Lauren Tegnander, LCSW and Jenny Crave, MS, CAS Program Directors Rehabilitation Support Services, Inc.

REHABILITATION SUPPORT SERVICES, INC.

 Serves individuals with psychiatric disabilities and substance abuse issues  Services include:  Residential programs (OMH Certified, Supported Housing, Community Residence, SRO)  Care Coordination Services  PROS (Personalized Recovery Oriented Services)  Supported Employment  Mental Health Clinic

RSS/MCCDC Counties Served Clinton St. Lawrence Franklin Essex Jefferson Chautauqua Lewis Hamilton Warren Niagara Erie Cattaraugus Oswego Oneida Orleans Monroe Wayne Onondaga Genesee Wyoming Livingston Ontario Yates Sene ca Cayuga Schuyler Tompkins Cortland Madison

Chena ngo

Allegany Steuben Chemu ng

Tioga

Broome Herkimer

Otsego Delaware

Fulton Montgomery

Schoh arie

Greene Saratoga

Albany

Washington Rennss elaer Columbia

Schenectady Ulster Dutchess

DOTS Orange/Sullivan Division A Division C WUD MCCDC

Sullivan Orange

Rockland Bronx Kings Richmond Putnam

Westchester

New York Suffolk Nass au Queens

SOME FACTS…

   Individuals living with mental illness have an increased risk for chronic medical conditions and generally die, on average, 25 years earlier than the average American population as result of these treatable medical conditions One in four adults−approximately 61.5 million Americans−experiences mental illness in a given year. One in 17−about 13.6 million−live with a serious mental illness such as schizophrenia, major depression or bipolar disorder.

Suicide is the tenth leading cause of death in the U.S. (more common than homicide). More than 90 percent of those who die by suicide had one or more mental disorders. (Reference: National Alliance on Mental Illness (NAMI) http://www.nami.org/factsheets/mentalillness_factsheet.pdf)

IN THE MIDST OF CHANGE…

 Health Home Care Management Services and DSRIP  Statewide goal to reduce avoidable hospitalization and ER visits by assigning a care manager to coordinate services  Full system transformation that will bring previously independent professions together to work collaboratively in order to provide care to the whole person (i.e. collaboration amongst substance abuse, medical, and mental health providers)  Look at alternative solutions and be creative when problem solving!

   

BEST PRACTICES

Collaboration     Know who is involved in a client’s life (family, social, mental health, medical, and other providers?) Talk to everyone who is involved-regularly!

Listen to one another and be honest about what your thoughts are Ensure that an individual has all of the necessary support they need Coordination   Implementing a plan that is right for the client Everyone involved knows what their role in the plan is and how to go about implementing their role Person Centered Focus   The client is an informed participant in making decisions about their own care Just because we think we know what is best doesn’t mean it is best for that person Outcome based care  A focus on outcomes to ensure that quality care is being provided

LESSONS LEARNED THUS FAR…

       Change is challenging and uncomfortable Working together and listening to what others have to say can provide you with great ideas and insight Everyone wants what is best for our clients and community There are a lot of great providers and programs in our community that we may not have realized existed previously Open, honest, and direct communication is key Don’t get stuck in the “us vs. them” mentality or else it will not work!

Everyone can bring something to the table

WHAT WE STILL NEED TO WORK ON….

 Training across systems and professions to provide our staff with the resources they need to make appropriate referrals  Communication can always be improved!

 Our ability to look at the world and service delivery system differently  Developing best practices for outreach and engagement to hard to reach populations

Let’s keep educating each other to work together!

     RSS has many programs that may be beneficial to the individuals you serve!

Most of our programs require individuals to be diagnosed with a Serious and Persistent Mental Illness as part of the admission criteria An intake assessment will be done upon receipt of a referral to determine which level of care would be most appropriate and beneficial A large percentage of the clients we serve have comorbid medical conditions—so we do not only manage mental health!

We are always trying to find new places to refer our clients to and think outside of the box when we are serving them

OUR SERVICES

 Health Home Care Management  What is it?

   Individuals are assigned a Care Manager to coordinate amongst all providers/social supports involved in a patient’s life Care Manager ensures necessary referrals are submitted for all wrap around services Care Manager problem solves should an impending avoidable ER visit be foreseen

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Our Services

Residential Programs-all residential programs require documented SPMI as a criteria for admission   Types:   Community Residences-24 hour per day staff support, group living, medication management, daily living skills, budgeting assistance, symptom management, etc.

Treatment Apartment Programs-individuals live in individual scattered sites within community, visits by staff one-two times per week, medication management, budgeting assistance, symptom management, etc.

 Supported Housing Programs-varying level of supports. Individual pays 30% of income towards rent, permanent housing, staff primarily assist with housing needs including: landlord communication, apartment searches, and signing a lease. In each county there are programs that may be specific to client needs (i.e. MICA, medically compromised, diversion, etc.).

Our Services

 Personalized Recovery Oriented Services (PROS)  Programs in Albany and Orange Counties  Assists individuals with mental illness in achieving their life goals  Combination of treatment, psychiatric rehabilitation, and vocational services  Individual identifies their goal and services are tailored to assist in attaining this goal  Services are provided individually, in a classroom, or offsite as needed

Our Services

 Capital District Clinic  Albany County  Provides treatment services for individuals diagnosed with mental illness  Services include: clinical visits, psychiatry appointments, and a nurse for health monitoring

How to find out more…

 Each county follows a slightly different procedure for referrals  Most housing referrals go through the Housing SPOA process  Care Management referrals can be sent directly to the program to be engaged  Go to rehab.org and click on the county that you would like to contact for more information including phone numbers

Case Review

Demographics

       41 year old male.

Referred by a list from the Health Home in June 2013. Conducted outreach and consented in August 2013.

Homeless.

No clinical or medical linkages in the area.

High utilizer of ER services-panic attacks and high anxiety. Difficult time engaging initially as his phone number was frequently disconnected and he was difficult to locate.

Moved to Pennsylvania for a short time-got in a motorcycle accident-no support and moved back -reached out to his Care Manager.

Successes

       Re-engaged the individual after he moved from the area.

Referred him to OMH MRT Supported Housing and is currently housed in a safe neighborhood.

Referred to a Primary Care Provider to follow up with medical concerns.

Linked with clinical services .

ER visits have decreased and he has not been seen in the ER since November 11, 2013.

Independently obtained employment at a local college.

Care Manager acted as a central contact during the referral and transition processes that took place!

Questions?

 Contact Information:  Lauren Tegnander: [email protected]

 Jenny Crave: [email protected]

 (518) 372-1100 ext. 222