Rule 132 New Services Clinical Overview

Rule 132 New Services Clinical Overview
April 2007

Introduction & Overview

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

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

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

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

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

New Taxonomy – Rule 132 Services
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 *Sunset

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

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

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

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

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 President’s New Freedom Commission 2003

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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. Mayo Clinic Website President’s New Freedom Commission, 2003

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

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

Fundamentals of Effective Community Support (CS)

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

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

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

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

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!

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

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

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

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

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

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).

Assist the person to develop and maximize support from family and significant others Consumer focused Support and consultation to the individual’s family and their support system Interventions must be to directed to the primary well-being and benefit of the individual and related directly to the individual’s treatment plan.

Psychoeducation and skill building for individuals’ families and their support systems With or without the individual being present Family or support system psychoeducation or skill building must relate to a need identified in the assessment of the individual and be reflected on the Individual Treatment Plan

Interpersonal, family, community and functional skills training and support Assist the person to develop: Functional skills with respect to adaptation to the home, school, family, and work negatively impacted by the individual’s mental illness. The ability to cope at the following levels: Interpersonal Family Community

Assist the individual with mental illness(es) to develop tools to self-monitor, reduce and manage symptoms in order to improve the quality of life Help to foster the ability to identify & minimize the negative effects of mental illness, serious emotional disturbance, and co-occurring disorders Assist the person in putting together a proactive relapse management plan In conjunction with the individual, identify risk factors and related strategies to manage relapse.

Explore trauma management skills Assist the individual with mental illness(es) to develop skills for coping with trauma and trauma issues Encourage the use of these skills

Staff Competencies for CS
Embracing Recovery and Resiliency Principles Designing & Delivering CS Interventions Recovery-supportive approaches Assisting with skill-building Assisting individuals with mental illnesses to develop capacity to acquire resources & supports Training families & natural supports in effective support strategies Learning from individuals with mental illnesses and their families/natural supports Cultural literacy and competency

Differentiating Community Support v. Case Management
Helping individual or family build capacity to assess, access, and self-monitor Active, rehabilitative, recovery-oriented set of interventions Teaches “how” Limits “doing for” CASE MANAGEMENT (MH, TLA, CCC) Assessment of resource needs Provide Access/Linkage Monitoring Client-focused professional communications Expressly precludes direct provision of underlying service

A Sidebar on Case Management in IL
MENTAL HEALTH CASE MANAGEMENT Assessment Planning & Coordination Identifying/investigating resources Advocacy Clients with multiple service needs Explaining options Linkage (non-transition) Maximum 240 hours/year (including CCC) For persons who need assistance getting or using services like: - Mental health - Housing - Social - Vocational - Public benefits CLIENT CENTERED CONSULTATION Client-focused professional communication Maximum of 240 hours/year (including MH Case Manage.) Face to face or phone contacts with other professionals involved in treatment (internal and external providers) Contacts with SOF, educational, medical system NOT supervision or utilization review

A Sidebar on Case Management in IL
TRANSITION LINKAGE, & AFTERCARE Transition to different living arrangements consistent with improvement & development Maximum of 40 hours/year Includes when: The person is discharged from psychiatric hospital or psychiatric nursing home services A young person is transitioning to adult services Assisting client’s family with transition related issues

Community Support Options
CS-Res Extended high acuity Multi-disciplinary Intensity of service CS-Team CS-Individual CS-Group (can flex to high intensity when needed)

Four Ways of Delivering CS
Choice of intensity, frequency and modality is governed by a matrix of factors including individual/family preference, level of consumer need (medical necessity), types of specific interventions prescribed, and safety considerations. Individual (1 staff : 1 person) Group (1 staff : 2 or more persons) Team (Team : 1 person) Residential (Individual and Group)

Community Support-Individual
A Core Service for the Target Population Example… Assisting the client/family to build a natural support team, such as working with the child’s parents to enroll the child in community recreation activities or working with an adult to join a church, temple or mosque. Provided face to face, by phone or via video conference in order to maximize accessibility

Community Support-Group
Services to assist a group of individuals to achieve and practice rehabilitative, resilience and recovery goals. Example… A group of consumers practicing appropriate social interaction skills. Skill application and integration/practice in the community.

Community Support-Team
Provided to persons with moderate to severe mental health symptoms meeting admission criteria, who need more intense, coordinated and complex intervention. Services are delivered by a multidisciplinary team. Example… Client loses their medication and experiences a crisis then requires support to problem solve on a weekend. Interventions to address consumer’s needs are divided among team members This is the first team intervention also available to children and adolescents.

Community Support-Team
A strong vehicle to develop community-based supports for the transition age (17-25) population. A step-down from more intense services such as ACT, SASS or supervised residential. A step-up from less intensive community support-individual.

Community Support-Residential Interventions delivered to a person residing in a state-approved living arrangement. “State-approved living arrangement” is a non-Institutes for Mental Diseases (IMD) residential setting that requires State-authority approval and is funded in part with State (non-Medicaid) dollars (used to pay for room, board, and non-Medicaid services). Examples include crisis residential, congregate living, and group home arrangements.

Community Support-Residential
For Adults Supervised & CILA Residential sites Crisis Residential For Children and Adolescents Children who are wards of DCFS in residential treatment facilities Youth placed in residential facilities by DCFS and Department of Corrections Persons served through Division of Mental Health’s Individual Care Grant Program.

Ten Best Practices for CS
Primary worker delivers service rather than ‘brokering’ referrals Natural community supports are the primary partners Interventions occur in the community Both individual and team modalities work Individual has a consistent CS Worker Rapp & Gosha

Ten Best Practices for CS
Workers can be paraprofessionals. Supervisors are experienced and fully credentialed Caseload size (and/or acuity mix) is small enough to allow frequent contact, if necessary Services are time unlimited, if medically necessary Individuals have access to familiar staff on a 24/7 basis Workers foster individuals’ choices Rapp & Gosha

Community Support Leads to Progress
Community Support interventions are the “in-between” steps Where does individualwant to go? Where is individual now? Start at individual’s current capacity. Move toward capacities needed to meet recovery goals

CS Summary Concepts Builds Capacity
Assists the individual to do for self rather than doing for the person Active Intervention Develops, teaches, and supports rather than simply observing and monitoring Core Service to Support Recovery/Resilience 80% + of enrolled target population individuals should participate in some modality of this service

Psychosocial Rehabilitation Service
(PSR)

What Consumers Identified as Important “Being able to choose mental health services from among those the agency has to offer in order to best meet the identified treatment goals and priorities per the individual is imperative in learning/relearning and practicing the skills necessary for the individual to gain, sustain and maintain a healthy quality of life.” (Illinois Consumer Focus Group Report, 2006)

What Are the Differences?
PSR SERVICE New PSR service is defined in the revised Rule 132 Focus on agency -based skills development Intensive service that is a supplement to CS PSR PROGRAM Defined in the Mental Health Program Book Comprised of 5 core services Clinical home

What Happens to the Other Four Core PSR Components?
Peer Support Embedded in all mental health services Community Resource Development Incorporated into a Capacity Grant PSR Engagement New Non-Medicaid service Vocational Skills Development Included in PSR Service Included in new Non-Medicaid Services

The New PSR Model PSR Model has two separate components
Community practice, application, & integration (Community Support Service) Agency-based psychoeducation and skills training and development (PSR Service)

What is the New PSR Service?
A recovery oriented skill-building service to assist individuals to develop or regain skills to live, work, learn and participate fully in their communities.

What Consumers Identified as Important
Being able to choose … ~ what to practice ~ ~ where to practice ~

What does the New PSR Service Consist of?
Necessary individual or group skill building activities that focus on: Individual participation in setting goals Socialization, adaptation, problem solving and coping skills development Self management of symptoms and recovery Prevocational and work readiness Education readiness Identification of interests, strengths, and resources to leisure, recreational, and community social activities

~Example~ Several individuals have a goal to lose weight that is associated with their psychotropic medication Module from Healthy Lifestyle Solutions: Guide to Weight Management PSR skills training - developing a personal healthy menu plan Community support - shopping at their local grocery store (natural setting) to purchase food items on their individual plans (in-vivo practice)

~Example~ Individual(s) identify a goal to find a different place to live that will support their recovery PSR skills training - teaches how to locate resources and select locations to visit, identify questions, role play questions Community support – support (go with) individual(s) to tour available apartments, ask questions and request application

What does the New PSR Service Consist of?
Cognitive-behavioral interventions Interventions to address co-occurring psychiatric disabilities, medical issues, and substance abuse issues

Core PSR Principles/Activities
Create a recovery-oriented environment where hope is evident and success is celebrated Provide interventions that are recovery oriented, person driven, evidence-based, fully integrated, flexible, and available as needed Assist individuals to achieve desired roles and activities Focus on skills development relevant to the individual’s life

Core PSR Principles/Activities
Develop Empowerment through Active Involvement in: one’s own rehabilitation setting personal recovery goals setting priorities choosing strategies to meet personal recovery goals

How Does the PSR Service Relate to Community Support Services?
The new PSR Service is a supplement to Community Support Service Community Support is the “clinical home”

Why Does PSR Require Community Support Services?
Research indicates that skill transfer is best facilitated in the individual’s natural living environment and / or community The emphasis of rehabilitation services needs to be shifted to community integration and recovery

Who Receives the New PSR Service?
Individuals who are receiving community support services and need some additional assistance to meet one or more of their recovery goals. Example: Individual is not making progress toward their self-identified recovery goals and identifies a need for more assistance

~Example~ Community Support + PSR
Client is severely depressed and at risk for hospitalization as evidenced by: lack of energy, increased anxiety, not eating adequately, not caring for physical self, lack of interests, difficulty sleeping and awakening. Community Support – Individual service has not resulted in improvement over 4 months. Referral to PSR as an adjunct to Community Support. Focused PSR interventions including helping person to learn and practice relaxation and anxiety reduction techniques. PSR Groups to identify strengths, interests, goals, barriers to meeting goals, strategies (use of strengths, ways to avoid barriers, skills to develop natural supports) Community Support – Individual/Group used to practice and integrate skills learned in PSR, into community. Once integrated, PSR discontinues and Community Support continues

Staff Competencies for PSR
Embracing Recovery/Resiliency principles Orientation and integration of persons with mental illnesses as part of the staff team Inclusion of persons with mental illnesses in service design

Assessing skills and supports Identifying natural environments/natural supports Identifying, using and promoting strengths Using Motivational Interviewing

Converting all areas of life into skills training Designing and implementing diverse skills program Planning program design Including Evidence Based Practice Introducing skills training modules Adapting skills training Individualizing skills sessions Engaging individuals Providing clinical supervision

Summary The new PSR service is a supplement to Community Support
The new PSR service is designed to help individuals become fully-integrated members of their community thru: Helping individuals identify their personal goals Providing individuals with services choices Providing Recovery oriented skills training Integrating of skills training with Community Support

Assertive Community Treatment (ACT)

Presentation Goals Brief review on why the ACT definition is being changed. Describe who receives the new ACT service. Discuss ACT service interventions and activities. Define who delivers the new ACT service. During this segment we’ll cover four major areas, which are… 1. Brief review on why the ACT definition is being changed. 2. Describe who receives the new ACT service. 3. Discuss ACT service interventions and activities. 4. Define who delivers the new ACT service TRANSITION TO SLIDE #3

Principles Driving the Change to the New ACT Definition
Belief in recovery driven services. Need to focus limited ACT resources on people with most acute needs. Compliance with Medicaid expectation that ACT services be comprehensive, wrap-around package. Before we get started… it’s worth reviewing a few facts… ILLINOIS has a LONG and ILLUSTRIOUS history of providing ACT services, contributing to the body of research and knowledge on ACT. Illinois teams have used this approach in very innovative ways to help people who are DEAF & HARD OF HEARING, people who are HOMELESS, people with dual disorders (or MISA), and even people leaving JAILS & PRISONS. So why change a thing? Good question! This slide touches on three main principles behind the changes to the ACT service definition we’ll be discussing today…. They are FIRST – The belief in recovery driven services. People can and do get better. SECOND – If you believe that people get better and move on, then it becomes even more important to assure that the limited ACT resources in the state be FOCUSED on the people MOST IN NEED or people in ACUTE NEED. THIRD – We had to change the language to be crystal clear on the Medicaid expectation that ACT services be a COMPREHENSIVE, WRAP-AROUND PACKAGE This makes perfect sense, because ACT should function as a real alternative to the other, more costly wrap-around alternative of inpatient hospitalization. So, with these things in mind, what did we do? TRANSITION TO SLIDE #4

Strengthening ACT to be Evidence-Based Service
Admission criteria assure that persons most in need receive ACT for the appropriate length of time. Service planning is a participatory process. Interventions build on strengths of the person served. Skills training to occur in natural settings as a strategy to restore functioning and promote recovery. The modifications to the service definition can best be characterized as changes to STREGTHEN ACT so that it meets the test of an EVIDENCE-BASED SERVICE… and the next two slides detail eight of the changes made (not al but 8 we want to emphasize here), and these are NOT presented in any particular order of importance, they are: Admission criteria that assures that persons most in need of the service receive it for an appropriate length of time. That the service planning is a PARTICIPATORY process with the person served. That the ACT interventions build on the STRENGTHS of the person served. ACT uses SKILLS TRAINING IN NATURAL SETTINGS to focus on the restoration of functioning and to promote recovery. TRANSITION TO SLIDE #4

Strengthening of ACT (cont.)
The recipients receive comprehensive, wrap–around services & supports. The team has the capacity to respond to emergency psychiatric needs (24/7). The service includes solid peer support. The documentation always supports the medical necessity for ACT level of care. · Changes to meet the threshold for being a COMPREHENSIVE, WRAP-AROUND service package (we’ll give a little more detail on this later). The capacity to DIRECTLY respond to emergency psychiatric needs (24/7). The inclusion of PEER SUPPORT opportunities for persons served. Documentation expectations that would be sufficient to support the medical necessity for the ACT level of care. Again, these were some of the changes made to the Illinois ACT definition to make it clear to Medicaid that Illinois could meet the EVIDENCE BASED SERVICE test… TRANSITION TO SLIDE #6

About Evidence Based Service
To be an evidence based service, you must: Deliver the service to the population for whom the service has been proven to be effective; Deliver the service interventions and activities consistent with those that have been tested and proven effective; and, Provide the service interventions by the staff who have the qualifications, case loads, and integrated team-functioning that have been tested and proven effective. SO, let’s take a look at what we consider, from a clinical standpoint, to be the three KEY FEATURES of any EBP… To be an evidence based service, you must: 1. Deliver the service to the POPULATION for whom the service has proven to be effective; 2. Deliver the service INTERVENTIONS and ACTIVITIES consistent with those tested as effective; and, 3. Provide the interventions in a way that has been proven most effective… by staff who have the QUALIFICATIONS, the proper CASE LOAD, and who function as an INTEGRATED TEAM. So, to paraphrase… the right recipient, getting the right intervention, delivered by a dynamic team approach. OR… WHO GETS THE SERVICE, WHAT SERVICE DO THEY GET, AND WHO CAN DELIVER THE SERVICE. Let’s go on to look at these three features… TRANSITION TO SLIDE #7

Who To Enroll in ACT ACT to engage persons with:
High acuity and/or complex needs Episodes of repeat or chronic homelessness Episodes of incarceration in jail and prisons Multiple psychiatric hospitalizations History of poor engagement or response to traditional approaches Documented functional impairments to community living Most severe and persistent mental illnesses WHO GETS THE SERVICE… WHO do we envision being enrolled in the new ACT service… Some of this is familiar ground for anyone providing the service now… DMH wants ACT teams to engage persons with: High acuity and/or complex needs Episodes of repeat or chronic homelessness Episode of incarceration in jails or prisons Multiple psychiatric hospitalizations History of poor engagement or response to traditional approaches Documented functional impairments to community living Most severe and persistent mental illnesses What is meant by severe and persistent forms of mental illness?…. TRANSITION TO SLIDE #8

ACT is an Evidence Based Practice for…
Schizophrenia Schizophreniform Disorder Schizo-Affective Disorder Delusional Disorder Shared Psychotic Disorder Psychotic Disorder Brief Psychotic Disorder NOS Bi-Polar Disorder Here are the diagnoses for which ACT has proven clinical value as an EBP… I’ll not read these, but just give you a chance to peruse TRANSITION TO SLIDE #9

Core ACT Interventions & Activities
Comprehensive assessment by the team. Individualized treatment/service and recovery planning. Person’s participation in the service plan meeting; Person’s service priorities are addressed in service plan; Service plan has skills training activities that build on strengths; and, Service plan uses natural surroundings and not the agency setting. The next few slides will review in a little detail 4 of the core activities that comprise EVIDENCE BASED ACT interventions…. 1. Comprehensive assessment by the team (multi-disciplinary make-up should equate to multi-disciplinary assessment approach). 2. Person-centered service planning, as evidenced by: Person’s participation in the SP meeting with the team. The needs as prioritized by the person served. Action plan for skills training activities that build on strengths. Services provided in natural settings, not a program site TRANSITION TO SLIDE #10

Assignment of primary service coordinator to: Write the service plan with the individual; Ensure immediate changes to the service plan are made as needs change; Act as “point person” for family, and, Etc. Assignment of a primary service coordinator to: Write the SP with the individual; Ensure immediate changes to the SP are made as needs change; Act as “point person” for family, and, ETC., A few other things itemized in the full text of the rule TRANSITION TO SLIDE #11

Provide dual diagnosis substance abuse services, including : Stage-based approaches, such as: Engagement Assessment Motivational enhancement Active treatment Continuous relapse prevention The new ACT service is expected to provide dual diagnosis substance abuse services, including : Stage-based approaches, such as: Engagement Assessment Motivational enhancement Active treatment Continuous relapse prevention TRANSITION TO SLIDE #12

Work and education related services. Peer Support Services: Peer counseling and support Linking to self-help programs and organizations that promote recovery. Environmental and other Support Services: Medical & Dental Housing Benefits 5. There is an expectation that ACT teams provide work and education related services. Peer Support Services: Peer counseling and support Linking to self-help programs and organizations that promote recovery. Environmental and other Support Services: Medical & Dental Housing Benefits TRANSITION TO SLIDE #13

Distinguishing ACT Requirement “Services must be available 24 hours/day, 7 days a week with emergency response coverage, including psychiatric coverage. Crisis services shall be provided 24 hours per day, seven days per week by the ACT team assigned to the individual.” Now it is a good point to insert a separate statement about a required feature of this new ACT service that distinguishes it from all others, that is the requirement that … “Services must be available 24 hours/day, 7 days a week with emergency response coverage, including psychiatric coverage. Crisis services shall be provided 24 hours per day, seven days per week by the ACT team assigned to the individual.” TRANSITION TO SLIDE #14

Who Delivers ACT Service
“ACT team requires a minimum 6.0 FTE staff (excluding the psychiatrist and the program assistant).” NOW let’s move on to WHO DELIVERS THE SERVICE…. The first major feature is this requirement that the… “ACT team requires a minimum 6.0 FTE staff (excluding the psychiatrist and the program assistant).” TRANSITION TO SLIDE #15

ACT Team Composition Full-time team leader (licensed clinician)
Full-time registered nurse Four rehabilitation services associates (RSAs) Plus: Psychiatrist (minimum 10 hrs/wk/60 registered individuals) A program/administrative assistant. THE ACT TEAM is composed of Full-time team leader (who is a licensed clinician) Full-time registered nurse (we’ll talk about a grandfather clause for existing ACT teams later) Four (4) rehabilitation service associates (or RSAs) PLUS – Psychiatrist (minimum 10 hrs/wk/50 registered individuals) A program/administrative assistant TRANSITION TO SLIDE #16

ACT Team Leader “Full-time team leader who is the clinical and administrative supervisor of the team and also functions as an ACT clinician. The team leader shall be a licensed clinician.” Now because of the comprehensive wrap-around nature of this service, the role of the team leader becomes vitally important to the delivery of care and supports, the quality assurance, and the rule compliance functions for the program. Because of the high accountability of this position, were have the following language… THE ACT TEAM LEADER is a… “Full-time team leader who is the clinical and administrative supervisor of the team and also functions as an ACT clinician. The team leader shall be a licensed clinician.” TRANSITION TO SLIDE #17

ACT Registered Nurse “A full-time registered nurse who provides services to all ACT individuals and who works with the ACT team to monitor each individuals clinical status and response to treatment. The registered nurse functions as a primary practitioner. For a period of two years following the adoption of this service, existing ACT providers may use an LPN with two years experience in mental health services as part of an ACT team…” The ACT Registered Nurse position; the definition states… “A full-time registered nurse who provides services to all ACT individuals and who works with the ACT team to monitor each individuals clinical status and response to treatment. The registered nurse functions as a primary practitioner. For a period of two years following the adoption of this service, existing ACT providers may use an LPN with two years experience in mental health services as part of an ACT team…” Of course the definition goes on to say that… New ACT providers shall be required to utilize an RN on all ACT teams.” TRANSITION TO SLIDE #18

Other ACT Team Positions… “Four rehabilitation service associates who work under the supervision of a licensed clinician and function as primary practitioners for a caseload of individuals and who provide rehabilitation and support functions” Other ACT Team Positions (that round out the 6.0 FTE team)… “Four rehabilitation service associates who work under the supervision of a licensed clinician and function as primary practitioners for a caseload of individuals and who provide rehabilitation and support functions” Now, of course this is a simple statement on the minimum requirement for RSA positions, but in practice an ACT team will likely have a mix of staff with different credentials, qualifications, and life experiences in these positions. These positions could be filled by a combination of LPHA, QMHP, and RSA level staff. As you will see in a couple of slides, there are some other clinical requirements (or competencies) that will influence hiring strategies for the team. TRANSITION TO SLIDE #19

The ACT Psychiatrist “A psychiatrist who works on a full- or part-time basis for a minimum of 10 hours per week for every 60 individuals. The psychiatrist must provide clinical and crisis services to all team individuals, work with the team leader to monitor each individual’s clinical and medical status and response to treatment, and direct psychopharmacologic and medical treatment…” In addition to the 6.0 FTE positions we just reviewed, the definition calls for a psychiatrist who is an integrated part of the ACT team… so, not a agency doc or doctors that works in a parallel fashion to the ACT team, but a clearly integrated member of the team. The definition states… “A psychiatrist who works on a full- or part-time basis for a minimum of 10 hours per week for every 50 individuals. The psychiatrist must provide clinical and crisis services to all team individuals, work with the team leader to monitor each individual’s clinical and medical status and response to treatment, and direct psychopharmacologic and medical treatment…” Although not noted here, there is also a provision that with a certification waiver, an Advanced Practice Nurse may substitute for up to half of the psychiatrist time. TRANSITION TO SLIDE #20

ACT Program Admin Assistant
“…is responsible for organizing, coordinating, and monitoring all non-clinical operations of ACT, including managing medical records; operating and coordinating the management information system; maintaining accounting and budget records for individual and program expenditures; and providing receptionist activities, including triaging calls and coordinating communication between the team and individuals.” If you look to successful ACT teams, that meet the National standards for the service and have proven effectiveness with the population, you will pretty consistently find that these programs have administrative support designed into their day-to-day operations. For that reason, the Illinois definition also includes a requirement for a program/administrative assistant, and as we see here the assistant … …is responsible for organizing, coordinating, and monitoring all non-clinical operations of ACT, including managing medical records; operating and coordinating the management information system; maintaining accounting and budget records for individual and program expenditures; and providing receptionist activities, including triaging calls and coordinating communication between the team and individuals.” TRANSITION TO SLIDE #21

Required Competencies
At least one member of the team must be trained and certified to provide substance abuse and/or co-occurring disorders. At least one member of the team should be a person in recovery and, if available, credentialed as a Certified Recovery Support Specialist. At least one member of the team must have training in rehab counseling, especially vocational, work readiness, and educational support. Now, here are the competencies I referred to a few slides previous… and when you read the rule, perhaps like me it might take a few reviews of the language to understand the mechanics of how this works, but within the 6.0 FTE team positions we described earlier, the definition requires that…. At least one member of the team must be trained and certified to provide substance abuse and/or co-occurring disorders. At least one member of the team should be a person in recovery and, if available, credentialed as a Certified Recovery Support Specialist. At least one member of the team must have training in rehab counseling, especially vocational, work readiness, and educational support. TRANSITION TO SLIDE #22

Requirements for the Whole ACT Team
Each ACT team is expected to maintain a staff to individual ratio of no more than 1:10. Each team is expected to reflect the language, culture, and ethnicity of the population being served. Now we would like to consider two important “expectations” of the team operations… (FIRST) Each ACT team is expected to maintain a staff to individual ration of no more than 1:10. (AND) Each team is expected to reflect the language, culture, and ethnicity of the population being served. The first is a widely recognized cornerstone feature of the ACT model, that among other things, makes the comprehensive, wrap-around, in-vivo approach work. The second is of course, an ingredient for success in many models of care. TRANSITION TO SLIDE #23

Competencies for Successful ACT Team Leaders
Ability to lead a recovery-focused service planning process that fully includes the person served. Leadership to assure clinical focus and orientation Model for continuous learning. Good leadership skills with ability to keep team members from different disciplines working together. Management to assure that documentation supports medical necessity. We want to speak to what the new definition, although not specifically stated, does strive for in terms of the competencies of staff for EACH INDIVIDUAL ACT staff, for the TEAM LEADER, and for the team AS A WHOLE. The next 3 slides will do this beginning with the Team Leader… Ability to lead a recovery-focused service planning process that fully includes the person served. Leadership to assure clinical focus and orientation Model for continuous learning. Good leadership skills with ability to keep team members from different disciplines working together. Management to assure that documentation supports medical necessity. TRANSITION TO SLIDE #24

Competencies for Successful ACT Team Members
Belief that people can and will recover. Respect for individuals regardless of level of recovery. Ability to work as a team member. Ability to work and do assessments in-vivo. Ability to be creative when engaging people in services and a corresponding avoidance of “coercive” techniques. Respect for an individual’s cultural and trauma background. Competencies for Successful ACT Team Members Belief that people can and will recover. Respect for individuals regardless of level of recovery. Ability to work as a team member. Ability to work and do assessments in-vivo. Ability to be creative when engaging people in services and a corresponding avoidance of “coercive” techniques. Respect for an individual’s cultural and trauma background. TRANSITION TO SLIDE #25

Competencies for Successful ACT Teams
Ability to support and train in the basic community living skill areas of: Safe affordable housing Accessing entitlements and benefits Activities of daily living Medication management Health care needs TRANSITION TO SLIDE #26

ACT Team vs. CS-Team 1:10 staff to persons served ratio
Serves narrower range of people Serves broader range of persons Requires at least 6.0 FTE staff Requires at least 3.0 FTE staff Requires M.D., R.N., on team MD, RN not required on team Requires person in recovery Person in recovery not required Requires SA/MISA specialist SA/MISA specialist not required Requires Rhb/Voc/Sp Ed spcl Rhb/Voc/Sp Ed spcl not rqrd Requires 24/7 crisis intervention May use auxiliary crisis services. This is our last slide, and because earlier today we spoke about the new definition for community support services, and because we realize that the Community Support Team (or CST) service can and will be applied to people with the serious and persistent mental illnesses, we wanted to take this opportunity to point out some of the SALIET DIFFERENCES between the two, so Let’s look at 8 elements across both services… ACT Team CS-Team 1:10 staff to persons served ratio 1:18 staff to persons served ratio Serves narrower range of people Serves broader range of persons Requires at least 6.0 FTE staff Requires at least 3.0 FTE staff Requires M.D., R.N., on team MD, RN not required on team Requires person in recovery Person in recovery not required Requires SA/MISA specialist SA/MISA specialist not required Requires Rhb/Voc/Sp Ed spcl Rhb/Voc/Sp Ed spcl not rqrd Requires 24/7 crisis intervention May use auxiliary crisis services. TRANSITION TO SLIDE #27

Thank You! IN CLOSING… Thank you very much for your attention to this presentation on ACT, as we stated, DMH will address questions you may have from this presentation if you’ll just jot them down and submit them to us. Thanks,

Non-Medicaid Services
DMH Contracted Only

Evidence-Based SE Principles
Find & keep competitive employment Vocational interventions are fully integrated w/mental health treatment Anyone who wants to work is eligible Rapid job search Time unlimited service Jobs seen as transitions Consumer preferences are important Benefits planning Competitive employment = work in the community that anyone can apply for & pays at least minimum wage. The wage should not be less than the normal wage (and level of benefits) paid for the same work performed by individual who do not have a mental illness. Must be a job anyone can apply for. Not a set aside job. Eligibility - people are not excluded because they are not “ready” or because of prior work history, substance use, or symptoms. Rapid job search - instead of requiring extensive pre-employment assessment & training, or intermediate work experiences (like prevocational work units, transitional employment, or sheltered workshops). Jobs as transitions: people commonly try several jobs before finding a job they want to keep. Emp specialists help consumers find further jobs when they leave jobs. All choices and decisions about work and support are individualized, based on the person’s preferences, strengths, and experiences.

Vocational Engagement
Activities for a specific person to engage them in making a decision to actively seek competitive employment or formal credit/certificate bearing education. Note: this does not include pre-vocational agency based work programs or agency based education programs that do not result in credentials recognized by an employer. Intent is to have the idea that competitive employment is possible fully imbedded into the culture of the agency.

Vocational Assessment
Developing a vocational profile to guide individual choices in seeking and maintaining competitive employment. Work history, interests, skills, strengths, education, impact of symptoms, job preferences. Note: This does not include pre-vocational work experiences or simulated/situational work experiences at the agency.

Job Finding Supports Activities for a specific individual, directed toward helping them find and procure a job, when provided under the following conditions: placement based on consumer job preferences, competitive employment in integrated work settings, ongoing supports as needed and integration of supported employment services with other mental health services. Note: does not include general job development. Italics: general conditions of evidence-based supported employment.

Job Retention Supports
Directed toward helping the individual keep his/her competitive integrated job. Interventions that are specific to work and the job are considered job retention supports. Note: therapeutic support to help individuals manage their mental health symptoms and illness as they work toward achieving their recovery goals is a Rule 132 service. Recovery goals can include employment goals.

Job Leaving/Termination Supports
Directed toward helping the person leave a job in good standing, or view unplanned job loss as transitional and a learning experience that will help them with the next job. Intent: Job loss is not seen as a reason to discontinue participation in supported employment.

Outreach and Engagement & Stakeholder Education

Two related services… Outreach and Engagement – Reaching out to people with mental illnesses or emotional disorders and bringing them into the public mental health system. Stakeholder Education – Going into community to speak/train/educate groups about mental illnesses, treatment alternatives, access issues, etc.

Outreach & Engagement: Activities & Interventions
Case finding to identify adults, adolescents, and children suspected to have a mental illness or emotional disturbance who have not consented to services, require engagement or re-engagement to services. Interventions to link to emergency medical or psychiatric care. Repeat contacts over extended periods of time to engage. Developing strategies to reduce or eliminate risk.

Facts About Outreach & Engagement
No prior authorization needed. Funded with State dollars only. A new FFS option; however, NO new contract dollars involved in roll-out. This first iteration of the service is based on the experience of Illinois providers working with these special populations. Division has more freedom to revise the definition and intends to monitor & modify as desired.

Outreach & Engagement: Service & Clinical Exclusions
People already engaged in DMH provider service not eligible for Outreach & Engagement. Discontinuation of O&E should happen when person found to have certain non-MH disorders. Not intended to cover activities of PATH or other federally funded project staff.

Stakeholder Education: Activities & Interventions
Educational meetings with stakeholder groups to provide information about the signs and symptoms of mental illnesses/emotional disturbances. Meetings to collaborate with other community service sites and build opportunities for referral and engagement of people in need. Public speaking engagements that strengthen the relationships among stakeholder groups and the public MH system.

Stakeholder Education: Goals
To support collaboration between DMH providers and community stakeholders that have regular contact with high risk populations. To fight stigma with information about the signs and symptoms of mental illnesses & emotional disturbances and the availability of public MH services. To promote innovative service access strategies.

Stakeholder Education: Facts
No prior authorization needed. Funded with State dollars only (non-Medicaid). A new FFS option; however, NO new contract dollars. This first iteration of service is based on provider history of performing these activities. Division has more freedom to revise the definition and intends to monitor & modify as desired.

Stakeholder Education: Service Exclusions
The following activities are not covered: Ad hoc gatherings or impromptu presentations lacking advance preparation. Repetitious trainings with regard to content or attendees. The service is provided as an activity of a Program to Aid in the Transition from Homeless (PATH) or any other federally funded project operated by the provider.

Thanks Again!

Supplemental Materials

Parameters and Medical Necessity
Medicaid Overview Parameters and Medical Necessity

Medicaid Overview Medicaid is a health entitlement program for people who are low-income and/or disabled that is jointly funded by the federal government and the state government The federal government sets basic parameters and approves State customization of a Medicaid plan (called a ‘State Plan’) The basic Medicaid plan primarily covers in-clinic and in-hospital services.

Three Primary Medicaid Options
Clinic Option In clinic and in hospital services Physician directed Targeted Case Management (TCM) Option Specific population Assessment, planning, linkage, follow up No direct interventions Rehabilitation (Rehab) Option

IL Mental Health Services by Medicaid Option
Targeted Case Management Transition Linkage & Aftercare Mental Health Case Management Rehabilitation Option All other Rule 132 services

Medicaid Psychiatric Rehabilitation Option
Used with behavioral healthcare Focuses on community-based services that actively encourage rehabilitation and progress toward a return to optimal functioning Emphasizes participation and choice Requires rehabilitation from a psychiatric disability

Federal Guidance says Rehabilitation Is:
Restoration of basic skills necessary to function independently/developmentally appropriate in the community Examples: food planning and preparation, maintenance of living environment, community awareness, mobility skills, academic participation

Redevelopment of communication and socialization skills Especially those skills that help individuals with mental illnesses move toward recovery/resiliency, maintain age appropriate community living, and achieve optimal independence from disability

Family education and other family services exclusively related to treatment or rehabilitation of the covered individual.

Interventions which will assist individuals to build capacity to gaining access to needed medical, social, educational and other services. These services might include housing, social services, vocational training and education.

Federal Guidance says Rehabilitation Is NOT:
Vocational services (especially job training) Academic education Purely Socialization Purely Recreation Transportation Watchful Oversight

BUT Rehabilitation CAN provide:
Skills teaching and support critical to successful job functioning, including ability to get along with peers and supervisors, concentrate on tasks at hand, work at a reasonable pace, persist at tasks, present self (cleanliness, attire and communication) appropriately for the work site, maintain work schedule (show up on time), and follow instructions.

AND Rehabilitation CAN provide:
Social skills and basic and daily-living skills required for success in an academic program. Note: Academic goals can be included in Service Plan as long as focus is on rehabilitative skills that allow person to complete that education, reduce disability, and restore the individual to his or her best functional level.

AND Rehabilitation CAN provide:
Skills development and practice of skills necessary to structure and use leisure time, recreational opportunities, and social occasions. Improving natural support systems Developing relationship skills Planning skills Reducing isolation and withdrawal

Federal Guidance says Rehabilitation Is Medically Necessary:
What does that mean? Focus on issues caused or impacted by psychiatric disability and directly related to the mental illness Not just beneficial – necessary to remediate the disability

Demonstrating Medical Necessity: Five Basic Steps
Assessment documents psychiatric condition and impact on functioning Service Plan addresses areas identified on assessment and includes steps to returning to baseline (Signed by authorized person) Service Plan prescribes services in amount & duration reasonably expected to foster change Interventions (& notes) directly relate to Service Plan Notes demonstrate progress

Eleven Essential Skills
Building Resilience Eleven Essential Skills

Resilience Skills: Getting Connected
Building strong, positive relationships with family and friends Getting involved in civic groups, faith groups or volunteer organizations Fulfilling the need for a sense of belonging and banishing loneliness through relationships/connectedness

Resilience Skills: Using Humor and Laughter
Remaining positive/finding humor in distressing situations does not mean a person is in denial Humor is a helpful coping mechanism Funny books and movies can add humor to life

Resilience Skills: Learning From Our Experiences
Recalling how you have coped with hardships in the past, either in healthy or unhealthy ways Building on what helped you through the rough times; not repeating actions that did not help Figuring out what lessons you learned and how you will apply them when faced with similar situations

Resilience Skills: Remaining Hopeful and Optimistic
Looking toward the future, even if it’s just a glimmer of how things might improve Finding something in each day that signals a change for the better Believing things happen for a reason often helps to sustain people

Resilience Skills: Taking Care of Yourself
Tending to your own needs and feelings, both physically and emotionally Participating in hobbies you enjoy; exercising regularly Getting plenty of sleep; eating a well-balanced diet

Resilience Skills: Accepting and Anticipating Change
Being flexible: change and uncertainty are part of life Trying not to be so rigid that even minor changes upset you or that you become anxious in the face of uncertainty Expecting changes to occur makes it easier to adapt to them, tolerate them, and even welcome them

Resilience Skills: Working Toward Goals
Doing something every day that gives you a sense of accomplishment Recognizing that even small, everyday goals are important Having goals which help direct you toward the future

Resilience Skills: Taking Action
Figuring out what needs to be done Making a plan to do it Taking action to resolve your problems Wishing problems away, or ignoring them, does no good

Resilience Skills: Learning New Things About Yourself
Looking back on past experiences and thinking about how you’ve changed as a result Recognizing that you may be stronger than you thought Exploring new interests, such as taking a cooking class or visiting a museum

Resilience Skills: Thinking Better of Yourself
Congratulating yourself for enduring hard times, loss or stress Being proud of yourself Trusting yourself to solve problems and make sound decisions Thinking positive thoughts about yourself Nurturing your self-confidence and self-esteem so that you feel you’re a strong, capable and self-reliant person

Resilience Skills: Maintaining Perspective
Recognizing that perspective is not about comparing yourself to others Comparing yourself to someone who may be worse off may only make you feel worse or feel guilty Perspective is about looking at your situation in the larger context of your own life, and the world It is about keeping a long-term perspective and knowing that your situation can improve if you actively work to make it better

A Brief Bibliography on Recovery/Resiliency
Anthony, William. A Recovery-Oriented Service System: Setting Some System Level Standards. Psychiatric Rehabilitation Journal, Vol. 24, No. 2. (2000). National Consensus Statement on Mental Health Recovery. U.S. Department of Health & Human Services. Substance Abuse & Mental Health Services Administration. Center for Mental Health Services New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. (2003)

Additional New Services Information

4 Ways of Delivering CS: Quick Review
Person Receiving: CS-Individual: An individual staff member will work with you. CS-Group: One or two staff members work with you and other consumers together. CS-Team: A team of staff members will work with you CS-Residential: You’ll receive service in a residential setting from several staff members Factors common to all four ways: ALL work toward mutually agreed upon rehabilitative, resilience-oriented, and recovery-focused goals. A minimum of 60% of all CS services must be delivered in natural settings. CS occurs at locations that reasonably accommodate the person’s needs,and at hours that do not interfere with work, educational, and other community activities.

A Brief C.S. Bibliography
Center for Psychiatric Rehabilitation, Sargent College of Health and Rehabilitation Sciences. Boston University: Recovery from Serious Mental Illness. Farkas & Anthony (Eds.). Psychiatric rehabilitation programs: Putting theory into practice. Baltimore, MD: Johns Hopkins University Press The President’s New Freedom Commission: Goals and Recommendations for a Transformed Mental Health System. available at: Rapp. The strengths model. NY: Oxford U. Press, 1998 Rapp and Gosha: The Principles of Effective Case Management; Psychiatric Rehabilitation Journal, Spring 2004—Volume 27, Number 4

EVIDENCE-BASED ACT WEB SITE
SAMSHA' National Mental Health Information Center Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Rule 132 New Services Clinical Overview

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