Community Psychiatric Rehabilitation

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Community Psychiatric Rehabilitation

• Presented by Susan Blume, M.Ed.
• Certification Coordinator
• Department of Mental Health
• Division of Comprehensive Psychiatric Services

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The goal of todays presentation is to answer
questions such as

• What is the community psychiatric rehabilitation
  (CPR) program?
• What is the philosophy of this program?
• Who is eligible for services?
• What services are available through CPR?
• What is the funding stream for services?

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Community Psychiatric Rehabilitation

• was established in Missouri in 1989
• is funded by both the Missouri Department of
  Mental Health (DMH) and by Medicaid
• is part of the rehabilitation option to the
  Missouri State Medicaid Plan

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Community Psychiatric Rehabilitation

• is administered jointly by the DMH Division of
  Comprehensive Psychiatric Services (CPS) and the
  Division of Medical Services, which is part of
  the Department of Social Services
• the development and implementation of the
  Community Psychiatric Rehabilitation program is
  an important component of the DMH community-based
  system of care

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Community Psychiatric Rehabilitation

• CPR programs provide a range of mental health
  services to adults with serious and persistent
  mental illness and children and youth with
  serious emotional disturbances

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Services are designed to

• maximize independent functioning
• promote the recovery and self-determination
  process
• increase interagency coordination and
  collaboration in all aspects of the treatment
  planning process and
• reduce inpatient hospitalizations and out-of-home
  placements

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The core services that must be provided in order
for an agency to be certified by DMH as a CPR
program are

• Evaluation
• Community Support
• Crisis Intervention
• Medication Administration
• Medication Services
• Consultation and
• Psychosocial Rehabilitation

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Evaluation

• Assessment and evaluation are crucial to the
  delivery of quality services since the findings
  of the assessment provide a foundation for
  determining service delivery needs and developing
  strategies for intervention and level of care
• Evaluation occurs at intake and annually after
  that

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The intake evaluation focuses on

• presenting problems
• history of treatment
• history in areas such as family, vocation,
  education and community
• current functional strengths and weaknesses
• physical and medical complaints and
• recommendations for treatment

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Annual evaluations focus on

• changes over the past year in all areas of
  assessment
• update of diagnostic formulation and
• recommendations for treatment

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Treatment Planning

• Treatment plans and treatment plan reviews are
  part of the evaluation package
• Treatment plans are developed from the assessment
  and in partnership with the consumer in order to
  have goals that are individualized and realistic
• Treatment plan reviews summarize progress toward
  goals for a three month period

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Community Support Services

• Many individuals with mental illness experience
  difficulty being included in the community and
  accessing community resources
• This is due in part to the segregation and
  isolation that they may have experienced, and in
  part to the disabilities associated with their
  mental illness

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Community Support Services

• Is defined as those activities designed to ease
  an individuals immediate and continued community
  adjustment

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Community support activities include

• teaching community living skills
• advocating for individuals and families
• coordinating delivery of mental health services
  with services provided by other agencies
• providing individualized guidance and support and
  
• monitoring progress in organized treatment
  programs

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Community Support Services

• Community support workers (CSW) are responsible
  to assure that appropriate resources are
  available to individuals and to support them in
  attaining their highest level of functioning in
  their families and in the community

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Community Support Services

• In order to be included in the community,
  individuals are assisted in filling legitimate,
  valued social roles such as worker, student,
  neighbor, voting citizen, church member,
  volunteer, spouse and parent

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A typical day for a team of CSWs might include

• helping a person with a medical or psychiatric
  appointment
• monitoring a persons mental health
• developing or reviewing a treatment plan
• providing support to someone in the hospital and
  participating in hospital discharge planning

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A typical day (continued)

• training/coaching in daily living skills such as
  housekeeping, cooking, grooming, budgeting
• training/coaching in community living skills such
  as paying bills, taking the city bus, shopping
  for groceries within a budget or within special
  dietary constraints
• helping someone with an appointment at DFS, the
  housing authority or vocational rehabilitation

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A typical day (continued)

• For example, with vocational rehabilitation,
  CSWs can help their client remember and keep
  appointments, complete paper work, and understand
  what is required when receiving services

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Crisis Intervention

• Crisis intervention services include telephone
  access and face-to-face emergency response.
  Interventions are available to the consumer 24
  hours a day, 7 days a week
• Services are provided by Access Crisis
  Intervention (ACI) providers regionally (see
  handout) with back-up by program staff locally

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Crisis Intervention

• Crisis personnel have access to a physician for
  consultation purposes 24 hours a day
• Crisis personnel assist clients in utilizing
  natural supports or perhaps, if needed, in
  admission to an inpatient psychiatric facility

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Crisis Intervention

• The goals of crisis service are to
• Provide immediate response, intervention and
  referral for persons experiencing mental health
  crisis, whether in a rural, urban or metropolitan
  area
• Respond to crisis by providing community-based
  intervention in the least restrictive
  environment, e.g. home, school

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Crisis Intervention

• Avert the need for hospitalization to the
  greatest extent possible
• Stabilize persons in crisis and refer them to
  appropriate services to regain an optimal level
  of functioning and
• To mobilize and link individuals with services,
  resources and supports needed for ongoing care
  following a crisis, including natural support
  networks

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Medication Services

• Psychiatrists or Advanced Practice Nurses assess
  individuals in the need for medication as well as
  e ongoing management of the medication regimen.
• Services also include reviewing for side effects
  and providing education about medications

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Medication Administration

• Medication administration services provide for
• coordination with pharmacies and indigent drug
  programs
• setting up medication boxes
• monitoring of medication compliance
• consumer and family education
• therapeutic injection of medication

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Consultation Services

• CPR personnel often consult with human service
  and other government agencies as well as natural
  and professional supports
• The goals of consultation services are to
• provide direction to treatment
• promote effective working relationships
• heighten awareness of the characteristics and
  needs of the population
• advocate for an individual or group

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Psychosocial Rehabilitation Services

• Psychosocial rehabilitation services (PSR) are
  defined as a combination of goal-oriented
  rehabilitative services provided in a group
  setting as outlined in the persons treatment
  plan

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Psychosocial Rehabilitation Services

• Services focus on development of behaviors and
  abilities that allow the person to
• fully participate in community living
• maximize independence
• enhance interpersonal relationships
• develop support systems
• Participate in meaningful recreation and
  socialization activities that are appropriate to
  the age and interest of the person

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Psychosocial Rehabilitation Services

• Some agencies may include pre-vocational
  services as part of PSR. These services are
  designed to assist a person in preparing for
  employment, including
• interview and job application skills
• therapeutic work opportunities
• temporary employment opportunities
• referral to a community-based agency that
  specializes in the provision of vocational
  services

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CPR Program Philosophy

• The CPR program is based on the following ten
  specific principles and values
• Persons with mental illness should be active
  participants in program planning as well as
  individualized treatment planning, consistent
  with individual abilities. In the case of
  children, the child and parent(s) are an integral
  part of the treatment team and have ownership of
  the plan.

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CPR Program Philosophy

• 2. To the extent possible, community
  integration, inclusion, recovery and
  self-determination shall be goals for service
  delivery.
• 3. Outreach, engagement and ease of service
  access are essential characteristics of
  successful programs serving adults with serious
  mental illness and children with serious
  emotional disturbance.

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CPR Program Philosophy

• 4. Continuity and coordination of care are
  essential to the delivery of quality mental
  health services.
• 5. Services shall be available in varying levels
  of intensity based on the individuals need.
• 6. An interdisciplinary and interagency team
  approach to service delivery is a model which
  best assures the quality and continuity of care.

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CPR Program Philosophy

• 7. Services and programs shall be responsive to
  the needs of those it serves and sensitive to the
  individuals community, ethnic and cultural
  context.
• 8. Natural supports existing within the
  community shall be utilized whenever possible.

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CPR Program Philosophy

• 9. The focus of the CPR program is on the
  strengths of the individual.
• 10. Services are community-based.

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Service Linkages

• Consistent with the principles of coordination
  and continuity of care, the CPR program must
  establish linkages with service/government
  agencies and natural supports that interact with
  individuals served by the program

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Service Linkages

• Key service functions in brokering a range of
  services to individuals include
• developing working relationships with other
  service providers
• possessing knowledge of access to and operation
  of other service providers
• identifying interventions to support or enhance
  the quality of services received through other
  service providers

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Service Linkages

• These types of activities must take place to
  assure that individuals are referred to other
  service providers as necessary to meet their
  needs and to maximize the benefit of those
  services

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Standards for mental health programs further
state that the CPR provider shall

• provide services and liaison activities to state
  and local public assistance/housing agencies and
  employment/training agencies in order to provide
  assistance to persons with serious mental illness
  in seeking public benefits
• work closely with the staff of state and local
  public assistance/housing and employment/
  training agencies, within the limits of
  confidentiality, to expedite the application
  process and continuation of the clients
  eligibility

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Service Linkages

• Additionally, standards (also known as the code
  of state regulation) indicate that a key service
  function of the community support service is to
  assist the client in accessing and utilizing a
  variety of community agencies and resources to
  provide ongoing social, educational, vocational
  and recreational supports and activities

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Service Linkages

• As a result, consultation with these agencies can
  significantly influence the quality and quantity
  of services provided to individuals
• Consultation and education by CPR program staff
  with criminal justice, juvenile courts, public
  assistance, housing and employment agencies,
  schools and DFS is critical

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Department Oversight

• Community Mental Health programs that provide CPR
  services must be certified by the Department of
  Mental Health
• Each agency is reviewed on an annual basis to
  determine compliance with the code of state
  regulation as defined by the CPS division

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Department Oversight

• Certification activities may consist of a team
  going to an agency for four or five days to
  review governing authority, environmental safety,
  policy and procedure guidelines, quality
  assurance systems, fiscal management, personnel
  qualifications/background/training, as well as,
  clinical review of client records for service
  provision and documentation

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DMH Visions and Values

• In addition to being in compliance with the code
  of state regulation, agencies are expected to
  fall in line with the Department of Mental
  Healths vision and values
• These values should be recognized and reflected
  in the operation of the CPR program

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Eligibility

• To be eligible for CPR program services,
  individuals must be determined to be seriously
  and persistently mentally ill, or, for children,
  have a serious emotional disturbance, as measured
  against diagnostic, disability and duration
  criteria.

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Disability

• There is clear evidence of serious and/or
  substantial impairment in the ability to function
  at an age or developmentally appropriate level in
  each of the following two areas of behavioral
  functioning

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Disability

• 1. Social role functioning/family life the
  ability to sustain functionally the role of
  worker, student, homemaker, family member or a
  combination of these.
• For children, consider their play and
  leisure activities, ability to establish or
  maintain satisfactory relationships with peers
  and adults, capacity to live in a family or the
  equivalent of a family, learning ability, self
  expression or ability to communicate effectively
  with others, and their ability to function in
  school.

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Disability

• 2. Daily living skills/self-care skills the
  ability to engage in personal care (grooming,
  personal hygiene, etc.) and community living
  (handling individual finances, using community
  resources, performing household chores,
  interacting with peers, etc.), learning
  ability/self-direction and activities appropriate
  to the individuals age and social role
  development.

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Diagnosis

• A physician, advanced practice nurse, or
  licensed psychologist shall certify a primary
  diagnosis of any of the following, which may
  coexist with other psychiatric or medical
  diagnoses

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Diagnosis

• Schizophrenia (7 types)
• Delusional disorder
• Bipolar I disorders (4 types)
• Bipolar II disorders
• Psychotic disorders NOS
• Major Depressive disorder recurrent
• Obsessive-Compulsive Disorder
• Post Traumatic Stress Disorder
• Borderline personality disorder
• Anxiety disorders (5 types)

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Diagnosis(for children and youth only)

• Major depressive disorder, single episode
• Bipolar disorder, not otherwise specified
• Reactive attachment disorder of infancy or early
  childhood

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Duration

• is evidenced by one or more of the following
  occurrences
• Psychiatric treatment more intensive than
  outpatient and received more than once in a
  lifetime (crisis services, alternative home care,
  partial hospital, inpatient)

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Duration

• Continuous residential care other than
  hospitalization, for a period long enough to
  disrupt the normal living situation
• Psychiatric disability has been present for one
  year or more and/or
• Treatment of a psychiatric disorder has been or
  will be required for longer than six months

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Funding Stream

• CPR program services have multiple funding
  sources, including Medicaid for Medicaid eligible
  individuals, Division of Comprehensive
  Psychiatric Services general revenue Purchase of
  Service (POS) funds for those providers who have
  a POS contract, and individual fee for services

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Funding Stream

• Because CPR is a Medicaid supported program, the
  federal government pays approximately 60 percent
  of the costs for clients with Medicaid
  eligibility
• The departments of Mental Health and Social
  Services assume responsibility and accountability
  for administration and reimbursement of service
  delivery consistent with requirements

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Funding Stream

• The Department of Mental Health monitors each CPR
  provider through an annual billing audit, that
  coincides with the certification survey, to
  review for adequate service provision and
  compliance with Medicaid requirements

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Any questions?