Home & Community Services

1. Home & Community Services Provider Orientation

2. Wraparound Services • Also known as BHRS (Behavioral Health Rehabilitative Services). • Current regulations regarding policy, role of staff, and supervision guidelines resulted from a lawsuit known as Kirk T, that was settled in 2001.

3. Wraparound Services • Who are they for? -Any child or adolescent under the age of 21 with an Axis I diagnosis -Any child or adolescent presenting with a social, emotional or behavioral issue that substantially interferes with his/her functioning in family, school, or community activities

4. Wraparound Services -What are they? • Services are based on Medical Necessity • Services are funded through the Department of Public Welfare (DPW) or, in some cases, by Act 62 Insurance. • Services are designed to be short-term • Services are not intended for crisis situations • Services are based on the statewide CASSP Principles

5. CASSP • Child and Adolescent Service System Program • Child-centered • Family-focused • Community Based • Multi-system • Culturally competent • Least restrictive/least intrusive

6. Wraparound Services • Positive Approaches Principles • Two basic assumptions: • people always have good reason to do what they’re doing • people always do the best they can with what they know in that context and at that point in time -- Success is dependent upon building appropriate therapeutic relationships

7. Referral Process • Client must apply for Medical Assistance (MA) through the Department of Public Welfare (DPW). • If the client is eligible for Act 62 Insurance, the parent/guardian will contact their private insurance for additional information. • Client receives an axis I diagnoses such as PDD, ADHD, ODD, etc from a licensed Psychologist, Psychiatrist, or Physician. • The client’s guardian contacts the county office of MHIDD (still known as MH/MR in some counties) or Managed Care Organization (MCO) to express an interest in receiving Wraparound Services.

8. Referral Process • A Core Provider is located. • An intake is done to determine the need for Wraparound Services. • A psychological evaluation is completed. • If services are found to be medically necessary then an Interagency Systems Planning Team Meeting (ISPT) is held and an approved provider of wraparound services is located.

9. Psychological Evaluation • Within the psychological evaluation: • The types of services prescribed: • TSS – Therapeutic Staff Support • MT – Mobile Therapy • BSC – Behavior Specialist Consultant • CM – Case Management • The hours recommended for each type of service • The goals for therapy - The location of services

10. Interagency Team Meeting • ISPT’s are held every 4 to 6 months. • The team will meet to discuss the recommendations in the psychological evaluation • The team will review and develop treatment recommendations • An authorization “packet” is generated and sent to the MCO which has 2 days to approve or deny the request • If the request for services is denied, the family has the right to file a grievance

11. Interagency Team The team consists of: • parent/guardian • provider of services • BSC (if identified) • MT (if identified) • Case Management Team • school representatives • client (if 14 and over) • MCO and/or County representative • Licensed Prescriber • Others involved with the welfare of the client

12. Interagency Team Cross-Systems Initiatives • Office of Children and Youth and Families • Bureau of Drug and Alcohol Programs • Juvenile Justice System • School-Based Mental Health Services • Family Centers

13. Other Available Services • Resource Coordination • MH/IDD Case Management • Blended Case Management • Intensive Case Management services • Outpatient services • Student Assistance Program • Crisis Intervention Services • Family-Based Mental Health Service

14. Other Available Services • Partial hospitalization services • Therapeutic Foster Care • Residential treatment facilities • Psychiatric inpatient hospitalization

15. Wraparound and You The Team

16. Who Are We? • As a TSS, BSC or MT, you will be providing services for Chester County Intermediate Unit’s (CCIU) Home and Community Services program (H&CS). • You were sent to us by CCRES, a staffing agency.

17. Who Are You? • When introducing yourself to families and other professionals, please say that you provide services for CCIU Home and Community Services. • REMEMBER: WE ARE NOT CCRES!!!!

18. The Team • Behavioral Specialist Consultant • Therapeutic Staff Support • Behavioral Health Personal Care Assistant • Mobile Therapist • Case Management Team

19. Behavioral Specialist Consultant • The BSC is a master’s or doctoral level mental health professional • Serves as the clinical team leader • Provides behavioral intervention consultation services to the treatment team • These services are generally designed to be consultative in nature, rather than direct service to the child or family

20. Behavioral Specialist Consultant • Responsibilities of the BSC include: • Collaboration with other members of the treatment team • Develop and direct the implementation of a treatment plan • Monitor the effectiveness of the treatment plan • consultation with TSS on at least a bi-weekly basis • collaboration with other team members

21. TSS The TSS provides one-to-one behavioral health interventions to a child or adolescent with serious emotional/behavioral disturbance. TSS services are intended to prevent more restrictive services or out of home placement and to promote age-appropriate psychosocial growth The TSS should work collaboratively with the parents, caregivers, teachers and other school personnel to transfer the skills and techniques needed to fulfill the goals of the treatment plan.

22. TSS • The TSS will produce daily documentation and collect data. All documentation and paperwork must be completed during prescribed scheduled time with client • The TSS should consult with the BSC at least on a bi-weekly basis

23. TSS Appropriate roles for TSS include: • Demonstrate alternative activities to redirect challenging behaviors • Demonstrate therapeutic structure and limits for the child • Demonstrate behavioral intervention plan for caregivers • Demonstrate positive relationships with parents, siblings, teachers, aides, and peers • Assist the parent/teacher in assuring safety to the child and others

24. TSS Inappropriate roles for TSS include: • Continued observation of the child’s behavior w/o any planned follow-up intervention • Adding time with the TSS worker as a reward for good behavior or as a reward for the child controlling his or her outbursts • Providing services to children without knowledge and/or permission of the parent(s) or primary care giver(s) • Providing TSS services without appropriate supervision

25. TSS Inappropriate roles for TSS include: • Performing the duties of school personnel and/or academic tutoring • Providing services not included or specified in the treatment plan • Substituting for any type of caregiver • General child care or housekeeping • Therapeutic interventions not consistent with the treatment plan or goals

26. Behavioral Health Personal Care Assistant (BHPCA) • School Districts or Early Intervention (EI) Programs contract with Home and Community Services directly. • Rendered to students with both physical and mental/behavioral health needs. • Behavioral Health Personal Care Assistant is considered a one-on-one service; but their skills may be used within the classroom/home as needed and some weekends if approved. • BHPCAs may provide services to more than one student in a given day, but not at the same exact time. • BHPCAs encourage and support students by utilizing behavioral interventions necessary for the student’s successful progress throughout the school day.

27. Behavioral Health Personal Care Assistant (BHPCA) Examples of BHPCA Responsibilities: • Assisting the student to use equipment including augmentative communication devices. • Monitoring the incidence and prevalence of designated health problems or medical conditions, e.g., seizure precautions or extreme lethargy. • Can do toileting including physical care if they are trained appropriately. • Accompanying students on school buses or other vehicles. A BHPCA’s presence is necessary because of a student’s physical disability or mental health disability. • Basically, they can do anything a TSS can do plus all of the above.

28. Behavioral Health Personal Care Assistant (BHPCA) BHPCA-Teacher-Child Communication • Staff work for the school and follow teacher's direction • Teachers need to deal directly with the student as they would with any other student in their class, and the BHPCA is there to support the child in following directions of the teacher. • The students need to learn to deal directly with the people in charge of the classroom and to decrease dependence on the BHPCA. • The BHPCA may remind the student what the teacher has said, or to redirect the child when off task, not following directions or not obeying the rules.

29. Mobile Therapist • The Mobile Therapist is a Master’s level mental health professional that provides child-centered, family focused, face-to-face individual or family counseling services. • Mobile Therapy services are intended to support the child and family in coping with issues related to the child’s diagnosis. • Mobile Therapy may extend to assist family members with issues related to the child’s diagnosis/behavioral issues. • The child need not be present when other family members receive Mobile Therapy. • Mobile Therapist may not provide services to the same person at the same time as the TSS or BSC. • In some instances the Mobile Therapist may serve as the clinical leader, if no BSC is assigned to the case. In these cases, the MT is able to follow the same role and responsibilities of a BSC.

30. Mobile Therapist • Participants in mobile therapy sessions may include any of the following combinations: • The child alone • The child and other members of the child’s family • The child and teacher, and/or other school personnel • Mobile Therapy is not a crisis service.

31. Case Management Team • YOUR FIRST POINT OF CONTACT • Is who you contact when you have a problem or need to discuss concerns, etc. • Ensures that the multiple BHRS services are provided in a coordinated, timely and appropriate manner • Serves as a liaison between BHRS providers and team members, including the family • Completes and coordinates paperwork in order to obtain all authorizations • Facilitates the transition of families to other services OR supports as needed

32. Case Management TeamRoles • Each client is assigned to a specific Case Management Team, consisting of a Case Manager and a Case Specialist. • Although there may be some differences between the counties, the role of the Case Manager is generally to assist with clinical questions or concerns. The role of the Case Specialist is to staff each case and to be responsible for many of the administrative issues. • In case one member of the CM Team is not available, the other member can usually assist you or provide you with the next step to take.

33. Who Are Our Clients? • Children between the ages of 0-21 • Focusing on stages of development and behavior in the domains of : • Social • Cognitive/language • Emotional Development • Physical Development

34. About Our Clients Autism Spectrum Disorders DSM-5 299.00

35. About Our Clients Criteria for Autism Spectrum Disorders: • Deficits in social-emotional reciprocity • Qualitative impairment in nonverbal communicative behavior used for social interaction • Deficits in developing, maintaining, and understanding relationships • Restrictive, repetitive patterns of behavior, interests or activities including stereotypical motor movements, echolalia, scripting, insistence on sameness, difficulties with change and transitions, interests that are fixated and abnormal in intensity, and hyper or hypo-reactivity to sensory input (pain, temperature, sounds, smells, textures)

36. ASD • Symptoms must be present in the early developmental period • Symptoms cause clinically significant impairment in social, occupational or other important areas of current functioning • These disturbances are not better explained by intellectual disability or global developmental delay (although they may co-occur)

37. Severity Level: ASD Severity is based on level of impairment: Level 1: Requiring Support Level 2: Requiring Substantial Support Level 3: Requiring Very Substantial support

38. About Our Clients Autism Facts: • 3 out of 4 children diagnosed with Autistic Spectrum Disorder are male. • Most children are diagnosed prior to 3 years of age. • Clients with Level I ASD may do well academically, but have poor social skills (ex: may have formerly been diagnosed as “Asperger’s Disorder”. • 1 in 50 school-aged children are diagnosed with an Autistic Spectrum Disorder (US Centers for Disease Control Prevention, 2013)

39. Other Diagnoses • We also have clients who have been diagnosed with ADHD, Disruptive Behavior Disorders (Oppositional Defiant Disorder, Intermittent Explosive Disorder or Conduct Disorder) Obsessive-Compulsive and Related Disorders, Bipolar Disorder and Anxiety Disorders, among others. • Our online trainings on Moodle will provide you with information about some of these disorders. TSS and PCAs can begin taking elective trainings beginning with the next training year-- July 1st following the year in which they completed their 6-month probationary requirements. • Example: You are hired in September, 2013. You complete your probationary trainings in December, 2013. Your probationary 6 months ends in March, 2014. You do not begin taking any other trainings until July 1, 2014.

40. What Will You Be Doing?

41. Behavioral Interventions Home and Community Services adheres to the philosophy of Applied Behavioral Analysis: “…the science in which procedures derived from the principles of behavior are systematically applied to improve socially significant behavior to a meaningful degree and to demonstrate experimentally that the procedures employed were responsible for the improvement in behavior. (Cooper, Heron, & Heward, 1987)

42. Behavioral Interventions Principles of Challenging Behaviors • Problem behavior usually serves a purpose • Goal of intervention is skill building, not simply behavior reduction/elimination • Effects of Problem Behaviors • Interfere with learning opportunities • Hinder quality of life • Results in exclusion

43. Behavioral Interventions 1.) Determine Function of Behavior • Attain • Attention • Objects • Internal Stimulation • Avoid/Escape • Attention • Tasks/Events • Internal Stimulation 2.) Determine if Function is Acceptable • Yes- teach replacement behavior • No- rearrange antecedents/consequences to eliminate behavior

44. Behavioral Interventions Guidelines for Interventions: • Least restrictive • Natural supports willing/able to continue once professional implementation has ended • Procedures will be modified as determined by on-going evaluation • Procedures chosen based on hypotheses and confirming data

45. Behavioral Interventions Guidelines for Interventions (con’t): • Treatment plan should include specific instructions on how to implement client-specific clinical methods • BSC is responsible for describing to the TSS his/her role in the implementation of the clinical methods • BSC is responsible for training the TSS on utilization of the clinical methods • The TSS only provides interventions that have been described in the Treatment Plan by the BSC.

46. Behavioral Interventions Some of examples of Programs/Techniques • Accepting “No” • “Planned Ignoring” with Differential Reinforcement • Putting a behavior on extinction • Use of various reinforcement procedures and schedules • Use of visual schedules • Behavioral Contracting • Prompting • Shaping • Establishing and Maintaining Positive Social Interactions • Redirection • Modeling

47. TSS Interventions • TSS Interventions are directed by the treatment plan. They may include: • Obtaining information about the child’s problematic behavior • Reinforcing parental roles and responsibilities with the child • Helping the child integrate into an identified community setting

48. TSS Interventions • They may also include: • Helping the child improve social interactions with peers. • Helping the child de-escalate when engaging in inappropriate behavior • Promoting appropriate attitudes and decision making by the child • Promoting positive behaviors • Identifying triggers of negative behaviors

49. Crisis Plan Definition of a crisis: • The child or youth is actively endangering him/herself or others; the situation has escalated to require the immediate intervention of multiple professionals or family members, and the situation has by definition long-term consequences

50. Crisis Plan • Crisis Plan • The team should have developed a de-escalation plan for this specific child. • There should also be a crisis plan for the child if de-escalation does not work. • When in doubt contact supervisory staff.