I. Present Managed Care Involvement Percentage of current reimbursement for services coming from managed care Less than 10% 26 to 50% More than 75% 10 to 25% 51% to 75% I do not know/not applicable Insurance coverage for your current service enrollees % Medicaid Only % Medicaid and Medicare % Medicare Only % Medicare and commercial insurance % Commercial insurance % No Coverage Please identify which types of programs your agency operates (check all that apply) OMH (Office of Mental Health) OASAS (Office of Alcoholism and Substance Abuse Services) Both OMH and OASAS OCFS (Office of Children and Family Services) Other (please specify): I do not know/ Not applicable This assessment was completed by: This readiness assessment is being filled out for an agency that provides services in which COUNTY OR COUNTIES? Please specify: II. Early Identification and Screening Please list the screening and evaluation tools used in your program for children and families (e.g., the CBCL, BDI, PHQ). If your program does not use any screening tools, please indicate by writing NONE in the space provided below. 1
III. Treatment Models and Evidence-Based Practices Please list the specific treatment models used in your program currently (e.g., CBT, TF-CBT, FFT, MST, etc.). If none, please indicate by writing NONE in the space provided below. IV. Outcome Measures and Tracking How does your program track client progress and outcomes? Please list any measures you utilize to track outcomes (standardized or non-standardized). If none, please indicate by writing NONE in the space provided below. 2
V. Agency Assessment of Service Array MCTAC / CTAC Please indicate whether you provide each of the services listed within your organization: Service STATE PLAN SERVICES Crisis Intervention Services - provided to a child and his/her family/caregiver who is experiencing a psychiatric or substance use crisis, are designed to interrupt and/or ameliorate a crisis experience including an assessment, immediate crisis resolution and de-escalation, and development of a safety plan. Example services: Crisis Response, Immediate Crisis Response Community Psychiatric Treatment and Support Services - goal-directed supports and solution-focused interventions intended to achieve identified goals or objectives as set forth in the child s plan of care. Example services: Intensive In-Home Services; Crisis Avoidance, Management, and Training; Evidence Based Practices; School-Based Interventions If yes, what services do you provide and who provides this service? (list services, number of staff, and their credentials) If no, do you collaborate with others (e.g., outside agencies) to provide these services? 3
Psychosocial Rehabilitation Services - work with children and their families to implement interventions outlined on a treatment plan to compensate for or eliminate functional deficits and interpersonal and/or environmental barriers associated with a child/youth s behavioral health needs MCTAC / CTAC If yes, what services do you provide and who provides this service? (list services, number of staff, and their credentials) If no, do you collaborate with others (e.g., outside agencies) to provide these services? Family Peer Support Services - array of formal and informal services and supports provided to families caring for/raising a child who is experiencing social, emotional, developmental, substance use and/or behavioral challenges provided by a peer with lived experience Youth Peer Advocacy and Training Services services that provide the training and support necessary to ensure engagement and active participation of the youth in the treatment planning process and with the ongoing implementation and reinforcement of skills learned throughout the treatment process by a youth peer with lived experience 4
HOME AND COMMUNITY BASED SERVICES (HCBS) Care Coordination - activities that will support engaging children and families in care and promoting continuity of care; assessment of needs; creating an individualized, child and family/caregiver centered plan of care; coordinating and arranging for the provision of services; building the family or caregiver s natural supports; and monitoring and evaluating a child and family or caregiver s needs If yes, what services do you provide and who provides this service? (list services, number of staff, and their credentials) If no, do you collaborate with others (e.g., outside agencies) to provide these services? Habilitative Skill Building - provided to the child and the child s family/caregiver to support the development and maintenance of skills sets, utilizing an individualized, strength based approach in assisting the child in recognizing his/her functional assets/strengths and those that need developing. Family Caregiver Supports and Services - enhance the child s ability to function as part of a family/caregiver unit and enhance the family/caregiver s ability to care for the child in the home and/or community 5
Crisis Respite - short-term care and intervention strategy for children and their families as a result of a child s mental health/substance use crisis event, medical crisis or trauma that creates an imminent risk for an escalation of symptoms without supports and/or a loss of functioning If yes, what services do you provide and who provides this service? (list services, number of staff, and their credentials) If no, do you collaborate with others (e.g., outside agencies) to provide these services? Planned Respite - short-term relief for family/caregivers that are needed to enhance the family/caregiver s ability to support the child s functional, mental health/substance use disorder and/or health care issues Prevocational Services -individually designed to prepare a youth to engage in paid work, volunteer work or career exploration Supported Employment - individually designed to assist youth with severe functional challenges to engage in paid work or volunteer work. Community Advocacy and Support - improves the child s ability to gain from the community and educational experience and enables the child s environment to respond appropriately to the child s disability and/or health care issues 6
Non-Medical Transportation - offered, in addition to any medical transportation furnished under the 42 CFR 440.17(a) in the State Plan. Non-medical Transportation services are necessary, as specified by the service plan, to enable participants to gain access to authorized services that enable them to integrate more fully into the community and ensure the health, welfare, and safety of the child/youth If yes, what services do you provide and who provides this service? (list services, number of staff, and their credentials) If no, do you collaborate with others (e.g., outside agencies) to provide these services? Day Habilitation Services - assists children with developmental disabilities with the self-help, socialization, and adaptive skills necessary for successful functioning in the home and community when other types of skill-building services are not appropriate Adaptive and Assistive Equipment - provides technological aids and devices that can be added to the home, vehicle, or other eligible residence of the enrolled child to enable him/her to accomplish daily living tasks that are necessary to support the health, welfare, and safety of the child 7
Accessibility Modifications - provides internal and external physical adaptations to the home or other eligible residences of the enrolled child that are necessary to support the health, welfare, and safety of the child If yes, what services do you provide and who provides this service? (list services, number of staff, and their credentials) If no, do you collaborate with others (e.g., outside agencies) to provide these services? Palliative Care - set of services offered to help families deal with end-of-life related issues due to child s illness. Types of services included: Family Palliative Care Education (Training); Bereavement Therapy; Pain and Symptom Management; Expressive Therapy (Art, Music and Play); and Massage Therapy Completed by: Date: Title: Agency: E-mail: 8