Mental Health Community Support Services – General

Mental Health Community Support Services – General A. Community Support Services provide an array of support services delivered by community-based, mobile Community Support Specialists. Community Support Services are only provided by certified DMH/C and DMH/P providers. Community Support Services are directed towards adults, children, adolescents, and families and will vary with respect to hours, type, and intensity of services, depending on the changing needs of each person. The purpose/intent of a Community Support Specialist is to provide specific, measurable, and individualized services to each person served. Community Support Services should be focused on the person’s ability to succeed in the community; to identify and access needed services; and, to show improvement in school, work, family, and community participation (Excludes IDD). B. Community Support Services should be person-centered and focus on the person’s recovery and ability to succeed in the community; to identify and access needed services; and, to show improvement in home, health, purpose, and community. Community Support Services shall include the following: 1. Identification of strengths which will aid the person in their recovery and the barriers that will challenge the development of skills necessary for independent functioning in the community. 2. Individual therapeutic interventions that directly increase the acquisition of skills needed to accomplish the goals set forth in the Individual Service Plan. 3. Monitoring and evaluating the effectiveness of interventions, as evidenced by symptom reduction and progress toward goals. 4. Psychoeducation on the identification and self-management of prescribed medication regimen and communication with the prescribing provider. 5. Direct interventions in de-escalating situations to prevent crisis. 6. Assisting a person in accessing needed services such as medical, social, educational, transportation, housing, substance use, personal care, employment, and other services that may be identified in the Recovery Support Plan as components of Health, Home, Purpose, and Community. 7. Assisting the person and natural supports in implementation of therapeutic interventions outlined in the Individual Service Plan. 8. Relapse prevention and disease management strategies. 9. Psychoeducation and training of family, caregivers, and/or others who have a role in addressing the needs of the person. 10. Facilitation of the Individual Service Plan and/or Recovery Support Plan which includes the active involvement of the beneficiary and the people identified as important in the person’s life. C. Providers of Community Support Services must, at a minimum: 1. Have a designated Director of Community Support Services to supervise the provision of Community Support Services; position requirements outlined in Chapter 11. 2. Assign a full-time, DMH Credentialed Community Support Specialist for each person enrolled in the service; position requirements outlined in Chapter 11. 3. Maintain a list of each Community Support Specialist’s caseload that must be available for review by DMH personnel. 4. Maintain a current, comprehensive file of available formal and informal supports that is readily accessible to all Community Support Specialists. 5. Electronically maintained resource information is encouraged. This resource file must include at a minimum: (a) Name of entity. (b) Eligibility requirements (if applicable). (c) Contact person. (d) Services and supports available. (e) Phone number. D. The following priority groups must be offered Community Support Services within 14 days of the date of their initial assessment. Community Support Services must be provided within 14 days of the initial assessment unless the person states, in writing, that they do not want to receive the service. 1. People discharged from an inpatient psychiatric facility. 2. People discharged from an institution. 3. People discharged or transferred from Crisis Residential Services. 4. People referred from Crisis Response Services. E. People with serious mental illness or serious emotional disturbance not included in these priority groups should be assessed to determine the need for Community Support Services within 30 calendar days of their initial assessment. Community Support Services must be provided within 30 calendar days of the initial assessment if the assessment indicates a need for such, unless the person declines the service, and such is documented. F. Caseloads of Community Support Specialists must not exceed 80 people receiving services. G. Frequency of the provision of Community Support Services should be based on the needs of the person receiving the service. H. The Recovery Support Plan must clearly state and justify the frequency of contact.