C omprehensive Community Services

1. Comprehensive Community Services Milwaukee County Behavioral Health Division Wraparound Milwaukee Disability Services Division Department On Aging and Community Provider Partners introduce…

2. CCS website • http://county.milwaukee.gov/CCS.htm

3. CCS Core Values • Participant Participation – The consumer cooperates and demonstrates ownership of their treatment. The consumer and their family are full and meaningful partners in all aspects of decision making affecting their lives and their service plan. • Building on Natural Support/Community Supports – the services are family centered. The “family” is defined by the consumer. Families are respected and listened to. We support them in meeting their needs, reducing system barriers, and promoting change that can be sustained over time. Recognizes and utilizes all resources in our communities creatively and flexibly, including formal and informal supports. Every attempt is made to include the family, neighbors, friends, faith community, co-workers, or anyone that the consumer would like to include in the team process. • Strength Based – Builds on the family’s unique qualities and identified strengths that can be used to support strategies to meet the consumer/family needs. Strengths should be found in attitudes, values, skills, abilities, preferences and aspirations.

4. Collaboration Among Systems/Partnerships - An interactive process in which people with diverse expertise generate solutions to mutually defined needs and goals building on strengths. All systems understand each others program and are committed to working together. Systems will collaborate to coordinate a single system of care. • Team Approach – Planning, decision making, and strategies rely on the strengths, skills, mutual respect, creative, and flexible resources of a diverse and committed team. All family, formal, and informal team members share responsibility, accountability, authority, and understand and respect each other’s strengths, roles and limitations. • Gender/ Age/Cultural Intelligence – Services reflect an understanding of the issues specific to gender, age, disability, race, ethnicity, and sexual orientation and reflect support, acceptance, and understanding of cultural and lifestyle diversity.

5. Self-Sufficiency – Families will be supported, resources shared, and team members held responsible in achieving self-sufficiency in essential life domains. • Outcome oriented, Evidenced-Based – From the onset of team meetings, personal responsibility and accountability for all team members are discussed and agreed upon. Progress is monitored and outcomes are measurable. • Service access/Welcoming – Unconditional care means that we care for the consumer and family. It is the responsibility of the service team to adapt to the needs of the family – not for the family to adapt to the needs of the program. If difficulties arise, services and supports will change to meet their needs.

6. Person Centered Planning – Takes into consideration what the consumer wants and values. The process of continued listening and learning to focus on what is important to each individual. • Education and Work Focus – Dedicated to positive education and employment related activities which result in resiliency and self-sufficiency, improved quality of life. • Recovery Principles – the process of a person’s growth and improvement, in attitudes, values, feelings, goals, skills and behavior and is measured by a decrease in dysfunctional symptoms and an increase in maintaining the person’ highest level of health, wellness, stability, self-determination and self-sufficiency.

7. CCS is a voluntary program • In respect to the values, all consumers would need to choose to be in the CCS program. • The consumer is required to sign an agreement, agreeing to participation in CCS. • If a consumer has a guardian, the guardian would need to sign for participation in the program. • The CCS staff cannot monitor commitments or stipulations. • Probation/Parole does not make a consumer ineligible, but it is cause for concern and investigation as to whether the consumer wants the service voluntarily as opposed to the services being a requirement of the PO.

8. CCS is Psycho-Social Rehabilitative Services • The services and supportive activities provided to or arranged for a consumer by a comprehensive community services program authorized by a mental health professional to assist individuals with mental disorder or substance use disorder to achieve the individual’s highest possible level of independent functioning, stability and independence and to facilitate recovery. • Examples of services being rehabilitative in nature.

9. CCS is a Recovery Benefit • Supporting consumers to shift from an illness-dominated identity to a sense of well being and purpose • Consumer and their Team Chooses services they feel that they need or desire. Consumer chooses where and how services will take place. Consumers chooses who their providers will be. (Available providers for each Service Array can be found in the Provider Directory on the CCS website.) • Care Coordinator assists and supports the consumer with their choices. When choices are risky or not appropriate, the CC will need to support the consumer in making better choices. • Services are not time limited based on caseloads. Per Medicaid, “If a CCS program does not provide a service that is covered under the CCS benefit, the CCS program must determine a way to provide a service that meet the needs of the member.” • Caseloads will be determined by the amount of time spent with each consumer, not be contract caps. Thus, caseloads will vary in size (probably anywhere from 7-17).

10. CCS is an Entitlement Benefit • Any person who is interested in CCS is entitled to information. • Consumers can call or walk into CARS, or any designated CCS Branch office. • CARS has already been working closely with current service providers, such at CSP, TCM, and RSC’s to help them learn about and access CCS services. • CARS will develop an Outreach Plan to communicate CCS to our community.

11. CCS Eligibility • T-19/Medicaid/Badger Care Plus • Diagnosis documented in a Prescription via MD (Either Mental Health Disorder or a Substance Use Disorder, or both) • Must meet functional requirements via the Mental Health/AODA functional screen

12. Physician Prescription/Referral for CCS (found on the website, and hand out) • Provides the Diagnosis • Must be signed by an MD. If the consumer’s provider is an APNP, it must be signed off by an MD. • Needs to be dated. MD’s name legibly printed.

13. T19/Medicaid/Badger Care Plus eligible + Doctor’s Prescription = Presumptive Eligibility • With these 2 things, CARS will assign the case to an agency that is qualified to do Service Array #1, Screening and Assessment. • The consumer can pick the agency. Current agencies will be listed on the website within the Provider Directory. Currently, we have APC, LaCausa, TLS, and St. Charles. We are planning to add 4 new Care Coordination agencies in May: Bell Therapy, Outreach, Guest House, and Justice Point.

14. MH/AODA Functional Screen – Determines Final Eligibility • Consumers being admitted into CCS must be determined to have a functional impairment that interferes with or limits one or more major life activities, and results in the consumer needing services that are ongoing. • The Screening and Assessment CCS agency will conduct the MH/AODA Functional Screen. • If eligible, consumer continues on with CCS. • If ‘not eligible’, consumer is oriented to the Appeal Process • CARS will make final approval after reviewing all documentation.

15. Service Opportunities • There are 14 services on the CCS service array, which can be found within the Forward Health update, which is on the CCS website. • The first service is “Screen and Assessment”. This service is not limited to intake. • The second service is “Service Planning”. Anytime the IRP is reviewed and/or consulted during supervision then it is considered “planning”.

16. The third service is “Service Facilitation”. Milwaukee County is calling this service “Care Coordination”. The CC is intended to do the “planning” and coordinate the care with ancillary service providers from their own agency as well as other agencies. • Currently, many CC’s are performing other services on the Array due to a limited amount of ancillary service providers. Med management as an example.

17. Service Array #7 is employment. Milwaukee County will be utilizing the Evidence Based Practice of IPS, which stands for Individualized Placement Support. • IPS supports people in their efforts to achieve steady employment in mainstream competitive jobs, either part-time or full-time. • Criteria for a consumer to get involved with IPS is that they express a desire to work. • Goodwill and Easter Seals will be the two providers and will be attached to Care Coordination teams.

18. CCS Service Array includes Psychotherapy. Intensive Outpatient programs are a form of psychotherapy and can be covered by CCS. • Day Treatment in itself is not a covered service, but every group that has a corresponding Service Array can be covered by CCS for that array (e.g. psycho-education, wellness management, physical health monitoring, individualized skill development) • While in CCS – Therapy and/or Mental Health Day Treatment services cannot be reimbursed separately, they must be covered under CCS. Providers will be listed in the Provider Directory on the Website. • If a consumer has a relationship with a therapist (including IOP) or day treatment (including PHP) that is not a CCS provider yet, CARS can be notified to begin working to bring that therapist into our network. The Consumer should not enroll in CCS until that process is complete.

19. Services Begin • Individualized Recovery Plan (IRP) is developed as a collaboration between the consumer and their Recovery Team. • Services provided are based on IRP and must be rehabilitative in nature. • Psychiatry services can be billed under CCS or reimbursed separately through Medicaid/BC+ • Services are to be provided • in the most natural setting • in the least restrictive manner • in the most integrated settings • with frequency to support achievement of goals identified

20. CCS can serve all ages • State approved 12-month Roll Out Plan • CARS/Youth • Wraparound Milwaukee • Project O-YEAH • REACH • FISS • Disabilities Services Division • Department On Aging

21. Who CANNOT be co-enrolled? • TCM • CSP • Who CAN be co-enrolled? • Wraparound Milwaukee • Project O-YEAH • REACH • FISS • Individuals enrolled in Family Care MAY be eligible for co-enrollment in CCS