Revised December 2009 Updated 12/1/10

1. Behavioral Health Service Delivery in Southern Arizona: A Roadmap to the System Revised December 2009Updated 12/1/10

2. Introduction Every behavioral health service system has distinctive features that influence how quality care is provided to individuals and families needing services. This training is designed to help you understand the various avenues of the Arizona Behavioral Health Service system in Pima County. This is your ‘roadmap’ to the system.

3. Module Objectives As you complete this module you will: • Understand several overarching national and state principles driving Arizona’s behavioral health services • Discover valuable information about the behavioral health system throughout the state and specifically in Pima County • Learn how to help individuals access services and understand what they can expect while receiving services • Gain knowledge of resources available to assist you with any questions

4. Module Contents These are the main topics this module will focus on: • Language and common terms • Definitions and acronyms • Overarching behavioral health principles • The Arizona behavioral health system • Regional Behavioral Health Authorities (RBHAs) • Community Partnership of Southern Arizona (CPSA) • Operations • Services

5. Some Thoughts on Language We recognize how important words are in our profession and our daily work. Words can hold much power, and the language we use has a direct impact on the quality of the services we provide. So, to begin this module we will briefly consider language - the importance of ‘people first’ language, and definitions of terms used in the behavioral health field. “The difference between the right word and almost the right word is the difference between lightning and the lightning bug.” - Mark Twain

6. ‘People First’ Language Unfortunately, stigma related to behavioral health needs is still very prevalent in our society. As professionals working in behavioral health, we can work to combat this by seeing the individual first before focusing on their illness. One way to accomplish this is by using People First Language(click on link to learn more) • People First Language describes what an individual HAS, not what an individual IS by putting the individual before the disability: “She has a diagnosis of autism” not “She’s autistic” • People First Language can change how individuals with disabilities feel about themselves - it is communication rooted in respect and inclusion. Using a diagnosis as a person’s main defining characteristic reflects prejudice, and also robs the person of the opportunity to positively define his/herself.

7. Defining Common Terms Individualrefers to member, patient, client, resident, user, consumer, or person served. References to the individualoften include references to family. Family may be defined in traditional terms or in terms unique to the individual, and could include a constellation of relatives and friends, as determined by the individual. Cultural influences often impact the makeup and functioning of the family. The family network plays an essential part in supporting behavioral health services. Services refers to what may be labeled treatment, care, support, therapy, rehabilitation, etc. This term implies a neutrality that encompasses different modalities, models, philosophies, and attitudes.

8. Language Resources • Behavioral health, like many professions, depends on terminology that is unique to this field. • Along with terminology, acronyms are an ever-present feature of communication in the behavioral health field. • To assist you in understanding terms and acronyms, two useful documents accompany this learning module: • Definitions of Common Terms • Acronym List These documents are found as additional course sections of this module and must reviewed / downloaded prior to completing this module. Let’s start down our road by looking at some principles that guide the behavioral health field…

9. Overarching Principles Behavioral health services are provided based on several principles.

10. Guiding Principles It’s an exciting time in the behavioral health field. The way services are provided and the interactions with individuals we serve are changing. It’s important to understand some of the national initiatives, trends and service concepts that have led to significant changes in the field. Later in this module we’ll examine some state-wideprinciples that guide behavioral health services. On a national level, many of the guiding principles for behavioral health came from a federal commission…

11. New Freedom Commission on Mental Health In recent years, there has been increased attention on the need to improve services offered to individuals/families in the behavioral health system. This initiative was brought to the forefront in 2002 when President George W. Bush established the New Freedom Commission on Mental Health to identify policies to maximize existing resources, improve coordination of treatment and services, and promote community integration for individuals with mental illnesses. After much study, the Commission reported that the mental health system was in need of transformation…

12. Goals in the Transformation The Commission’s Goals for this Transformation: • Americans understand that mental health is essential to overall health • Mental health care is consumer and family driven • Disparities in mental health services are eliminated • Early mental health screening, assessment, and referral to services are common practice • Excellent mental health care is delivered and research is accelerated • Technology is used to access mental health care and information Click on graphic to learn more

13. Trends and Best Practices The Commission’s report and goals tie in closely with other national trends and best practices: • Recovery-oriented services • The concept of team • Cultural competency • Coordination of care We’ll look at each of these on the upcoming slides…

14. Trends and Best Practices Recovery-oriented Services The cornerstone of recoveryis hope - instilling the belief that an individual who has a severe and persistent psychiatric and/or substance use disorder can not only manage their illness, but also accomplish his/her hopes and dreams, and achieve independence as well as meaning and purpose in their life. Recovery means: • Achieving independence and self-esteem • Having fulfilling relationships • Being a productive member of a community Recovery-oriented services should: • Empower individuals • Be client/member-centered • Focus on strengths • Incorporate natural supports • Be culturally appropriate

15. Trends and Best Practices The Concept of Team One of the best ways to promote recovery is through the utilization of a team to meet the needs of individuals and families receiving services. • The team concept is utilized by all CPSA Providers, with each Member receiving services through a Child and Family Team (CFT) or Adult Recovery Team (ART). • The individual or family is at the center of the team. Parents, children, and adults receiving services are treated as partners in the assessment, planning, delivery, and evaluation of services. • The composition of each team varies, depending on the Member’s needs and the different entities or agencies with which the Member is involved. We will discuss Teams in more detail later in this module

16. Trends and Best Practices Cultural Competency As our population and Members become more diverse, it is crucial that we not only provide culturally appropriate services, but also become more culturally competent as helping professionals. ADHS/DBHS requires that behavioral health staff periodically attend cultural competence training, and our agencies are guided by the National Standards on Culturally and Linguistically Appropriate Services (CLAS). These 14 standards are organized by themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14).

17. Trends and Best Practices Coordination of Care To provide effective services and have an effective team, it is critical, and required, that the behavioral health worker coordinate care for the Member - working in collaboration with the other agencies providing services to Members and/or their families. This could include coordinating care with such entities as primary care providers, Child/Adult Protective Services, the courts, schools, and the Division of Developmental Disabilities. The requirements and procedures for coordination of care are further explored in the ‘Coordination of Care’ self-study module.

18. Let’s pull into a rest stop to review… Putting the individual before their disability by describing the type of illness an individual has, not what an individual is was referred to as: Click on correct answer below A Diagnosis People first language A Treatment plan

19. The correct answer is: People first language Remember, it is respectful and empowering to the Member to see them as a person first, before the mental illness that they are experiencing!

20. One more question before we’re back on the road… The belief that people with substance use disorders and/or mental health illnesses can be expected to achieve independence and live meaningful and purposeful lives is the cornerstone of: Click on correct answer below Group therapy Residential treatment Recovery-oriented services

21. The correct answer is: Recovery-oriented services The cornerstone of recoveryis hope - the belief that an individual who has a mental and/or substance use disorder can not only manage their illness, but also accomplish his/her hopes and dreams, and achieve independence as well as meaningful and purposeful lives. With terminology and best practices behind us, the next stop on our road trip is a look at the state behavioral health system…

22. The Arizona Behavioral Health System “All Arizona residents are easily able to access high quality prevention, support, rehabilitation and treatment services that have resiliency and recovery principles at their core…” - from DBHS vision statement

23. Arizona Department of Health Services/ Division of Behavioral Health Services (ADHS/DBHS) Under the direction of the Governor’s Office and the Arizona Legislature, ADHS/DBHS serves as the single state authority to provide coordination, planning, administration, regulation, and monitoring of all facets of the state public behavioral health system. Publicly-funded behavioral health care is administered by the state through contracted entities called Regional Behavioral Health Authorities (RBHAs). (Click on picture below to reach the ADHS/DBHS website)

24. Regional Behavioral Health Authorities (RBHAs) ADHS/DBHS contracts with Regional Behavioral Health Authorities (RBHAs) to administer behavioral health services throughout the State. Arizona is divided into 6 Geographical Service Areas (GSAs) served by 4 RBHAs. CPSA is the RBHA that serves Pima County The map on the next slide shows the current RBHAs and the areas of the state they cover…

25. The RBHAs GSA 1 NARBHA GSA 1 NARBHA Cenpatico Behavioral Healthserves Yuma, La Paz, Pinal, Gila, Graham, Greenlee, Santa Cruz, and Cochise Counties. Community Partnership of Southern Arizona (CPSA) serves Pima County.  Northern Arizona Behavioral Health Authority (NARBHA) serves Mohave, Coconino, Apache, Navajo, and Yavapai Counties. Magellan Health Servicesserves Maricopa County. GSA 6 Magellan GSA 2 Cenpatico GSA 4 Cenpatico GSA 3 Cenpatico GSA 5 CPSA The next slide discusses the role of American Indian Tribes in state-wide behavioral health…

26. Behavioral Health Services for American Indians In addition to the four state RBHAs, ADHS/DBHS has Intergovernmental Agreements (IGAs) with five of Arizona’s American Indian Tribes - including three Tribal RBHAs (T/RBHAs) - to deliver behavioral health services to American Indian individuals and families: • Gila River Indian T/RBHA • Pascua Yaqui Tribe T/RBHA • White Mountain Apache Tribe T/RBHA The following tribes have an IGA for both Title XIX (Medicaid) and State Subvention Services (state monies): • Colorado River Indian Tribes • Navajo Nation

27. Behavioral Health Services for American Indians Other American Indian Tribes are provided services by the RBHA in which the tribal reservation is located. • RBHA’s are responsible for providing services to American Indian peoples within their GSA, if those Tribes are not a Tribal RBHA (T/RBHA). • American Indian members enter the RBHA system through the same process as all other members within the GSA who are AHCCCS eligible. • American Indian individuals can also choose to utilize their Tribal behavioral health services along with RBHA-provided services. Now that we’ve examined the State system, let’s look at the principles and tools that guide delivery of behavioral heath services in our state…

28. Arizona’s System of Care Arizona has embraced the nationally recognized need for change and development in both children and adult systems of care. Recent transitions have allowed for the implementation of services designed to empower individuals and their families to be partners in their own recovery. ADHS/DBHS supports a behavioral health delivery system that includes: • Easy access to care • Member and family involvement • Collaboration with the greater community • Effective innovation • Expectation for improvement • Cultural competency Vision and principles have been developed to guide service delivery. First let’s consider the Children’s system…

29. Service Delivery: Arizona Vision for Children’s Services In collaboration with the child, family, and others, the state will ensure that services are accessible and designed to: • Aid children to achieve academic success • Allow children to live with their families • Help children avoid delinquency • Assist children in becoming stable and productive adults Services are tailored to the child and family. They will be provided in the most appropriate setting, in a timely manner and in accordance with best practices, while respecting the child’s and family’s cultural heritage and preferences. Twelve Principles have been developed to guide Children’s Services…

30. The Twelve Principles 1.Collaboration with the child and family is essential. Parents and children are treated as partners in all stages of service delivery. 2. Behavioral health services are designed and implemented to aid children to be successful in school, live with their families, avoid delinquency and become stable and productive adults. 3. Children with multi-system involvement will have a jointly established child/family centered service plan. 4. Children will have access to a wide array of behavioral health services which will be adapted or created when not available. 5. Behavioral health services are provided according to best practices and are continually evaluated and modified to achieve desired outcomes. 6. Children are provided services in their home andcommunity to the extent possible.

31. The Twelve Principles Children identified as needing behavioral health services are assessed and served promptly. 8. Services are tailored to the child and family with their unique strengths and needs driving the service array provided. 9. Behavioral health services strive to minimize multiple placements and prevent crisis situations. 10. Behavioral health services are provided in a manner that respects the cultural tradition of the child and family. 11. Behavioral health services include support and training for both parents and children to gain independence. 12. Natural supports will be used from the family’s own community network including friends, neighbors, and organizations. We’ll look at Adult Services next…

32. Service Delivery: Adult Services The adult system is designed to foster a coordinated, flexible, individually driven process that supports and helps those accessing services to: • Attain an optimum level of functioning • Develop healthy interpersonal relationships • Experience recovery • Become a self-determined, productive member of society • Utilize unique strengths, recovery processes, and culture Like Children’s Services, principles also guide the delivery of Adult Services…

33. Guiding Principles for Delivery of Services to Adults 1. Respect 2. Persons in recovery choose services and are included in program decisions and program development efforts 3. Focus on individual as a whole person, while including and/or developing natural supports 4. Empower individuals taking steps toward independence and allowing risk taking without fear of failure 5. Integration, collaboration, and participation with the community of one’s choice 6. Partnership between individuals, staff, and family members/natural supports for shared decision making with a foundation of trust 7. Persons in recovery define their own success 8. Strengths-based, flexible, responsive services reflective of an individual’s cultural preferences 9. Hope is the foundation for the journey toward success

34. Principles for Delivery of Services to Adults To help guide the service delivery for adults, established principles of service have been adopted. According to these principles, behavioral health assessments and service plans: • Are developed with the understanding that the system has an unconditional commitment to individuals seeking services. • Have at their foundation empathetic relationships that foster ongoing partnerships and expect equality and respect throughout the service delivery. • Are developed collaboratively to engage and empower individuals, include other people involved in the individual’s life, provide opportunity for meaningful choice, and are accepted by the individual. • Are strengths-based and clinically sound. • Are developed with the expectation that the individual is capable of positive change, growth, and leading a life of value. Whether children or adults are being served, a team approach is utilized…

35. Service Delivery: A Team Approach When we consider behavioral health services in Arizona, the concept of team arises. In alignment with the national trend, teams are utilized extensively by CPSA’s Comprehensive Service Providers (CSPs) and Service Providers (SPs) to aid individuals and families. Teams are an essential part of planning for and providing services. Further, teams are important in implementing the vision and principles detailed in previous slides. Teams in our system, depending on the age of the Member being served, are referred to as Child and Family Teams (CFTs) and Adult Recovery Teams (ARTs). CSP and SP staff are assigned upon hire to attend training on one or both of these team initiatives. Let’s look at who might be part of a CFT or ART…

36. A Team Approach The makeup of the Team… Team membership may include: • family members • community members • various professionals - examples include Child Protective Services, schools, courts, and Vocational Rehabilitation personnel • extended family, friends, neighbors, coaches, clergy, teachers, or other natural supports - any person who plays a positive role in the Member’s life The state provides some useful tools for effective delivery of services…

37. Service Delivery: Useful Tools The State provides many useful tools that guide the effective delivery of behavioral health services in Pima County. These are excellent resources regarding procedures, service requirements, services covered by state funds, and information on Member services. • The upcoming slides will introduce: • Clinical and Recovery Practice Protocols • The Provider Manual • The Covered Services Guide

38. Clinical and Recovery Practice Protocols In addition to recommended values and principles, the DBHS, under the direction of the ADHS/DBHS Medical Director and Assistant Medical Director, has researched and published Clinical and Recovery Practice Protocols. These documents are specifically designed to assist behavioral health providers in Arizona’s public behavioral health system.Current protocol examples include: • The Child and Family Team (CFT) • Comprehensive Assessment and Treatment for Substance Use Disorders in Children and Adolescents • Children’s Out of Home Services • Psychiatric best Practice Guidelines for Children: Birth to Five Years of Age It is important to be familiar with these protocols as they apply to your job. You may review them at http://azdhs.gov/bhs/guidance/guidance.htm

39. Provider Manual The state also ensures the delivery of quality behavioral health services through the Provider Manual(click on title to link to manual) The Provider Manual: • Details direct service delivery requirements for behavioral health service providers across the state. • Contains concise and easily understood information that supports the efficient and effective management of the public behavioral health system. • Contains specific forms and tools needed for behavioral health staff to provide effective and timely service.  

40. Provider Manual Manual Contents include information about: • Clinical Operations • Fact sheets and definitions • Communication and Care Coordination • Member Rights and Provider Claims Disputes • Data and Billing Requirements • Reporting Requirements • Periodic Audits and Surveys • Training and Development • T/RBHA Specific Requirements Each contracted Regional Behavioral Health Authority (RBHA) has added information specific to its area to create RBHA-specific versions of this manual. Take a moment to get oriented to the CPSA Provider Manual (found on the CPSA Website)

41. Covered Services Guide ADHS/DBHS has developed a comprehensive array of covered behavioral health services that will assist, support, and encourage each eligible individual to achieve and maintain the highest possible level of health and self-sufficiency. It is important for behavioral health professionals to be familiar with the services that are contained in the Covered Services Guide since it is these services that you will be providing. For a complete list of services provided, please reference the Covered Services Guide on the ADHS/DBHS website. More information on Covered Services is offered in New Employee Orientation; in the Covered Services self-study module; and in the classroom training “Covered Services - Back to Basics”

42. Covered Services Guide Examples of Covered Services include: Treatmentservices: counseling, therapy, assessment, evaluation, screening, other professional services. Rehabilitation services:skills training, cognitive rehabilitation, support to maintain employment. Medical services: medications, laboratory, radiology. Support services: case management, personal care, respite care, supported housing, interpretive services, transportation. Crisis Intervention services: mobile, telephone, stabilization. Inpatient services: hospital, sub-acute facility, residential treatment center. Residential services: short-term and long-term residential. Behavioral Health Dayprograms: supervised and therapeutic. Preventionservices: designed to prevent community members from developing substance use or mental health disorders. Let’s wrap up our overview of the State system by looking how all these services are funded…

43. Funding • The chart on the following slide illustrates the flow of service funding. ADHS/DBHS receives funds for behavioral health services from the federal and state government. • Federal funds, generally from Title XIX (Medicaid), are dispersed through Arizona Health Care Cost Containment System (AHCCCS). AHCCCS carves out the behavioral health funds from general medical funds and gives them to ADHS/DBHS for distribution. • Children under age 19 may receive services through Title XXI (KidsCare). • The Arizona legislature appropriates other various funds to ADHS/DBHS. These state monies are generally referred to as subvention funds. • Other funds, including federal resources for eligible people through Mental Health, Alcohol and Drug Block Grants, are also received by ADHS/DBHS.

44. Federal Government Health and Human Services Arizona State Government Center for Medicare and Medicaid Services (CMS) Substance Abuse and Mental Health Services Administration (SAMHSA) Arizona Health Care Cost Containment System (AHCCCS) Funding Flow Chart Arizona Department of Health Services (ADHS) Division of Behavioral Health Services (DBHS) Regional Behavioral Health Authorities (RBHAs) Tribal Regional Behavioral Health Authorities (T/RBHAs) Comprehensive Service Providers

45. Look, another rest stop - must be time to review… Which of the following people might be part of a Child and Family Team (CFT)? Click on correct answer below Teacher Extended family members Probation officer Family pastor

46. The correct answer is: Any of these! CFTs can be made up of people who play a positive role in the Member’s life: • Various professionals - examples include Child Protective Services, schools, courts, and Department of Developmental Disabilities personnel • Extended family, friends, neighbors, coaches, clergy, teachers, or other natural supports

47. Another question before we hit the road again… Which of the following is not a tool provided by the state to help in the delivery of services? Click on correct answer below Covered Services Guide Provider Manual Clinical and Recovery Practice Protocols Treatment Planning Chart

48. The correct answer is: Treatment Planning Chart The Provider Manual, Covered Services Guide, and Clinical and Recovery Practice Protocols are all Documents/tools provided by the state and available on the ADHS/DBHS website. Time to continue our trip by cruising through a review of CPSA, the RBHA that oversees behavioral health agencies in this part of the state…

49. Community Partnership of Southern Arizona (CPSA) “Building on community strength and spirit.”

50. CPSA The Community Partnership of Southern Arizona (CPSA) is the RBHA responsible for the coordination of behavioral health treatment and prevention services in Pima County. CPSA contracts with behavioral health agencies in Pima County to provide mental health, substance use treatment and supportive services for eligible individuals.