C omprehensive Community Services

1. Comprehensive Community Services

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

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

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

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

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

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

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

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

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

11. CCS Eligibility • T-19/Medicaid/Badger Care Plus (QMB and SLMB Medicaid are NOT full benefit and will not cover CCS) • Diagnosis documented in a Prescription via MD (Either Mental Health Disorder or a Substance Use Disorder, or both) • Physician Prescription/Referral for CCS (found on the website, and hand out) • Provides the Diagnosis • Must be signed by an MD. If the consumer’s provider is an APNP, it must be signed off by an MD. • Needs to be dated. MD’s name legibly printed. • Must meet functional requirements via the Mental Health/AODA functional screen

12. T19/Medicaid/Badger Care Plus eligible + Doctor’s Prescription = Presumptive Eligibility • With these 2 things, CARS will assign the case to an agency that is qualified to do Service Array #1, Screening and Assessment. • The consumer can pick the agency. Current agencies will be listed on the website within the Provider Directory.

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

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

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

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

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

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

19. CCS can serve all ages • Youth is considered less than 18, but the youth CCS can serve consumers to the age of 23. • To enroll in Youth CCS, call 257-7607

20. Who CANNOT be co-enrolled? • TCM • CSP • Individuals enrolled in Family Care MAY be eligible for co-enrollment in CCS

21. All CCS providers need to be familiar with the CCS Policies and Procedures • They can be found on the CCS website.

22. P&P 603 – Service Delivery and Agency Collaboration • CCS will provide every individual the opportunity to live a life that achieve his/her maximum recovery potential. • The CCS program will act in a Consumer advocacy role. • CCS is a voluntary benefit and the individual must have the capacity to volunteer. • An Assessment and IRP are completed to assist the CCS staff and consumer in crisis prevention and resolution. • The consumer will receive written information on how to access on-call coverage and the BHD Crisis Line. • CARS will provide each agency with an Administrative Coordinator to be their “Liaison” and primary point of contact. • Agencies can request consultation on specific issues to their Liaison, or present the case at an Operations/work group meeting. • Milwaukee County will ensure that CCS will be delivered in an integrated setting with reasonable promptness and build on natural supports available within the community that supports the recovery pathway of the individual service recipient.

23. P&P 608 – Receiving and Making Referrals • Consumers need to self refer by either calling CARS at 257-6060 or directly presenting to one of the branch offices (list can be found in the provider directory.) • If the consumer uses the phone line, CARS staff will assist them to choose an agency and then place a 3 way call to connect the consumer to an Intake Coordinator within 3 days. • After signing an Application and Admission Agreement, the Intake Coordinator will assist the consumer to get a physician prescription from a Medicaid approved physician. • A Functional Screen will be completed to determine final eligibility. • If the consumer does not meet eligibility guidelines, they will receive written notice and referred to a non-CCS program at the appropriate level of care, and informed of the appeal process.

24. P&P 609 – Communication to Consumer of Comprehensive Community Services Information • Consumers will be informed about CCS. They will be given a brochure and a copy of the Program Description. • Consumers will be given a copy of the Admission Agreement, which includes the Agency name, hours, and phone numbers. • Consumers will be given a copy of their RPOC that lists all the services and providers. It lists any copays required. • Consumers will be given a copy of the Grievance Procedure. • Consumers will need to sign an Informed Consent. • Consumers will receive a listing of CCS staff members, titles, responsibilities and means to contact them.

25. P&P 610 – Cultural Heritage & Primary Language • The Care Coordinator will ensure that the RPOC is responsive to the cultural heritage and primary language of the consumer. • The Care Coordinator will monitor the delivery of all other supportive services to ensure that their delivery is responsive to cultural background, personal life experiences, and that mental health and/or substance use disorders are addressed. • Assure that if the CCS program is unable to meet the consumer’s needs due to cultural issues or language barriers, additional information and/or an appropriate referral to an outside service will be made once the consumer is admitted to CCS. • Ensure that consumers are given choices of secular vs. non-secular services, gender specific, culturally intelligent, and linguistically appropriate service provision.

26. P&P 613 – Application and Screening Process • Once referred for CCS, a consumer would be screened for eligibility and appropriateness. No consumer should be denied or subjected to discrimination on the basis of age, race or ethnicity, religion, color, sexual orientation, marital status, arrest or conviction record, ancestry, national origin, disability, gender, or physical condition.

27. P&P 619 – Support and Mentoring for Consumer • Consumers shall be provided the opportunity to gain support from others to promote hope, healing, and empowerment on his/her recovery journey. • The Care Coordinator and Recovery Team shall assist the consumer to learn from others in recovery how to handle challenges, develop coping skills, feel empowered, and enjoy a sense of accomplishment. • Empower consumers to gain support through gaining knowledge, developing self-advocacy skills, exercising their civil rights, acquiring skills needed to exercise control and responsibility over other services provided by the CCS program, providing the consumer education on t he ways to access necessary resources throughout their community when formal supports are not available, and connecting with Peer Support Services. • Accompanying consumers to meetings and appointments to advocate for them and also to demonstrate positive and appropriate examples of advocacy. • Facilitate networking amongst consumers to provide opportunity for support and mentoring with peers. • Engaging the consumer in community based activities that may be non-traditional to support wellness and recover.