Transcript Comprehensive Community Support Services H2015

Comprehensive Community Support
Services Competency & CSA Training
Heather A. Clark
MS, CPRP, LPCC
Presbyterian Medical Services
Purpose of the Training
To provide participants with a strong
knowledge base and necessary skills
required for successful delivery of
Comprehensive Community Support
Services (CCSS) consistent with Core
Service Agency (CSA) Values
Outline
• H2015 Service Definition as CCSS
overview
• CSA Criteria
• Wraparound Approach
• Key Concepts for CSW’s and CPS’s
• Research
• CSA Standards
• Crisis Planning
Comprehensive Community Support
Services Revised 7.30.2010 HCPCS
Service Definition:
The purpose of Community Support Services is to
surround individuals/families with the services and
resources necessary to promote recovery,
rehabilitation and resiliency. Community support
activities address goals specifically in the following
areas: independent living; learning; working;
socializing and recreation. Community Support
Services consist of a variety of interventions,
primarily face-to-face and in community locations,
that address barriers that impede the development
of skills necessary for independent functioning in the
community.
Comprehensive Community Support
Services Revised 7.30.2010 HCPCS
• Community Support Services also include
assistance with identifying and coordinating
services and supports identified in an
individual’s service plan; supporting an
individual and family in crisis situations; and
providing individual interventions to develop
H2015
Revised 7.30.2010 HCPCS
Individuals having problems accessing services and/or receiving multiple
services from a single or multiple providers and/or systems and
• Individuals needing support in functional living
• Individuals transitioning from institutional or highly restrictive settings to
community-based settings or
• Children at risk of/or experiencing Serious
Emotional/Neurobiological/Behavioral Disorders or
• Adults with severe mental illness (SMI) or
• Individuals with Chronic Substance Abuse or
• Individuals with a co-occurring disorder (mental illness/substance abuse)
and/or dually diagnosed with a primary diagnosis of mental illness
H2015
Revised 7.30.2010 HCPCS
Designated agency
Individuals that meet the target population
criteria for community support services must
have one designated agency that will have the
primary responsibility of assisting the
recipient and family with implementing the
service plan.
H2015
Revised 7.30.2010 HCPCS
Designated community support worker
The designated community support worker
will coordinate and may facilitate family team
meetings/treatment team meetings.
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H2015 Revised 7.30.2010 HCPCS- Activities
Assistance to the individual in the development and coordination of the
individual’s service plan including a recovery a management plan and a crisis
management plan;
Assessment support and intervention in crisis situations including the
development and use of crisis plans which recognize the early signs of
crisis/relapse, use of natural supports, use of alternatives to emergency
departments and inpatient services,
Assistance to the individual in the development of advanced directives related to
his/her behavioral healthcare; and
Individualized interventions, with the following objectives:
Identification, with individual, of barriers that impede the development of skills
necessary for independent functioning in the community; as well as strengths,
which may aid the individual in recover;
Services and resources coordination to assist the individual in gaining access to
necessary rehabilitative, medical and other services;
Support to facilitate recovery and resiliency;
H2015 Revised 7.30.2010 HCPCSActivities Continued…
• Assistance in the development of interpersonal, community coping and functional
skills (including adaptation to home, school and work environments);
• Encouraging the development and eventual succession of natural supports in
workplace and school environments;
• Assistance in learning symptom monitoring and illness self-management skills (e.g.
symptom management, behavioral management, relapse prevention skills,
knowledge of medication and side effects and motivational/skill development in
taking medication as prescribed) in order to identify and minimize the negative
effects of symptoms which interfere with the individual’s daily living;
• Assistance with financial management and skill development;
• Assistance with personal development and school/work performance;
• Assistance in enhancing social and coping skills that ameliorate life stresses resulting
from the individual’s disability;
• Assistance to individuals with illness self-management as it relates to maintaining
employment and school tenure;
• Assisting the individual to obtain and maintain stable housing;
• Any necessary monitoring and follow-up to determine if the services accessed
H2015
Revised 7.30.2010 HCPCS
The majority (60% or more) of non
facility-based community support
services provided must be face-to-face
and in vivo (where the client is). The
community support worker must
monitor and follow-up to determine if
the services accessed have adequately
met the individual’s treatment needs.
H2015
Revised 7.30.2010 HCPCS
For individuals and/or their families: The
community support worker will make
every effort to engage the client in
achieving treatment/recovery goals.
H2015
Revised 7.30.2010 HCPCS
When the service is provided by a Certified Peer Specialist, the above
functions/interventions should be performed with a special emphasis on
recovery values and processes such as:
• Empowering the individual to have hope for and participate in his or her
own recovery;
• Helping the individual identify strengths and needs related to attainment of
independence in terms of skills, resources, and supports, and to use
available strengths, resources and supports to achieve independence;
• Helping the individual to identify and achieve their personalized recovery
goals (which should include attainment of meaningful employment if
desired b the individual); and
• Promoting an individual’s responsibility related to illness self-management.
H2015
Revised 7.30.2010 HCPCS
• Only one provider organization at a time can
serve as an individual’s clinical home. This
does not preclude that other organizations
provide community support activities. These
community support activities and providers
must be clearly identified in the service plan,
be coordinated by the primary community
support worker and not duplicate community
support services provided by the primary
community support worker
Core Service Agency
What is a Core Service Agency (CSA)?
A Core Service Agency (CSA) coordinates care and provides
essential services to children, youth and adults who have a
serious mental illness, severe emotional disturbance, or
dependence on alcohol or drugs. For those eligible to receive
services, the CSAs provide or coordinate:
1. psychiatric services (medication management)
2. everyday crisis services, and
3. comprehensive community support services (CCSS) that
support an individual’s self‐identified recovery goals, and
other clinical services.
CSA Criteria- Adult Target Populations
1.
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3.
Severe Mental Illness (SMI)
Chronic Substance Dependence (CSD)
Co-Occurring Disorders (COD)
*SMI with substance disorder
*SMI with developmental disability
AND
Symptom severity
causing functional impairment in activities of daily living,
interferes with functioning by inhibiting recovery and resiliency goals.
OR
Transition concerns
*from inpatient treatment
*from residential treatment
*from prison
CSA -Target Populations- Youth
Child/Youth Consumer is documented with
* diagnosis of Severe Emotional Disturbance (SED)
AND
Symptom severity
causing functional impairment in activities of daily living
interferes with functioning by inhibiting recovery and
resiliency goals
OR
Transition concerns
*from inpatient treatment
*from residential treatment
*from a juvenile justice facility
CSA – Special Populations
If Adult CSA:
*persons who are homeless
*persons with DD/MI
If Youth CSA:
*0-5 year olds; AND,
*persons who are homeless; AND,
*persons with DD/MI
Wraparound Approach
Oral
surgeon
PCP
Family
Natural
Support
Payee
Individual
Neurologist
Psychiatrist
CSW
Therapist
Drop In
Center
Wraparound Principles
1. Individual Voice & Choice:
The Individual has ownership over their plan
and represents their own perspective,
choices reflect their culture and preferences.
Cultural Competence, sensitivity, instills hope
Wraparound Principles
2. Team Based
A collaborative team based process that
consists of formal, informal, family/natural
and community supports chosen by the
individual. Be engaging with the individual,
family and team build a strong therapeutic
alliance.
Wraparound Principles
3. Natural Supports
Encouragement of community and
interpersonal supports that are key in
providing necessary intervention. Natural
supports help in managing crisis and risk –
connectedness.
Wraparound Principles
4. Collaboration
The team collaborates and guides a plan that
guides each team members work. Team
helps individual to identify strengths/needs.
Wraparound Principles
5. Community Based
Inclusive, accessible, least restrictive settings
Wraparound Principles
6. Culturally Competent
Respects and builds on value, beliefs and
culture
Wraparound Principles
7. Individualized
Plan/Team is uniquely tailored to fit the
individual
Wraparound Principles
8. Strengths-Based
Validate, expand and build on assets
Wraparound Principles
9. Persistence
Despite challenges and a limited system the
team continues to work towards stated goals.
Wraparound Principles
10. Outcome Based
The Team is accountable for achieving the goals
laid out in the plan. Ongoing monitoring and
assessing is the plan is required.
Key CCSS Concepts
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Life Domains
Independent and community living
Work
Learn
Socializing
Recreation
Key CCSS Concepts
*CSW’s and CPSW’s address the functional
limitations created by the illness that interfere
with the person reaching their recovery and
resiliency goals. We do this by focusing on
individual strengths that will help them
overcome the limitations. This must be
reflected in all documentation.
Key CCSS Concepts
• Resiliency – being able to rebound from
adversity and challenges.
• Recovery – the process by which people are
able to live, work, learn and participate fully in
their communities.
Key CCSS Concepts
Recovery Components: www.samhsa.gov
(SAMHSA, 2004)
1. Self Direction
2. Individualized & Community focused
3. Empowerment
4. Holistic- Medical/Behavioral Health Wellness
5. Non-linear- Stages of Change
6. Strengths-based
7. Peer Support
8. Respect
9. Responsibility
10. Hope & Optimism
Key CCSS Concepts
• Self – Directed
Individuals & families lead, control, choose, and
determine their own path. Individual/Family
centered, sensitive to culture, instills hope,
understandable language
Key CCSS Concepts
• Self-Determination- Personal decision to do
something and think in a certain way
Key CCSS Concepts
CSW’s have a responsibility to adopt language
that conveys respect & that is person
centered.
“Person with Schizophrenia”
Vs.
“Schizophrenic”
Key CCSS Concepts
Doing With not Doing For:
Doing With- Teaching, Coaching, Sharing,
Modeling, Developing, Designing,
Coordinating, Linking, Promoting, Evaluating,
Crisis Planning, Safety Planning
Doing For- Telling people what to do, making
appointments for them, calling, shopping for.
Key CCSS Concepts
Personal Safety
• Differentiate between self/others- your personal
issues vs. individual’s issues- be self aware, take
responsibility, don’t use the helper relationship to
meet personal needs (to be liked, do well, be
needed)
• Practice de-escalation techniques- be smart, carry
phone, let supervisor know where you are, go
with someone on first home visit, scan
surroundings
• Protect yourself against burnout.
Key CCSS Concepts
Manage Crisis/Risk
• Complete Detailed CCSS Crisis plan that detect
warning signs/triggers to things breaking down
with appropriate action plans and steps for the
individual to manage crisis- UPDATE THEM!!!
• Listen and report abuse, neglect, exploitation &
danger to self/others.
• Focus on Behavior Changes that might indicate
concern.
Key CCSS Concepts
• Remember face-to-face visit must occur within
48 hours after a crisis.
• Adult Crisis Plans should include Advance
Directives, risk factors and development of
interventions developed from knowledge of
past crisis situations
• Indicate escalating risk and levels of crisis
support-
Research:
Patricia E. Deegan, Ph.D.
Institute for the
Study of Human Resilience
“Offer support like you offer a cup of tea.”
http://www.bu.edu/resilience/staff/pdeegan.html
Research:
Recovery After an Initial Schizophrenia Episode
(RAISE): A Research Project of the NIMH
• Patricia Deegan is currently a member of the executive and
intervention committees of a study funded by the National
Institute of Mental Health called R.A.I.S.E (Recovery After Initial
Schizophrenia Episode). This is a multi-year study of an
intervention aimed at young folks who have a first psychotic
episode. The intervention includes a team of professionals who
work in a coordinated fashion to outreach and engage people in
recovery-oriented services including supported employment and
supported education. Active linkage to peer support, natural
supports, substance abuse services and trauma services (if
indicated) are part of the study protocol.
Psychosocial Rehabilitation (PSR)
Psychiatric Rehabilitation promotes recovery—full
community integration and improved quality of life for
persons who have been diagnosed with any mental health
condition that seriously impairs functioning. Psychiatric
rehabilitation services are collaborative, person-directed,
and individualized, an essential element of the human
services spectrum, and should be evidence-based. They
focus on helping individuals develop skills and access
resources needed to increase their capacity to be
successful and satisfied in the living, working, learning and
social environments of their choice. www.USPRA.org
Research:
12 PSR Principles of Recovery
• PSR practitioners convey hope and respect, and believe that all
individuals have the capacity to learn and grow.
• PSR practitioners recognize that culture is central to recovery, and
strive to ensure that all services are culturally relevant to individuals
receiving services.
• PSR practitioners engage in the processes of informed and shared
decision-making and facilitate partnerships with other persons
identified by the individual receiving services.
• PSR practices build on the strengths and capabilities of individuals.
• PSR practices are person-centered; they are designed to address
the unique needs of individuals, consistent with their values, hopes
and aspirations.
• PSR practices support full integration of people in recovery into
their communities where they can exercise their rights of
citizenship, as well as to accept the responsibilities and explore the
opportunities that come with being a member of a community and
larger society.
www.USPRA.org
Research:
12 PSR Principles of Recovery
• PSR practices promote self-determination and empowerment. All
individuals have the right to make their own decisions, including decisions
about the types of services and supports they receive.
• PSR practices facilitate the development of personal support networks by
utilizing natural supports within communities, peer support initiatives, and
self-and mutual-help groups.
• PSR practices strive to help individuals improve the quality of all aspects of
their lives; including social, occupational, educational, residential,
intellectual, spiritual and financial.
• PSR practices promote health and wellness, encouraging individuals to
develop and pursue individualized wellness plans.
• PSR services emphasize evidence-based, promising and emerging best
practices that produce outcomes congruent with personal recovery.
Programs include structured program evaluation and quality improvement
mechanisms that actively involve persons receiving services.
• PSR services must be readily accessible to all individuals whenever they
need them. These services also should be well coordinated and integrated
with other psychiatric, medical and holistic treatments and practices.
www.USPRA.org
Research:
Courtenay M. Harding, Ph.D.
The American Psychological Foundation awarded
Dr. Harding its 2004-2005 Alexander Gralnick
Research Investigator Award. This prestigious
prize "recognizes exceptional contributions to the
study of schizophrenia and other serious mental
illness and for mentoring a new generation of
researchers." She was appointed Professor of
Psychiatry at the Boston University School of
Medicine in 2007. www.bu.edu
Service Planning
Stages of Change
• Pre-contemplation = Engagement
• Contemplation & Preparation= roll with
resistance listen for “change talk”
• Action= identify goals/strengths/coping
strategies to avoid crisis/relapse
• Maintenance= ongoing movement towards
goals & objectives
Service Planning
• Assessment- minimally documents diagnosis/illness &
impact on functioning
• Baseline Functional Assessment- further documents
functional limitations and barriers to recovery
• Service Plan- address Life domains, goals in person’s own
words, steps to restore functioning in frequency/duration
(objectives)
• Activities/Interventions relate to Plan/Medically Necessary
• Progress Notes- demonstrate progress
• Enhanced Assessment
• Review Revise
Service Planning
Enhanced Assessment
If Adult CSA, use HOO31 U8 for consumer who meets one of the following:
_____Significant current danger to self or others
_____Has 3 or more emergency room visits or psychiatric hospitalizations
w/in last year
_____Meets ASAM Placement Criteria for Level III or IV services and must
have a high score on the following dimensions: intoxicated/withdrawal
potential, biomedical condition, emotional/behavioral/cognitive
conditions
_____Person is experiencing trauma symptoms related to traumatic event
_____Severe impairment in at least one Axis IV functional domain
_____Moderate functional impairment in multiple domains
_____Substance Dependency diagnosis and any mental illness that affects
functionality
_____SMI or Substance Dependence and potentially life-threatening medical
condition
_____SMI or Substance Dependency and Developmental Disability
Assessment Adult
Service Planning
Enhanced Youth
If Youth CSA, use HOO31 U8 for consumer who meets at least 2 of below 6
criteria:
_____Multi-system involvement
_____At risk of out-of-home placement due to SED
_____Current psychiatric hospitalization or 2+ psychiatric admissions within
last year
_____Recent or pending discharge from a residential facility or 2+ placements
within residential facility within last year
_____History of 2+ suicide attempts within past year resulting in medical
intervention
_____History of significant trauma
Adult and/or Youth CSA initiated 90801 assessment when:
_____consumer met neither of above criterion
CSA Standards
• Provide basic assessment 90791- 48 hours if
urgent/5 calendar days if routine
• OHNM Service Registration 48 Hours
CSA Standards
• CSA Eligibility
Determination Target
Population Checklist
(no eject/reject expectation)Every
referral (hard copy to file)
SMI Criteria Checklist
CSD Criteria Checklist
COD Criteria Checklist
Adult CSA Criteria (H0031 w/
U8 Modifier)
Within 48 hours if
• Individuals w/Urgent needs
• Incarcerated adult
• APS
Within 5 business days
• Individuals who do not meet
the above listed criteria
CSA Standards
Crisis Plan
All Qualified CSA individuals
• Urgent 1 calendar day
• Within 14 calendar days
CSA Standards
Enhanced Assessment (H0031 U8)- if necessary
• Within 10 calendar days (10-20% predicted to
be necessary; if collateral data available based
on severity)
• See Teambuilders flowchart)
CSA Standards
• Baseline Functional Assessment for eligible
CSA recipients (90806 or bill to CCSS) ANSA or
DL20 or Multnomah
All Qualified CSA individuals
Within 10 calendar days of admission into
CCSS
CSA Standards
CCSS and other appropriately identified services
(Direct CSA Services Crisis, Psychiatric, CCSS)
• Urgent 1 calendar day
• Routine 14 Calendar days
CSA Standards
CCSS Service Plan
Within 30 Calendar days
CSA Standards
Coordination of Care for CSA Individuals
• 90 Day Reviews (brief intervention, EOC,
Solution Focused)
Service Planning
• Teaming: Develop a Treatment Team based off
of the recommendations of the enhanced
assessment and coordinate Team Meetings.
CCSS Crisis Plan
• Presenting Problems:
to include SI’s/HI’s, risk of overdose, risk of
morbidity (death), self-injurious behaviors,
anger/aggressive outburst- things that cause
harm to self or others
CCSS Crisis Plan
• Natural supports – if they don’t have any
specify on the plan- the intent of CCSS is to
build natural supports & improve the person’s
ability to self-sooth or use community
supports before using paid supports.
CCSS Crisis Plan
• Coping strategies –
The intent of CCSS is to build their person’s
ability to manage life’s challenges using
natural or community supports – coping
strategies are to be used as a the first level of
defense for harmful behavior, must be
reflective of the persons real environment
congruent with presenting problem– i.e. don’t
say go for a walk if they are not able to walk
CCSS Crisis Plan
• Warning Signs- indicators things are breaking
down – often happen a day before the crisis,
these can be internal or external i.e. isolation,
racing thoughts, anger
CCSS Crisis Plan
What is an Advance Directive?
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It is a legal document. It defines what future treatment you want if you are not able to
make decisions about your mental health care. An advance directive empowers you
to make treatment preferences known.
An advance directive will improve your communication with a physician. It can
prevent clashes with professionals over treatment and may prevent forced treatment.
Having an advance directive may shorten a hospital stay.
Advance Directives in New Mexico: PAD
The Mental Health Care Treatment Decisions Act is the New Mexico law about
advance directives. It allows written instructions for psychiatric treatment if you are
unable to make or communicate your instructions.
In New Mexico, " an advance directive for mental health treatment" is called a PAD
(Psychiatric Advance Directive). The law includes a standard form. It is not mandatory
but is recommended. Get a copy of the form to use from Optum Health NM website.
You have to be 18 or older to create a PAD.
You may use an advance directive for mental health treatment to express any and all
wishes a consumer has about their mental health treatment, including refusals of
treatment.
CCSS Crisis Plan
You can appoint an agent
You can name someone in writing to have your "Power of
Attorney." That means the person can make mental health
care service decisions for you if you are not able to. The
decisions should be in your best interests and in accordance
to your wishes. There are some rules about who can be your
agent: The agent must know you and be willing to take this
responsibility.
• You both sign the PAD naming the person.
• A witness must sign it too. The witness must not be your
agent, an employee of your health care organization, a
beneficiary of your estate or a relative of yours.
• A PAD is valid until you change or end it.
CCSS Crisis Plan
• Triggers:
internal or external – i.e. loss of love, feeling
disrespected, when someone says “no”- not
taking meds, lack of sleep, anniversary of a
loved one’s death
CCSS Crisis Plan
• Before and After a Crisis:
What led to the last overdose or
hospitalization, events leading up to it, what
happened after – what supports were helpful,
or what would be helpful after a crisis –
CCSS Crisis Plan
Escalating Risk:
1. feeling depressed/angry- use coping strategies,
call CSW/therapist/psychiatrist
2. feeling depressed/angry and have
suicidal/homicidal ideations or thoughts of acting
out aggressively towards others/ thoughts of selfinjurious behaviors- call crisis numbers- reach out
for help
3. feeling depressed/angry have Suicidal/Homicidal
Ideations and a plan to hurt self/others- call 911.
CCSS Crisis Plan
Safety Plan:
Crisis Response of Santa Fe
1-888-920-6333
Lifeline Suicide Prevention
1-800-273-TALK (8255)
CCSS Crisis Plan
• Other professional/Community Resources
Waking Up Alive, Center for Hope and
Recovery, NA, AA- when and where can they
access self-help supports
groups they were referred to- times and
dates- their psychiatrist name and numbertheir therapist.
CCSS Crisis Plan
• Respite Apartment :
If homeless – put down shelter info. times to
call and phone numbers, put down friends
they can stay with – I put down UNM Hospital
waiting room on cold nights (this is how he
stayed alive when he couldn’t get to the
winter shelter).