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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:
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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.
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Work with enrollees to develop individualized services
plans. |
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Work with providers to arrange admission into desired
or needed services. |
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Coordinate mental health, chemical dependence, medical,
legal, housing and needed support services |
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Provide ongoing case management services. |
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Participate in systematic efforts to monitor the appropriateness
of treatment. |
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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:
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Development of an Individualized Services Plan (ISP)
that is unique to the needs and desires of the individual. |
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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.
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Services should be delivered in the least restrictive,
most normative environment that is appropriate to the
individual recipient. |
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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. |
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Participating providers agree to give persons admitted
to the program priority access to services. |
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Participating providers agree to cooperate and collaborate
with the Care Coordinator to implement the ISP. |
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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. |
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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. |
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Coordination of mental health, medical, substance
abuse and all other human services. |
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Linkages with all health and other human support services. |
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Cultural competency in service delivery; and |
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Continuous improvement of the Care Coordination Program
by monitoring utilization and outcomes on an individual
basis. |
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Promotion of implementation of evidence based best
practices. |
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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:
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Work with recipient to develop an ISP, identify services
needed to help in recovery, and select providers to
deliver services. |
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Use best efforts to provide or arrange for recipients
to receive needed services. |
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Monitor implementation of the ISP and ensure that
providers are delivering services in accordance with
the ISP. |
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Play a formal or informal role relative to the utilization
of inpatient services. |
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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. |
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Assist recipients in establishing and maintaining
eligibility for Medicaid and other public assistance
benefits. |
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Work with counties to monitor services to program
participants. |
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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:
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The Care Coordinator will obtain the initial referral
information regarding a person who might participate
in the program from the SPOA. (People who enroll in
the program are referred to as "Participants".) |
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The Care Coordinator will use his or her best efforts
to contact the individual within 24 hours of a referral
from the SPOA. |
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If a Participant needs immediate assistance to address
significant risk or safety issues, the Care Coordinator
will use his or her best efforts to meet with the Participant
within forty-eight hours. |
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The Care Coordinator will have face-to-face contact
with the individual within 7 days from the date of referral
from the SPOA. |
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The Care Coordinator will arrange for an Assessment
and/or medical examination of the Participant as needed.
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The Care Coordinator will help the Participant with
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.
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The Participant and the Care Coordinator will discuss
the self-assessment and develop an initial Individual
Service Plan. The form for the Individualized Services
Plan can be found here. |
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If possible, the initial Individual Services Plan
should be developed within 30 days after the initial
contact between the Care Coordinator and the Participant.
If necessary, an ISP may be completed in phases. |
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Once the initial ISP is prepared, the Participant
and the Care Coordinator will engage Service Providers.
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Participants and Service Providers listed on the ISP
will receive a copy of the completed ISP. |
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A licensed outpatient service provider that serves
a Participant will develop a treatment plan describing
the services it will deliver, and how those services
relate to the goals of the ISP. |
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When the ISP is revised, the Participant and the Care
Coordinator will again contact Service Providers to
inform them of changes to the ISP, and to coordinate
the delivery of services to the Participant. |
Standards for Individual Services Plans
The standards for development of the Individual Services
Plan are as follows:
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Individuals are full participants in all aspects of
the development of the ISP and provider specific treatment
plans. |
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Participants 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
Participant, the Care Coordinator may invite such persons
to participate in the process of the development of
the ISP. |
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Participants can request changes to the ISP. |
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The ISP is unique to the needs and desires of the
individual. |
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The ISP should describe the resources available to
the individual, including income and other financial
supports, housing, natural supports or significant others,
transportation, etc. |
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The ISP is goal oriented as articulated by the individual.
It must reflect the Participant's self-identified recovery
goals as well as indicators of goal completion or achievement
of milestones, strengths, and supports. |
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The treatment, rehabilitation, support, self-help,
and empowerment services necessary to help the Participant
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. |
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The ISP should identify all necessary linkages with
health care (including managed care plans) and human
service providers. |
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The ISP should identify supports or services to be
purchased with ICM/SCM/ACT wrap around dollars or Care
Coordination Funds. |
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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.
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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. |
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The Participant, 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. |
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The ISP is a dynamic document and must reflect any
significant clinical development or change that affect
the delivery of care. |
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The Individual Services Plan form approved by the
Department 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 Participants and work with
Participants to update ISPs as follows:
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Each week, the Care Coordinator will monitor Participant's
attendance at programs listed in the ISP, based on Provider
reporting. |
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The Care Coordinator will conduct a monthly review
of each Participant's progress in achievement of the
goals described in the ISP. The Care Coordinator will
update the Participant's Case Record and share information
as appropriate with Service Providers and the SPOA. |
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Care Coordinators will conduct a formal review of
all Individual Services Plans every six months, and
meet with Participants, individuals designated by the
Participant, and Providers to review their progress
and update the ISP. |
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If a Care Coordinator learns of a critical event that
may endanger a Participant or threaten his/her recovery,
he or she will take action as appropriate to contact
the Participant, update the Individual Services Plan,
and arrange for needed services to the Participant.
Treatment services, Medication, and the Crisis Plan
must be reviewed if the Participant is no longer following
the Individual Services Plan or the treatment plan,
uses the emergency room for psychiatric reasons, is
admitted to inpatient psychiatric hospitalization, or
is arrested. |
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