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 designates "Care Coordination Organizations"
that:
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 initial "values and principles" statement
for the program is as follows:
Development of an Individualized Service 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.
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.
