Rule 132 New Services Clinical Overview

1. Rule 132 New Services Clinical Overview April 2007

2. Introduction & Overview

3. Objectives for the Day • Understand the history and process of development for the new services • Understand the role of new services in supporting Recovery/Resiliency • Understand the clinical framework of new services • Community Support • Psychosocial Rehabilitation • Assertive Community Treatment • Non-Medicaid Vocational & Outreach

4. History and Development Process • System Restructuring Initiative (SRI) • Statewide advisory task group (consumer chaired, included consumers, providers, trade associations, advocates, state) • SRI Workgroups • Services • Financial • Access and Eligibility • Services Workgroup • Approx. 130 individuals counting all • Individuals with mental illnesses, providers, trade associations, hospitals, state departments, consultants

5. History and Development Process • Services Workgroup Objectives • Review service array and Rule 132 with focus on: • Supportive of recovery/resiliency • Accessible to individuals with mental illnesses • Compliance with Medicaid State Plan and other guidance • Identify gaps • Findings • Current service definitions did not fully promote recovery/resiliency • Medicaid State Plan and Rule should be updated

6. History and Development Process • Workgroup established service priorities • Community Support • Psychosocial Rehabilitation • Assertive Community Treatment • Subgroups formed for each of the above: • Researched Evidence-Based Practices (EBP)/Best Practices • Reviewed other states’ definitions • Reviewed recent federal CMS/OIG audits/actions

7. History and Development Process • Services Workgroup Results • Developed new definitions which • promote recovery/resiliency • support Evidence Based Practices/Best Practices • Minimize audit compliance risk • New non-Medicaid services • Recommended improvements to current definitions • New definitions and recommendations were used to develop revised Rule 132 and Medicaid State Plan Amendment

8. Assertive Community Treatment Case Management – MH Case Management – Transition Linkage, Aftercare Client Centered Consultation Community Support – Individual Community Support – Group Community Support – Team Community Support – Residential Comprehensive Mental Health Services* Crisis Intervention Mental Health Assessment Mental Health Intensive Outpatient Psychological Evaluation Psychosocial Rehabilitation Psychotropic Medication Administration Psychotropic Medication Monitoring Psychotropic Medication Training Therapy/Counseling Treatment Plan Development, review and modification New Taxonomy – Rule 132 Services *Sunset 6-30-08

9. New Taxonomy – DHS/DMH Non-Medicaid Services • Vocational Assessment • Vocational Engagement • Job Finding Supports • Job Retention Supports • Job Leaving/Termination Supports • Oral Interpretation and Sign Language • Outreach & Engagement • Stakeholder Education

10. Primary Changes to Medicaid Taxonomy • Service labels deleted and activities subsumed under new definitions • Skills Training & Development • Therapeutic Behavioral Services • Activity Therapy • Day Treatment • New/expanded services • Community Support (Indiv., Group, Team, Residential) • Psychosocial Rehabilitation • Assertive Community Treatment

11. Status of Approval & Implementation • Medicaid State Plan Amendment (SPA) • Accepted proposed language • Alignment between SPA and Rule • Revised Rule 132

12. Recovery and Resilience The Goal of Services in a Transformed Mental Health System

13. Recovery • Refers to a process • The outcome of the process of recovery is that individuals are able to live, work, learn and participate fully in their communities • The life picture of recovery is unique for each individual • According to research, hope is an essential element in recovery

14. Facilitating Recovery: Ten Fundamental Components • Hope • Self-Direction • Individual and Person-Centered • Empowerment • Holistic

15. Facilitating Recovery: Ten Fundamental Components (cont.) • Non-Linear • Strengths-Based • Peer Support • Respect • Responsibility

16. Recovery Components: Hope • The catalyst to the recovery process • Provides the essential and motivating message of a better future • People can and do overcome the barriers and obstacles that confront them • Hope is internalized, but it can be fostered by peers, families, friends, providers and others

17. Recovery Components: Self-Direction • By definition, the recovery process must be self-directed by the individual • The individual defines his or her own life goals and designs a unique path towards those goals

18. Examples of Self-Direction in Mental Health Services • Strengthening ACT service planning to be a participatory process • Community Support: promote active participation in decision-making • Psychosocial Rehabilitation: participating in curriculum/strategy choices and selection

19. Recovery Components: Individualized and Person-Centered • There are multiple pathways to recovery • Services take into consideration: an individuals’ unique strengths and resiliencies; his/her needs, preferences and experiences; past trauma; cultural background

20. Examples of Individualized and Person-Centered Mental Health Services • Community Support: point out strengths and suggest ways to use them; consider barriers and suggest ways to overcome them • Community Support: include the development of such examples as crisis contingency and Wellness Recovery Action Plans (WRAP)

21. Recovery Components: Empowerment • Individuals with mental illnesses have the authority to choose from a range of options • Individuals with mental illnesses have the authority to participate in all decisions that will affect their lives, and are educated and supported in so doing

22. Recovery Components: Empowerment (cont.) • Individuals with mental illnesses have the ability and opportunity to join with one another to collectively and effectively speak for themselves about their needs, wants, desires and aspirations • Through empowerment, an individual gains control of his or her own destiny

23. Examples of Empowerment in Mental Health Services • ACT: person-centered service planning as evidenced by person’s participation in service planning meetings with the team • PSR: inclusion of individuals with mental illnesses in program design, development, planning, implementation, evaluation

24. Recovery Components: Holistic • Encompasses an individual’s whole life, including • Mind • Body • Spirit • Community

25. Recovery Components: Holistic (cont.) • Embraces all aspects of life, including • Housing • Employment • Education • Mental Health and Healthcare Treatment Services • Complementary and Naturalistic Services • Addictions Treatment • Spirituality, Creativity, Social Networks, Community Participation, and Family Supports as determined by the person

26. Examples of Holistic Strategies in Mental Health Services • Community Support: Encourage identification and enhancement of the existing natural supports in the individual’s social system • Community Support: Assist the individual to maximize the degree to which natural supports can be used

27. Recovery Components: Non-Linear • Not a step-by-step process • Based on continual growth, occasional setbacks, and learning from experience • Begins with an initial stage of awareness in which a person recognizes that positive change is possible

28. Examples of Non-Linear Components of Mental Health Services • If a person is receiving Community Support and has a temporary increased need: • Add PSR for a period of time • Intensify Community Support • When increased need has resolved or changed, the person can elect discontinuance of PSR and/or reduction in Community Support

29. Recovery Components: Strengths-Based • Focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals • By building on strengths, individuals with mental illnesses leave stymied life roles behind and engage in new life roles

30. Examples of Strengths-Based Focus in Mental Health Services • Designing ACT interventions to build on the strengths of the persons served • PSR: identifying, using and promoting strengths

31. Recovery Components: Peer Support • Mutual support, including the sharing of experiential knowledge and skills and social learning • Individuals with mental illnesses encourage one another and engage each other in recovery • Individuals with mental illnesses provide each other with a sense of belonging, supportive relationships, valued roles and community

32. Examples of Peer Support in Mental Health Services • Strengthening ACT teams to have solid peer support opportunities for all persons served • Peer support is encouraged throughout the taxonomy via the RSA credential

33. Recovery Components: Respect • Includes respecting persons’ rights and eliminating discrimination and stigma • Ensures the inclusion and full participation of persons in all aspects of their lives • Self-acceptance and regaining belief in oneself are particularly vital

34. Recovery Components: Responsibility • Individuals have a personal responsibility for their own self-care and journeys of recovery • Taking steps toward one’s own personal goals may require great courage • Identifying coping strategies and healing processes to promote one’s own wellness

35. Examples of Responsibility in Mental Health Services • Community Support: Teaches “how,” does not “do for” • Community Support: Assists the individual to do for self rather than doing for the person

36. Resilience • Refers to the ability to harness inner strengths and rebound from setbacks or challenges • People who are less resilient may dwell on problems, feel victimized, become overwhelmed and turn to unhealthy coping mechanisms • Allows individuals to go on with life with a sense of mastery, competence and hope • If you aren't as resilient as you'd like, you can teach yourself to become more resilient.

37. Building Resilience: Eleven Essential Skills • Getting Connected • Using Humor and Laughter • Learning From Your Experiences • Remaining Hopeful and Optimistic • Taking Care of Yourself

38. Building Resilience: Eleven Essential Skills • Accepting and Anticipating Change • Working Toward Goals • Taking Action • Learning New Things About Yourself • Thinking Better of Yourself • Maintaining Perspective

39. Fundamentals of Effective Community Support (CS)

40. Pop Quiz Of persons in the U.S. who have been diagnosed with Schizophrenia, how many function well with no or minimal professional supports? • 10% • 20% • 35% • 50% New Freedom Commission Report

41. Pop Quiz (cont’d) In what location do individuals with mental illnesses learn and retain skills best? • Counselor’s/case worker’s office • Classroom • Structured psychoeducational groups • Natural settings New Freedom Commission Report

42. Pop Quiz (cont’d) Do individuals with mental illnesses or case managers better predict the mental health outcomes for individuals? • Case managers • Individuals with mental illnesses New Freedom Commission Report

43. Overview • Purpose of Community Support (CS) • What Does the Community Support Worker Do? • IL CS Definition/Core Service Activities • Areas of Core Competence for Community Support • Differentiating Community Support from Case Management • The Four Modalities of Community Support • 10 Common Denominators of Good Community Support

44. Purpose of Community Support Provide mental health rehabilitation interventions and supports necessary to assist individuals with mental illnesses to achieve rehabilitative, resilience and recovery goals primarily in a person’s own environment Goes beyond just treating symptoms!

45. What Does the CS Worker Do? Assists individuals with mental illnesses and families with skills teaching and support with respect to: • Symptom self-management and reduction • Environmental modification for stability and growth • Resource acquisition • Recovery planning • Development of resilience

46. What Does Community Support Consist Of? Necessary Mental health rehabilitation interventions and supports: • To build capacity with the person to achieve their self identified rehabilitative, resiliency, and recovery goals • Designed to meet the following types of treatment support needs of the person: Educational Vocational Residential Mental Health Co-occurring disorders Financial Social Others

47. Who Gets Community Support? When & Where Do They Get It? • Who: Services are directed toward • Adults, Children, Adolescents, Families • The primary beneficiary of the services must be the individual with the mental illness • When: The changing needs of the individual dictate: • Services hours, type, intensity, staff credential • Where: Interventions are delivered • Primarily in natural settings (off site) • By telephone, videoconference, face to face

48. What are the Goals of Community Support? Interventions and activities are targeted toward: • Development of person’s capacity to manage his or her symptoms • Fostering the ability of the person to reduce symptoms as much as possible • Assist the person in promoting stability in his or her life • Development of person’s ability to foster mastery & independence

49. IL CS Core Principles/Activities • Promote active participation in decision-making. • Build a context in which shared decision-making is the norm • Assist the person to: • Identify his or her strengths & ways to use them • Identify his or her barriers to recovery & ways to overcome them

50. IL CS Core Principles/Activities • Suggest strategies/interventions for greatest independence • Promote recovery-oriented treatment in the least restrictive setting • Support self determination • Education, training and assistance in the development of the individual’s strengths, resources, preferences, and choices • Includes the development of such examples as crisis contingency and Wellness Recovery Action Plans (WRAP).