supports?
A. 10%
B. 20%
C. 35%
D. 50%
New Freedom Commission Report
Pop Quiz (cont’d)
In what location do individuals with mental
illnesses learn and retain skills best?
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Counselor’s/case worker’s office
Classroom
Structured psychoeducational groups
Natural settings
New Freedom Commission Report
Pop Quiz (cont’d)
Do individuals with mental illnesses or case
managers better predict the mental health
outcomes for individuals?
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Case managers
Individuals with mental illnesses
New Freedom Commission Report
Overview
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Purpose of Community Support (CS)
What Does the Community Support Worker Do?
IL CS Definition/Core Service Activities
Areas of Core Competence for Community
Support
Differentiating Community Support from Case
Management
The Four Modalities of Community Support
10 Common Denominators of Good Community
Support
Purpose of Community
Support
Provide mental health rehabilitation
interventions and supports necessary to assist
individuals with mental illnesses to achieve
rehabilitative, resilience and recovery goals
primarily in a person’s own environment
Goes beyond just treating symptoms!
What Does the CS Worker Do?
Assists individuals with mental illnesses
and families with skills teaching and
support with respect to:
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Symptom self-management and reduction
Environmental modification for stability and
growth
Resource acquisition
Recovery planning
Development of resilience
What Does Community Support
Consist Of ?
Necessary Mental health rehabilitation
interventions and supports:
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To build capacity with the person to achieve their
self identified rehabilitative, resiliency, and recovery
goals
Designed to meet the following types of treatment
support needs of the person:
Educational
Residential
Co-occurring disorders
Social
Vocational
Mental Health
Financial
Others
Who Gets Community Support?
When & Where Do They Get It?
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Who: Services are directed toward
 Adults, Children, Adolescents, Families
 The primary beneficiary of the services must be the
individual with the mental illness
When: The changing needs of the individual dictate:
 Services hours, type, intensity, staff credential
Where: Interventions are delivered
 Primarily in natural settings (off site)
 By telephone, videoconference, face to face
What are the Goals of
Community Support?
Interventions and activities are targeted toward:
 Development of person’s capacity to manage
his or her symptoms
 Fostering the ability of the person to reduce
symptoms as much as possible
 Assist the person in promoting stability in his
or her life
 Development of person’s ability to foster
mastery & independence
IL CS Core Principles/Activities
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Promote active participation in decision-making.
Build a context in which shared decision-making
is the norm
Assist the person to:
Identify his or her strengths & ways to use them
 Identify his or her barriers to recovery & ways to
overcome them
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IL CS Core Principles/Activities
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Suggest strategies/interventions for greatest
independence
Promote recovery-oriented treatment in the least
restrictive setting
Support self determination
Education, training and assistance in the development
of the individual’s strengths, resources, preferences, and
choices
Includes the development of such examples as crisis
contingency and Wellness Recovery Action Plans
(WRAP).
IL CS Core Principles/Activities
Assist the person to develop and maximize
support from family and significant others
 Consumer focused
 Support and consultation to the individual’s
family and their support system
Interventions must be to directed to the primary well-being
and benefit of the individual and related directly to the
individual’s treatment plan.
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IL CS Core Principles/Activities
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Psychoeducation and skill building for
individuals’ families and their support systems
 With or without the individual being
present
 Family or support system psychoeducation
or skill building must relate to a need
identified in the assessment of the
individual and be reflected on the
Individual Treatment Plan
IL CS Core Principles/Activities
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Interpersonal, family, community and functional
skills training and support
Assist the person to develop:
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Functional skills with respect to adaptation to the home,
school, family, and work negatively impacted by the
individual’s mental illness.
The ability to cope at the following levels:
• Interpersonal
• Family
• Community
IL CS Core Principles/Activities
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Assist the individual with mental illness(es) to
develop tools to self-monitor, reduce and manage
symptoms in order to improve the quality of life
Help to foster the ability to identify & minimize the
negative effects of mental illness, serious emotional
disturbance, and co-occurring disorders
Assist the person in putting together a proactive
relapse management plan
In conjunction with the individual, identify risk
factors and related strategies to manage relapse.
IL CS Core Principles/Activities
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Explore trauma management skills
 Assist the individual with mental illness(es)
to develop skills for coping with trauma
and trauma issues
 Encourage the use of these skills
Staff Competencies for CS
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Embracing Recovery and Resiliency Principles
Designing & Delivering CS Interventions
Recovery-supportive approaches
 Assisting with skill-building
 Assisting individuals with mental illnesses to develop capacity to
acquire resources & supports
 Training families & natural supports in effective support
strategies
 Learning from individuals with mental illnesses and their
families/natural supports
Cultural literacy and competency
Differentiating Community
Support v. Case Management
COMMUNITY SUPPORT
 Helping individual or
family build capacity to
assess, access, and selfmonitor
 Active, rehabilitative,
recovery-oriented set of
interventions
 Teaches “how”
 Limits “doing for”
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CASE MANAGEMENT
(MH, TLA, CCC)
Assessment of resource
needs
Provide Access/Linkage
Monitoring
Client-focused professional
communications
Expressly precludes direct
provision of underlying
service
A Sidebar on Case Management
in IL
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MENTAL HEALTH CASE
MANAGEMENT
Assessment
Planning & Coordination
Identifying/investigating resources
Advocacy
Clients with multiple service needs
Explaining options
Linkage (non-transition)
Maximum 240 hours/year (including
CCC)
For persons who need assistance
getting or using services like:
- Mental health
- Housing
- Social
- Vocational
- Public benefits
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CLIENT CENTERED
CONSULTATION
Client-focused professional
communication
Maximum of 240 hours/year
(including MH Case Manage.)
Face to face or phone contacts
with other professionals involved
in treatment (internal and
external providers)
Contacts with SOF, educational,
medical system
NOT supervision or utilization
review
A Sidebar on Case Management
in IL
TRANSITION LINKAGE, & AFTERCARE
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Transition to different living arrangements consistent with improvement
& development
Maximum of 40 hours/year
Includes when:
 The person is discharged from psychiatric hospital or psychiatric
nursing home services
 A young person is transitioning to adult services
 Assisting client’s family with transition related issues
Community Support Options
CS-Res
• Extended high acuity
• Multi-disciplinary
• Intensity of service
CS-Team
CS-Individual
CS-Group
(can flex to high intensity when needed)
Four Ways of Delivering CS
Choice of intensity, frequency and modality is
governed by a matrix of factors including
individual/family preference, level of consumer need
(medical necessity), types of specific interventions
prescribed, and safety considerations.
Individual
(1 staff : 1 person)
Group
(1 staff : 2 or more persons)
Team
(Team : 1 person)
Residential
(Individual and Group)
Community Support-Individual
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A Core Service for the Target Population
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Example… Assisting the client/family to build a
natural support team, such as working with the
child’s parents to enroll the child in community
recreation activities or working with an adult to
join a church, temple or mosque.
Provided face to face, by phone or via video
conference in order to maximize accessibility
Community Support-Group
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Services to assist a group of individuals to
achieve and practice rehabilitative, resilience
and recovery goals.
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Example… A group of consumers practicing
appropriate social interaction skills.
Skill application and integration/practice in
the community.
Community Support-Team
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Provided to persons with moderate to severe
mental health symptoms meeting admission
criteria, who need more intense, coordinated and
complex intervention.
Services are delivered by a multidisciplinary team.
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Example… Client loses their medication and
experiences a crisis then requires support to problem
solve on a weekend.
Interventions to address consumer’s needs are
divided among team members
This is the first team intervention also available to
children and adolescents.
Community Support-Team
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A strong vehicle to develop community-based
supports for the transition age (17-25)
population.
A step-down from more intense services such as
ACT, SASS or supervised residential.
A step-up from less intensive community
support-individual.
Community SupportResidential
Interventions delivered to a person residing in
a state-approved living arrangement.
“State-approved living arrangement” is a nonInstitutes for Mental Diseases (IMD) residential
setting that requires State-authority approval and is
funded in part with State (non-Medicaid) dollars
(used to pay for room, board, and non-Medicaid
services). Examples include crisis residential,
congregate living, and group home arrangements.
Community Support-Residential
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For Adults
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Supervised & CILA Residential sites
Crisis Residential
For Children and Adolescents
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Children who are wards of DCFS in residential treatment
facilities
Youth placed in residential facilities by DCFS and
Department of Corrections
Persons served through Division of Mental Health’s
Individual Care Grant Program.
Ten Best Practices for CS
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Primary worker delivers service rather than
‘brokering’ referrals
Natural community supports are the primary
partners
Interventions occur in the community
Both individual and team modalities work
Individual has a consistent CS Worker
Rapp & Gosha
Ten Best Practices for CS
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Workers can be paraprofessionals. Supervisors are
experienced and fully credentialed
Caseload size (and/or acuity mix) is small enough
to allow frequent contact, if necessary
Services are time unlimited, if medically necessary
Individuals have access to familiar staff on a 24/7
basis
Workers foster individuals’ choices
Rapp & Gosha
Community Support Leads to
Progress
Where is
individual
now?
Community Support
interventions are the “inbetween” steps
Where
does
individual
want to
go?
1. Start at individual’s current capacity.
2. Move toward capacities needed to meet
recovery goals
CS Summary Concepts
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Builds Capacity
 Assists the individual to do for self rather than doing
for the person
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Active Intervention
 Develops, teaches, and supports rather than simply
observing and monitoring
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Core Service to Support Recovery/Resilience
 80% + of enrolled target population individuals
should participate in some modality of this service
Psychosocial
Rehabilitation Service
(PSR)
What Consumers Identified as
Important
“Being able to choose mental health services from
among those the agency has to offer in order to best
meet the identified treatment goals and priorities per the
individual is imperative in learning/relearning and
practicing the skills necessary for the individual to gain,
sustain and maintain a healthy quality of life.”
(Illinois Consumer Focus Group Report, 2006)
What Are the Differences?
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PSR SERVICE
New PSR service is
defined in the revised
Rule 132
Focus on agency -based
skills development
Intensive service that is a
supplement to CS
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PSR PROGRAM
Defined in the Mental
Health Program Book
Comprised of 5 core
services
Clinical home
What Happens to the Other Four
Core PSR Components?
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Peer Support
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Community Resource Development
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Incorporated into a Capacity Grant
PSR Engagement
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Embedded in all mental health services
New Non-Medicaid service
Vocational Skills Development
Included in PSR Service
 Included in new Non-Medicaid Services
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The New PSR Model
PSR Model has two separate components
 Community practice, application, &
integration (Community Support Service)
 Agency-based psychoeducation and skills
training and development (PSR Service)
What is the New PSR Service?
A recovery oriented skill-building service to assist
individuals to develop or regain skills to live,
work, learn and participate fully in their
communities.
What Consumers Identified as
Important
Being able to choose …
~ what to practice ~
~ where to practice ~
What does the New PSR Service
Consist of ?
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Necessary individual or group skill building activities
that focus on:
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Individual participation in setting goals
Socialization, adaptation, problem solving and coping skills
development
Self management of symptoms and recovery
Prevocational and work readiness
Education readiness
Identification of interests, strengths, and resources to leisure,
recreational, and community social activities
~Example~
Several individuals have a goal to lose weight that is
associated with their psychotropic medication
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Module from Healthy Lifestyle Solutions: Guide
to Weight Management
PSR skills training - developing a personal healthy
menu plan
 Community support - shopping at their local grocery
store (natural setting) to purchase food items on
their individual plans (in-vivo practice)
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~Example~
Individual(s) identify a goal to find a different place
to live that will support their recovery
PSR skills training - teaches how to locate resources
and select locations to visit, identify questions, role
play questions
 Community support – support (go with)
individual(s) to tour available apartments, ask
questions and request application
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What does the New PSR Service
Consist of ?
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Cognitive-behavioral interventions
Interventions to address co-occurring
psychiatric disabilities, medical issues, and
substance abuse issues
Core PSR Principles/Activities
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Create a recovery-oriented environment where
hope is evident and success is celebrated
Provide interventions that are recovery oriented,
person driven, evidence-based, fully integrated,
flexible, and available as needed
Assist individuals to achieve desired roles and
activities
Focus on skills development relevant to the
individual’s life
Core PSR Principles/Activities
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Develop Empowerment through Active
Involvement in:
one’s own rehabilitation
 setting personal recovery goals
 setting priorities
 choosing strategies to meet personal recovery goals
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How Does the PSR Service Relate
to Community Support Services?
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The new PSR Service is a supplement to
Community Support Service
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Community Support is the “clinical home”
Why Does PSR Require
Community Support Services?
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Research indicates that skill transfer is best
facilitated in the individual’s natural living
environment and / or community
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The emphasis of rehabilitation services needs
to be shifted to community integration and
recovery
Who Receives the New PSR
Service?
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Individuals who are receiving community
support services and need some additional
assistance to meet one or more of their recovery
goals. Example:
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Individual is not making progress toward their selfidentified recovery goals and identifies a need for
more assistance
~Example~
Community Support + PSR
Client is severely depressed and at risk for hospitalization as evidenced by: lack
of energy, increased anxiety, not eating adequately, not caring for physical
self, lack of interests, difficulty sleeping and awakening. Community
Support – Individual service has not resulted in improvement over 4 months.
Referral to PSR as an adjunct to Community Support.
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Focused PSR interventions including helping person to learn and practice
relaxation and anxiety reduction techniques.
PSR Groups to identify strengths, interests, goals, barriers to meeting goals,
strategies (use of strengths, ways to avoid barriers, skills to develop natural
supports)
Community Support – Individual/Group used to practice and integrate skills
learned in PSR, into community. Once integrated, PSR discontinues and
Community Support continues
Staff Competencies for PSR



Embracing Recovery/Resiliency principles
Orientation and integration of persons with
mental illnesses as part of the staff team
Inclusion of persons with mental illnesses in
service design
Staff Competencies for PSR




Assessing skills and supports
Identifying natural environments/natural
supports
Identifying, using and promoting strengths
Using Motivational Interviewing
Staff Competencies for PSR


Converting all areas of life into skills training
Designing and implementing diverse skills program







Planning program design
Including Evidence Based Practice
Introducing skills training modules
Adapting skills training
Individualizing skills sessions
Engaging individuals
Providing clinical supervision
Summary


The new PSR service is a supplement to Community
Support
The new PSR service is designed to help individuals
become fully-integrated members of their community
thru:




Helping individuals identify their personal goals
Providing individuals with services choices
Providing Recovery oriented skills training
Integrating of skills training with Community Support
Assertive Community
Treatment
(ACT)
Presentation Goals
1) Brief review on why the ACT definition is
being changed.
2) Describe who receives the new ACT service.
3) Discuss ACT service interventions and
activities.
4) Define who delivers the new ACT service.
Principles Driving the Change to the
New ACT Definition
1) Belief in recovery driven services.
2) Need to focus limited ACT resources on
people with most acute needs.
3) Compliance with Medicaid expectation that
ACT services be comprehensive, wraparound package.
Strengthening ACT to be
Evidence-Based Service
A. Admission criteria assure that persons most in
need receive ACT for the appropriate length
of time.
B. Service planning is a participatory process.
C. Interventions build on strengths of the person
served.
D. Skills training to occur in natural settings as a
strategy to restore functioning and promote
recovery.
Strengthening of ACT (cont.)
E. The recipients receive comprehensive, wrap–
around services & supports.
F. The team has the capacity to respond to
emergency psychiatric needs (24/7).
G. The service includes solid peer support.
H. The documentation always supports the
medical necessity for ACT level of care.
About Evidence Based Service
To be an evidence based service, you must:
1) Deliver the service to the population for whom
the service has been proven to be effective;
2) Deliver the service interventions and activities
consistent with those that have been tested and
proven effective; and,
3) Provide the service interventions by the staff who
have the qualifications, case loads, and
integrated team-functioning that have been
tested and proven effective.
Who To Enroll in ACT
ACT to engage persons with:







High acuity and/or complex needs
Episodes of repeat or chronic homelessness
Episodes of incarceration in jail and prisons
Multiple psychiatric hospitalizations
History of poor engagement or response to traditional
approaches
Documented functional impairments to community living
Most severe and persistent mental illnesses
ACT is an Evidence Based Practice
for…
Schizophrenia
Schizophreniform Disorder
Schizo-Affective Disorder
Delusional Disorder
Shared Psychotic Disorder
Psychotic Disorder
Brief Psychotic Disorder NOS
Bi-Polar Disorder
Core ACT Interventions
& Activities
1) Comprehensive assessment by the team.
2) Individualized treatment/service and
recovery planning.
 Person’s participation in the service plan meeting;
 Person’s service priorities are addressed in service
plan;
 Service plan has skills training activities that build
on strengths; and,
 Service plan uses natural surroundings and not the
agency setting.
Core ACT Interventions &
Activities
3) Assignment of primary service coordinator
to:




Write the service plan with the individual;
Ensure immediate changes to the service plan
are made as needs change;
Act as “point person” for family, and,
Etc.
Core ACT Interventions &
Activities
4) Provide dual diagnosis substance abuse
services, including :
a. Stage-based approaches, such as:





Engagement
Assessment
Motivational enhancement
Active treatment
Continuous relapse prevention
Core ACT Interventions &
Activities
5) Work and education related services.
6) Peer Support Services:
a. Peer counseling and support
b. Linking to self-help programs and
organizations that promote recovery.
7) Environmental and other Support Services:
 Medical & Dental
 Housing
 Benefits
Distinguishing
ACT Requirement
“Services must be available 24 hours/day, 7
days a week with emergency response
coverage, including psychiatric coverage.
Crisis services shall be provided 24 hours per
day, seven days per week by the ACT team
assigned to the individual.”
Who Delivers ACT Service
“ACT team requires a minimum 6.0 FTE
staff (excluding the psychiatrist and the
program assistant).”
ACT Team Composition




Full-time team leader (licensed clinician)
Full-time registered nurse
Four rehabilitation services associates (RSAs)
Plus:

Psychiatrist (minimum 10 hrs/wk/60 registered
individuals)

A program/administrative assistant.
ACT Team Leader
“Full-time team leader who is the clinical
and administrative supervisor of the
team and also functions as an ACT
clinician. The team leader shall be a
licensed clinician.”
ACT Registered Nurse
“A full-time registered nurse who provides
services to all ACT individuals and who works
with the ACT team to monitor each individuals
clinical status and response to treatment. The
registered nurse functions as a primary
practitioner. For a period of two years
following the adoption of this service, existing
ACT providers may use an LPN with two years
experience in mental health services as part of
an ACT team…”
Other ACT Team Positions…
“Four rehabilitation service associates who work
under the supervision of a licensed clinician and
function as primary practitioners for a caseload of
individuals and who provide rehabilitation and
support functions”
The ACT Psychiatrist
“A psychiatrist who works on a full- or parttime basis for a minimum of 10 hours per
week for every 60 individuals. The psychiatrist
must provide clinical and crisis services to all
team individuals, work with the team leader to
monitor each individual’s clinical and medical
status and response to treatment, and direct
psychopharmacologic and medical
treatment…”
ACT Program Admin Assistant
“…is responsible for organizing, coordinating, and
monitoring all non-clinical operations of ACT,
including managing medical records; operating and
coordinating the management information system;
maintaining accounting and budget records for
individual and program expenditures; and providing
receptionist activities, including triaging calls and
coordinating communication between the team and
individuals.”
Required Competencies
A. At least one member of the team must be trained and
certified to provide substance abuse and/or cooccurring disorders.
B. At least one member of the team should be a person
in recovery and, if available, credentialed as a
Certified Recovery Support Specialist.
C. At least one member of the team must have training
in rehab counseling, especially vocational, work
readiness, and educational support.
Requirements for the
Whole ACT Team
1) Each ACT team is expected to maintain a
staff to individual ratio of no more than
1:10.
2) Each team is expected to reflect the
language, culture, and ethnicity of the
population being served.
Competencies for Successful
ACT Team Leaders
1) Ability to lead a recovery-focused service planning
process that fully includes the person served.
2) Leadership to assure clinical focus and orientation
3) Model for continuous learning.
4) Good leadership skills with ability to keep team
members from different disciplines working
together.
5) Management to assure that documentation
supports medical necessity.
Competencies for Successful
ACT Team Members
1) Belief that people can and will recover.
2) Respect for individuals regardless of level of
recovery.
3) Ability to work as a team member.
4) Ability to work and do assessments in-vivo.
5) Ability to be creative when engaging people in
services and a corresponding avoidance of
“coercive” techniques.
6) Respect for an individual’s cultural and trauma
background.
Competencies for Successful
ACT Teams
Ability to support and train in the basic
community living skill areas of:





Safe affordable housing
Accessing entitlements and benefits
Activities of daily living
Medication management
Health care needs
ACT Team vs. CS-Team
ACT Team
CS-Team
1:10 staff to persons served ratio 1:18 staff to persons served ratio
Serves narrower range of people
Serves broader range of persons
Requires at least 6.0 FTE staff
Requires at least 3.0 FTE staff
Requires M.D., R.N., on team
MD, RN not required on team
Requires person in recovery
Person in recovery not required
Requires SA/MISA specialist
SA/MISA specialist not required
Requires Rhb/Voc/Sp Ed spcl
Rhb/Voc/Sp Ed spcl not rqrd
Requires 24/7 crisis intervention
May use auxiliary crisis services.
Thank You!
Non-Medicaid
Services
DMH Contracted Only
Evidence-Based SE Principles








Find & keep competitive employment
Vocational interventions are fully integrated
w/mental health treatment
Anyone who wants to work is eligible
Rapid job search
Time unlimited service
Jobs seen as transitions
Consumer preferences are important
Benefits planning
Vocational Engagement
Activities for a specific person to engage them
in making a decision to actively seek
competitive employment or formal
credit/certificate bearing education.
Note: this does not include pre-vocational agency based
work programs or agency based education programs that
do not result in credentials recognized by an employer.

Vocational Assessment
Developing a vocational profile to guide
individual choices in seeking and maintaining
competitive employment.
 Work history, interests, skills, strengths,
education, impact of symptoms, job preferences.
Note: This does not include pre-vocational work experiences
or simulated/situational work experiences at the agency.

Job Finding Supports
Activities for a specific individual, directed toward
helping them find and procure a job, when provided
under the following conditions: placement based on
consumer job preferences, competitive employment in
integrated work settings, ongoing supports as needed
and integration of supported employment services with
other mental health services.
Note: does not include general job development.

Job Retention Supports
Directed toward helping the individual keep his/her
competitive integrated job.
 Interventions that are specific to work and the job are
considered job retention supports.
Note: therapeutic support to help individuals manage their mental
health symptoms and illness as they work toward achieving their
recovery goals is a Rule 132 service. Recovery goals can include
employment goals.

Job Leaving/Termination
Supports
Directed toward helping the person leave a job
in good standing, or view unplanned job loss as
transitional and a learning experience that will
help them with the next job.
Intent: Job loss is not seen as a reason to discontinue
participation in supported employment.

Outreach and Engagement
&
Stakeholder Education
Two related services…

Outreach and Engagement – Reaching out to
people with mental illnesses or emotional
disorders and bringing them into the public
mental health system.

Stakeholder Education – Going into
community to speak/train/educate groups
about mental illnesses, treatment alternatives,
access issues, etc.
Outreach & Engagement:
Activities & Interventions




Case finding to identify adults, adolescents, and
children suspected to have a mental illness or
emotional disturbance who have not consented to
services, require engagement or re-engagement to
services.
Interventions to link to emergency medical or
psychiatric care.
Repeat contacts over extended periods of time to
engage.
Developing strategies to reduce or eliminate risk.
Facts About
Outreach & Engagement





No prior authorization needed.
Funded with State dollars only.
A new FFS option; however, NO new contract dollars
involved in roll-out.
This first iteration of the service is based on the
experience of Illinois providers working with these
special populations.
Division has more freedom to revise the definition
and intends to monitor & modify as desired.
Outreach & Engagement:
Service & Clinical Exclusions
 People already engaged in DMH provider
service not eligible for Outreach & Engagement.
 Discontinuation of O&E should happen when
person found to have certain non-MH disorders.
 Not intended to cover activities of PATH or
other federally funded project staff.
Stakeholder Education:
Activities & Interventions



Educational meetings with stakeholder groups to
provide information about the signs and symptoms of
mental illnesses/emotional disturbances.
Meetings to collaborate with other community
service sites and build opportunities for referral and
engagement of people in need.
Public speaking engagements that strengthen the
relationships among stakeholder groups and the
public MH system.
Stakeholder Education:
Goals
 To support collaboration between DMH
providers and community stakeholders that have
regular contact with high risk populations.
 To fight stigma with information about the signs
and symptoms of mental illnesses & emotional
disturbances and the availability of public MH
services.
 To promote innovative service access strategies.
Stakeholder Education:
Facts





No prior authorization needed.
Funded with State dollars only (non-Medicaid).
A new FFS option; however, NO new contract
dollars.
This first iteration of service is based on provider
history of performing these activities.
Division has more freedom to revise the definition
and intends to monitor & modify as desired.
Stakeholder Education:
Service Exclusions
The following activities are not covered:
1. Ad hoc gatherings or impromptu presentations
lacking advance preparation.
2. Repetitious trainings with regard to content or
attendees.
3. The service is provided as an activity of a Program to
Aid in the Transition from Homeless (PATH) or any
other federally funded project operated by the
provider.
Thanks Again!
Supplemental
Materials
Medicaid Overview
Parameters and Medical Necessity
Medicaid Overview



Medicaid is a health entitlement program for
people who are low-income and/or disabled that
is jointly funded by the federal government and
the state government
The federal government sets basic parameters
and approves State customization of a Medicaid
plan (called a ‘State Plan’)
The basic Medicaid plan primarily covers inclinic and in-hospital services.
Three Primary Medicaid Options



Clinic Option
 In clinic and in hospital services
 Physician directed
Targeted Case Management (TCM) Option
 Specific population
 Assessment, planning, linkage, follow up
 No direct interventions
Rehabilitation (Rehab) Option
IL Mental Health Services
by Medicaid Option
Targeted Case Management


Transition Linkage &
Aftercare
Mental Health Case
Management
Rehabilitation Option

All other Rule 132
services
Medicaid Psychiatric Rehabilitation
Option




Used with behavioral healthcare
Focuses on community-based services that
actively encourage rehabilitation and progress
toward a return to optimal functioning
Emphasizes participation and choice
Requires rehabilitation from a psychiatric
disability
Federal Guidance says
Rehabilitation Is:

Restoration of basic skills necessary to function
independently/developmentally appropriate in
the community
 Examples: food planning and preparation,
maintenance of living environment,
community awareness, mobility skills,
academic participation
Federal Guidance says
Rehabilitation Is:

Redevelopment of communication and
socialization skills
 Especially those skills that help individuals
with mental illnesses move toward
recovery/resiliency, maintain age
appropriate community living, and achieve
optimal independence from disability
Federal Guidance says
Rehabilitation Is:

Family education and other family services
exclusively related to treatment or
rehabilitation of the covered individual.
Federal Guidance says
Rehabilitation Is:

Interventions which will assist individuals
to build capacity to gaining access to
needed medical, social, educational and
other services.
 These services might include housing,
social services, vocational training and
education.
Federal Guidance says
Rehabilitation Is NOT:






Vocational services (especially job training)
Academic education
Purely Socialization
Purely Recreation
Transportation
Watchful Oversight
BUT Rehabilitation CAN
provide:

Skills teaching and support critical to successful
job functioning,
 including ability to get along with peers and
supervisors, concentrate on tasks at hand,
work at a reasonable pace, persist at tasks,
present self (cleanliness, attire and
communication) appropriately for the work
site, maintain work schedule (show up on
time), and follow instructions.
AND Rehabilitation CAN
provide:

Social skills and basic and daily-living skills
required for success in an academic program.
 Note: Academic goals can be included in
Service Plan as long as focus is on
rehabilitative skills that allow person to
complete that education, reduce disability,
and restore the individual to his or her best
functional level.
AND Rehabilitation CAN
provide:

Skills development and practice of skills
necessary to structure and use leisure time,
recreational opportunities, and social occasions.
 Improving natural support systems
 Developing relationship skills
 Planning skills
 Reducing isolation and withdrawal
Federal Guidance says
Rehabilitation Is Medically
Necessary:

What does that mean?
 Focus on issues caused or impacted by
psychiatric disability and directly related
to the mental illness
 Not just beneficial – necessary to
remediate the disability
Demonstrating Medical Necessity:
Five Basic Steps





Assessment documents psychiatric condition and
impact on functioning
Service Plan addresses areas identified on
assessment and includes steps to returning to
baseline (Signed by authorized person)
Service Plan prescribes services in amount & duration
reasonably expected to foster change
Interventions (& notes) directly relate to Service Plan
Notes demonstrate progress
Building Resilience
Eleven Essential Skills
Resilience Skills: Getting
Connected



Building strong, positive relationships with
family and friends
Getting involved in civic groups, faith groups or
volunteer organizations
Fulfilling the need for a sense of belonging and
banishing loneliness through
relationships/connectedness
Resilience Skills: Using Humor
and Laughter



Remaining positive/finding humor in distressing
situations does not mean a person is in denial
Humor is a helpful coping mechanism
Funny books and movies can add humor to life
Resilience Skills: Learning From
Our Experiences



Recalling how you have coped with hardships in
the past, either in healthy or unhealthy ways
Building on what helped you through the rough
times; not repeating actions that did not help
Figuring out what lessons you learned and how
you will apply them when faced with similar
situations
Resilience Skills: Remaining
Hopeful and Optimistic



Looking toward the future, even if it’s just a
glimmer of how things might improve
Finding something in each day that signals a
change for the better
Believing things happen for a reason often helps
to sustain people
Resilience Skills: Taking Care of
Yourself



Tending to your own needs and feelings, both
physically and emotionally
Participating in hobbies you enjoy; exercising
regularly
Getting plenty of sleep; eating a well-balanced
diet
Resilience Skills: Accepting and
Anticipating Change



Being flexible: change and uncertainty are part
of life
Trying not to be so rigid that even minor
changes upset you or that you become anxious
in the face of uncertainty
Expecting changes to occur makes it easier to
adapt to them, tolerate them, and even welcome
them
Resilience Skills: Working
Toward Goals



Doing something every day that gives you a
sense of accomplishment
Recognizing that even small, everyday goals are
important
Having goals which help direct you toward the
future
Resilience Skills: Taking Action




Figuring out what needs to be done
Making a plan to do it
Taking action to resolve your problems
Wishing problems away, or ignoring them, does
no good
Resilience Skills: Learning New
Things About Yourself



Looking back on past experiences and thinking
about how you’ve changed as a result
Recognizing that you may be stronger than you
thought
Exploring new interests, such as taking a
cooking class or visiting a museum
Resilience Skills: Thinking Better
of Yourself





Congratulating yourself for enduring hard times,
loss or stress
Being proud of yourself
Trusting yourself to solve problems and make
sound decisions
Thinking positive thoughts about yourself
Nurturing your self-confidence and self-esteem
so that you feel you’re a strong, capable and selfreliant person
Resilience Skills: Maintaining
Perspective




Recognizing that perspective is not about comparing
yourself to others
Comparing yourself to someone who may be worse off
may only make you feel worse or feel guilty
Perspective is about looking at your situation in the
larger context of your own life, and the world
It is about keeping a long-term perspective and
knowing that your situation can improve if you actively
work to make it better
A Brief Bibliography on
Recovery/Resiliency
Anthony, William. A Recovery-Oriented Service System: Setting
Some System Level Standards. Psychiatric Rehabilitation
Journal, Vol. 24, No. 2. (2000).
National Consensus Statement on Mental Health Recovery. U.S.
Department of Health & Human Services. Substance Abuse &
Mental Health Services Administration. Center for Mental
Health Services. 2006
New Freedom Commission on Mental Health, Achieving the
Promise: Transforming Mental Health Care in America. Final
Report. (2003)
Additional New
Services Information
4 Ways of Delivering CS:
Quick Review
Person Receiving:




Factors common to all four
ways:
CS-Individual: An individual
staff member will work with
you.

ALL work toward mutually agreed
upon rehabilitative, resilienceoriented, and recovery-focused goals.
CS-Group: One or two staff
members work with you and
other consumers together.

A minimum of 60% of all CS
services must be delivered in natural
settings.

CS occurs at locations that reasonably
accommodate the person’s needs,and
at hours that do not interfere with
work, educational, and other
community activities.
CS-Team: A team of staff
members will work with you
CS-Residential: You’ll receive
service in a residential setting
from several staff members
A Brief C.S. Bibliography
Center for Psychiatric Rehabilitation, Sargent College of Health and
Rehabilitation Sciences. Boston University: Recovery from Serious
Mental Illness.
Farkas & Anthony (Eds.). Psychiatric rehabilitation programs: Putting
theory into practice. Baltimore, MD: Johns Hopkins University Press
The President’s New Freedom Commission: Goals and Recommendations
for a Transformed Mental Health System.
available at: http://www.mentalhealthcommission.gov/
Rapp. The strengths model. NY: Oxford U. Press, 1998
Rapp and Gosha: The Principles of Effective Case Management; Psychiatric
Rehabilitation Journal, Spring 2004—Volume 27, Number 4
EVIDENCE-BASED ACT WEB
SITE
SAMSHA' National Mental Health
Information Center
Evidence-Based Practices: Shaping Mental
Health Services Toward Recovery
http://mentalhealth.samhsa.gov/cmhs/com
munitysupport/toolkits/