Developing and Implementing a Systems Navigator Approach for Dual Services

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BEST OF BOTH
Developing and Implementing a Systems Navigator
Approach for Dual Services
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Developed by the Clearfield/Jefferson MH/MR
Program, a rural Pennsylvania joinder located
approximately 100 miles northeast of
Pittsburgh. Population (2005 estimate)128,542
Mission Statement The Clearfield-Jefferson MH/MR
Program assures access to a comprehensive array
of quality services that are reflective of the
needs of the residents of the two county area.
The services are effectively managed and
responsive to a changing community.
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Mission of Dual Services

• To insure the coordination of treatment and
  support for children and adults with a diagnosis
  of serious mental illness and intellectual
  disability (including borderline intellectual
  functioning) in Clearfield and Jefferson Counties.

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BACKGROUND

• No special needs group strains the service
  capacity of community mental health/mental
  retardation services to a greater extent than
  people with dual diagnoses of developmental
  disabilities and psychiatric conditions
• (National Association for the Dually Diagnosed,
  2006).

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Estimating the Dual Services population in the
Clearfield/Jefferson MH/MR joinder

• 3 of the general population has some level of
  mental retardation defined as an I.Q. of 70 or
  below
• 20-35 of all persons with mental retardation
  have a mental illness (National Association of
  Developmental Disabilities, 2002).
• 8-10 Estimated number of persons with mental
  retardation who have a serious mental illness.
• In the Clearfield/Jefferson MH/MR joinder, it is
  estimated that approximately 350 persons are
  dually-diagnosed (of which about 125 are
  receiving case management services).

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THE BEST OF BOTH
MENTAL HEALTH INTELLECTUAL DISABILITIES
TWO SUPERPOWERS JOIN FORCES
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The Commitment . . .
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To Make Dual Services Work

• Administrator
• Senior MH/MR Staff
• MH/MR Staff (resources and time)
• Funding (CHIPP/Waiver)

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In-HouseEstablishing Dual Services

• Committee
• Administrator
• MH/MR Director
• Cross Section of Staff (Supports Coordinators,
  Case Managers serving children and adults,
  Housing, Crisis)

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Dual Assessment Form
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Dual AssessmentInstructions and Grading

• INSTRUCTIONS
• Fill out the identifying information located on
  the top of the assessment form.
• Underline all descriptions that apply to the
  individual, no matter what row or level the
  description is located.
• Use the comment section to record additional
  essential information.
• Place an X in the numbered box within each
  level that best describes the individuals
  current level. Each level has two boxes to
  choose from to allow the assessor to indicate if
  the person is functioning in a higher or lower
  within the overall level.

• GRADING
• Use the following guidance to determine the
  overall level of functioning for the individual
• A Crisis rating in one area results in an overall
  rating of Crisis
• A Vulnerable rating in one area results in an
  overall rating of Vulnerable
• Safe/Stable in two or three areas and Thriving in
  two or one area results in an overall rating of
  Safe/Stable.
• Thriving in three or four areas results in an
  overall rating of Thriving

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Dual Services Philosophy is based on
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EVOLUTION from a Case Manager to a Systems
Navigator
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DUAL SERVICES
NO DUMPING ALLOWED
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SYSTEMS NAVIGATOR
a few basic qualities

• Someone who is experienced with either the MH or
  ID systems (preferably experience with the best
  of both)
• Serves as a mentor to other Navigators and to
  other staff
• Has the proven ability to bring people together
  to collaborate on identifying what needs to be
  done to help an individual and to have the
  knowledge of the resources (and the power) to
  address the needs

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a few basic qualities page 2

• The ability to be creative with
  suggestions/guidance/options to solve problems
• Possesses, and has integrated within their
  approach to others, an understanding of Person
  First Language, Understanding the Person,
  Listening to Understand, Systems Coordination and
  a willingness to embrace other concepts that will
  help to guide others
• No caseload is assigned to the Navigator(s).

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a few basic qualities page 3

• Evaluates progress and outcomes of DS cases
  relative to quality management
• Identifies the need for new services and supports
  that need to be developed
• Must possess excellent problem-solving skills and
  the ability to be creative in resolving problems
• Authorizes additional services and supports that
  are not available to CMs in the existing array
• Must be a team player

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Dual Services Guiding Principles

• Everybody has a disability.
• Disability is natural.
• Follow the Golden Rule.
• Involve the person and their family. (nothing
  about me without me).
• Work with the person where they are in their
  life, not where you, or others, think they should
  be.
• We can all have challenging behaviors when our
  needs are not met.
• Get to know the person and help others who work
  with the person do the same.
• Respect a persons Dreams and support him/her to
  achieve them.
• Do not let your values system get in the way of
  helping a person.
• Dont assume-ASK!
• Listen to the person in order to understand the
  person.
• Assist the person to articulate his/her needs,
  desires to those that can help.
• Offer to help the person to develop their own
  plan for their wellness and life (Wellness
  Recovery Action Plan, Person-Centered Plan, etc.).

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Case Discussions
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Dual Diagnosis Guiding Questions

• Do you believe that you are understood, heard and
  respected?
• Do you believe that you have the control that you
  want over your life?
• Was the time that I spent with you useful?
• Did you have any fun today?
• Did we accomplish what you wanted today?
• How are you feeling today?
• Is there anything missing in the
  supports/services that you are receiving?
• Do you have difficulty in explaining how you
  feel, or what you want, with your case manager,
  psychiatrist, and primary care physician, others
  in your life?
• Do you have friends?
• Are your friends supportive of you and you of
  them?
• Do you believe that you have choices in your
  life?
• Are we helping you to achieve the life that you
  want?
• Is there anything else that we need to work on
  today?

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Not the end
It's the Beginning!
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Best of BothDual Services
Presenters Susan Hartzfeld, Mental Retardation
Program Manager Bob Fleming, Coordinator of Dual
Services and the Consortium Community/Hospital
Integration Project Program
Clearfield-Jefferson MH/MR Program Administrator,
Colette R. Dushac
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Thanks for Your Support!

• Estelle B. Richman, Secretary
• PA Department of Public Welfare
• Office of Developmental Programs (ODP)
• Cassandra Schalcosky
• Darla Perry
• Sharon Lipscomb
• Office of Mental Health Substance Abuse
  Programs (OMHSAS)
• Val Vicari
• John OConnor

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For more information, updates and to make a
comment please visit our websitewww.cljmhmr.com
Clearfield-Jefferson MH/MR Program Suite
U-110 1200 Wood Street Brockway, PA
15824 814-265-1060