community case management using a systems approach to serving individuals with complex needs
TRANSCRIPT
Community Case Management
Using a systems approach to serving individuals with complex needs
Identifying Complex Needs• Human Service Agencies• Social Services• 911/211 Systems• Mental Health/Substance Abuse Systems• Schools• Hospital Systems• Courts & Correctional Systems• Community Support Agencies• Law Enforcement• Family & Friends• Community at Large• Etc, etc, etc
System of Care
• A valued-based approach/philosophy for serving people with complex needs that is client driven, community-based, and culturally and linguistically competent.
Case Management
• Case management is a collaborative service that provides assessment, planning, facilitation and advocacy for options and services to meet an individual’s holistic needs through communication and available resources to promote quality cost-effective outcomes.
Historical Overview
Child, Adult
and/or Family
Mental Health
Social Services
Court Services
Corrections
Alcohol & Drug
Schools
Human Services
Historical Overview
Child, Adult
and/or Family
Mental Health
Social Services
Court Services
Corrections
Alcohol & Drug
Schools
Human Services
SOC Approach
Child, Adult
and/or Family
Mental Health
Social Services
Court Services
Corrections
Alcohol & Drug
Schools
Human Services
Informal Community
Supports
ASSIST
ANCECOM
MUNITY
RESOURCES
EMPOW
ERM
ENT
SYSTEMS of CARE
Community Case Management
Pennington County Health and Human Services
Changing Lives….. Changing Courses…..
A diversion program empowering people to make positive changes!
REBOUND
Social Security
Pennington
County Housing
John T. Vucurevic
h Foundati
onCommunit
y Food Bank of
the Black Hills
Department of Social Services
City County Alcohol
and Drug Programs
States Attorneys
Office
Public Defenders Office
7th Judicial Circuit Court
Court Services
US Probatio
n
Parole Services
Community Action Program
Rapid City ReEntry
ProgramSalvation
Army
Behavior Management Systems
South Dakota Dept of Labor
Career Learning Center
Western Resources
for the Disabled
Community Health
Center of the Black
Hills
Family Practice
Residency
Church Respons
e
Rapid City Transit
Community
Transitions
Cornerstone Rescue Mission
Goodwill Industrie
s
Sioux San
Hospital
Community Resources Committed to Rebound Members
• Intensive case management provides the tool in reducing the barriers clients often face when obtaining services.• Since 2006, Rebound caseworkers have made 2,948 physical contacts with 709 members in the program.
Pennington County Health and Human ServicesRebound
Community Referrals to Rebound Program12/01/2006 to 04/30/2012
Court Services58
CCADP/Detox119
Family2
Friend2
Mission2
Adams Street Facility121
Meth Program11 Parole
36
Probation11
PC Jail235
Penn. Co. Housing1
Sioux San1
Public Defender18
Community Al-ternatives of BH
4
RCPD Street Crimes Unit
2RC Regional West
3Crisis Care Center
7Dept. of Labor
1
Behavior Management
6
Dept. of Social Services
1
Veterans Service Office
1
Self 56
US Probation11
• Barriers that once complicated members success have been resolved.• Multiple agencies have come together to assist in the success of these individuals.
Pennington County Health and Human ServicesRebound
Rebound Referrals to the Community01/01/2011 to 04/30/2012
Behavior Management Systems89
John T. Vucurevich 86
Community Action Program130
CCADP (Detox)14
Dept. of Social Services45Salvation Army & Goodwill
75
Dept. of Labor39
Food Bank69
Pennington Co. Heath and Human Services
116
Career Learning Center, Community Health Center,
Residency Clinic, Church Response, Community
Transistions, Cornerstone Mission & Lions Club, HUD,
Shelter Plus, RC Schools, DMV, Hope Center, New
Start64
Pennington Co. Housing37 Social Security
24Sioux San
19
John T. Vucurevich Foundation 2011Grant Report
Pennington County Health & Human Services
October 12, 2011
Pennington County Health and Human ServicesJohn T. Vucurevich Foundation Grant
Referrals From Community Agencies01/01/2011 to 12/31/2011
TOTAL: 310 Referrals
Self; 70
Unknown; 1
Community Health
Center, 2
211; 25
BMS; 4
CAP; 3
CCADP Detox; 4
CCADP Treatment; 1
CCC; 20Church; 2
CSRM; 4Doctor; 3
DSS; 5Friend; 12
Family; 24Goodwill; 1
HHS; 6
Landlord; 3
Parole; 3
PCH; 4Political Office;
1
Probation; 1
Rebound; 50
Salvation Army; 22
Church Response;
4
School System; 4
US Probation; 3
VA-Vash; 12VOA; 2
WAVI; 4 Dept of Labor; 4Hope Center; 2LSS; 1
Utility Co; 1VA; 2
Pennington County Health and Human ServicesJohn T. Vucurevich Foundation Grant
Financial Assistance Provided on Behalf of Community Referrals Received01/01/2011 to 12/31/2011 $35,000.00 Total Expended
211; $2,570.45BMS; $407.94
CAP; $626.50CCADP-Detox;
$445.00
CCADP-Treatment; $20.00
CCC; $1,619.03Rebound; $5,093.07
CHCBH; $60.64
CSRM; $805.37Doctor; $130.54
DSS; $462.77
VOA; $289.99
Family; $3,532.61Salvation Army; $2,259.12Political Office; $1,653.45
Unknown; $20.00
Self, $6,967.23
HHS; $462.59
School System, $860.00
Landlord; $464.00
Probation; $157.36
US Probation; $35.64
VA-Vash; $1,331.44
Friend; $1,766.88WAVI; $525.83
Goodwill; $240.00Church Response; $356.76
Dept of Labor; $305.31Hope Center,
$270.00
Parole; $117.93
PCH; $990.00Utility Co; $100.00
VA; $25.00
Pennington County Health and Human ServicesJohn T. Vucurevich Foundation Grant
Financial Assistance by the Type of Service Provided01/01/2011 to12/31/2011 $35,000.00 Total Expended
Bean Bag,$923.78 Bike Repairs; $59.94Birth Certificate; $526.11Client Storage; $64.00
Clothing; $250.87Dr Copay; $45.00
ID/Liscense; $480.00Education Exps;
$107.99
Home Deposit; $15,809.00
Groceries; $10.00Laundry; $8.00
Medical Supplies; $26.49Medication Copay; $1,362.21Mortgage; $360.70
Phone Minutes; $194.89
Additional Educa-tion; $190.00
Household Ap-pliance; $56.48
Utility Deposit; $1,219.17
Utility Fees; $506.65
Utility Past Due; $3,566.52
Phones , $79.95
Rent, $2,435.36
Rent Application, $105.00
Household Misc, $1,226.34
Bus Daily; $30.00
Bus Monthly; $400.00
Bus Ticket; $846.93
Car Maintenance; $657.54
Work Clothes; $357.58
Home Taxes; $1,653.45
Work Tools; $420.03Car Repair; $141.77
Marriage Certif; $15.00
Meds, $78.25
Program Fees, $25.00
Student Buss, $460.00
CCC Room, $300.00
Cost Share with Client; 31
Cost Share with Client
and Agency; 3
Cost Share with
Agency; 17
No Cost Share; 197
Pennington County Health and Human ServicesJohn T. Vucurevich Foundation Grant
Cost Share with Client and Agency01/01/2011 to 10/17/2011
Total: 248
• From January 1, 2011 through April 30, 2012, a total of 219 new individuals were referred to HHS/transitional case management (TCM) for services.
• HHS/TCM now tracks ongoing previous referrals receiving case management services from HHS/TCM. In April 2012 HHS/TCM worked with 9 ongoing CCC clients.
Crisis Care CenterTransitional Case Management
Client Referrals01/01/2011 to 04/30/2012
Apr May Jun Jul Aug Sep Oct Nov Dec Jan-12 Feb-12 Mar-12 12-Apr0
5
10
15
20
25
30
87
1617
16
1213
11 11
21
18
28
25
67
12 12
16 16
19
17
11
20
17
22
13
11
7
12
89
Total CCC ReferralsHHS/TCM New ClientsHHS/TCM Ongoing Previous Referrals
As of April 30, 2012 transitional case management staff have coordinated services with 24 community agencies. A total of 165 referrals have been made to these agencies.
Crisis Care Center Transitional Case Management
Referrals to Community Agencies01/01/2011 to 04/30/2012
Total: 165
Behavior Management32
BH Workshop2
Catholic Social Services
2
Lutheran Social Services
4
CCADP/Detox7
Community Health13
Church Response1
Dept. of Labor4
Dept. of Social Services
19
Job Corps1
Food Bank16
Goodwill2
Lions Club1 Southern Hills Alcohol/Drug (SHAD)
1
Mission20
Salvation Army11 Penn. Co. Housing
1
Social Security4
Sioux San7
Volunteers of Amer-ica3
Western Resources for Disabled
1
WAVI2
Hope Center2
Rebound9
As of April 30, 2012 Health & Human Services Transitional Case Management staff, as well as varied community agencies, have coordinated and provided a total of 230 services for Crisis Care Clients.
Crisis Care CenterTransitional Case Management
Coordinated/Provided Services 01/01/2011 to 04/30/2012 Total: 230
Medical3
Medicaid/Medicare4
Medica-tions/Med
Mgt.30
Counseling31
Case Mgmt11 Education
1
Drivers License/
ID3Em-
ploy-ment
4Phone Service
3
Rent1
Food (voucher, pantry, SNAP)36
Emergency Housing
24
Glasses1
Household 3
Housing32
Social Se-curity
4
Transportation30
Clothing9
• Physical client contacts refer to actual face-to-face contact with a CCC client.
• Agency transport refers to transports given to a CCC client by Transitional Case Management with a company vehicle for the purposes of getting to appointments, obtaining food, shelter, clothing, etc.
• Phone calls made by Transitional Case Management to both the CCC client and community agencies on the clients behalf.
Caseworker Activity01/01/11 – 01/31/12
Crisis Care CenterTransitional Case Management
Caseworker Activity01/01/2011 to 4/30/2012 Total: 1,049
Physical Client Contacts
445
Phone Calls423
Agency Transports
181
Pennington County Health and Human ServicesRebound, JTV Grant and Crisis Care Transitional Case Management
Total Referrals IN FROM Community Agencies01/2011 to 02/29/2012
Court Services, 58CCADP/Detox
123
Family23
Friend7
Mission5
Adams Street Facility121
Meth Program11
Parole37
Probation11
PC Jail230
Penn. Co. Housing2
Sioux San1 Public Defender
18Community Alterna-
tives of BH 4
RC Regional West3Crisis Care Center
20Behavior Management
9
Dept. of Social Services2
Self 54
US Probation14
School System3
Salvation Army19
Rebound45
VA-Vash12
VOA2
21124
CSRM3
Church Response2
Community Health2
HHS6
Landlord, Political Office, Goodwill, Church, CAP, Doctor, Unknown
8
Total: 879
Behavior Management Systems
114
John T. Vucurevich 83
Community Action Program
128
CCADP (Detox)26
Dept. of Social Services77
Volunteers of America5
Lutheran Social Services4Catholic Social Services
2
Pennington Co. Heath and Human Services124
211, Career Learning Cen-ter, Community Health Cen-
ter, Residency Clinic, Church Response, Commu-nity Transistions, Corner-
stone Mission & Lions Club, HUD, Shelter Plus, RC
Schools, DMV, Hope Center, New Start, Job Corps,
SHAD, WAVI207
Pennington Co. Housing36
Social Security 26
Sioux San25
Rebound50BH Workshop
2
Salvation Army & Goodwill103
Dept. of Labor40
Food Bank81
Pennington County Health and Human ServicesRebound, JTV Grant and Crisis Care Transitional Case Management
Total PCHHS Referrals OUT TO Community Agencies01/01/2011 to 02/29/2012
Total: 1,137
• Agencies Working Together • Motivational Interviewing • Effective Case Managers
Creates• Changed Lives
• Empowered Clients• Moving to the
Steps for Getting There
• An agreed upon definition and role of community case management.
• A forum for training new case managers and linking new and seasoned case managers together.
• Develop processes that result in integrated community case service plans.
• Develop web-based software to monitor services to individuals with complex needs.