Care Coordination

What is Care Coordination?

Care coordination is indispensable to the effective operation of a System of Care/Community Collaborative. It is both a service to children and families and a function of a responsive system. As a service, care coordination is carried out in children’s mental health in Connecticut on three levels, which are explained below. As a service, care coordination involves direct client contact by someone who has clinical knowledge but does not function as the clinician on the case. Rather, the Care Coordinator, as an architect of the service plan along with the family, uses clinical and community systems knowledge to broker and advocate for services, and coordinates and monitors the implementation of the plan.

• Community Collaboratives (List of, by Region)
• Community Collaboratives (List of)
• Connecticut Care Coordination Referral Form
• Crisis Stabilization

Target Population

Care coordination services are provided to children and youth who are "Seriously Emotionally Disturbed" (SED) and have complex behavioral health needs and require an intensive coordination of multiple services to meet those needs. Consistent with DCF’s practice standards for Systems of Care/Community Collaboratives, care coordination services shall also be available to other children and youth with complex service needs with priority to those children and youth who are at imminent risk for residential or hospital levels of care or who are returning from these levels of care.

The term "Seriously Emotionally Disturbed" children or adolescents, refers to those children defined in the Connecticut Children's Mental Health Plan and federal agencies NIMH/CASSP as published in the Federal Register on May 20, 1993. It is a broader definition than that used by the adult population to define "mental illness.” SED refers to children or adolescents with a mental, behavioral, or emotional disorder, which has resulted in functional impairment that substantially interferes with or limits the child's role or functioning in family, school, or community activities.

Specifically, Serious Emotional Disturbance is a mental, emotional or behavioral disorder for children who are:

• from age birth to eighteen years (note: children age 16-18 qualify with the understanding that the youth must be willing to participate in the Child Specific Team). Although, services can be received up to age 21 if client is still receiving services from their local educational authority;
• currently or at any time in the past year, had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet the diagnostic criteria specified within DSM-IV; and
• resulted in functional impairment which substantially interfered with or limited the child's role or functioning in family, school, or community activities.

Crisis Stabilization

Mobile Crisis Intervention Services

Overview: Crisis stabilization is a 24 hour, short term residential program that offers the child and family a “cooling off” period from a particular crisis. This short term intervention is designed to enable crisis stabilization staff an opportunity to make good, appropriate assessments and interventions that may prevent a longer out of home disruption.

There are two crisis stabilization programs in Connecticut. One located in Farmington on the UCONN Medical Center Campus a program of Wheeler Clinic and one in Hamden a program of the Children’s Center.

Target Population:  The target population for crisis stabilization includes children and/or youth age 7 – 18 who present with a Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Axis I diagnosis, or who exhibit complex behavioral health service needs and are at imminent risk of requiring longer term, out of home levels of care.

Admission Criteria:   Crisis stabilization will accept all referrals made by Emergency Mobile Psychiatric Service (EMPS) providers that meet the following criteria:

• Age 7-18 and agree to a voluntary admission
• Psychiatric status is not acute and the child and/or youth is able to enter into a written safety contract
• Separation from the family is required in order to stabilize the immediate crisis within a 15 day perod
• A viable discharge resource is in place

Services:  Crisis stabilization will accept referrals seven days a week, 52 weeks per year.

The length of service for crisis stabilization service is intended to be a maximum of 15 nights unless authorization is received for an extension from the DCF Area Office Mental Health Program Director or designee.

The crisis stabilization or EMPS provider will complete an assessment on each child and/or youth within 24 hours of admission. The assessment will provide a clinical integration of medical, psychosocial, educational and previous treatment history information and will address the needs of the child and/or youth within the context of his/her family and community.

Clinical services include screening and referral, individual, group and family treatment, consultation, linkage to family substance abuse screening or other services, family sessions and age appropriate therapy. Clinical staff members coordinate their clinical interventions with community providers delivering services to the child and/or family. In addition, contractors have access to a psychiatrist in order to provide consultation, assessment and evaluation services.

Empowerment and family support services include parental guidance, empowerment and support, inclusion in transition/discharge planning and linkage to other community services, such as parent education and instructional modeling. Clinical programming for families should accommodate family work schedules.

Medication management includes consultation and assessment from a psychiatrist or an APRN under the direction of a psychiatrist

Other services include transition to psychiatric, medical care or other appropriate services as necessary upon discharge; case management, including the development of a child specific treatment plan and coordination with local community service providers; and aftercare.

Respite Care

• Core Values
• Guiding Principles
• Overview
• Target Population

Overview

Respite care services have two main goals as part of a treatment/service plan: to provide home care, thus avoiding “burnout,” reducing stress and preventing family disruption (or out–of–home placement) of the child/adolescent with serious emotional disturbances and to provide socialization opportunities and age appropriate activities for children as specified in the child/youth’s treatment/service plan.

Target Population

The target population is children under age 18 whose emotional and/or behavioral special needs require constant attention from their caregivers. These behaviors, e.g. impulsiveness, poor self-control, constant activity, tantrums, aggressiveness, put these children at risk of being removed from their biological, adoptive, or foster homes. Provision of respite care is intended for children involved with DCF and non-DCF children involved in the local System of Care.

Core Values

• Respite care services should be child-centered, with the needs and strengths of the child and family dictating the types and mix of services provided.
• Respite care services are community-based, with the locus of services as well as management and decision-making responsibility resting at the community level, and always are implemented in partnership with the family.

Guiding Principles

• Children with an emotional disturbance should have access to a comprehensive array of services that address the child’s physical, emotional, developmental, social and educational needs.
• Children with an emotional disturbance should receive individualized services in accordance with the unique needs and potential of each child, and guided by an individualized service plan.
• Children with an emotional disturbance should receive services within the least restrictive, most normative environment that is clinically appropriate.
• The families and surrogate families of children with an emotional disturbance should be full participants in all aspects of the planning and delivery of services.
• Children with an emotional disturbance should receive services that are integrated, with linkages between child-caring agencies and programs and mechanisms for planning, developing and coordinating services.
• Children with an emotional disturbance should be provided with service coordination/case management or similar mechanisms to ensure that multiple services are delivered in a coordinated and therapeutic manner, and that they can move through the system of care in accordance with their changing needs.
• Children with an emotional disturbance should be ensured smooth transitions to the adult service system as they reach maturity.
• The rights of children with an emotional disturbance should be protected and effective advocacy efforts for emotionally disturbed children and youth should be promoted.
• Children with an emotional disturbance should receive services without regard to race, religion, national origin, sex, physical disability or other characteristics.
• Services should be sensitive and responsive to cultural differences and special needs.