The heart of this program is client centered individualized services planning and assistance in securing access to services to help recipients in their recovery. Each participating county will designate "Care Coordination Organizations" that will:

• Collaborate with county sponsored "single point of access" systems to identify individuals who might benefit from the care coordination program and offer them the opportunity to enroll in the program.
• Work with enrollees to develop individualized services plans.
• Work with providers to arrange admission into desired or needed services.
• Coordinate mental health, chemical dependence, medical, legal, housing and needed support services
• Provide ongoing case management services.
• Participate in systematic efforts to monitor the appropriateness of treatment.
• Work with county governments to coordinate access to supportive housing.

Eligible Persons

The Care Coordination program is targeted to adults diagnosed with serious mental illness with a high need for clinical and support services. These are persons with histories of repeated hospitalization or incarceration, frequent crises, absence of a constructive social or family network, a lack of daily structure, and difficulties engaging in treatment, taking prescribed medications and self-monitoring.

Values and Principles

The following values and principles underlie this program:

• Development of an Individualized Services Plan (ISP) that is unique to the needs and desires of the individual.
• Individuals are full participants in all aspects of the development of the ISP and in the selection of services and providers. Family members, peers, or others may participate in this process with agreement of the individual.
• Services should be delivered in the least restrictive, most normative environment that is appropriate to the individual recipient.
• Best efforts are made to ensure that individuals have access to services within the first 24-hours following referral from the SPOE and as needed on an ongoing basis.
• Participating providers agree to give persons admitted to the program priority access to services.
• Participating providers agree to cooperate and collaborate with the Care Coordinator to implement the ISP.
• Coordinated, flexible use of available financial resources empowers Care Coordinators to purchase services and make effective linkages to providers to meet the needs of individual recipients.
• Progress towards a rehabilitation and recovery model by ensuring access to a comprehensive array of all human services that addresses the individual's specific needs.
• Coordination of mental health, medical, substance abuse and all other human services.
• Linkages with all health and other human support services.
• Cultural competency in service delivery; and
• Continuous improvement of the Care Coordination Program by monitoring utilization and outcomes on an individual basis.
• Promotion of implementation of evidence based best practices.
• Respect for the privacy of individuals.
  

Care Coordinators

Each person who enrolls in the program will work with a Care Coordinator. Care Coordinators will provide the following services:

• Work with recipient to develop an ISP, identify services needed to help in recovery, and select providers to deliver services.
• Use best efforts to provide or arrange for recipients to receive needed services.
• Monitor implementation of the ISP and ensure that providers are delivering services in accordance with the ISP.
• Play a formal or informal role relative to the utilization of inpatient services.
• Coordinate with organization(s) designated by the counties as single point of access (SPOA) for Case Management and housing services as well as other critical services.
• Assist recipients in establishing and maintaining eligibility for Medicaid and other public assistance benefits.
• Work with counties to monitor services to program participants.
• Complete outcome reports and provide information consistent with program requirements.
  

Development of Individual Service Plan

The process for development of an ISP will be as follows:

• The Care Coordinator will obtain the initial referral information regarding a person who might participate in the program from the SPOA.
• The Care Coordinator will use his or her best efforts to contact the individual within 24 hours of a referral from the SPOA.
• If an individual needs immediate assistance to address significant risk or safety issues, the Care Coordinator will use his or her best efforts to meet with the person within forty-eight hours.
• The Care Coordinator will have face-to-face contact with the individual within 7 days from the date of referral from the SPOA.
• The Care Coordinator will aid in the arrangements of an Assessment and/or medical examination of the individual as needed.
• The Care Coordinator will assist the individual to complete a Quality of Life Self-Assessment of his or her needs and desires in preparation of the ISP. A Self Assessment form can be found here.
• The individual and the Care Coordinator will discuss the self-assessment and develop an initial Individual Service Plan. The form for the Individual Service Plan can be found here.
• If possible, the initial Individual Service Plan should be developed within 30 days after the initial contact between the Care Coordinator and the person. If necessary, an ISP may be completed in phases.
• Once the initial ISP is prepared, the individual and the Care Coordinator will engage service providers.
• Individuals and service providers listed on the ISP will receive a copy of the completed ISP.
• A licensed outpatient service provider that serves an individual will develop a treatment plan describing the services it will deliver, and how those services relate to the goals of the ISP.
• When the ISP is revised, the individual and the Care Coordinator will again contact service providers to inform them of changes to the ISP, and to coordinate the delivery of services.

Standards for Individual Services Plans

The standards for development of the Individual Service Plan are as follows:

• Individuals are full participants in all aspects of the development of the ISP and provider specific treatment plans.
• Individuals are entitled to have a family member, peer, or other person of their choice present during the process of development of their ISP, if such persons are reasonably available. With the agreement of the individual, the Care Coordinator may invite such persons to participate in the process of the development of the ISP.
• Individuals can request changes to the ISP.
• The ISP is unique to the needs and desires of the individual.
• The ISP should describe the resources available to the individual, including income and other financial supports, housing, natural supports or significant others, transportation, etc.
• The ISP is goal oriented as articulated by the individual. It must reflect the person's self-identified recovery goals as well as indicators of goal completion or achievement of milestones, strengths, and supports.
• The treatment, rehabilitation, support, self-help, and empowerment services necessary to help the individual achieve recovery goals should be identified in the ISP. The description of required services must include, for each service, the provider name, relationship of the service to the recovery goals, anticipated frequency and duration of service, and the anticipated outcomes of the service.
• The ISP should identify all necessary linkages with health care (including managed care plans) and human service providers.
• The ISP should identify supports or services to be purchased with ICM/SCM/ACT wrap around dollars.
• The ISP should include a Crisis Plan that describes recommended services and options to be pursued and individuals to be notified in the event of a crisis situation such as hospitalization, medical emergency or loss of housing.
• The ISP should record the existence of any Advanced Directive and a copy should be attached to all copies of the ISP distributed to providers.
• The individual, Care Coordinator, and service providers will negotiate a "best service available" plan if services identified in the ISP are not immediately available (e.g. other services to be provided in the interim). A "best service available" plan can also be used in the case of an emergency or as unplanned needs arise.
• The ISP is a dynamic document and must reflect any significant clinical development or change that affect the delivery of care.
• The Individual Service Plan form approved by WNYCCP and OMH for use in the Care Coordination Program will be used to document the ISP.

Ongoing Monitoring; Update of Individual Services Plans

Care Coordinators will monitor engagement and delivery of services and work with individuals to update ISP's as follows:

• Each week, the Care Coordinator will monitor the engagement of services by the individual as identified on the ISP.
• The Care Coordinator will review on a monthly basis each individual's progress in achievement of the goals described on the ISP. The Care Coordinator will update the individual's case record and coordinate information as appropriate with service providers and the SPOA.
• At a minimum of every six months, Care Coordinators will meet with the individual, persons designated by the individual, and providers to review an individual's progress toward recovery and to update the ISP. A Periodic Reporting Form (PRF) will be sent to WNYCCP to track overall progress towards recovery.
• If a Care Coordinator learns of a critical event that may endanger an individual or threaten his/her recovery, he or she will take action as appropriate to contact the individual, update the Individual Service Plan, and arrange for needed services for the person. Treatment services, medication, and the Crisis Plan must be reviewed if the person is no longer following the ISP or the treatment plan, uses the emergency room for psychiatric reasons, is admitted to inpatient psychiatric hospitalization, or is arrested.