COMPREHENSIVE COMMUNITY SERVICES CCS CCS WEBSITE https county
COMPREHENSIVE COMMUNITY SERVICES CCS
CCS WEBSITE • https: //county. milwaukee. gov/EN/DHHS/Provider-Portal/BHD-Providers
• Community based program that provides Psychosocial Rehabilitative services • Consumers must have a Mental Health or Substance Abuse diagnosis. CCS • CCS started in Milwaukee County in September 2014 and has grown to over 1600 adult consumers. • CCS is a voluntary program – consumer has to sign their own admission paperwork to be in the program (guardian if applicable) • The consumer is expected to be motivated for treatment, to fully participate, and demonstrate ownership of their treatment
RECOVERY BENEFIT • Consumers continue on their journey of recovery focusing on wellness and purpose • Consumers build a team of both formal and informal supports • When a consumer lacks an informal support system, CCS can put services in place to assist the consumer to build one • Staff in CCS practice Person-Centered Planning • Consumer and team together choose the services they feel they need and desire • CCS is strengths based and strengths are used to support the consumer and choose services • CCS values system collaborations
CARE COORDINATION MODEL • The Care Coordinator only coordinates the services, does not provide direct services • Ancillary providers are hired to perform direct services • CCS has over 60 ancillary providers in the network
REFERRAL Substance Use Application & Admission Agreement 30 Days Maximum Intake Coordinator leads this process at Screenintake & Assessme nt (annually) CC leads process @six-month and annually Recovery Plan (every 6 months) Diagnostic Psychotherapy Wellness Management & RSS Medication Prescriber Service Facilitation Medication Monitoring (Care Coordination) Psychoeducatio n Physical Health Monitoring Employment Individual Skill Development & Enhancement Peer Support
• Services are teaching, coaching, mentoring • Progress needs to be identified – outcomes oriented, and evidences based PSYCHOSOCIAL REHABILITATIVE SERVICES • Assists the consumer to reach their highest possible level of independent functioning, stability, and independence • Examples • Medication Management • Yoga – meditation • Healthy cooking group
ELIGIBILITY - MEDICAID • CCS is solely funded by Medicaid • Prior to encouraging a consumer to enroll in CCS, ensure that they have the proper Medicaid (full coverage).
ELIGIBILITY – PSYCHOTHERAPY RULE • CCS – Medicaid rule • If a consumer is in CCS and receives psychotherapy (individual, group, IOP, PHP) then that psychotherapy must be funded by CCS. • If a consumer has a psychotherapist that is not in the CCS network, that could be a deal breaker for enrolling in CCS • If the consumer is dissatisfied with their current psychotherapy, or isn’t yet invested, then to enroll in CCS they would need to discontinue that therapy and begin with CCS network therapy/groups. • Consumers are never encouraged to sever a long-term health relationship with a therapist
ELIGIBILITY – FUNCTIONAL SCREEN • The Intake/admission appointment is referenced in the “How to get into CCS” slides • The Intake/admission appointment includes the consumer signing paperwork to enroll themselves into the program • The next visit includes a Comprehensive Assessment • After the Comp Assessment is complete, the CCS worker needs to utilize the information learned to enter data into the Mental Health / AODA Functional Screen • In order to remain in CCS, the MH/AODA FS must reveal eligibility for CCS
HOW TO GET INTO CCS 1. Phone Line – 414 -257 -6060 1. 2. 3. 4. 5. 6. 7. Leave a message and someone from CARS/CCS will try to call you back within one business day Conversation will ask the consumer to talk about their current situation, why they are calling, who suggested they call, etc. Need to establish either a mental health or substance abuse diagnosis Does the consumer have a means for a prescription for CCS services? Conversation will include education about the CCS program A brochure and provider directory can be emailed or mailed for the consumer to consider If/when the consumer is ready to enroll in CCS, the CARS/CCS worker will assist the consumer to choose a Care Coordination agency and set up the first appointment within three business days.
HOW TO GET INTO CCS II. CARS Intake Team. 1. Intake Team receives referrals from community providers on behalf of consumers 2. Intake Team meets with/talks to the consumer and screens for potential CCS candidates 3. Conversation will ask the consumer to talk about their current situation, what services they are interested in, how motivated they are, who referred them to CARS, etc. 4. Need to establish either a mental health or substance abuse diagnosis 5. Does the consumer have a means for a prescription for CCS services? 6. Conversation will include education about the CCS program 7. A brochure and provider directory can be shared with the consumer 8. If/when the consumer is ready to enroll in CCS, the CARS Intake Team worker will assist the consumer to choose a Care Coordination agency and set up the first appointment within three business days.
HOW TO GET INTO CCS III. Branch Presentation. 1. Care Coordination teams are considered “Branch Offices” of CCS 2. As CCS is an entitlement, consumers are entitled to inquire to any branch office about CCS services 3. Branch office presentations are most often from internal programs such as CSP, TCM, RSC. Some other examples could be CLASP, Access Point, any other internal agency program. 4. Branch offices sometimes come from word of mouth of consumers. 5. Conversation will ask the consumer to talk about their current situation, what services they are interested in, how motivated they are, who referred them to CARS, etc. Need to establish either a mental health or substance abuse diagnosis 6. Does the consumer have a means for a prescription for CCS services? 7. Conversation will include education about the CCS program 8. A brochure and provider directory can be shared with the consumer 9. If/when the consumer is ready to enroll in CCS, the Branch Office Intake worker will conduct the intake appointment and sign the admission paperwork.
HOW TO GET INTO CCS IV. Youth 1. Youth CCS is administered by the Milwaukee County Children’s Mental Health Services 2. To enroll, call 414 -257 -7607 3. Youth CCS can serve consumers up to 23 years of age • However, 21 and over should be considered first for Adult CCS due to the impending transfer at 23.
REFERRAL Substance Use Application & Admission Agreement 30 Days Maximum Intake Coordinator leads this process at Screenintake & Assessme nt (annually) CC leads process @six-month and annually Recovery Plan (every 6 months) Diagnostic Psychotherapy Wellness Management & RSS Medication Prescriber Service Facilitation Medication Monitoring (Care Coordination) Psychoeducatio n Physical Health Monitoring Employment Individual Skill Development & Enhancement Peer Support
MEDICAL NECESSITY All CCS interventions and services need to be justified with medical necessity. Identify the consumer’s symptoms of their mental health and/or substance abuse problems Establish a reason for the consumer to need CCS services Link the services to the symptoms Give an example of a symptom and intervention/service This is required for Medicaid (health insurance) to fund the services
CCS SERVICES Diagnostic • • • Specialized evaluations Neuropsychological Geropsychiatric Specialized trauma Eating Disorders Medication Prescriber • Diagnosis • Prescribing Medications Medication Non. Prescriber • Supporting the consumer to take medications • Increase understanding and benefits • Monitoring changes in symptoms • Staff who demonstrate competency, Nurses, Pharmacists
CCS SERVICES Physical Health Monitoring • Focuses on how the mental health and/or substance abuse affect the consumer’s ability to manage their own physical health • Personal Trainer • Yoga • Adaptive Exercise Equipment • Dance/movement therapy Peer Supports • Individuals with lived experiences • Wide range of supports to assist in the recovery process • Must be certified Individual Skill Development and Enhancement – Individual and/or Groups • Training, coaching, teaching, mentoring • Financial Coaching (with or without payeeship) • Daily Living Skills • Healthy Cooking Groups • Nutrition consultants • Housing search and/or stability assistance • Parenting Coaches • Social Security Applications • Benefits Specialist
CCS SERVICES Employment and Education • IPS – Individual Placement Services • Goodwill, Easter Seals, MCFI, & MMHA • IPS teams are embedded in the Care Coordination teams. Psychoeducation • Individual or Group • Consumer and/or their family Substance Abuse Services • Individual or Group • Groups that are a part of a day program
CCS SERVICES Wellness Management and Recovery Support Services – Individual or Groups • Empowering consumers to manage their mental health and substance use. • Teaching the knowledge and skills necessary to help consumers make informed treatment decisions • Yoga – meditation – guided relaxation • Gardening and Horticulture • Spiritual care and reconnection • Social Skills training • Tai Chai Psychotherapy – Individual or Groups • In office or in-home • Traditional therapies included but not limited to CBT, DBT, Trauma Informed, personcentered, brief solution focused, psychodynamic, EMDR, motivational interviewing • Art Therapy or art assisted therapy • Animal assisted therapy • Music therapy • Equine therapy (horses) • Play therapy
CARS COMMUNITY CASE MANAGEMENT • CCS • Targeted Case Management • Crisis Case Management • CSP
PERSONCENTERED PLANNING
LIFE VISION A Consumer’s life vision needs to guide their treatment. Often providers approach treatment planning like any/all services must be related to the reduction of a symptom. Person-centered care focuses of the Consumer’s life vision and all things that are meaningful to the Consumer. When a Consumer is focused on making impactful life changes with more personal meaning this helps sustain motivation.
How you speak to Consumers reflects your ability to embrace the concept of being “personcentered. ” LANGUAGE EXAMPLE: Instead of labeling someone as being “non-compliant, ” try reframing this “The Consumer is choosing to not do something right now. ” Best practice suggests that the professional explore with the Consumer why they’re making a choice and try to gain a better understanding of their motivation behind the decision.
• Vital to the process of person-centered planning is the development of trusting relationships. • Recovery-oriented services first attend to the needs and desire of the person, rather than being dictated by their diagnosis or illness. TRUSTING RELATIONSHIPS • Providers MUST be actively interested in the person’s everyday life, and adopt a conversational approach, versus an interrogational one. • It’s crucial that providers not label or view personal goals as “unrealistic, ” but instead, hold hope that all is possible to promote a sense of personhood and connection • It’s important to remember that the person is the expert in his or her own life, and the person’s past experiences of what worked and what didn’t work should be reflected in the recovery plan.
ENGAGEMENT STRATEGIES Per Mark Sanders: At your initial contact, create a welcoming environment. Minimize confrontation. Role with resistance. Have an effective opening statement. Activity from Mark Sanders: Think of one of your favorite consumers. Now, answer these questions: 1. What is their middle name? 2. What is their mom’s name? 3. Who is their best friend/biggest support? 4. What is their favorite holiday? 5. What is their favorite food? 6. Where do they go to celebrate the holidays? 7. Where did they grow up? 8. Do they have any beloved traditions that they continue to this day? Check out Mark’s presentation from the CCS statewide conference about Strengths based engagement: https: //www. dhs. wisconsin. gov/non-dhs/dcts/strength-based-engagements. pdf
SHARED DECISION MAKING Let the person do whatever they want Neglect Recovery Zone Get the person to do what I want Control
WHAT IS MEASUREMENT BASED CARE? CCS is awesome! It’s helping people get better. Everyone outside of CCS: “Prove It!” Definition of Measurement Based Care: the practice of basing clinical care on collected client data throughout treatment. Benefits of Measurement Based Care: a. Informs conversations between the provider and the consumer regarding the efficacy of care and direction future care should take to be most effective for the individual b. Allows the consumer the opportunity to visualize their progress over time and make desired adjustments accordingly (person-centered and empowering) c. Provides clear and consistent data to demonstrate program efficacy and helps stakeholders identify improvement needs at the program/staff level.
WHAT DOES MEASUREMENT BASED CARE LOOK LIKE? • https: //www. youtube. com/watch? v=UTw. IYZo-Ows&t=313 s
WISCONSIN RECOVERY THERMOMETER • https: //www. dhs. wisconsin. gov/publications/p 01289. pdf
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