The heart of this program is client centered individualized
service planning and assistance in securing access to services
to help individuals in their recovery. Each participating
county designates "Care Coordination Organizations"
that:
Collaborate with county sponsored Single Point of
Access (SPOA) 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 service
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 provides support to adults diagnosed
with serious mental illness with a high need for clinical
and support services. Individuals may have histories of
repeated hospitalization or incarceration, experience frequent crises,
experience an absence of a constructive social or family network, lack
meaniful activity, and experience difficulties engaging in treatment,
taking prescribed medications and/or managing their symptoms of illness.
Values and Principles
The following "values and principles" underlie this program:
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.
Best efforts are made to ensure that individuals have
access to services within the first 24-hours following
referral from the Single Point of Access (SPOA) and as needed on an ongoing basis.
Participating providers agree to give individuals priority access to services.
Participating providers agree to cooperate and collaborate
with the Care Coordinator to implement the Individual Service Plan.
Coordinated, flexible use of available financial resources
empowers Care Coordinators to purchase services and make
effective linkages to providers to meet the needs of individuals.
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.
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 individuals to develop an ISP, identify services
needed to support recovery, and select providers who will partner with them in their recovery.
Use best efforts to provide or arrange for individuals
to receive needed services.
Monitor implementation of the ISP and support the empowerment of individuals to ensure that the delivery of services are 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 individuals in establishing and maintaining eligibility
for Medicaid and other public assistance benefits.
Work with counties to monitor access to services for individuals.
Complete outcome reports and provide information consistent
with program requirements.
