The Community Navigator“Finding A Way”

Community Mental Healthcare Inc.

Dover, OhioServing Tuscarawas and Carroll

County

JJ Boroski, Executive DirectorMichelle Coon, Community NavigatorGwen Malcuit, Program Supervisor, Manager

of Crisis Services, Forensic Monitor

The Community Navigator Program at Community Mental Healthcare was made possible by a grant from the Margaret Clark Morgan Foundation in September of 2012. The grant was written by JJ Boroski, Executive Director at CMH Inc.The purpose of the program was to provide intensive, needs based, individualized support and assistance to high risk mentally ill or addicted individuals experiencing repeated hospitalizations, incarcerations, or are at risk of such. The program was designed to be holistic in its approach to the recovery process. Typically, these individuals have not been successful in traditional services or have been unable to access them.

The Community Navigator in Tuscarawas and Carroll County

The identified need and the target population

The projected goals

One year outcomes

The Identified PopulationHigh level of vulnerability and risk in the community

due to homelessness, symptom instability, substance abuse, lack of access to medical care, lack of access to healthy diet, lack of healthy supports, involvement with legal system

Experiencing high rates of recidivism or incarceration or at risk of such

Inability to navigate benefits and resourcesCase complexityInability to access traditional services or past failure

in traditional servicesHigh risk of harm to self or others

The Identified Community ProblemsRural area with limited resourcesNo public transportationPoor follow up rates post hospital dischargeLack of effective communication across systems,

between organizationsTraditional CPST struggle to provide level of

intensity neededAvailable resources and benefits not widely known

or difficult to navigateLack of community awareness regarding SPMI

individuals and substance abusing individuals

GoalsDecrease bed day use and recidivism ratesDecrease length of stayDevelop improved methods of communication between

organizations and within our own organizationIncrease compliance and post discharge follow up ratesIncrease access to basic needsDevelop and foster healthy and supportive relationshipsProvide advocacy and promote self advocacyIncrease reliance on natural supportsProvide support and education to communityProvide guidance in accessing benefits and resourcesDevelop means of identifying at risk individuals in other

community systemsProvide leadership in the development of new resources

Activities of the Community Navigatorat Heartland Behavioral Healthcare Engages at least weekly with clients at HBH Contacts assigned social worker within one business day of

admission Point person for all follow up scheduling Takes part in treatment team meetings Provides support and assistance in level movement process Conducts Needs Assessment, begins linkage to benefits and

resources on site Determines need for Navigator services versus traditional

services Develops rapport and provides the client a link to post hospital

environment Involves family/ involved others per client’s wishes Facilitates step down to CSU Provides support, guidance and contact following discharge and

up to first post discharge appointment Facilitates referral to Community Treatment Team if appropriate Provides continuity of care from time of admission into the

community

Activities of the Community Navigatorat Community Mental HealthcareCommunicates back to existing providersRefers to appropriate services and assures services are

accessed in a timely mannerWorks in tandem with existing CPST to provide additional

support, needed intensity, or when transferring to CPSTCollects needed recordsLiaison to community providersWorks in tandem with the Forensic Monitor as neededCommunicates with Pharmacological Services to assure

timeliness of appointments, availability of medicationProvides support and assistance to clients in CSU,

including Needs Assessment, referrals, linkage to benefits and resources

Activities of the Community Navigatorin the CommunityAssisted in the development of and participates in bi-

weekly Community Treatment TeamMonthly team meetings with Probation and Courts Is present in court at Judge request and conducts Needs

Assessment on site at courtEngages with clients in jail at jail request Improved communication with local guardians and

attendance at guardianship hearingsWorks closely with local group homes, facilitates training

as neededDeveloped a close working relationship with local homeless

shelterGathers records to improve timeliness of access to benefitsDevelops reports requested by Probation for PSI

What Have We Achieved?Over 100 clients served over the past yearShow rate for post hospital discharge went from 64% to

95%Individual client readmissions (Navigator clients)

decreased by ?Only two 30 day readmissions in past yearLOS remained fairly stable, however early linkage and

engagement with Community Navigator improved compliance and outcomes post discharge

Of clients not previously linked to services, 100% were linked, with 83% still active in services

76% of Navigator clients successfully “stepped down” to more traditional services

Communication, Communication, Communication…Community Treatment TeamCommunity Corrections collaborativeMunicipal Court and Municipal Court

Probation collaborativeHomeless ShelterGuardiansTuscarawas County JailNorthview Group HomeRisk TeamHBH

The Community Navigator From Community to CommunityNo two communities are the same Systems of care are different from county to

countyResources differ Existing services differEach community has its own unique

strengths and weaknessesThe Community Navigator looks different

from community to community but the goal of helping our most vulnerable citizens is the SAME

Our Navigator “Mission”If there’s a GAP… BRIDGE itIf there’s a BARRIER… FIND another way

If there’s a STRENGTH…USE itIf there’s NOTHING… ENVISION it, BELIEVE in it, BUILD it!!

“The true beauty of this position is that we have an individual free from the constraints and demands of billing and productivity, free from the rigid limitations of more traditional services, who can not only guide those with mental health or substance abuse issues around the gaps in the system that people often fall into, but also has the ability to address the reasons those gaps are there in the first place and work across multiple systems of care, with multiple providers, and in multiple venues to close them for good. In this sense the Community Navigator is not just an advocate for the clients he or she serves, but an advocate for communities, organizations, families, and all who may in the future be touched by mental illness or substance abuse issues.”

Questions?

Much gratitude and Many thanks to…The Margaret Clark Morgan FoundationJJ Boroski MA, LPCC-S, Executive Director, CMH

Inc.The ADAMHS Board of Tuscarawas and Carroll

CountiesThe staff and administration of Heartland

Behavioral Healthcare, especially Linda Ellis and Jeff Sims

Nicole Cooperider and Linda BlumODMHASAnd of course MICHELLE COON, COMMUNITY

NAVIGATOR!