Cenpatico Integrated Care

Guidance Document


High Needs Recovery Centers for Adults

Developed by

Cenpatico Integrated Care

Effective Date: November 2016

1

TITLE

High Needs Recovery Centers for Adults

Purpose of HNRC for Adults

Members who meet the High Needs and High Cost thresholds require focused care coordination, advanced engagement, connection with appropriate formal and informal services and natural and community supports, and flexible individualized plans for treatment. These members are often involved with system partners such as adult justice in addition to behavioral health and multiple specialty services, as well as having chronic health conditions that require focused care coordination to improve the quality of the member’s plan. These members are often difficult to engage due to their multiple areas of need and require advanced engagement skills to determine appropriate goals and individualize treatment in a way that promotes member involvement and buy-in. These members are often in the wrong services that do not meet the need of keeping them in a community based setting, and are often disconnected from their community and natural supports, requiring engagement in appropriate services and increasing the ratio of natural and informal supports in their community to formal and professional supports. These members have unique sets of risk factors requiring the time and ability to provide individualized attention and planning to meet their needs.

TARGET POPULATION

Adult members meeting multiple risk factors leading to a risk score considered as High Needs and meeting High Cost thresholds on the Cenpatico Integrated and Non-Integrated risk rosters.

PRACTICE GUIDANCE

In serving members determined by Cenpatico Integrated Care to be High Needs at a High Needs Recovery Center, these are the recommended programming features:

  1. An appropriate ratio for a Recovery Coach serving adult members designated as High Needs is 1:25 for adults.
  2. An adequate number of Direct Support Staff is employed to meet the needs adult members designated as High Needs. Direct Support Staff may include Peer or Family Supports in addition to other roles that are dedicated to serving adult members designated as High Needs.
  3. Support and Rehabilitation services will be available to members 24/7/365 when coordinated and planned in advance.
  4. A full array of Support and Rehabilitation services is available to members.
  5. Staff serving adult members designated as High Needs are actively involved in Adult Recovery Team/Treatment Team meetings and use High Fidelity Wraparound practice.
  6. Services that are tailored by the Adult Recovery Team to meet the needs of members are coordinated by High Needs Recovery Center staff.
  7. Members at risk of out of home placement are connected with direct supports that provide Support and Rehabilitation Services.
  8. At least 60% of Support and Rehabilitation Services are provided in the home or community.
  9. At least 60% of Support and Rehabilitation Services are provided in an individual setting rather than group setting.
  10. Natural supports and community supports are identified and engaged.
  11. Direct Support Staff are available to assist in preventing and/or responding to crisis-related needs, including the ability to respond outside of pre-scheduled hours.
  12. A Recovery Coach or Direct Support staff is available to provide Case Management to adult members designated as High Needs 24/7/365.
  13. Monitoring of the following items occurs on a monthly basis: array of support and rehabilitation services provided; percentage of adult members designated as High Needswho received a support and rehabilitation service in per month; the percentage of support and rehabilitation services provided in home/in community/in office; the percentage of support and rehabilitation services provided individually versus in a group setting; the units of service being provided by Direct Support Staff; the ratio of adult members designated as High Needsto Recovery Coaches.
  14. Policies exist within the agency regarding collaboration with system partners, Specialty Providers, hospitals, physical health providers and health plans and other systems and agencies.
  15. Update the Crisis Plans for adult members designated as High Needs at least every six months.
  16. Provide integrated coordination of behavioral health and physical health care for integrated members, including providing appropriate supervision and training to Recovery Coaches in coordination with physical health providers and establishing policies regarding coordination with PCPs and other physical health providers.

APPLICABLE TRAINING AND SUPERVISION

Provider staff working within Adult HNRCs should have separate clinical supervision that is available 24/7/365 to staff working with High Needs adult members.

Training of staff working with HN Adults:

Adult Recovery Team Facilitation

High Fidelity Wraparound Facilitation

Peer and Family Supports

Medical and Behavioral Health Integration Training

Supportive Housing Practices

Supportive Employment Practices

Direct Rehabilitation and Support Services

Discharge Planning and Transition

ANTICIPATED OUTCOMES

Outcomes for adult members designated as High Needs being served by High Needs Recovery Centers that are monitored by Cenpatico Integrated Care include:

  1. Reduced ED re-utilization for both behavioral health and physical health presentations
  2. Reduced contact with law enforcement and the justice system
  3. Reduced physical health inpatient stays
  4. Increase in physical wellness and medical care
  5. Reduced behavioral health inpatient stays
  6. Decreased Out of Home Length of Stay
  7. Decreased CMT, CRC, and other outside crisis interventions
  8. Increased employment
  9. Increased stable housing
  10. Increased stability following a crisis event
  11. Decreased re-admits to Out of Home care after discharge

1