2. Connecting Young Adults with Behavioral Health Needs
MERCY MARICOPA INTEGRATED CARE
Connecting Young Adults with Behavioral Health Needs
Heather Williams, BS
Transitional Youth Coordinator, Mercy Maricopa Integrated Care
Jessica Woodruff, LCSW
Clinical Manager, Transition to Adulthood Program, Jewish Family and Children’s Services

3. Connecting Young Adults with Behavioral Health Needs
Objectives
Learn about Mercy Maricopa and it’s role in managing behavioral health services for transitioning youth in Maricopa County
Define system changes that contribute to successful transitions to adulthood
Define Mercy Maricopa’s role in collaborating with stakeholders and community partners
Identify challenges facing “disconnected youth” with behavioral health needs
Identify best practices for addressing behavioral health needs with “disconnected youth”

4. Who is Mercy Maricopa?
Mercy Maricopa Integrated Care is a local not-for-profit health plan sponsored by Mercy Care Plan (MCP) and Maricopa Integrated Health System (MIHS)
Both of Mercy Maricopa’s sponsors have a long history of caring for Maricopa County residents
MCP is a 28-year-old Medicaid plan, also a not-for-profit, that is sponsored by Dignity Health and Carondelet Health Network, faith-based health care systems
MCP already serves nearly half the AHCCCS SMI population for their physical health care needs
MIHS is a public health care system, serving AHCCCS members, privately insured and uninsured citizens of Maricopa County for 135 years.

5. Values and Principles Focus on members and the whole person
Collaboration with providers and stakeholders
Use of data and information in decision making and system improvements
Improve the member – provider interaction
Integration occurs at multiple levels: state, managed care, provider, member and family
Integration will include children and GMHSA
Ultimately about recovery and resiliency

6. How does Mercy Maricopa serve Transition-age Youth?
Children’s Services
Serve youth and young adults between the ages of 14 and 17
Responsible for coordinating the transition from the children’s service delivery system to the adult service delivery system
General Mental Health/ Substance Abuse (GMH/SA) Services
Serve young adults between the ages of with general mental health needs (medication monitoring, therapy)
Seriously Mentally Ill (SMI) Services
Serve young adults between the ages of 18-25
Additional supportive services to meet complex needs of young persons diagnosed with a Serious Mental Illness

7. Establishing Priorities
Putting transition-age youth and families at the center
TAY Transition-
Age Youth
Natural Supports
Skills Training
Peer
Support
Community Based Services
Voice and Choice
Futures Planning
Leadership Opportunities

8. How will Mercy Maricopa improve the system for transition-age youth?
Mercy Maricopa will enhance service delivery to this population by:
Utilizing Mercy Maricopa’s Youth Leadership Council as advisors to system changes effecting transition-age youth
Encourage the use of recognized best /promising practices for working with Transition-age Youth (TAY) aged 16-21
Utilize data to influence system changes that may benefit transition-age youth

9. The Value of Collaboration
Engaging system partners in transition to adulthood discussions will encourage:
Sharing of information on program successes and barriers
Sharing of community resources relevant to transition-age youth
Young adults to share their perspectives and provide leadership
Development of training opportunities for transition providers and community members

10. Who are the Transitioning Youth?
Young adults between the ages of 14 and 25 are considered to be within the transition period
Youth with mental health needs struggle to achieve the hallmarks of adulthood such as finishing their education, entering the labor force, establishing an independent household, forming close relationships, and potentially getting married and becoming parents.

11. Why is transition to adulthood so important to us?
Young adults with mental health concerns are at a higher risk of:
Dropping out of high school
Not finishing college
Abusing drugs or alcohol
Having unplanned pregnancies
Being unemployed
Arrests
Incarceration

12. Best Practices Child and Family Team (CFT) Model Arizona Vision
In collaboration with the child and family and others, Arizona will provide accessible behavioral health services designed to aid children to achieve success in school, live with their families, avoid delinquency, and become stable and productive adults.
Services will be tailored to the child and family and provided in the most appropriate setting, in a timely fashion and in accordance with best practices, while respecting the child’s family’s cultural heritage.

13. Best Practices Child and Family Team (CFT) Model 12 Arizona Principles
1. Collaboration with the child and family
2. Functional outcomes
3. Collaboration with others
4. Accessible services
5. Best practices
6. Most appropriate setting
7. Timeliness
8. Services tailored to the child and family
9. Stability
10. Respect for the child and family’s unique cultural heritage
11. Independence
12. Connection to natural supports

14. Best Practices Child and Family Team (CFT) Model: Transition Planning
The CFT begins transition planning no later than 16
For youth who are age 16 and older at the time they enter the behavioral health system, planning begins immediately
At age 17, the team should begin to create the adult services plan and determine whether or not the youth meets criteria for Seriously Mentally Ill (SMI) services
Once a plan has been determined, the children’s provider begins outreach to the adult provider to ensure continuity of care

15. Best Practices
Incorporating transition planning into the Individualized Service Plan includes an assessment of:
Self-care and independent living skills
Social skills
Work and education plans
Earning potential
Psychiatric stability

16. Best Practices Strengths, Needs, Cultural Discovery Support System
A general approach rather than a specific intervention
Identifies possibilities and options vs. limitations
Enhances engagement and builds relationships
Focuses on identifying solutions
Support System
Young Adult
Family

17. Best Practices Strengths, Needs Cultural Discovery
Supports exploring additional natural supports throughout transition process
Provides a way to show the youth and family’s strength and abilities.
Opens the door to the future, giving hope, which is a key component to transition planning
Assists in identifying cultural considerations, such as norms, values, health considerations, and sexual identity. 17

18. Best Practices Positive Behavioral Support
Decreases the need for more intrusive intervention
Considers both physiological and environmental factors that influence behavior
Community based support, focused on “meeting the young person where they’re at”
Implement multiple interventions in complex systems with many variables

19. Best Practices Peer Support
Helps individual develop a better understanding of their circumstances
Provides opportunity to engage with others who are in recovery
Occurs in both formal and informal contexts
Promotes youth involvement

20. Best Practices Transition to Independence Process (TIP)
Engage youth and young adults (14-29 years) in their own future’s planning process
Provide them with developmentally-appropriate services and supports
Involve the young adult, their families and other informal key players in a process that prepares and facilitates them in their movement toward:
greater self-sufficiency and
successful achievement of their goals

21. Best Practices Transition To Independence Process (TIP): SODAS
Situation
Who/What/When/Where/How
Options
Brainstorming
Judgment Free
Disadvantages/Advantages
Solutions
Young Persons Choice

22. Best Practices Transition To Independence Process (TIP): Rationales
Bridges behavior and natural consequences that are likely to incur
Link likelihood of positive natural consequences for following appropriate behavior and likelihood of negative consequences for inappropriate behavior
Rationales will not change behavior immediately.
‘In-Vivo’ Teaching – when you are showing, modeling, or educating something.

23. Jewish Family & Children’s Service
The Approach
Program began at the request of Department of Child Safety (DCS) to meet the needs of Transition Age Youth dually enrolled in DCS and Behavioral Health.
Focus on working with youth/young adults in areas of education, career/employment, stable living situation, community life functioning and personal effectiveness and wellbeing.
The teams are community-based: Transition facilitators have cell phones, laptops, wireless cards; Services are delivered where the youth/young adult lives.
Skills training is done with the youth/young adult in their environment through a combination of role playing, role modeling and coaching

24. Jewish Family & Children’s Services
Unique Needs
Understand that youth/young adult culture is a distinct and separate culture.
Unique population with special needs
Transition-age youth are not transitioning into adult services but are transitioning into adulthood.
Need for developmentally appropriate services specific to the distinct needs of a young person just entering adulthood
Effective behavioral health services must be mindful of the unique needs, interests and goals of young adults

25. Jewish Family & Children’s Services
Explore and determine barriers and inefficiencies in the quality and effectiveness of services in order to strengthen outcomes across (5) transition domains:
Employment/Career
Education
Living Situation
Personal Effectiveness/Wellbeing
Community-Life Functioning

26. Jewish Family & Children’s Services
Staff Commitment
The Youth in Transition Facilitators are diverse racially and ethnically. Each one was recruited for a compilation of skills and talents which makes the entire program greater than the sum of its parts.
Transition Facilitators take youth to job interviews, college registrations, meetings with P.O.s, apartment hunting, help with homework, rush them to the emergency room, intervene in the middle of the night when someone is suicidal, take them to court (to list just a few of the activities).
Each interaction/activity is used to teach the life skills identified as necessary by the youth/young adult and their family and/or Child and Family Team.

27. Jewish Family & Children’s Services
TIP Today
Over 210 youth and young adults currently active in the Program from the Department of Economic Security/Division of Children, Youth & Families, the Arizona Department of Juvenile Corrections, Partners in Recovery and from the community at large.
JFCS partners with state and community stakeholders to provide service and support for the youth/ young adults we serve.
Just as we partner with diverse agencies we recruit staff that reflect the diversity of the youth/young adults we serve; developing a strong racial and ethnic identity is crucial to the development of personal effectiveness and wellbeing.

28. Jewish Family & Children’s Services
The Rewards
25% of youth are employed.
18% of youth are enrolled in post high school academic or trade program.
70% of young adults have demonstrated a positive change in their interpersonal relationships.
68% of youth have achieved improvement in their personal health.
75% of young adults are using and developing the daily living skills they have learned.
65% of youth are participating in the community.
82% of young adults in a home-type permanent setting.

29. Questions?
Thank you!