Community Case Management Using a systems approach to

Identifying Complex Needs • • • Human Service Agencies Social Services 911/211 Systems Mental

System of Care • A valued-based approach/philosophy for serving people with complex needs that

Case Management • Case management is a collaborative service that provides assessment, planning, facilitation

Historical Overview Schools Corrections Mental Health Child, Adult and/or Family Human Services Court Services

SOC Approach Schools Corrections Mental Health Court Services Informal Community Supports Child, Adult and/or

SYSTEMS of CARE M ER W PO EM TA S CE UR SO RE

Pennington County Health and Human Services Changing Lives…. . Changing Courses…. . A diversion

Community Resources Committed to Rebound Members Sioux San Goodwill Hospital Industries Social Security Cornerstone

Pennington County Health and Human Services Rebound Community Referrals to Rebound Program 12/01/2006 to

Pennington County Health and Human Services Rebound Referrals to the Community 01/01/2011 to 04/30/2012

Pennington County Health and Human Services John T. Vucurevich Foundation Grant Referrals From Community

Pennington County Health and Human Services John T. Vucurevich Foundation Grant Financial Assistance Provided

Pennington County Health and Human Services John T. Vucurevich Foundation Grant Financial Assistance by

Pennington County Health and Human Services John T. Vucurevich Foundation Grant Cost Share with

Crisis Care Center Transitional Case Management Client Referrals 01/01/2011 to 04/30/2012 30 28 Total

Crisis Care Center Transitional Case Management Referrals to Community Agencies Total: 165 01/01/2011 to

Crisis Care Center Transitional Case Management Coordinated/Provided Services Total: 230 01/01/2011 to 04/30/2012 Medical

Crisis Care Center Transitional Case Management Caseworker Activity 01/01/2011 to 4/30/2012 Total: 1, 049

Pennington County Health and Human Services Rebound, JTV Grant and Crisis Care Transitional Case

• Agencies Working Together • Motivational Interviewing • Effective Case Managers Creates •

Steps for Getting There • An agreed upon definition and role of community case

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Community Case Management Using a systems approach to serving individuals with complex needs

Identifying Complex Needs • • • Human Service Agencies Social Services 911/211 Systems Mental Health/Substance Abuse Systems Schools Hospital Systems Courts & Correctional Systems Community Support Agencies Law Enforcement Family & Friends Community at Large Etc, etc

System of Care • A valued-based approach/philosophy for serving people with complex needs that is client driven, community-based, and culturally and linguistically competent.

Case Management • Case management is a collaborative service that provides assessment, planning, facilitation and advocacy for options and services to meet an individual’s holistic needs through communication and available resources to promote quality cost-effective outcomes.

Historical Overview Schools Corrections Mental Health Child, Adult and/or Family Human Services Court Services Social Services Alcohol & Drug

SOC Approach Schools Corrections Mental Health Court Services Informal Community Supports Child, Adult and/or Family Human Services Social Services Alcohol & Drug

SYSTEMS of CARE M ER W PO EM TA S CE UR SO RE EN T Y AS SIS IT UN M M NC E CO Community Case Management

Pennington County Health and Human Services Changing Lives…. . Changing Courses…. . A diversion program empowering people to make positive changes!

Community Resources Committed to Rebound Members Sioux San Goodwill Hospital Industries Social Security Cornerstone Rescue Mission Penningto n County John T. Housing Vucurevic h Foundatio. Community n Food Bank of the Black Hills Department of Social Services Community Transitions City County Alcohol and Drug Programs Rapid City Transit States Attorneys Office Church Response REBOUND Family Practice Residency Public Defender s Office Community Health Center of the Black Hills 7 th Judicial Circuit Court Western Resources for the Disabled Career Learning Center Court Services US Probation South Dakota Dept of Labor Behavior Managemen t Systems Salvation Army Rapid City Re. Entry Program Community Action Program Parole Services

Pennington County Health and Human Services Rebound Community Referrals to Rebound Program 12/01/2006 to 04/30/2012 Probation 11 Meth Program 11 Parole 36 Adams Street Facility 121 PC Jail 235 Friend 2 Family 2 Mission 2 CCADP/Detox 119 Penn. Co. Housing 1 Sioux San 1 Court Services 58 Self 56 Veterans Service Office 1 Dept. of Social Services US Probation 1 11 • Public Defender 18 Community Alternatives of BH 4 RCPD Street Crimes Unit 2 RC Regional West 3 Crisis Care Center 7 Behavior Management Dept. of Labor 6 1 Intensive case management provides the tool in reducing the barriers clients often face when obtaining services. • Since 2006, Rebound caseworkers have made 2, 948 physical contacts with 709 members in the program.

Pennington County Health and Human Services Rebound Referrals to the Community 01/01/2011 to 04/30/2012 Career Learning Pennington Center, Co. Housing Social Security. Sioux San Community Health 37 24 19 Center, Residency Clinic, Church Response, Community Transistions, Cornerstone Mission & Lions Club, HUD, Shelter Plus, RC Schools, DMV, Hope Center, New Start 64 Pennington Co. Heath and Human Services 116 Behavior Management Systems 89 John T. Vucurevich 86 Community Action Program 130 Food Bank 69 Dept. of Labor 39 • Salvation Army & Goodwill 75 CCADP (Detox) 14 Dept. of Social Services 45 • Barriers that once complicated members success have been resolved. Multiple agencies have come together to assist in the success of these individuals.

Pennington County Health and Human Services John T. Vucurevich Foundation Grant Referrals From Community Agencies TOTAL: 310 Referrals 01/01/2011 to 12/31/2011 VA-Vash, 12 US Probation, 3 School System, 4 Church Response, 4 Hope Center, 2 Utility Co, 1 LSS, 1 VA, 2 Dept of Labor, 4 WAVI, 4 VOA, 2 Self, 70 Salvation Army, 22 Community Unknown, 1 Health Center, 2 211, 25 Rebound, 50 CCC, 20 Probation, 1 Political Office, 1 PCH, 4 Parole, 3 Landlord, 3 HHS, 6 Goodwill, 1 Family, 24 Friend, 12 DSS, 5 Church, 2 CSRM, 4 Doctor, 3 BMS, 4 CAP, 3 CCADP Detox, 4 CCADP Treatment, 1

Pennington County Health and Human Services John T. Vucurevich Foundation Grant Financial Assistance Provided on Behalf of Community Referrals Received 01/01/2011 to 12/31/2011 Hope PCH, $990. 00 Utility Co, $100. 00 Parole, $117. 93 Center, Dept of Labor, $305. 31 Church Response, $356. 76 Goodwill, $240. 00 WAVI, $525. 83 $270. 00 211, $2, 570. 45 Friend, $1, 766. 88 $35, 000. 00 Total Expended VA, $25. 00 BMS, $407. 94 CAP, $626. 50 CCADP-Detox, $445. 00 CCADP-Treatment, $20. 00 CCC, $1, 619. 03 VA-Vash, $1, 331. 44 US Probation, $35. 64 Probation, $157. 36 Landlord, $464. 00 School System, $860. 00 HHS, $462. 59 Rebound, $5, 093. 07 Self, $6, 967. 23 Family, $3, 532. 61 Unknown, $20. 00 Political Office, $1, 653. 45 Salvation Army, $2, 259. 12 CHCBH, $60. 64 CSRM, $805. 37 Doctor, $130. 54 DSS, $462. 77 VOA, $289. 99

Pennington County Health and Human Services John T. Vucurevich Foundation Grant Financial Assistance by the Type of Service Provided 01/01/2011 to 12/31/2011 $35, 000. 00 Total Expended Student Buss, CCC Room, Program Fees, Bean Bag, $923. 78 $460. 00 $300. 00 Car Repair, $141. 77 Meds, $78. 25 Bike Repairs, $59. 94 Marriage Certif, $15. 00 $25. 00 Work Tools, $420. 03 Birth Certificate, $526. 11 Client Storage, $64. 00 Clothing, $250. 87 Dr Copay, $45. 00 ID/Liscense, $480. 00 Home Taxes, $1, 653. 45 Education Exps, $107. 99 Work Clothes, $357. 58 Car Maintenance, $657. 54 Bus Ticket, $846. 93 Bus Monthly, $400. 00 Bus Daily, $30. 00 Household Misc, $1, 226. 34 Rent Application, $105. 00 Rent, $2, 435. 36 Phones , $79. 95 Home Deposit, $15, 809. 00 Utility Past Due, $3, 566. 52 Utility Fees, $506. 65 Utility Deposit, $1, 219. 17 Household Appliance, $56. 48 Additional Education, $190. 00 Phone Minutes, $194. 89 Mortgage, $360. 70 Medication Copay, $1, 362. 21 Medical Supplies, $26. 49 Groceries, $10. 00 Laundry, $8. 00

Pennington County Health and Human Services John T. Vucurevich Foundation Grant Cost Share with Client and Agency 01/01/2011 to 10/17/2011 Cost Share with Client; 31 Total: 248 Cost Share with Client and Agency; 3 Cost Share with Agency; 17 No Cost Share; 197

Crisis Care Center Transitional Case Management Client Referrals 01/01/2011 to 04/30/2012 30 28 Total CCC Referrals HHS/TCM New Clients HHS/TCM Ongoing Previous Referrals 25 25 21 19 20 17 16 16 16 15 12 10 8 6 7 12 20 18 17 16 12 22 13 17 13 12 11 11 7 8 7 9 5 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan-12 Feb-12 Mar-12 12 -Apr • From January 1, 2011 through April 30, 2012, a total of 219 new individuals were referred to HHS/transitional case management (TCM) for services. • HHS/TCM now tracks ongoing previous referrals receiving case management services from HHS/TCM. In April 2012 HHS/TCM worked with 9 ongoing CCC clients.

Crisis Care Center Transitional Case Management Referrals to Community Agencies Total: 165 01/01/2011 to 04/30/2012 Job Corps 1 Food Bank 16 Mission 20 Dept. of Social Services 19 Dept. of Labor 4 Church Response 1 Goodwill Lions Southern Club Hills 2 Alcohol/Drug 1 (SHAD) 1 Salvation Army 11 Penn. Co. Housing 1 Community Health 13 CCADP/Detox 7 Lutheran Social Services 4 Social Services Catholic 2 BH Workshop 2 Social Security 4 Behavior Management 32 Rebound 9 Sioux San 7 Volunteers of America Western Resources for 3 WAVI Disabled Hope 2 Center 1 2 As of April 30, 2012 transitional case management staff have coordinated services with 24 community agencies. A total of 165 referrals have been made to these agencies.

Crisis Care Center Transitional Case Management Coordinated/Provided Services Total: 230 01/01/2011 to 04/30/2012 Medical Medicaid/Medicare 3 4 Clothing 9 Social Security 4 Transportation 30 Medications/Med Mgt. 30 Counseling 31 Housing 32 Household 3 Glasses 1 Emergency Housing 24 Food (voucher, pantry, SNAP) 36 Case Mgmt 11 Education Drivers 1 License/ID Employment 3 4 Phone Service Rent 3 1 As of April 30, 2012 Health & Human Services Transitional Case Management staff, as well as varied community agencies, have coordinated and provided a total of 230 services for Crisis Care Clients.

Crisis Care Center Transitional Case Management Caseworker Activity 01/01/2011 to 4/30/2012 Total: 1, 049 Agency Transports 181 Physical Client Contacts 445 Phone Calls 423 • • • Physical client contacts refer to actual face-to-face contact with a CCC client. Agency transport refers to transports given to a CCC client by Transitional Case Management with a company vehicle for the purposes of getting to appointments, obtaining food, shelter, clothing, etc. Phone calls made by Transitional Case Management to both the CCC client and community agencies on the clients behalf.

Pennington County Health and Human Services Rebound, JTV Grant and Crisis Care Transitional Case Management Total Referrals IN FROM Community Agencies 01/2011 to 02/29/2012 Probation Parole 11 Meth Program 37 11 PC Jail 230 Penn. Co. Housing Sioux San Public 2 1 Defender Community 18 RC Regional. Alternatives West 4 Crisis Care Center 3 of BH 20 Management Behavior 9 Dept. of Social Services Self 2 54 Adams Street Facility 121 Mission Friend 5 7 Family 23 Total: 879 CCADP/Detox 123 US Probation School 14 System Salvation 3 Army 19 Wavi VA-Vash VOA 0 211 2 12 CSRM Church Response Community Health HHS Landlord, Political 24 Office, 3 22 Court Services, 58 Goodwill, 6 Church, CAP, Doctor, Unknown 8 Rebound 45

Pennington County Health and Human Services Rebound, JTV Grant and Crisis Care Transitional Case Management Total PCHHS Referrals OUT TO Community Agencies Total: 1, 137 01/01/2011 to 02/29/2012 Salvation Army & Goodwill 103 BH Workshop 2 Rebound Dept. of Labor 40 Food Bank 81 50 Sioux San 25 Social Security 26 Pennington Co. Housing 36 Behavior Management Systems 114 John T. Vucurevich 83 Community Action Program 128 211, Career Learning Center, Community Health Center, Residency Clinic, Church Response, Community Transistions, Cornerstone Mission & Lions Club, HUD, Shelter Plus, RC Schools, DMV, Hope Center, New Start, Job Corps, SHAD, WAVI 207 CCADP (Detox) 26 Pennington Co. Heath and Human Services 124 Dept. of Social Services 77 Volunteers of America Lutheran Social Services Catholic Social Services 2 45

• Agencies Working Together • Motivational Interviewing • Effective Case Managers Creates • Changed Lives • Empowered Clients • Moving to the

Steps for Getting There • An agreed upon definition and role of community case management. • A forum for training new case managers and linking new and seasoned case managers together. • Develop processes that result in integrated community case service plans. • Develop web-based software to monitor services to individuals with complex needs.