Support Services

This service provides structured activities within a peer support center that promote socialization, recovery, wellness, self-advocacy, development of natural supports, and maintenance of community living skills. Activities are provided between and among individuals who have common issues and needs, are consumer motivated, initiated and/or managed, and assist individuals in living as independently as possible. 

Activities must promote self-directed recovery by exploring individual purpose beyond the identified mental illness, by exploring possibilities of recovery, by tapping into individual strengths related to illness self-management (including developing skills and resources and using tools related to communicating recovery strengths, communicating health needs/concerns, self-monitoring progress), by emphasizing hope and wellness, by helping individuals develop and work toward achievement of specific personal recovery goals (which may include attaining meaningful employment if desired by the individual), and by assisting individuals with relapse prevention planning. A Consumer Peer Support Center may be a stand-alone center or housed as a “program” within a larger agency and must maintain adequate staffing support to enable a safe, structured recovery environment in which individuals can meet and provide mutual support.   

This service provides interventions which promote socialization, recovery, wellness, self-advocacy, development of natural supports, and maintenance of community living skills. Activities are provided between and among individuals who have common issues and needs, are individual motivated, initiated and/or managed, and assist individuals in living as independently as possible. 

Activities must promote self-directed recovery by exploring individual purpose beyond the identified mental illness, by exploring possibilities of recovery, by tapping into individual strengths related to illness self-management (including developing skills and resources and using tools related to communicating recovery strengths, communicating health needs/concerns, self-monitoring progress), by emphasizing hope and wellness, by helping individuals develop and work toward achievement of specific personal recovery goals (which may include attaining meaningful employment if desired by the individual), and by assisting individuals with relapse prevention planning. Peer Supports must be provided by a Certified Peer Specialist. 

Case Management services consist of providing environmental support and care coordination considered essential to assist the individual with improving his/her functioning, gaining access to necessary services, and creating an environment that promotes recovery as identified in his/her Individual Recovery Plan (IRP). The focus of interventions includes assisting the individual with:

• Developing natural supports to promote community integration
• Identifying service needs
• Referring and linking to services and resources identified through the service planning process
• Coordinating services identified on the IRP to maximize service integration and minimize service gaps
• Ensuring continued adequacy of the IRP to meet his/her ongoing and changing needs.

The performance outcome expectations for individuals receiving this service include decreased hospitalizations, decreased incarcerations, decreased episodes of homelessness, increased housing stability, increased participation in employment or job-related activities, increased community engagement, and recovery maintenance. Case Management Services will consist of four (4) major components that cover multiple domains that impact one’s overall wellness including medical, behavioral, wellness, social, educational, vocational, co-occurring, housing, financial, and other service needs of the individual: Engagement & Needs Identification The case manager engages the individual in a recovery-based partnership that promotes personal responsibility and provides support, hope, and encouragement.

The case manager assists the individual with developing a community-based support network to facilitate community integration and maintain housing stability. Through engagement, the case manager partners with the individual to identify and prioritize housing, service and resource needs to be included in the IRP. Care Coordination The case manager coordinates care activities and assists the individual as he/she moves between and among services and supports. Care coordination requires information sharing among the individual, his/her Tier 1 or Tier 2 provider, specialty provider(s), residential provider, primary care physician, and other identified supports in order to:

• Ensure that the individual receives a full range of integrated services necessary to support a life in recovery that includes health, home, purpose, and community
• Ensure that the individual has an adequate and current crisis plan
• Reduce barriers to accessing services and resources
• Minimize disruption, fragmentation, and gaps in service
• Ensure all parties work collaboratively for the common benefit of the individual.

Referral & Linkage The case manager assists the individual with referral and linkage to services and resources identified on the IRP including housing, social supports, family/natural supports, entitlements (SSI/SSDI, Food Stamps, VA), income, transportation, etc. Referral and linkage activities may include assisting the individual to:

• Locate available resources
• Make and keep appointments
• Complete the application process
• Make transportation arrangements when needed

Monitoring and Follow-Up The case manager visits the individual in the community to jointly review progress made toward achievement of IRP goals and to seek input regarding his/her level of satisfaction with treatment and any recommendations for change.

The case manager monitors and follows-up with the individual in order to:

• Determine if services are provided in accordance with the IRP
• Determine if services are adequately and effectively addressing the individual’s needs
• Determine the need for additional or alternative services related to the individual’s changing needs or circumstances
• Notify the treatment team when monitoring indicates the need for IRP reassessment and update.