OVERVIEW COMPREHENSIVE COMMUNITY SERVICES CCS WELCOME TO THE

OVERVIEW COMPREHENSIVE COMMUNITY SERVICES (CCS)

WELCOME TO THE MEETING HERE ARE SOME HELPFUL TIPS TO MAKE THE MEETING A GREAT EXPERIENCE FOR EVERYONE v Camera on is encouraged! kindness and compassion v Mute your mic when you’re not speaking v Minimize distractions and disruptions v Use the chat function to ask questions and share resources v Listen actively to gain understanding of one another's experiences and perspectives v Avoid blame, speculation, and inflammatory language v Assume positive intent v Commit to learning, not debating v Hold the people we serve in the highest regard, highlighting their strengths and speaking of them with v Allow others to learn what you already know BHD Values Ø Systems and Services Integration Milwaukee County Ø Person-Centered Ø Recovery-Oriented Ø Culturally Intelligent Ø Accessible Ø Trauma-Informed Ø Welcoming Ø Stage Matched Recovery Planning Ø Co-Occurring Capable Ø Our Mission: Empowering safe, healthy, meaningful lives. Ø Our Vision: Together, creating healthy communities Ø Our Values: Partnership, Respect, Integrity, Diversity, Excellence

INTRODUCTION S We will use the same small group throughout the training. First, you will be sent to your small group room. Introduce yourself: Name Role Agency What is one thing that you hope to learn more about in this training today? 5 minutes

INTRODUCTION Pre-Requisites for this training: Enrolled in the CCS Share. Point. • The following videos can be found by following the links, or by going to the CCS Orientation and Training Library in Share. Point. • Watch the Share. Point walk through video: https: //milwaukeecountywi. sharepoint. com/site s/external/ccs/Lists/CCS%20 Orientation%20 a nd%20 Training%20 Library/Disp. Form. aspx? ID =17&e=Rf. HRAn • Watch the Medicaid overview and CCS: https: //milwaukeecountywi. sharepoint. com/site s/external/ccs/Lists/CCS%20 Orientation%20 a nd%20 Training%20 Library/Disp. Form. aspx? ID =15&e=Sss. SIk • Watch the Orientation and Training Checklist video: https: //milwaukeecountywi. sharepoint. com/sites/external/ccs/Lists/CCS Orientation and Training Library/Attachments/32/Orientation and Training log training. mp 4

INTRODUCTION Throughout this training, we are providing several links to resources. The Power. Point will be emailed to everyone after the training. Please take the time to walk through the training again and click on all the links to truly understand what they are.

There are several resources available in the Share. Point and online to help you learn more about CCS: • LEARNING RESOURCES WATCH INFORMATIONAL VIDEO – SHARE IT WITH CONSUMERS AND THEIR NATURAL SUPPORTS CCS INFORMATIONAL VIDEO – YOUTUBE • • • Educational Vlogs are in the Orientation and Training Library: Comprehensive Community Services (CCS) - CCS Orientation and Training Library - All Items (sharepoint. com) • Sharepoint Tutorial (pre-requisite) • Guardianship (coming soon!) • Medicaid (pre-requisite) • Orientation and Training Logs (pre-requisite) • And More Sharepoint files under documents: Comprehensive Community Services (CCS) - Documents - All Documents (sharepoint. com) • Templates • How-to Guides • And more CARS Website (Provider Portal): BHD Providers (milwaukee. gov) • Policies • Contact Numbers • And more CARS Website (Training): BHD Training (milwaukee. gov) • Avatar • Provider Connect • And more

CARS POLICIES AND PROCEDURES • Each agency contracted with CARS is obliged to ensure that their Direct Service Providers have access, read, understand, and implement all applicable policies and procedures. • All of the “applicable” P&P’s will be found on the CARS Provider website, link below: CARS website: https: //county. milwaukee. gov/EN/DHHS/Provider. Portal/BHD-Providers

CCS POLICIES AND PROCEDURES Available on the CARS provider website under the CCS sub-category CARS website: https: //county. milwaukee. gov/EN/DHHS/Provider. Portal/BHD-Providers

WHAT IS CARS Community Access to Recovery Services • CARS is a branch of Milwaukee County Behavioral Health Division, working with adults • CCS is a program run by CARS. • CCS is certified through the state of Wisconsin and CARS is the certificate holder. • CARS also oversees the Community Support Programs (CSP) and Targeted Case Management Programs (TCM) Training in the Share. Point Orientation and Training Library: • https: //milwaukeecountywi. sharepoint. com/sites/external/ccs/Lists/CCS%20 Orientation%20 a nd%20 Training%20 Library/Disp. Form. aspx? ID=24&e=zf. SL 1 O

CCS ELIGIBILITY

CCS IS AN ENTITLEMENT BENEFIT Any person who is interested in CCS is entitled to information.

CCS ELIGIBILITY Medicaid • T-19, Badgercare, HMOs • Not only QMB and SLMB • Not only Medicare MH or SUD Diagnosis • CCS Rx signed by Prescriber Pass Functional Screen • Level of need deemed severe enough for services

CCS CAN SERVE ALL AGES • Youth CCS: Ages 3 – 23 • Adult CCS: Ages 18 and up Youth CCS phone number: 414 -2577607 Adult CCS phone number: 414 -2576060

CCS IS A VOLUNTARY PROGRAM • • • YES NO - - Consumer chooses to join program* Consumer chooses goals and services Consumer is an active participant Consumer can be on probation/parole Consumer is willing to develop a team If consumer is under guardianship, guardian would need to sign on for consumer participation. Reference the policy regarding systemic interface: Policy. Stat : : Policy. Stat - Monitoring commitments or stipulations Joining program only to fulfill PO requirements or because they are mandated Joining program only to meet My Home or other housing requirements

CCS BROCHURE AND INFORMATION • CCS Brochure: BHDCCSbrochure_new. pdf (milwaukee. gov) • CCS Adult Provider Directory (brief version for potential consumers to review services available and Care Coordination teams): CCSadultdirectoryupdated 4 -192021. pdf (milwaukee. gov)

WHAT MAKES CCS UNIQUE?

Voluntary Entitlement WHAT MAKES CCS UNIQUE? Core Values Psychosocial Rehabilitation Outcomes oriented Measuring progress

Building skills Empowering Doing with WHAT MAKES CCS UNIQUE? 1. Consumer and CC develop a team. 2. Consumer works with team. 3. Ongoing CC support in accessing, engaging, and changing services

10 GUIDING PRINCIPLES OF RECOVERY • • • Hope Person Driven Many Pathways Holistic Peer Support Relational Culture Addresses Trauma Strengths/Responsibility Respect More information: https: //store. samhsa. gov/sites/default/files/d 7/priv/pep 12 -recdef. pdf https: //www. samhsa. gov/sites/default/files/rosc_resource_guide_book. pdf

CCS CORE VALUES CCS QUALITY IMPROVEMENT POLICY – ATTACHMENT IS QAPI PLAN, WHICH CONTAINS ALL CCS CORE VALUES IN DEPTH POLICYSTAT : : POLICYSTAT Rehabilitative Welcoming Education and Work Focus Gender/Age/Cultur ally Responsive Treatment Self-sufficiency Team Approach Across Agencies Belief in Growth, Learning and Recovery Unconditional Care Consumer Involvement Collaboration Across Systems Outcome-oriented Strength-Based Ensuring Safety Self Determination Team Based Builds on Natural and Community Supports Family-Centered

PSYCHOSOCIAL REHABILITATIV E SERVICES DHS 36 The services and supportive activities provided to or arranged for a consumer by a comprehensive community services program authorized by a mental health professional to assist individuals with mental disorder or substance use disorder to achieve the individual’s highest possible level of independent functioning, stability and independence and to facilitate recovery. Give a someone a fish and they can eat for the day. Teach someone to fish and offer encouragement, Help them get a fishing rod and a well stocked lake, And they can feed themselves and their community.

CCS SERVICES • Rehabilitative “help people return to daily life and live in a normal or near-normal way. ” (NCI, 2020) • Services are to be provided • most natural setting • least restrictive manner • most integrated settings • with frequency to support achievement of goals identified

CASE MANAGEMENT VS. CARE COORDINATION Instead of… Try to… Finding me a job Introduce me to an employment specialist, brainstorm options, review my resume, practice interviewing skills, etc. Delivering my meds Call the pharmacy together, support me in taking inventory of my current meds, review discharge instructions with me, etc. Telling me what to do Help me explore my internal values and motivations, support me in thinking through my decision, validate my experiences Driving me to the bank weekly Explore community transportation options, ride the bus with me, review my budget with me

SMALL GROUP ACTIVITY • Can you think of a time in your career where you helped a consumer. Looking back, you could have approached it in a more rehabilitative manner? Please describe. • 5 minutes to discuss in your small groups

CARE COORDINATION AND ANCILLARY SERVICES

PHILOSOPHY OF CCS • Core philosophy is that “Care Coordination” is different than “Case Management”. • Person-centered • Team approach • Difference between Care Coordination and Ancillary • CCS tries to follow Core Values and the 10 guiding principles of Recovery per SAMHSA.

CARE COORDINATION • Values collaboration and a team approach – includes most of the Core Values. • A Care Coordinator will: • Help consumer set their goals • Select providers • Make referrals • Not do direct services • Coordinate with Ancillary providers • • Communicate often • Read their case notes • Invite them to Recovery Team Meeting (RTM) • Provide them with a copy of the Recovery Plan of Care (RPOC) Collaborate with non-CCS providers (housing, Family Care, probation, etc. )

CARE COORDINATION Jen Alfredson is the CARS Service Manager for CCS Care Coordination Each Care Coordination Agency needs to be certified as a “Branch Office” through the state Division of Quality Assurance (DQA) Each CC agency has an assigned Administrative Coordinator that works at CARS and oversees the dayto-day operations There is no specific size of a CCS case load. Caseloads should be based off billable time, which is determined by each agency.

DIMENSIONS OF WELLNESS Common Care Coordination Services: • Service Facilitation • Service Planning • Screening and Assessment

LARGE GROUP ACTIVITY • Trainer is going to list several barriers. Please type in the chat, which dimension of wellness (handout) this consumer’s barrier would fall under. There can be more than 1! • A symptom of bipolar disorder is that John gets manic and spends his money impulsively. • A symptom of stress and anxiety is Jed’s back pain. • A symptom of Joseph’s obsessive compulsive disorder is hoarding.

ANCILLAR Y PROVIDER S • Agency needs to be contracted with BHD for CCS • Each individual provider needs to be impaneled through BHD and listed on the Adult Provider Directory in Share. Point • Ancillary providers will accept referrals from Care Coordinators • Provide direct services in a rehabilitative manner • Communicate with the CC as the team leader • Receive a copy of the Recovery Plan Of Care (RPOC) to understand what their goals/objectives are and who else is on the team • Attend RTM at a minimum of every six months. • Tamara Layne is the CARS Service Manager for ancillary services

INDIVIDUAL PLACEMENT SERVICES (IPS) • Ancillary Service for Employment and Education • IPS 101 trainings offered monthly • Beth Lohman is the CARS Service Manager for IPS. • IPS is embedded in 11 out of 12 CCS Care Coordination agencies • IPS is also utilized in CSP services through CARS

DIMENSIONS OF WELLNESS AND THE SERVICE ARRAY Examples of Ancillary Services: • • • • Peer Support Psychotherapy Psychiatry Employment Skill Development Med Management Wellness Personal Trainer Equine Therapy Yoga and Meditation Spiritual Coach Housing Life Coach Float Therapy

MEDICAID DEFINED SERVICE ARRAY • You will find the Medicaid Service Array in the Share. Point or on the BHD Providers website. • It is Attachment 1 in the Forward Health Update June 2014 • Forward. Health Upadte 2014 -42 Changes to the Comprehensive Community Services Benefit as a Result of the Wisconsin 2013 -15 Biennial Budget

REFERRAL Substance Use Application & Admission Agreement Diagnostic Psychotherapy Intake Coordinator leads this process Medication Prescriber Wellness Management & RSS 30 Days Screen & Assessme nt CC’s complete again annually Recovery Plan Service Facilitation Medication Monitoring (Care Coordination) Psychoeducatio n Physical Health Monitoring Employment Individual Skill Development & Enhancement Peer Support

CCS SERVICE ARRAY • Wide variety of services that fall into each category • Services always need to be rehabilitative • The “CCS Service Array” is another mandatory training as a part of CCS Orientation

LARGE GROUP ACTIVITY TRAINER IS GOING TO LIST SEVERAL INTERVENTIONS. PLEASE TYPE IN THE CHAT, WHICH SERVICE ARRAY THIS CONSUMER’S INTERVENTION WOULD FALL UNDER. • Diabetic education • IPS (Individual Placement Services) • Financial coach & Payee • Nutritional education • Housing Specialist • Certified Music Therapist • Yoga/meditation for coping skills • Certified Peer Specialist • Neuropsychological Evaluation • Psychiatry • Yoga to improve chronic pain • Persons with lived experience supporting consumer to develop their own goals

CCS ADULT PROVIDER DIRECTORY

INTRODUCTION TO CONSUMERS AT INTAKE • A brief introduction to CCS services should be given to consumers at Intake. CCS services overview form can be found in the Share. Point in Documents – Intake Folder. • CCS Adult Provider Directory (brief for potential consumers to review services available and Care Coordination teams): CCSadultdirectoryupdated 4 -192021. pdf (milwaukee. gov) • Wide range of services

ADULT PROVIDER DIRECTORY – SHAREPOINT - PROVIDERS • List in Share. Point • Found in the menu on the left-hand side • Comprehensive Community Services (CCS) - CCS Adult Provider Directory - Test 1 (sharepoint. com)

MOST IMPORTANT THINGS TO KNOW! • Filters • Accepting new referrals • Filter by the Medicaid Service Array, then by Service Type to get more specific • Utilize the demographics to make a good match with your consumer • Identify the agency • Download when needed

GROUP ACTIVITY Large Group • Trainer will say what she’s looking for and Jen will filter and sort to find it! Small Group • Each group will have a description • Group leader will share their screen and demonstrate

RECOVERY TEAMS 1. RECOVERY TEAM MEETINGS 2. RECOVERY PLAN OF CARE 3. MEASUREMENT BASED CARE

RTM – RECOVERY TEAM MEETING This is a team driven process that puts the consumer at the center. Must occur every 6 months Members Ø Consumer Ø CC & MHP/SAP Ø Ancillary Providers Ø Non-CCS providers Ø Natural Supports

• Involve the consumer in the development of their team Involve • Incorporate cultural practices and values throughout the process Incorporate KEYS TO EFFECTIVE TEAM MEETINGS • Actively engage and integrate natural supports Engage and integrate • Brainstorm individualized strategies to meet the needs Brainstorm • Involve the consumer in community activities Involve • Develop pro-active crisis response plans Develop Ensure

BENEFITS OF HAVING THE MOST MEMBERS IN ATTENDANCE Change talk that occurs at a team meeting Distribute the weight among team members Natural Supports Core Values Collaboration is more powerful that several people doing things independently Understand their role and make contributions Most of CCS Core Values are incorporated into the RTM

THE RECOVERY PLAN OF CARE (RPOC) • The RPOC should be completed as a team during the Recovery Team Meeting (RTM) • There is a separate and more intensive training directed at the RPOC. It can be found in the Share. Point in the documents section: Comprehensive Community Services (CCS) - RPOC training tools - All Documents (sharepoint. com)

RPOC PROCESS Create the Recovery Plan of Care (RPOC) Action! Recovery Team provides services RPOC updated at the 6 -month RTM to make adjustments CC monitors how well the services are doing RTM – all members review how the services are doing

MEASURING PROGRESS WIRT: Wisconsin Recovery Thermometer Tool • 15 Recovery-oriented questions • Consumer select 1 -2 areas as focus • Reviewed periodically and used on RPOC

How do we know that the services we arranging/delivering are working? OUTCOME S ORIENTED (CORE VALUE) • Recovery team (RT) evaluates progress • Makes adjustments collaboratively • WIRT is used to measure success • Outcomes individualized to consumer’s preferences and recovery

SMALL GROUP ACTIVITY 8 MINS Intros Roles and Goals Discussio n Wrap Up Present

Consumer’s Goals Physical Health Education Mental Health Spiritual Wellness Environmental Support Finances Employment Spiritual Wellness Social Connection Substance use other Rehabilitative Activities CCS Team Member or CCS Service (bonus)

PERSON CENTERED CARE

A Consumer’s life vision needs to guide their treatment. LIFE VISION 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.

LANGUAGE HOW YOU SPEAK TO CONSUMERS REFLECTS YOUR ABILITY TO EMBRACE THE CONCEPT OF BEING “PERSONCENTERED. ” 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.

TRUSTING RELATIONSHIPS • 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. • 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.

ENGAGEMEN T 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-basedengagements. pdf

SHARED DECISION MAKING The person does whatever they want Neglect Recovery Zone Get the person to do what I want Control

HEALING CENTERED ENGAGEMENT Self advocacy and community connections Culture, identity and spirituality Strengths-based and asset-driven care Mental health of provider is important • Empowering consumers through supporting autonomy, focusing on strengths and recovery, and honoring culture. • Service timeline determined by consumer • Robust service array supports holistic view of recovery • Collaborative decision making that honors consumer’s autonomy • Lower caseloads allow for more individualized care and support for consumers