Comprehensive Community Support Services Competency & CSA Training

Heather A. ClarkMS, CPRP, LPCC

Presbyterian Medical Services

Purpose of the Training

To provide participants with a strong knowledge base and necessary skills

required for successful delivery of Comprehensive Community Support Services (CCSS) consistent with Core

Service Agency (CSA) Values

Outline• H2015 Service Definition as CCSS overview• CSA Criteria • Wraparound Approach• Key Concepts for CSW’s and CPS’s• Research• CSA Standards• Crisis Planning

Comprehensive Community Support Services Revised 7.30.2010 HCPCS

Service Definition: The purpose of Community Support Services is to surround individuals/families with the services and resources necessary to promote recovery, rehabilitation and resiliency. Community support activities address goals specifically in the following areas: independent living; learning; working; socializing and recreation. Community Support Services consist of a variety of interventions, primarily face-to-face and in community locations, that address barriers that impede the development of skills necessary for independent functioning in the community.

Comprehensive Community Support Services Revised 7.30.2010 HCPCS

• Community Support Services also include assistance with identifying and coordinating services and supports identified in an individual’s service plan; supporting an individual and family in crisis situations; and providing individual interventions to develop

H2015 Revised 7.30.2010 HCPCS

Individuals having problems accessing services and/or receiving multiple services from a single or multiple providers and/or systems and

• Individuals needing support in functional living • Individuals transitioning from institutional or highly restrictive settings to

community-based settings or • Children at risk of/or experiencing Serious

Emotional/Neurobiological/Behavioral Disorders or • Adults with severe mental illness (SMI) or • Individuals with Chronic Substance Abuse or • Individuals with a co-occurring disorder (mental illness/substance abuse)

and/or dually diagnosed with a primary diagnosis of mental illness

H2015 Revised 7.30.2010 HCPCS

Designated agency Individuals that meet the target population

criteria for community support services must have one designated agency that will have the primary responsibility of assisting the recipient and family with implementing the service plan.

H2015 Revised 7.30.2010 HCPCS

Designated community support worker

The designated community support worker will coordinate and may facilitate family team meetings/treatment team meetings.

H2015 Revised 7.30.2010 HCPCS- Activities• Assistance to the individual in the development and coordination of the

individual’s service plan including a recovery a management plan and a crisis management plan;

• Assessment support and intervention in crisis situations including the development and use of crisis plans which recognize the early signs of crisis/relapse, use of natural supports, use of alternatives to emergency departments and inpatient services,

• Assistance to the individual in the development of advanced directives related to his/her behavioral healthcare; and

• Individualized interventions, with the following objectives: • Identification, with individual, of barriers that impede the development of skills

necessary for independent functioning in the community; as well as strengths, which may aid the individual in recover;

• Services and resources coordination to assist the individual in gaining access to necessary rehabilitative, medical and other services;

• Support to facilitate recovery and resiliency;

H2015 Revised 7.30.2010 HCPCS- Activities Continued…

• Assistance in the development of interpersonal, community coping and functional skills (including adaptation to home, school and work environments);

• Encouraging the development and eventual succession of natural supports in workplace and school environments;

• Assistance in learning symptom monitoring and illness self-management skills (e.g. symptom management, behavioral management, relapse prevention skills, knowledge of medication and side effects and motivational/skill development in taking medication as prescribed) in order to identify and minimize the negative effects of symptoms which interfere with the individual’s daily living;

• Assistance with financial management and skill development; • Assistance with personal development and school/work performance; • Assistance in enhancing social and coping skills that ameliorate life stresses resulting from

the individual’s disability; • Assistance to individuals with illness self-management as it relates to maintaining

employment and school tenure; • Assisting the individual to obtain and maintain stable housing; • Any necessary monitoring and follow-up to determine if the services accessed

H2015 Revised 7.30.2010 HCPCS

The majority (60% or more) of non facility-based community support services provided must be face-to-face and in vivo (where the client is). The community support worker must monitor and follow-up to determine if the services accessed have adequately met the individual’s treatment needs.

H2015 Revised 7.30.2010 HCPCS

For individuals and/or their families: The community support worker will make every effort to engage the client in achieving treatment/recovery goals.

H2015 Revised 7.30.2010 HCPCS

When the service is provided by a Certified Peer Specialist, the above functions/interventions should be performed with a special emphasis on recovery values and processes such as:

• Empowering the individual to have hope for and participate in his or her own recovery;

• Helping the individual identify strengths and needs related to attainment of independence in terms of skills, resources, and supports, and to use available strengths, resources and supports to achieve independence;

• Helping the individual to identify and achieve their personalized recovery goals (which should include attainment of meaningful employment if desired b the individual); and

• Promoting an individual’s responsibility related to illness self-management.

H2015 Revised 7.30.2010 HCPCS

• Only one provider organization at a time can serve as an individual’s clinical home. This does not preclude that other organizations provide community support activities. These community support activities and providers must be clearly identified in the service plan, be coordinated by the primary community support worker and not duplicate community support services provided by the primary community support worker

Core Service AgencyWhat is a Core Service Agency (CSA)?

A Core Service Agency (CSA) coordinates care and provides essential services to children, youth and adults who have a serious mental illness, severe emotional disturbance, or dependence on alcohol or drugs. For those eligible to receive services, the CSAs provide or coordinate:

1. psychiatric services (medication management)

2. everyday crisis services, and

3. comprehensive community support services (CCSS) that support an individual’s self identified recovery goals, and ‐other clinical services.

CSA Criteria- Adult Target Populations

1. Severe Mental Illness (SMI) 2. Chronic Substance Dependence (CSD)3. Co-Occurring Disorders (COD) *SMI with substance disorder *SMI with developmental disability

ANDSymptom severity

causing functional impairment in activities of daily living, interferes with functioning by inhibiting recovery and resiliency goals.

ORTransition concerns*from inpatient treatment*from residential treatment*from prison

CSA -Target Populations- YouthChild/Youth Consumer is documented with

* diagnosis of Severe Emotional Disturbance (SED)AND

Symptom severity causing functional impairment in activities of daily living interferes with functioning by inhibiting recovery and resiliency goals

ORTransition concerns

*from inpatient treatment*from residential treatment*from a juvenile justice facility

CSA – Special Populations

If Adult CSA:*persons who are homeless*persons with DD/MI

If Youth CSA:*0-5 year olds; AND,*persons who are homeless; AND, *persons with DD/MI

Wraparound Approach

Individual

Oral surgeon

PCP

Payee

Psychiatrist

TherapistDrop In Center

CSW

Neurologist

Natural Support

Family

Wraparound Principles

1. Individual Voice & Choice:The Individual has ownership over their plan

and represents their own perspective, choices reflect their culture and preferences. Cultural Competence, sensitivity, instills hope

Wraparound Principles

2. Team Based A collaborative team based process that

consists of formal, informal, family/natural and community supports chosen by the individual. Be engaging with the individual, family and team build a strong therapeutic alliance.

Wraparound Principles

3. Natural Supports Encouragement of community and

interpersonal supports that are key in providing necessary intervention. Natural supports help in managing crisis and risk – connectedness.

Wraparound Principles

4. CollaborationThe team collaborates and guides a plan that guides each team members work. Team helps individual to identify strengths/needs.

Wraparound Principles

5. Community BasedInclusive, accessible, least restrictive settings

Wraparound Principles

6. Culturally CompetentRespects and builds on value, beliefs and

culture

Wraparound Principles

7. IndividualizedPlan/Team is uniquely tailored to fit the

individual

Wraparound Principles

8. Strengths-BasedValidate, expand and build on assets

Wraparound Principles

9. PersistenceDespite challenges and a limited system the

team continues to work towards stated goals.

Wraparound Principles

10. Outcome BasedThe Team is accountable for achieving the goals

laid out in the plan. Ongoing monitoring and assessing is the plan is required.

Key CCSS Concepts

Life Domains• Independent and community living• Work• Learn• Socializing• Recreation

Key CCSS Concepts

*CSW’s and CPSW’s address the functional limitations created by the illness that interfere with the person reaching their recovery and resiliency goals. We do this by focusing on individual strengths that will help them overcome the limitations. This must be reflected in all documentation.

Key CCSS Concepts

• Resiliency – being able to rebound from adversity and challenges.

• Recovery – the process by which people are able to live, work, learn and participate fully in their communities.

Key CCSS ConceptsRecovery Components: www.samhsa.gov

(SAMHSA, 2004)1. Self Direction2. Individualized & Community focused3. Empowerment4. Holistic- Medical/Behavioral Health Wellness5. Non-linear- Stages of Change6. Strengths-based7. Peer Support8. Respect9. Responsibility10. Hope & Optimism

Key CCSS Concepts

• Self – Directed Individuals & families lead, control, choose, and

determine their own path. Individual/Family centered, sensitive to culture, instills hope, understandable language

Key CCSS Concepts

• Self-Determination- Personal decision to do something and think in a certain way

Key CCSS Concepts

CSW’s have a responsibility to adopt language that conveys respect & that is person

centered.

“Person with Schizophrenia”Vs.

“Schizophrenic”

Key CCSS Concepts

Doing With not Doing For:Doing With- Teaching, Coaching, Sharing,

Modeling, Developing, Designing, Coordinating, Linking, Promoting, Evaluating, Crisis Planning, Safety Planning

Doing For- Telling people what to do, making appointments for them, calling, shopping for.

Key CCSS Concepts

Personal Safety• Differentiate between self/others- your personal

issues vs. individual’s issues- be self aware, take responsibility, don’t use the helper relationship to meet personal needs (to be liked, do well, be needed)

• Practice de-escalation techniques- be smart, carry phone, let supervisor know where you are, go with someone on first home visit, scan surroundings

• Protect yourself against burnout.

Key CCSS Concepts

Manage Crisis/Risk• Complete Detailed CCSS Crisis plan that detect

warning signs/triggers to things breaking down with appropriate action plans and steps for the individual to manage crisis- UPDATE THEM!!!

• Listen and report abuse, neglect, exploitation & danger to self/others.

• Focus on Behavior Changes that might indicate concern.

Key CCSS Concepts

• Remember face-to-face visit must occur within 48 hours after a crisis.

• Adult Crisis Plans should include Advance Directives, risk factors and development of interventions developed from knowledge of past crisis situations

• Indicate escalating risk and levels of crisis support-

Research:Patricia E. Deegan, Ph.D.

Institute for the Study of Human Resilience

“Offer support like you offer a cup of tea.”

http://www.bu.edu/resilience/staff/pdeegan.html

Research:Recovery After an Initial Schizophrenia Episode

(RAISE): A Research Project of the NIMH

• Patricia Deegan is currently a member of the executive and intervention committees of a study funded by the National Institute of Mental Health called R.A.I.S.E (Recovery After Initial Schizophrenia Episode). This is a multi-year study of an intervention aimed at young folks who have a first psychotic episode. The intervention includes a team of professionals who work in a coordinated fashion to outreach and engage people in recovery-oriented services including supported employment and supported education. Active linkage to peer support, natural supports, substance abuse services and trauma services (if indicated) are part of the study protocol.

Psychosocial Rehabilitation (PSR)

Psychiatric Rehabilitation promotes recovery—full community integration and improved quality of life for persons who have been diagnosed with any mental health condition that seriously impairs functioning. Psychiatric rehabilitation services are collaborative, person-directed, and individualized, an essential element of the human services spectrum, and should be evidence-based. They focus on helping individuals develop skills and access resources needed to increase their capacity to be successful and satisfied in the living, working, learning and social environments of their choice. www.USPRA.org

Research:12 PSR Principles of Recovery

• PSR practitioners convey hope and respect, and believe that all individuals have the capacity to learn and grow.

• PSR practitioners recognize that culture is central to recovery, and strive to ensure that all services are culturally relevant to individuals receiving services.

• PSR practitioners engage in the processes of informed and shared decision-making and facilitate partnerships with other persons identified by the individual receiving services.

• PSR practices build on the strengths and capabilities of individuals.• PSR practices are person-centered; they are designed to address the unique

needs of individuals, consistent with their values, hopes and aspirations.• PSR practices support full integration of people in recovery into their

communities where they can exercise their rights of citizenship, as well as to accept the responsibilities and explore the opportunities that come with being a member of a community and larger society. www.USPRA.org

Research:12 PSR Principles of Recovery

• PSR practices promote self-determination and empowerment. All individuals have the right to make their own decisions, including decisions about the types of services and supports they receive.

• PSR practices facilitate the development of personal support networks by utilizing natural supports within communities, peer support initiatives, and self-and mutual-help groups.

• PSR practices strive to help individuals improve the quality of all aspects of their lives; including social, occupational, educational, residential, intellectual, spiritual and financial.

• PSR practices promote health and wellness, encouraging individuals to develop and pursue individualized wellness plans.

• PSR services emphasize evidence-based, promising and emerging best practices that produce outcomes congruent with personal recovery. Programs include structured program evaluation and quality improvement mechanisms that actively involve persons receiving services.

• PSR services must be readily accessible to all individuals whenever they need them. These services also should be well coordinated and integrated with other psychiatric, medical and holistic treatments and practices.

www.USPRA.org

Research:Courtenay M. Harding, Ph.D.

The American Psychological Foundation awarded Dr. Harding its 2004-2005 Alexander Gralnick Research Investigator Award. This prestigious prize "recognizes exceptional contributions to the study of schizophrenia and other serious mental illness and for mentoring a new generation of researchers." She was appointed Professor of Psychiatry at the Boston University School of Medicine in 2007. www.bu.edu

Service Planning

Stages of Change• Pre-contemplation = Engagement• Contemplation & Preparation= roll with

resistance listen for “change talk”• Action= identify goals/strengths/coping

strategies to avoid crisis/relapse• Maintenance= ongoing movement towards

goals & objectives

Service Planning• Assessment- minimally documents diagnosis/illness & impact

on functioning• Baseline Functional Assessment- further documents functional

limitations and barriers to recovery• Service Plan- address Life domains, goals in person’s own

words, steps to restore functioning in frequency/duration (objectives)

• Activities/Interventions relate to Plan/Medically Necessary• Progress Notes- demonstrate progress• Enhanced Assessment• Review Revise

Service PlanningEnhanced Assessment If Adult CSA, use HOO31 U8 for consumer who meets one of the following:_____Significant current danger to self or others_____Has 3 or more emergency room visits or psychiatric hospitalizations w/in last

year_____Meets ASAM Placement Criteria for Level III or IV services and must have a high

score on the following dimensions: intoxicated/withdrawal potential, biomedical condition, emotional/behavioral/cognitive conditions

_____Person is experiencing trauma symptoms related to traumatic event_____Severe impairment in at least one Axis IV functional domain _____Moderate functional impairment in multiple domains_____Substance Dependency diagnosis and any mental illness that affects

functionality_____SMI or Substance Dependence and potentially life-threatening medical

condition _____SMI or Substance Dependency and Developmental Disability Assessment Adult

Service PlanningEnhanced YouthIf Youth CSA, use HOO31 U8 for consumer who meets at least 2 of below 6 criteria:_____Multi-system involvement_____At risk of out-of-home placement due to SED_____Current psychiatric hospitalization or 2+ psychiatric admissions within last year_____Recent or pending discharge from a residential facility or 2+ placements within

residential facility within last year_____History of 2+ suicide attempts within past year resulting in medical intervention_____History of significant trauma

Adult and/or Youth CSA initiated 90801 assessment when:_____consumer met neither of above criterion

CSA Standards

• Provide basic assessment 90791- 48 hours if urgent/5 calendar days if routine

• OHNM Service Registration 48 Hours

CSA Standards• CSA Eligibility

Determination Target Population Checklist

(no eject/reject expectation)Every referral (hard copy to file)

SMI Criteria ChecklistCSD Criteria ChecklistCOD Criteria ChecklistAdult CSA Criteria (H0031 w/ U8 Modifier)

Within 48 hours if• Individuals w/Urgent needs• Incarcerated adult• APSWithin 5 business days• Individuals who do not meet

the above listed criteria

CSA Standards

Crisis Plan

All Qualified CSA individuals• Urgent 1 calendar day• Within 14 calendar days

CSA Standards

Enhanced Assessment (H0031 U8)- if necessary

• Within 10 calendar days (10-20% predicted to be necessary; if collateral data available based on severity)

• See Teambuilders flowchart)

CSA Standards

• Baseline Functional Assessment for eligible CSA recipients (90806 or bill to CCSS) ANSA or DL20 or Multnomah

All Qualified CSA individualsWithin 10 calendar days of admission

into CCSS

CSA Standards

CCSS and other appropriately identified services (Direct CSA Services Crisis, Psychiatric, CCSS)

• Urgent 1 calendar day• Routine 14 Calendar days

CSA Standards

CCSS Service PlanWithin 30 Calendar days

CSA Standards

Coordination of Care for CSA Individuals• 90 Day Reviews (brief intervention, EOC,

Solution Focused)

Service Planning

• Teaming: Develop a Treatment Team based off of the recommendations of the enhanced assessment and coordinate Team Meetings.

CCSS Crisis Plan

• Presenting Problems: to include SI’s/HI’s, risk of overdose, risk

of morbidity (death), self-injurious behaviors, anger/aggressive outburst- things that cause harm to self or others

CCSS Crisis Plan

• Natural supports – if they don’t have any specify on the plan- the intent of CCSS is to build natural supports & improve the person’s ability to self-sooth or use community supports before using paid supports.

CCSS Crisis Plan

• Coping strategies – The intent of CCSS is to build their person’s ability to manage life’s challenges using natural or community supports – coping strategies are to be used as a the first level of defense for harmful behavior, must be reflective of the persons real environment congruent with presenting problem– i.e. don’t say go for a walk if they are not able to walk

CCSS Crisis Plan

• Warning Signs- indicators things are breaking down – often happen a day before the crisis, these can be internal or external i.e. isolation, racing thoughts, anger

CCSS Crisis PlanWhat is an Advance Directive?

It is a legal document. It defines what future treatment you want if you are not able to make decisions about your mental health care. An advance directive empowers you to make treatment preferences known.

• An advance directive will improve your communication with a physician. It can prevent clashes with professionals over treatment and may prevent forced treatment.

• Having an advance directive may shorten a hospital stay. • Advance Directives in New Mexico: PAD

The Mental Health Care Treatment Decisions Act is the New Mexico law about advance directives. It allows written instructions for psychiatric treatment if you are unable to make or communicate your instructions.

In New Mexico, " an advance directive for mental health treatment" is called a PAD (Psychiatric Advance Directive). The law includes a standard form. It is not mandatory but is recommended. Get a copy of the form to use from Optum Health NM website. You have to be 18 or older to create a PAD.

You may use an advance directive for mental health treatment to express any and all wishes a consumer has about their mental health treatment, including refusals of treatment.

CCSS Crisis PlanYou can appoint an agent

You can name someone in writing to have your "Power of Attorney." That means the person can make mental health care service decisions for you if you are not able to. The decisions should be in your best interests and in accordance to your wishes. There are some rules about who can be your agent: The agent must know you and be willing to take this responsibility.

• You both sign the PAD naming the person. • A witness must sign it too. The witness must not be your agent, an

employee of your health care organization, a beneficiary of your estate or a relative of yours.

• A PAD is valid until you change or end it.

CCSS Crisis Plan

• Triggers: internal or external – i.e. loss of love, feeling disrespected, when someone says “no”- not taking meds, lack of sleep, anniversary of a loved one’s death

CCSS Crisis Plan

• Before and After a Crisis: What led to the last overdose or

hospitalization, events leading up to it, what happened after – what supports were helpful, or what would be helpful after a crisis –

CCSS Crisis Plan

Escalating Risk: 1. feeling depressed/angry- use coping strategies, call

CSW/therapist/psychiatrist2. feeling depressed/angry and have suicidal/homicidal

ideations or thoughts of acting out aggressively towards others/ thoughts of self-injurious behaviors- call crisis numbers- reach out for help

3. feeling depressed/angry have Suicidal/Homicidal Ideations and a plan to hurt self/others- call 911.

CCSS Crisis Plan

Safety Plan: Crisis Response of Santa Fe1-888-920-6333Lifeline Suicide Prevention 1-800-273-TALK (8255)

CCSS Crisis Plan

• Other professional/Community ResourcesWaking Up Alive, Center for Hope and Recovery, NA, AA- when and where can they access self-help supports

groups they were referred to- times and dates- their psychiatrist name and number- their therapist.

CCSS Crisis Plan

• Respite Apartment : If homeless – put down shelter info. times to call and phone numbers, put down friends they can stay with – I put down UNM Hospital waiting room on cold nights (this is how he stayed alive when he couldn’t get to the winter shelter).