Crisis Resource Guide

Greater Kansas City Co-Occurring Collaborative

Revised: June 2019


Navigation


Overview and Purpose

The guide is for professional usage by community support specialists (CSS), support coordinators (SC), and other agency staff who work with adults who have co-occurring mental illness and intellectual/developmental disorders (I/DD) in the Jackson County area. The guide was developed to be used as a companion for decision making when faced with various forms of crisis situations. Crises may involve individuals, families, providers who are attempting to assist in alleviating problematic situations, or systems in place to support individuals in various residential and outpatient settings.

Because the individuals have co-occurring concerns, both the Department of Mental Health (DMH) Division of Development Disabilities (DD) and Division of Behavioral Health (DBH) are involved. Both Divisions strive to support individuals in community settings rather than institutions. DMH oversight for community programming and funding is provided by Kanas City Regional Office (KCRO) and the DBH Chief of Adult Community Operations and/or the Chief of Children’s Community Operations if the individual is enrolled in youth DBH services. Individuals in DBH services who are age 18 through 25 may receive adult services only, youth services only, or both adult and youth services simultaneously until the individuals’ 26th birthday.

For a quick reference, the Missouri child abuse/neglect hotline number is 1-800-392-3738. The adult abuse/neglect hotline number is 1-800-392-0210.


Usual Key Players and Roles

There are a few core key players that are typically involved in each category of commonly occurring crisis situation. These key players are listed below to avoid duplicating them throughout the document. This is not intended to be an exhaustive list.

Individual: A person receiving services from the DMH or DMH contracted providers. The individual is the center of his/her service delivery team, and has choice in services provided to him/her.

Family and other natural supports: The individual receiving services may choose to have his/her family and others outside of service providers included in his/her care and treatment.

Guardian: A person who has the legal authority and duty to care for the personal and property interests of another person, called a ward.

DD Contracted Provider: Agency contracted with DD to provide Medicaid waiver services. These are services such as residential services, respite, functional behavioral analysis, among others. The current DD waiver manual can be found at https://dmh.mo.gov/dd/manuals/waivermanuals.html. The manual lists and describes all services that can be authorized under the waiver. Contracted providers can only provide services listed on their DMH contract. Individuals supported are to be offered a choice of providers for each service. The Targeted Case Management (TCM) Support Coordinator facilitates choice of provider process as well as utilization review process for approval of service authorizations.

TCM Provider: This is a DMH contracted organization that provides targeted case management (TCM) services for an assigned county, portion of a county, or multiple counties. TCM is also referred to as Support Coordination. The TCM Provider may or may not be a Senate Bill (SB) 40 Board. An SB 40 Board administers the county tax levy for I/DD services and may contract with DD Providers for services. The TCM Provider cannot provide support coordination for an individual while they are also providing a Medicaid waiver service, per federal regulation. In this case, another TCM Provider is available for support coordination. The TCM is also responsible for monitoring of supports provided by DD contractors.

Support Coordinator (SC): Every individual who is determined eligible for services from the Division of DD is entitled to receive support coordination. This position assists individuals with disabilities and their families, identifies and obtains needed services and supports, regardless if these are natural supports, DMH funded, or local community resources. They also advocate for, monitor, and evaluate services with the individuals, their families, guardians and other involved supports. A key role of the SC is to assist individuals with explaining the processes and paperwork necessary to obtain services. Once an individual is eligible for services, the SC develops a Person-Centered Support Plan (PCSP) with the family and other team members. This position may also be referred to as the TCM.

Community Mental Health Center (CMHC): A DBH contracted community mental health center that provides psychiatric and substance use services. The target population includes the following individuals, in priority order:  forensic clients pursuant to Chapter 552 RSMo; adults and youth with severe and disabling mental illness (adults with a severe mental illness [SMI] and youth with serious emotional disturbance [SED]) and one of the following:  discharged from DBH operated inpatient facilities; individuals with SMI/SED who are eligible for Community Psychiatric Rehabilitation services (CPR); transitioning from DBH operated or contracted residential settings; transitioning from DBH alternatives to inpatient hospitalization; discharged from state-operated emergency departments; receiving housing assistance using DBH housing funds; youth referred through a Custody Diversion Protocol; and adults with a SMI qualifying diagnosis other than a principal diagnosis of substance use or intellectual disorder and youth with SED per the Department’s definition.

CMHCs provide services to the community at large for mental health and/or substance use concerns, in addition to individuals receiving specific DMH funded services. There are 25 service areas across the state with designated CMHCs to provide services in those specific areas.

Community Support Specialist (CSS): When individuals are determined eligible for the Community Psychiatric Rehabilitation (CPR) program, a CSS may be assigned.  This position may be called something unique within each individual agency, but for the purposes of this document, the term CSS will be used.  Examples of services may include: assessing, monitoring and interceding on behalf of the individual in achieving and maintaining community adjustment; monitoring participation and progress in treatment programs; participating in the development or revision of the person’s Individualized Treatment Plan (ITP); assisting individuals in accessing mental health, other health needs, public services (financial, medical, housing, basic needs for food, shelter and clothing), variety of community agencies and resources (social, educational, vocational and recreational); hospital post-discharge planning; training, coaching and supporting individuals in daily living skills (housekeeping, cooking, grooming, accessing transportation, budgeting, paying bills, maintaining a residence); assisting in creating personal support systems with those involved; encouraging and promoting recovery efforts, independence, self-care and responsibility; and provide support to families such as treatment planning, linking to services, disseminating information and providing guidance.


Medical Crisis

Medical Crisis: An individual has a medical condition (whether diagnosed/treated or not) that impacts their ability to live safely or independently and supports are not available OR an individual has a medical emergency that necessitates a change in supports that may not be available within the current support system (i.e. family, provider, other resource, etc.).

Level of Risk:

Urgent: gradual and significant change in health status, non-life threatening emergency, persistent signs or symptoms of medical or behavior(s) caused from a medical need

Emergent: significant, sudden and/or life-threatening change in health status

Unique Key Players and Roles (in addition to usual key players):

Primary Care Physician (PCP): The individual’s primary care physician should always be contacted for a change in health status, and asked for guidance in next steps.  Walk-in medical clinics may be necessary for urgent needs, but follow up with the individual’s PCP is critical to prevent recurrence of a medical crisis.

Quality Enhancement Nurse (QERN): The QERN is a nurse employed by KCRO that can assist with care coordination, identify best practices, and support potential community providers in meeting the medical needs of an individual.

Hospital Social Worker: Hospital social workers may play a key role in hospital discharge planning.

Options to consider:

Community RN for DD residential services

If an individual has a Medicaid Waiver, the need for nursing services (includes nursing oversight, care planning, training direct support staff, etc.) can be requested through the Utilization Review (UR) process. The necessary number of hours must be justified by an assessed need and detailed in the Individual Support Plan (ISP).

CMHC Behavioral Health Care Home

A service that provides comprehensive behavioral health care coordinated with comprehensive primary physical care to Medicaid enrollees with behavioral health and/or chronic physical health conditions, using a partnership or team approach between the Health Care Home’s health care staff and individuals served in order to achieve improved primary care and to avoid hospitalization or emergency room use. Eligibility must be met.

Primary Care Health Home

Care coordination services for individuals with two or more chronic health conditions, or having one chronic condition and at risk for a second chronic condition. More information can be found at https://dss.mo.gov/mhd/cs/health-homes/ as this service is not administered by DMH.

Home Health Care

Home and community services offered by Department of Health and Senior Services (DHSS) have in-home care services available to eligible recipients. This service is commonly referred to as Home Health. More information can be found at http://health.mo.gov/seniors/hcbs/info.php.

Home and Community Based Services to elderly and disabled who meet nursing home level of care and are eligible for Medicaid may qualify for In Home Care services. Oversight is provided by Missouri Medicaid Audit and Compliance under MO Healthnet (Medicaid).

Private funding and insurance may pay for Private Duty/Private Pay home healthcare services. No governmental oversight is provided. If the company provides nursing services, the nurses should be registered as compliant with Missouri State Board of Nursing.

Skilled Nursing Facilities (SNF)

Skilled Nursing Facilities are licensed by DHSS for intensive nursing services (i.e. feeding tubes and intravenous therapy) or rehabilitative needs. These facilities are not clinical treatment environments but rather facilities that care for medical needs that cannot be managed in home-like settings. The Central Office Medical Review Unit (COMRU) at 573-522-3092 or COMRU@health.mo.gov is available to answer questions about the skilled nursing home referral process. The referral process begins by completing the DA-124 A/B forms, signed by a physician. Nursing staff may be helpful in completing Part C of the forms.  Forms, copy of recent history, physical and psychiatric evaluation are sent to the designated address. More information about the forms can be found at http://health.mo.gov/seniors/nursinghomes/pasrr.php.

Intermediate Care Facility (ICF)

A non-skilled nursing home licensed by DHSS for individuals with medical needs, and provide intermediate and custodial care, but not intensive nursing services.

Best Practice Recommendations:

  • Follow agency policy and procedures. Contact 911 in emergent situations if the individual presents in immediate distress or it may be possible for provider staff to transport the individual to the local Emergency Department.

  • For some individuals who are unable to effectively express a medical discomfort the concern at hand may appear to be a behavioral need rather than an unmet medical need. Always consider and/or rule out medical needs.

  • Discharge planning from a hospital admission should include the DD Provider (if applicable), family as desired by the individual, guardian (if applicable), SC/CSS, hospital social worker, and the QERN. Discharge planning should start at admission to ensure the appropriate services and housing setting to meet the needs of the individual are identified and able to be accessed when the individual no longer requires acute care.


Behavioral Crisis

Behavioral Crisis: An individual is engaging in a pattern of behavior that presents or may escalate to a danger to themselves/others or is engaging in a behavior with significant intensity that creates an imminent risk.

Level of Risk:

Routine: no harm to self or others is currently present; however, interventions are necessary to prevent escalation to a crisis, to address patterns of behavior that may result in putting the individual or others at risk for harm, and to address behaviors that inhibit appropriate adjustment to the environment or situation

Urgent: individual is currently engaging in behavior that places themselves or others at significant risk and not responding to de-escalation interventions

Emergent: individual is actively harming themselves or others and immediate/additional intervention is required to prevent further harm

Unique Key Players and Roles (in addition to usual key players):

DD Regional Behavior Support Review Committee: A committee of Board Certified Behavior Analysts and other professionals to offer consultation regarding Behavior Support Plans. This committee is led by the Regional Behavior Analyst at the Kansas City Regional Office.

DD Behavior Support Team:  A team of DD staff trained in “universal strategies” of positive behavior support that can offer consultation and support to a team in the development of a Safety Crisis Plan to address challenging behaviors and prevent placement disruption.

Regional Behavioral Analyst: Position of KCRO (and other regions across the state) who have specialized training in applied behavior analysis. The Analyst works with provider teams to identify behaviors viewed as problematic and develop a plan for positive behavior replacement, which may be a new behavior for the individual to work toward or improve a skill level the individual already possesses.

CMHC Clinical Staff: The Behavioral Support Team and/or Behavioral Analyst may need to consult with involved CMHC staff providing services for consultation of other intervention strategies that should be considered.

Options to Consider:

Applied Behavior Analysis Services (if available)

Applied Behavior Analysis (ABA) uses the scientific principles of behavior to produce socially significant behavior change in humans, and can be applicable across a wide variety of settings. All interventions are research-based and individualized to address the maintaining contingencies of each individual’s problematic behaviors, areas of skill deficit, or behavioral excesses in the exact environments in which they are occurring.

ABA services are available to children under the age of 21 with an Autism diagnosis through the Medicaid state plan. Most private insurances also offer some coverage for ABA services for qualifying diagnoses.

Individuals qualifying for a Medicaid Waiver may be able to receive ABA services paid for through the Waiver if approved by UR and included in the ISP.

Board Certified Behavior Analysts can be located through the Behavior Analyst Certification Board website: http://info.bacb.com/o.php?page=100155.

Crisis Placement

Some DD providers provide short-term crisis services for individuals with significantly challenging behaviors who receive Medicaid waiver funding. This service is designed to provide assessment and behavior support planning, ameliorate immediate risk, and train an identified community provider to provide long-term services and supports. An assessed and justified need must be identified in the ISP, and UR approval is required.

Optimistic Beginnings and Compass Health Rolla crisis beds are residential DMH funded programs for individuals typically with diagnoses of Borderline Personality Disorder and I/DD. Treatment is based on Dialectical Behavior Therapy, and is intended to transition the person back to community placement as quickly as possible. Referrals are discussed with the Regional Behavioral Analyst at KCRO for the process required if the referral may be appropriate for the individual.

The Regional Behavior Analyst maintains a list of DD community and state-operated crisis placement providers.

Local Law Enforcement

Crisis Intervention Team (CIT) trained officers when the individual’s crisis/safety plan has been implemented but is not effective, and the individual escalates to dangerousness to self/others. CIT officers are a resource to the community at large and their response is not a replacement for crisis/safety plan strategies implemented by provider staff.

When calling to report an emergency, or if law enforcement becomes involved through another avenue, a CIT officer can be requested.

Best Practice Recommendations:

  • Assessment is required to hopefully determine the cause of dangerous behavior. Medical, psychiatric, and substance related causality should be considered.  Some behavioral crises are due to an unmet or new medical need. Knowledge of personal history, triggers, behavioral patterns, responses to interventions, etc. may assist in differential diagnosis and subsequent intervention.

  • All assessments should consider potential trauma and its impact on the behavior and chosen intervention strategies.

  • Crisis/safety plans, which may be known as Behavior Support Plans, are most effective when implemented consistently across environments. All team members should utilize the recommended interventions to increase the likelihood of success.

  • CMHC services and staff disciplines involved vary from one individual to another depending on the person’s needs, and should be included in planning meetings to provide input into the development of crisis/safety plans.

  • It is necessary to ensure potential providers have the capacity to support the individual, including appropriate training and staff competency related to the identified needs of the person, i.e. positive behavior support, physical crisis management, etc.

  • Any intervention must ensure an individual’s rights of privacy, dignity and respect, and freedom from coercion and restraint. Any modification or limitation to these rights must be supported by a specific, assessed need and justified in a support plan that includes teaching strategies intended to restore these rights as soon as safely possible.

  • Least restrictive interventions that will ensure a person’s health and safety is to be utilized in all treatment/support planning and implementation.

  • Anticipating situations that may trigger concerning behaviors (i.e. special dates/anniversaries, season changes, etc.) is helpful to the team in proactive planning of supports ahead of anticipated escalation.

  • Most DBH crisis placement options, outside of the Compass Health Rolla program, are not appropriate for this co-occurring population, but the SC may check with the CMHC on individual cases.

  • CIT officers are trained to recognize the signs and symptoms of mental illness, and to respond effectively and appropriately to individuals in crisis. CIT officers are skilled at de-escalating crises involving people with mental illness, and providing access to additional resources that may be beneficial to prevent further law enforcement involvement. CIT or other law enforcement officers should not be substituted for behavioral crisis intervention.


Psychiatric Crisis

Psychiatric Crisis: An individual is exhibiting a substantial increase in symptoms related to a severe emotional disturbance or mental illness based upon the individual’s baseline functioning. The reason(s) why the crisis occurred and how it is expressed by the individual differs from one person to another.  This may include harm to self/others, disorientation, out of touch with reality, compromised ability to function, or other expression of emotional distress not characteristic to the individual. Immediate clinical assessment and intervention is necessary to ensure the safety of the individual and others.

Level of Risk:

Routine: no significant impairment in the ability to function and no apparent harm to self or others is currently present, but services are necessary to address psychiatric needs

Urgent: risk is significant but not active, and harm to self or others or the inability to function may result without clinical intervention

Emergent: risk is active, with harm to self or others imminent

Unique Key Players and Roles (in addition to usual key players):

CMHC Access Crisis Intervention (ACI) personnel: ACI services are a core service provided by all CMHCs, and play a critical role in assessing for next steps when there is an individual who is experiencing a psychiatric crisis. This is not be confused with on-call or other support systems within DD for behavioral crises. Professional staff operate a 24-hour telephone service for crisis response, referral and other relevant information; provide mobile crisis response if indicated; coordinate next day psychiatric appointments with a CMHC; and assist in referral for inpatient care, hospital diversion, or substance use detox or treatment when indicated. For the Kansas City area, CMHCs provide ACI services for existing clients during normal business hours. CommCare provides after-hour coverage and services for individuals not enrolled in CMHC services.

CMHC Community Mental Health Liaison (CMHL) (if law enforcement/court involvement):  Assists law enforcement and the courts in addressing the individual’s mental health issues through facilitating access to behavioral health resources for those who come to the attention of the justice system. The individual may not be connected to a CMHC for services at the point of involvement. All CMHCs employ a CMHL.

Options to consider:

Access Crisis Intervention (ACI) services

CMHC ACI phone numbers.

  • Comprehensive Mental Health Services at 816-254-3652

  • ReDiscover at 816-966-0900

  • Swope Health Services at 816-922-1070

  • Truman Medical Center Behavioral Health at 816-404-5700

CommCare may be contacted at 888-279-8188 when the crisis is after normal business hours of the involved CMHC or a CMHC is not involved. The CMHC/CommCare crisis services are attempted by phone and on-site staff should explain the individual’s crisis/safety plan for guidance or potential next steps. Mobile assessment may be deployed, if indicated. Affidavit assistance can be provided, if needed. CommCare communicates with designated CMHC staff if a call is received from their respective service areas, which is reviewed by agency ACI staff the following day.

DD Behavioral Support Team and/or Regional Behavior Analyst

There are times when it is difficult to assess if the individual’s behaviors are a result of a psychiatric crisis, a behavioral disturbance, or a combination. If the individual is in crisis and behaviors being displayed are incorporated into the individual’s crisis/safety plan or Personal Care Plan, it may be helpful to seek consultation from the Behavioral Support Team and Regional Behavioral Analyst.

CMHC Emergency Room Enhancement/Hospital Diversion

Some individuals present themselves frequently to area psychiatric emergency departments. The Kansas City Community Treatment Team is a group that meets monthly that staffs cases for discussion of hospital diversion strategies, if acute hospitalization is not needed. The focus of the team is to discuss engagement with mental health services rather than ongoing issues with individuals served by the CMHCs.

If an individual has accessed an acute psychiatric hospital three times within a 90-day period, a request for Emergency Room Enhancement (ERE) may be an option through the CMHC. Options available through ERE can be discussed with the CMHC involved.

If the crisis is not emergent and the individual does not need a high level of supervision, the Assessment and Triage Center (ATC) may be a resource or 23 hour treatment/observation if the referral is made from the hospital Emergency Department or Law Enforcement and deemed appropriate for the individual. No referrals from state or community providers are accepted.

Local Law Enforcement

CIT or other local law enforcement officers may be contacted when the individual’s plan is not effective and the individual’s crisis escalates to dangerousness to self/others.

Best Practice Recommendations:

  • Providers need to ensure they are educated in what constitutes a psychiatric vs. behavioral crisis for individuals served. Both types of crises may occur with the same individual and it is often difficult to distinguish without specific knowledge from both systems of DMH. CMHCs are the clinical service provider for DBH, and should be consulted if there is suspicion that a co-occurring individual may have psychiatric crises. A psychiatric crisis is typically related to the individual’s serious mental illness. Crisis/safety plans should be developed in collaboration between the providers of the two DMH Divisions.

  • If an individual’s crisis is emergent, 911 should be contacted first. The CMHC (or CommCare, if the individual is not connected to the CMHC) can be contacted for further assistance.

  • ACI services will be more effective if the CMHC is involved in the development of Safety/Crisis Plans. ACI services are designed to respond to psychiatric, not behavioral crises.

  • If an individual is accessing an Emergency Room due to a psychiatric crisis, a mental health assessment can be requested. An assessment by a licensed clinician is necessary to rule out medical and/or substance related causes that may present as and/or cause psychiatric symptoms.

  • If an individual is NOT admitted following a mental health assessment, the crisis is no longer considered emergent and/or the situation may no longer be considered a psychiatric crisis.

  • Trauma may be an important factor in the assessment and intervention of a psychiatric crisis.

  • Crisis/safety plans are most effective when implemented consistently across environments, programs, and involved agencies.

  • Anticipating situations that may trigger psychiatric decompensation (i.e. special dates/anniversaries, cyclic recurrence/season changes, etc.) is helpful to the team in proactive planning of supports and interventions in anticipation of these situations.

  • Team members should become aware of hospital diversion alternatives through collaboration between providers from both Divisions.

  • Ensure team members are aware of natural supports that may be available for respite or other supportive intervention, and any change in support services that may have a direct/indirect impact on the individual’s care.


Placement Crisis

Placement Crisis:  A provider is unable to meet the needs of the individual, which may be due to a crisis listed in this document or other reason. This may occur because the current or prospective provider is not equipped to meet the needs of the individual, there is not capacity of “specialized” providers to accept new referrals, or the team agrees that what is ideal or needed for the individual may need to be developed through additional collaboration.

Levels of Risk:

Transition: An individual is “between” placement, in that a long term provider has been identified but cannot be prepared (i.e. staff training, home rental, etc.) immediately

Urgent: Individual has been given notice of having to vacate their placement and there are no identified providers currently available.

Emergent: Individual is need of immediate placement due to safety concerns, and there is no provider available.

Unique Key Players and Roles (in additional to usual key players):

Community Living Coordinator (DD): assists with facilitating transitions for community-based placement for individuals receiving Waivered residential services.

Hospital Social Worker (if hospital involvement): assists with discharge planning and resource coordination for individuals who are being discharged from hospitalization (psychiatric or medical).

Regional Behavioral Analyst/CMHC Clinical Leadership staff:  assists in coordinating with out of region alternatives/service providers or formulating ideas for development of new alternatives if local service providers are unable to resolve the placement crisis. KCRO Directors and DBH Community Operations staff may be consulted in this process to identify alternatives.

Options to consider:

Enhanced Services at Current DD Provider

For individuals who are currently receiving DD placement supports, additional services may be available with a justified need and UR approval. Examples of these services are Applied Behavior Analysis, increased Professional Assessment and Monitoring (DD-RN) services, modifications of staffing, etc.

For individuals who are not currently receiving DD placement supports, in-home services may be appropriate to provide for health and safety needs.

Optimistic Beginnings or Compass Health Rolla Crisis Programs

For individuals who have had behavioral or psychiatric crises which resulted in a placement crisis may be eligible for these options. Contact the Regional Behavioral Analyst at KCRO for consideration.

DD Waivered Crisis Programs

Individuals receiving residential placement services through the comprehensive waiver, may be able to access a limited number of community-based crisis programs. These services generally include assessment, safety/crisis planning, staff training, etc. and require a long-term placement option to be identified prior to admission.

These programs are accessed through a referral directly to the provider, generally coordinated by the SC and/or the Regional Behavior Analyst. The Behavior Analyst has access to the most up to date list of community based crisis providers.

There are some DD Contracted Providers who offer respite services which may or may not be an individual they are providing other support services to.

Placement Options with DBH or Private DBH Contracted Providers

Privately funded and DBH operated or contracted housing settings vary greatly from one to another. The involved CMHC can be consulted for options available in the area based on each individual’s circumstances and needs. Some of these options may include, but not limited to, Intensive CPR housing settings, state operated waiver group homes, DBH contracted residential care facilities.

DBH contracted residential care facilities are largely privately operated and have latitude in who they admit beyond their DMH contract, if they have one.  DHSS has oversight over privately funded individuals, although DBH may have a contractual relationship.

CMHC Respite Programs

Some CMHCs have short term respite programs for individuals receiving CPR services. The CMHC can evaluate if their respite program is appropriate for the individual.

Crisis Placement at a Habilitation Center

As a last resort, a referral can be made to a Habilitation Center. All referrals to Habilitation Center crisis placement programs must be approved by DMH Central Office (DD) and are facilitated by KCRO.

Best Practices:

  • Supports are driven by the desire of the individual and their family.

  • Guardians must have full understanding of the options available, potential barriers and safety risks, etc. and is ultimately responsible for the decision regarding placement provider.

  • The least restrictive placement that will ensure a person’s health and safety is to be utilized in all service planning and implementation.

  • Mediation or conflict-resolution may be effective to resolve the issues related to placement disruption should be pursued before looking for alternative placement unless there are concerns related to the immediate health and safety of the individual.

  • Whenever possible, the individual and the individual’s support team should be afforded as much choice as possible in all placement decisions (i.e. meeting housemates, selecting homes, etc.).

  • Comprehensive assessment and identification of an individual’s needs should take place before placement to ensure the placement provider has adequate resources to meet the needs (i.e. medical, behavioral, psychiatric, etc.) of the individual.

  • It is necessary to ensure potential placement providers have the capacity to support the individual, including appropriate training and staff competency related to the identified needs of the individual (i.e. specialized medical training, delegated nursing tasks, positive behavior supports/consultation with the Behavioral Analyst, physical crisis management, etc.). Providers should be informed of best practices and promising practices that may be available to and beneficial for the individual (i.e. Dialectical Behavior Therapy, etc.).

  • In situations where the individual resides in their natural home, ongoing monitoring is needed to ensure caregivers have the supports and resources available to care for the individual. Discussions should occur routinely and supports available so that plans are in place should the care giver become unable to continue to support the individual.

  • Development of a thorough crisis/safety plan (related to identified medical, behavioral support, or psychiatric needs) should occur prior to placement and be reviewed by due process for waivered services.

  • If an individual is incarcerated, involvement of the CMHL may be helpful to assist with ensuring appropriate supports within the jail setting and/or explore alternatives to jail. Request for CMHL services will not be duplicative of a SC/CSS, but rather for a targeted focus due to law enforcement involvement.

  • Planning for transition should begin immediately upon the receipt of formal notice for an individual.

  • When an individual transitions from one community to another, the transition plan should include the participation of the involved CMHC.

Note: If an individual is connected to the CMHC in their current placement, they will be discharged from this CMHC if the individual is moving out of the catchment area. A referral to the CMHC in the new community should be coordinated by the team as a part of the transition. Ensure to be specific what CMHC services are being requested. For example, it should not be globally termed “case management” because a SC provides TCM. Refer to the definition of a CSS when requesting those services a SC does not do.

  • DHSS may be contacted in addition to KCRO and CMHC if the placement situation warrants their review for abuse/neglect or inability to make appropriate care decisions.

  • The Regional Behavioral Analyst and CMHC clinical leadership will consult with KCRO and/or DBH regional leadership positions for consideration of exploring or developing new service/programming options not available in the Kansas City area.