COMMUNITY SUPPORT SERVICES

It is the mission of Community Support Services to provide supports and services to persons with serious mental illness in a manner that promotes recovery, personal choice and responsibility, as well as community inclusion.

The Community Support Services unit provides case management and a variety of clinical support services to adults with serious mental illness. Referrals to the program come from the SCCMHA Access Center. They may be initiated by consumers, family members, crisis interventions, or the hospital liaison. Once a referral is received, an assessment is completed to determine program eligibility and when appropriate, establish initial recommendations for treatment and an interim treatment plan.

If the person is determined to meet eligibility, he or she is assigned to a case manager and the person-centered planning process is initiated. A plan of service is developed through the person-centered planning (PCP) process.

Through the PCP process the case manager assists the consumer to design and implement strategies for obtaining services and supports that are goal-oriented and individualized with a focus on recovery. Services include assessment, planning, linking, advocacy, coordination and monitoring to assist the consumer in gaining access to needed services (health, financial assistance, housing, employment, education, social).

A plan of service is developed that links the consumer to other services provided through Community Support Services unit or needed services in the community. When available and appropriate, natural supports are utilized to help the consumer meet the desired outcomes.

Services are monitored and the plan is updated at intervals established through the person-centered planning process or when the need arises.

All services provided in the Community Support Services unit receive psychiatric supervision through the Medical Director.

• Case Management Services
• Psychiatric Services
• Health Services
• Individual/Group Therapy
• Other
• Crisis Services

Case Management Services

The core service provided through the Community Support Services unit is case management services. To meet criteria for services through the unit, a consumer must have a documented need for case management. This need is determined through the assessment process.

Case management is a service that assists consumers through the person-centered planning process to design and implement strategies for obtaining services and supports that are goal-oriented and individualized.

The core components of case management are assessment, planning, linking, advocacy, coordination and monitoring. Once a consumer has been assessed to need case management and a case manager has been chosen, the person-centered planning process begins. Through the person-centered planning process, the consumer needs and desires are established and the plan for meeting these is developed. Linking needs are established through the plan and the person responsible for each component of the plan is established. It is then the role of the case manager to coordinate the identified services and link the consumer to needed services. The case manger is then responsible to monitor progress toward the goals at intervals defined through the person-centered planning process or as the need arises. This monitoring includes the review of the consumer’s satisfaction with the services provided.

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Psychiatric Services

Because the Community Support Services unit services adults with serious mental illness, the majority of persons served also receive psychiatric services. These services include psychiatric evaluation and medication review.

Psychiatric evaluation: A comprehensive evaluation, performed face-to-face by a psychiatrist, that investigates a consumer’s clinical status, including the presenting problem; the history of the present illness; previous psychiatric, physical, and medication history; relevant personal and family history; personal strengths and assets; and a mental status examination. This examination concludes with a written summary.

Medication review: The process of evaluating and monitoring medications, their effects, and the need for continuing or changing the medication regimen. In the Community Support Services unit this service is typically provided by a psychiatrist but on occasion may also be provided by an RN.

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Health Services

In the Community Support Services unit, Health Services are typically provided by an RN and include an initial review of the consumer’s health-related needs. Additional services provided by the RNs include:

1. Injection Clinic – The Community Support Services nurses give injections of Haldol and Prolixin as are prescribed by agency physicians.
2. Clozaril Clinic – The Community Support Services nurses run a Clozaril clinic for clients who have been prescribed Clozaril. These clients are seen on a weekly basis for monitoring of their response to Clozaril.
3. Lab Tests – Along with the physicians, the Community Support Services nurses monitor the results of lab tests ordered for Community Support Services clients.
4. Monitoring – When clients are seen for medication reviews, a Community Support Services nurse checks their vitals, does AIMS test when required, and educates the clients, family members and AFC providers about expected results and possible side effects of the prescribed medications.

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Individual/Group Therapy

On occasion, it is assessed that a Community Support Services consumer might also benefit from individual or group therapy. This is a treatment activity designed to reduce maladaptive behaviors, maximize behavioral self-control or restore normalized psychological functioning, reality orientation, remotivation and emotional adjustment, thus enabling improved functioning and more appropriate interpersonal and social relationships. Individual/group therapy is performed by a mental health professional.

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Other

A variety of other services is available to consumers of the Community Support Services unit through referral to the SCCMHA Enhanced Health Services unit. These services include occupational therapy assessment, physical therapy assessment, physical therapy assessment, speech therapy assessment, dietary and behavioral services.

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Crisis Services

Crisis services are provided on an ongoing basis through the continued monitoring and outreach to consumers of the Community Support Services unit. However, after outreach efforts and other efforts to stabilize the consumer (e.g.: medication review, increased contacts) have proven ineffective the consumer is referred to the SCCMHA Crisis unit, which is available 24 hours a day, 7 days a week.

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