Salisbury Behavioral Health, Inc. ASSERTIVE COMMUNITY TREATMENT TEAM. Consumer & Family Handbook

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1 Salisbury Behavioral Health, Inc. ASSERTIVE COMMUNITY TREATMENT TEAM Consumer & Family Handbook Who is the ACT Team? There are a variety of mental health professionals and other trained staff on the ACT Team. Each staff person on the team has specific tasks and responsibilities based on their training and expertise. While involved with the ACT Team you will meet with the various staff on the team based on your treatment goals, needs and preferences. Here s a list of the staff on the team: Team Leader: This is a Mental Health Professional, who along with the Psychiatrist provides overall leadership and supervision to the staff on the team. Program Assistant: This is a specially trained staff person who assists consumers with scheduling appointments & transportation, communicates with other team members, can assist in answering questions and providing other information about the program. This is the person who typically answers the telephone at the ACT Office. The Program Assistant is also in charge of all money

2 management responsibilities for ACT consumers who request Salisbury Behavioral Health as their Representative Payee. Psychiatrist: This is a physician who is specially trained in treating psychiatric disorders. The psychiatrist evaluates each ACT consumer and provides on-going treatment such as prescribing medication, providing counseling and education and monitoring your overall health. Mental Health Professional: This is a person who is trained to provide individual, group and family therapy. MHPs work individually with consumers on the team to develop coping skills for mental health symptoms, to develop relationships with natural supports and assist you in learning how to get your needs met by the mental health system. The MHP conducts assessments, helps you determine what your treatment goals are and provides ongoing counseling, education, coaching and support. Housing Specialist: The Housing Specialist is a mental health professional who specializes in helping people obtain and maintain permanent housing. The Housing Specialist has relationships with local landlords, county officials and housing programs that assist you in finding the right housing for your needs. The Housing Specialist can also provide you with education regarding your rights as a tenant or homeowner as well as help you learn the skills necessary to live independently in your own home or apartment. Substance Abuse Specialist: This is a counselor who is specially trained to screen, assess and treat substance use disorders. The Substance Abuse Specialist provides individual, group and family therapy to individuals who identify drug or alcohol use that is negatively impacting their life or mental health symptoms. Nurse: This is a Registered Nurse who has training and experience in providing nursing services to people with mental health needs. The nurses on the team provide ongoing assessment of mental health and physical health needs, makes referrals to appropriate physicians if necessary, assists in coordinating your care with your primary care physician, administers medication, and provides you with education, counseling and support. Peer Specialist: This is a specially trained individual who shares their personal experience living with a mental illness to help you develop your personal recovery strategies. The Peer Specialist is specifically trained in WRAP (Wellness Recovery Action Plan) and can help you develop your own WRAP. The Peer Specialist can also be an advocate to assist you in getting your needs met both by the team and by the mental health system in general. Vocational Specialist: This is a specially trained counselor who can assist you with your vocational or educational goals. The Vocational Specialist works with the rest of the team to provide assessment, education, coaching and other services needed to help you get a job. Mental Health Worker: This is a trained individual who can assist you in developing coping strategies, engage in problem-solving and teach you life skills and other strategies that are helpful for your personal recovery experience. Individual Treatment Teams The ACT model of treatment is a team oriented approach. While you are receiving services from the ACT Team you will be seen by a variety of team members. Every consumer on the team is assigned an individual treatment team. This is a team of approximately 3-4 staff who have been chosen to work with you based on your goals, needs and preferences for treatment. Primary Case Coordinator- This is the person who takes the lead in coordinating your treatment. The staff member who is assigned as your primary case coordinator will work with you to determine your treatment goals. Nurse- Every consumer is assigned a nurse on the team. The amount of contact you have with a nurse will depend on your needs. Consumers with chronic or severe medical conditions are seen more frequently by the nurse than those without medical problems. Other team members on your Individual Treatment Team include the Team Leader, the Psychiatrist, and anyone else as determined by your recovery goals. Community Support Plans The Community Support Plan (CSP) is your recovery plan. Every consumer on the ACT Team develops their first CSP within the first 6-8 weeks of admission to the program. CSPs are then reviewed and revised at least every 6 months. In order to prepare for the Community Support Plan the team will coordinate the following activities: Goal Planning Worksheet (GPS) - This is a worksheet that a staff member from your individual treatment team will complete with you. This worksheet helps you determine which goals you want to focus on and how the team can help you achieve these goals.

3 CSP Meeting- This is a meeting with members of your Individual Treatment Team to develop and review your goals. The team will take time to review your progress since the last CSP Meeting and will work with you to determine if you would like to continue working on the same goals or if you ve accomplished your goals and would like to establish new goals. Discharge Readiness Assessment- This assessment is completed by your primary case coordinator and is used to determine your progress in a variety of areas relating to your recovery. Based upon the results of this assessment and your personal recovery goals the team may discuss your discharge from the program and develop a plan to prepare you for discharge from the program. Crisis Plans Each individual receiving ACT services develops an individualized crisis plan. The first crisis plan is typically done with you within your first week in the program. These plans are updated at least every 6 months but may be updated more frequently if necessary. A crisis plan is a tool for you and the ACT Team to help you when you are experiencing a crisis or mental health emergency. The plan outlines symptoms or behaviors that are signs of a potential crisis or relapse of mental health symptoms. The plan indicates things you can do to help yourself and how you want the ACT Team or other members of your support group to help you when you are experiencing a crisis. Crisis plans are meant to help prevent hospitalizations or other negative consequences of a mental health emergency. It is important that you keep your crisis plan somewhere you can find it. We also suggest that you share a copy of the crisis plan with your family, friends, roommates, or anyone else who could help you in a crisis situation. ACT Services There is a wide variety of services the ACT Program can provide based on your needs and Recovery goals. The ACT Program works with you to tailor this treatment experience specifically for you. This handbook provides a brief summary of some of the most commonly used services provided by the team. The team can provide many other services not listed in this handbook. If there are other services that you are interested in receiving please do not hesitate to call the ACT Office or talk to someone assigned to your Individual Treatment Team. Crisis Intervention Services (On-Call) The ACT Team provides crisis intervention services 24 hours a day 7 days a week. Consumers or other concerned family members or friends can call the ACT Office at any time if they are experiencing a crisis or psychiatric emergency. Evening telephone calls are received by an answering service who will have an ACT Team member return your call usually within 5 minutes. All crisis intervention services are provided by the team. Please do not call New Perspectives. The ACT Team member who receives your call will ask you some questions to gather basic information about the nature of your crisis. The ACT Team member will refer to your crisis plan and/or your Community Support Plan to determine how to provide you with the most appropriate help. Here are a few helpful reminders about crisis intervention services: Please be as specific as possible when calling the ACT Office about a crisis Crisis intervention services should only be used for crisis or emergent situations The crisis intervention line is not a warm line Please refer to your ACT Crisis Plan before calling the crisis intervention line Call 911if you are experiencing a medical emergency Therapy The ACT Team provides individual, group, couples and family therapy to members of the ACT Team. The team will discuss the treatment options most appropriate for you when you are developing your Community Support Plan. We strongly encourage you to participate in at least of the therapy options provided by the team. Individual Therapy The ACT Team offers individual therapy as part of its comprehensive treatment services. Individual therapy is typically offered once a week or every other week depending on your needs and preferences. Individual sessions are typically held at your home or community. We believe that it is important to engage in therapy outside of the ACT Office in a safe and comfortable setting such as your home or even a local coffee shop. In therapy you will work on goals that you develop with your therapist and are part of your community support plan. Group Therapy The team offers a variety of group therapies at the ACT Office. The team can help you arrange transportation or you can take the bus to the ACT Office. Most of these groups are educational and can help you develop skills to help you with your personal recovery journey. The team can provide you with a schedule and descriptions of the groups being offered at this time. The schedule changes every few months to provide ACT participants with different group options. Here is a list of some of the most commonly offered groups: Illness Management and Recovery Dual Recovery (for those in recovery from substance use disorders) Healthy Lifestyles Money Management Anger Management Couples & Family Therapy The ACT Team can meet with you and members of your family or other members of your support group for therapy. This can be brief (1-2 sessions) or ongoing based on your preferences and needs. The ACT Team may suggest that you consider participating in these sessions depending on your specific goals as listed on your community support plan. The team also provides Family Psychoeducation which is described in more detail in another section of this handbook.

4 Vocational Services The ACT Program provides individualized employment and education support services as part of its approach to comprehensive treatment. Employment or school is an essential part of the recovery process. We believe that everyone is capable of working. Here s a list of some of the service provided by the Vocational Specialist: Engagement Not sure if you are interested in working? The Vocational Specialist meets with you to educate you about employment opportunities and the benefits of working. Vocational Assessment How do you begin looking for employment? The Vocational Specialist will meet with you to determine your work history, strengths and interests. The Vocational Specialist will also help you in determining if you should disclose that you are diagnosed with a mental illness to potential employers. Job Development What is the Vocational Specialist doing behind the scenes? The Vocational Specialist is meeting with local employers to develop relationships with them and to collect information about potential job leads. Job Placement So far, you have a better idea of what type of work you are looking for. Now what? The Vocational Specialist will meet with you regularly to talk about job leads, to complete applications, to develop your resume, and to role-play job interviews. The Vocational Specialist may also help you with getting your GED or with going back to school for a advanced degree. Follow-Along Supports What if you need assistance after you have found a job? The Vocational Specialist is there to support you at your job or school. This support may involve communicating with employers or teachers or sitting down with you to talk about any difficulties that may arise at your job or school. Benefits Counseling And now for one of the biggest questions.how will work affect your benefits? The Vocational Specialist can answer most of your questions about how employment will affect your SSI or SSDI benefits. The Vocational Specialist can arrange appointments with Social Security to explain all the details if you are interested. Substance Abuse Services The Assertive Community Treatment Team, as part of its comprehensive approach to treating mental illness, provides individual, group and family therapy to help consumers who are struggling with substance abuse issues. The Substance Abuse Specialist is a Certified Alcohol and Drug Counselor (CADC) who specializes in treating substance use disorders. The Substance Abuse Specialist provides screening and assessment to help you determine if your substance use is a problem. The team can provide you with education, support and referral to other treatment providers if necessary in order to meet your needs. The ACT Team also has a weekly drug and alcohol group that meets at the ACT Office. This is an opportunity for you to meet with other consumers and to share your personal recovery experiences. Housing Services The Housing Specialist on the ACT Team is here to assist you with any of your housing needs. Some examples of services provided by the Housing Specialist include: Helping you locate low-cost housing Communicating/Advocating on your behalf with landlords and/or residential providers Locating community resources to help you furnish your home or assist with rent payments/security deposits, or utility costs Teaching or coaching life skills such as budgeting, meal & menu planning, shopping and using public transportation Peer Support We believe that getting support from someone who s been there is an essential part of the Recovery process. The Peer Specialist is on the team to help you learn how to navigate the mental health system and to help you learn skills so that you can advocate for yourself. The Peer Specialist also helps individuals develop Wellness Recovery Action Plans (WRAP). WRAP is a tool to help you discover what skills, resources, and supports are the most helpful in your recovery. The Peer Specialist can also assist you in developing a Mental Health Advance Directive or Mental Health Declaration. These are tools to make your wishes known to healthcare providers regarding mental health treatment in case of an emergency or crisis situation. If you would like to develop a WRAP or Mental Health Advance Directive tell someone on your Individual Treatment Team. Nursing The ACT Team provides nursing services to ACT participants in collaboration with the other recovery-oriented mental health services offered. The treatment services provided by the nurse on the team may include: Physical health assessments and screenings Coordination of treatment services with other medical providers including your Primary Care Physician Education and counseling regarding the prevention or management of chronic medical illness, management of your mental health symptoms

5 Teach you how to correctly take medication that has been prescribed for you by the psychiatrist other physician and help you develop strategies to remember to take your medication Administer medication (especially injectable medication) that has been prescribed by the psychiatrist Assist you in scheduling medical appointments and if necessary attend medical appointments to assist you in communicating your needs to other treatment providers Pharmacy The ACT Team provides pharmacy services through a contract with Hartzell s Pharmacy. Medications are directly ordered and delivered to the ACT Office. This allows the team to take a direct role in managing your medication and promotes communication between the team and your pharmacist. The psychiatrist will determine how much assistance you should receive in managing your medications. If necessary, the team has the ability to provide daily medication deliveries to you at your home. The Nurse can help you set up pharmacy services with Hartzell s or another pharmacy if you independently manage your own medication. Other doctors such as your primary care physician should be informed if you switch to Hartzell s Pharmacy while you are with the ACT Team. If you have billing questions or other questions about the pharmacy call your Primary Case Coordinator or Nurse. Family Psychoeducation Family Psychoeducation is an evidence-based practice, that gives consumers and families information about mental illness, helps them build social supports, and enhances problem-solving, communication and coping skills. Consumers who participate in FPE experience fewer relapses and less time in the hospital. Families who participate report greater knowledge of serious mental illnesses and less stress, confusion, and isolation. Family Psychoeducation consists of 3 different stages: Joining Sessions- these are introductory sessions with a consumer and their respective family members. These sessions are typically about an hour in length. Educational Seminar- this is a day long seminar offered to family members to provide education regarding mental illness. Ongoing Family Psychoeducation- these groups are held every other week at the ACT Office. These sessions are approximately 1 1/2 hours in length and are meant to provide families with a venue for ongoing support and assistance with problem solving current stressors or concerns. If you would like to participate in the Family Psychoeducation Program please call the ACT Office or tell someone on your team. ACT Resources Consumer Advisory Committee This meeting is held at the ACT office on the first Tuesday of every month. These meetings are open to all consumers and family members or friends of consumers enrolled in the ACT program. Consumer Advisory Committee meetings are held to provide an avenue for direct and frequent communication with consumers on the ACT team and the Team Leader. Discussions in these meetings will involve staff issues or changes, upcoming events, consumer feedback and suggestions, as well as any other agenda items that have been requested for further discussion by the Consumer Advisory Committee meeting members. Stakeholder s Advisory Committee This meeting is held quarterly in collaboration with Northwester Human Services and Salisbury Behavioral Health ACT teams. These meetings are open to various community stakeholders, both current and former recipients of mental health services, and family members. Meetings are held to provide support and assistance for ongoing operations of both ACT teams. Discussions in these meetings will involve promotion and development of the ACT programs, review of program audits and any relevant quality improvement plans, evaluation of program outcome measures, including consumer and family satisfaction, as well as a collaborative effort to promote and ensure the presence of consumer s empowerment and recovery values with the ACT Teams. Please contact the ACT office for further information if you are interested in attending this meeting. FOOD RESOURCES Community Resources Bushkill Outreach Program, Inc PO Box 103, 12 Rt. 209 (Old Reformed Church) Bushkill, PA Bushkill Outreach is a monthly Food Pantry that is available for emergency distributions. The Outreach also has donated clothing for children and adults, and some home furnishings. Bushkill Outreach also provides Christmas Toys for needy families. Hours of Operation: Tuesday - Thursday 8:00 am - 12:00 pm (Noon), other hours by appointment

6 Pocono Mountain Ecumenical Hunger Ministry Route 611 Tobyhanna Basement of Coolbaugh Municipal Building Tobyhanna, PA 18466, PA Food Pantry serving families and individuals in need that live in the Coolbaugh area, once per month. Pantry open 1st Wednesday and the 1st Saturday of each month, 9:00 am - Noon. Other hours by appointment. Salvation Army - Food Pantry , ext Washington Street East Stroudsburg, PA Food Pantry (4th Thursday of the month, 9:30 am - 11:30 (Must be registered 2 weeks prior to Food Distribution to be included) Office Hours Monday - Friday 8:30am - 4:30pm; for Food Pantry hours please see above or call for more information. TRANSPORTATION RESOURCES Monroe County Transit Authority (MCTA) - Shared Ride Contact: Sharon Onuskonych Shared Ride is a program designed to help any individual in Monroe County seeking access to otherwise unavailable transportation. Shared Ride programs can be used for trips to doctor appointments, grocery stores, and any other day-to-day errands. Shared Ride is only available by reservation. You must call the Shared Ride dispatch by 12 Noon the day before your trip to schedule a ride. Monroe County Transit Authority (MCTA) - Shared Ride for Seniors Contact: Sharon Onuskonych Shared Ride for Seniors serves many seniors, aged 65 and over, throughout Monroe County who live in outer lying areas where public transit is not accessible. Shared Ride programs can be used for trips to doctor appointments, grocery store, and any other day-to-day errands. Some Fees may apply for none-medical none-psychiatric appointments. Shared Ride is only available by reservation. You must call the Shared Ride dispatch by 12 Noon the day before your trip to schedule a ride. Senior rides must start Monday-Friday between 10:00 a.m. and 2:00 p.m. For Seniors Only, the PA State Lottery Program pays for 85% of the shared ride fare. In Monroe County, the Area Agency on Aging works with Seniors to help pay some of the remaining 15% cost. The amount of co-pay you will be required to pay can vary based on the current year budget allocations in our community, but never more than 15% of the total fare. Call MCTA for more information on fare rates. (Certain trips such as Kidney Dialysis may be available Monday through Friday). SUPPORT GROUPS NAMI Group Meetings Contact: (570) Brodhead Conference Room at Pocono Medical Center 206 East Brown Street East Stroudsburg, PA Bipolar/Depression Support Groups Contact: Brodhead Conference Room at Pocono Medical Center 206 East Brown Street East Stroudsburg, PA 18301

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