Senior Care Case Management

The Senior Care Case Management Team, a collaborative effort between Montgomery County Office of Aging and Adult Services and Central Montgomery MH/MR Center, provides services for individuals aged sixty and over who have mental health and/or substance abuse needs and live in Montgomery County. The programs’ goal is to provide emotional and resource support for seniors in need, through relationship building with Senior Adult Activity Centers, subsidized project-based housing providers, and local social service organizations that can assist in providing support to our consumers.

Services:

  • Providing outreach to older adults who may be homebound or in need of mental health services.
  • Providing resource connections for seniors.
  • Educating individuals and facilities as to available mental health support services.

Program Goals:

  • To eliminate or postpone the need for long term institutional placement
  • To promote a sense of independence, hope, meaningful life, and well being within the consumers
  • To create an ongoing network of community support services
  • To honor the choices and nurture the dreams of the consumer by looking beyond illness management
  • To advocate for and connect a person to supports.

Staff:

  • Two Senior Care Case Managers
  • Support from Central’s Senior Outreach Services (SOS Team)
    • Licensed Clinical Social Worker
    • Psychiatrist

Senior Outreach Services (SOS)

In-Home Services Available Through Senior Outreach Services Include:

  • Psychiatric Evaluations
  • Psychosocial Assessments
  • Ongoing Medication Monitoring
  • Intensive Support and Counseling
  • Emergency Intervention
  • Caregiver Support and Training

An Appropriate Referral for Senior Outreach Services is:

A person age 60 or older

  • who is a Medicare recipient (although other insurances may be accepted)
  • lives at home and
  • has a history of serious and persistent mental illness or substance abuse
  • is experiencing an acute emergence of significant mental health issues.

(may be depressed, agitated, irrational…)

  • who may be homebound isolated or frail.
  • who may be suspicious, fearful or unable to seek clinic-based services.

The Mental Health Professionals who make up the S.O.S. Team are:

  • A Board Certified Psychiatrist

 Licensed Clinical Social Worker experienced in the treatment of serious and persistent mental illness and trained in crisis intervention techniques, co-occurring, and in the management of psychiatric emergency situations.

The Treatment Outcomes We Work to Accomplish:

  • Eliminate or postpone the need for long-term institutional placement.
  • Resolve acute episodes with shorter hospital stays or without having to hospitalize at all.
  • Reduce symptoms and behaviors that are troublesome and distressing for both the elderly person and the caretaker.
  • Promote a sense of independence, self-reliance and well-being.
  • Create an ongoing network of community support services.

OASIS Program

OASIS is a partial hospital program tailored to meet the needs of the older adult with behavioral health and co-occurring challenges.  Special focus is placed on both problems arising from the aging process and the wisdom resulting from a multitude of life experiences. The OASIS program aims to implement interventions through various modalities and to maximize and improve an individual’s emotional, behavioral and physical health. In addition, the program works with older adult clients to assist as they develop and restore their resiliency and achieve personal fulfillment. Our goal is to help older adults prevent premature institutionalization by supporting the individual in living as independently as possible within the community.  OASIS utilizes treatment approaches to reduce symptoms and behaviors that are troublesome and distressing for both the individual and the caregiver.  Our program and staff promote a sense of independence, self-reliance and well-being.  We help the individual create an ongoing network of community supports. Our therapeutic groups are designed to meet these goals, increase social interaction and improve the individual’s sense of self-worth and competence.  Additionally, each person is assigned a therapist who develops an individualized plan which is the focus of treatment and is regularly reviewed with the individual.  Each person’s unique treatment plan is also overseen by the OASIS Program psychiatrist, who develops an appropriate medication intervention and maintains a link with involved general medical practitioners. 

Treatment at OASIS is addressed in a 6-hour therapeutic day which may be attended from 1 to 3 days a week (Monday, Wednesday and Friday). Group therapy topics include: Personal recovery issues, Grief and loss, Improving depression, Maintaining sobriety and stability, Exercise for the mind, Reminiscing group, Physical wellness, Wellness through art, Social Skills group, Wellness through music, and more!

Referrals

Individuals interested in the OASIS program will first complete an intake assessment in our Outpatient facility. Individuals must be at least 60 years of age or older, living in eastern or central Montgomery County, have a history of behavioral health issues/substance abuse or use and experiencing difficulty due to increase in symptoms, have the ability to interact with others and participate in a group therapy environment, ambulatory and able to manage their physical needs with minimal assistance. Call our Outpatient & Intake Services office to schedule your confidential intake appointment today.

Location

Central's Main Office

Behavioral Health Rehabilitation Services (BHRS)

Behavioral Health Rehabilitation Services are highly individualized mental health interventions that are designed to support a child in his home, school and community.

Central's BHRS staff includes…..

  • A., M.S.W. & Ph.D. level Behavioral Specialists
  • Bachelor's and Master's level Therapeutic Support Staff and Mobile Therapists
  • Child Psychiatrist available for consultation and a psychologist.
Examples
  • In-home family therapy for families who have been unable to access traditional services at community counseling centers
  • Intensive home and community therapeutic support and supervision for a child or adolescent just released from the hospital
  • One-on-one day care or schoolroom support for a young child whose behavior is seriously disruptive or inappropriate or for a child experiencing school phobia
  • In-home behavior management and parental skills training for children and parents experiencing acute difficulties in areas of discipline, toilet training, bedtime, etc.
Eligibility

Children under 21 years of age and their families.

The child must be enrolled in the state's Medical Assistance Program offered through the PA Dept. of Public Welfare. We can provide enrollment information.

The child and his or her family must choose to receive this service — BHRS cannot be mandated.

A psychiatrist or psychologist must evaluate and state that BHRS services are necessary to stabilize an acute situation.

Typically, a child for whom BHRS services are deemed necessary is a child who is receiving or who has received mental health services in the past, who is involved with other child-serving agencies, and who appears to need something more.

Referrals

To make a referral, call our Outpatient & Intake Services office and ask for the Children's Intake Coordinator.

Anyone can make a referral: school personnel, mental health professionals, family members, etc..

Location

Family Services

Family Based Services (FBS)

Central’s Family Based Services (FBS) program is designed to provide community based therapy and support services to children and adolescents with emotional and behavioral problems.  FBS provides therapy in a family’s home by a two-person team under the supervision of a Program Director.

Life can feel very challenging and frustrating at times when you are facing stress at work, home and within your family. We recognize that raising children is not an easy task and want to help you learn new strategies to better manage behavioral and emotional issues that are impacting your family. The goal of the program is to increase parents’ feelings of empowerment, effectiveness and self-efficacy while also increasing the emotional and behavioral stability of the children. The function of FBS is to assist families with maintaining their child in the home rather than in a psychiatric or residential facility.

Family members are encouraged to actively participate in assessment, treatment planning, development of treatment goals, and ongoing review of progress.  The child, family and FBS team work together to develop a plan that is individualized and designed to fit each family’s unique situation.

Services include:
  • Intensive Family Therapy
  • 24/7 Crisis Management
  • Case Management Services
  • Advocacy for the family
  • Support Services
Referrals

The identified client (child or young adult) must be 21 years or younger, at risk for out-of-home placement (juvenile detention, OCY, psychiatric hospitalization and residential placement), a Montgomery County resident, and have medical/behavioral health insurance coverage through Magellan. In addition, at least one parent or guardian must be willing to participate in the program and the child and family must be experiencing difficulties serious enough to warrant intervention from our Family Based Services program.

Location

Family Services

Extended Assessment

Central’s Extended Assessment Program is designed to provide a comprehensive assessment for children and adolescents who are thought to be in need of in-home services. The goals of the program are to provide immediate stabilization and to determine the most suitable service for the child being evaluated. Services are provided in the child’s home, school and/or community, as needed. Case Management services are available to assist the family and school staff in identifying some family and community supports and resources which may be available to help out the child and family. A Functional Behavioral Assessment may be completed to identify and understand a child’s behaviors and concerns. In order to complete the Extended Assessment process, the child or adolescent will have a psychological or psychiatric evaluation. This evaluation will prescribe the necessary level of treatment.

Eligibility

A child who is under the age of 21 and who has coverage from Health Choices Magellan Behavioral Health is eligible to receive Extended Assessment Services.

Location

Family Services

Children’s Case Management

Children’s Case Management Services are provided through various levels of care which include Blended Case Management (BCM), and Administrative Case Management (ACM). These programs are designed to reduce hospitalizations and avoid out of home placements for children and adolescents with emotional, behavioral and/or substance abuse problems. They promote family integration by providing assistance in coordinating appropriate mental health services and facilitating communication among treatment members. In addition, when a child or adolescent is enrolled in Blended Case Management services, he/she is assigned to a specific case manager.

Services

Children’s Case Management Services partner with the client and his/her family to coordinate, facilitate, or provide:

  • Family/Community Supports – Income Supports & Entitlements
  • Mental Health Treatment – Socialization/Peer Supports
  • Advocacy – Information & Referrals
  • Crisis Intervention – Physical Healthcare
  • Addressing Housing Needs – 24/7 On Call (Blended only)
Eligibility

Any Montgomery County resident under 21year old and still enrolled in school, living in Central Montgomery County and surrounding communities (Norristown, Conshohocken, Bridgeport, Lafayette Hill, King of Prussia) and being treated for emotional and/or behavioral problems is eligible for this service. Typically, eligible children and adolescents have many systems (Office of Children and Youth (OCY), Juvenile Probation Office (JPO), Special Education programs, Developmentally Disabled) involved and are prone to crisis.

Funding

There is no cost to the individual receiving Case Management Services; these programs are funded through federal, state, and county resources. If you have a child or adolescent you would like to refer to our Children’s Case Management program, please call our Child & Young Adult Services office. All calls are confidential.

Location

Child & Young Adult Services

Transition to Independence Process (TIP)

Life is a journey, but you don’t have to do it alone. If you are between the ages of 16 to 26, Central’s TIP Program can help navigate the road towards independence. TIP is an empirically supported model developed to work with young people experiencing emotional and/or behavioral difficulties.  TIP works to engage and support young people with the planning process for their future across five transition domains; Educational Opportunities, Living Situation, Employment and Career, Community Life Functioning, and Personal Effectiveness and Wellbeing. 

TIP provides a great deal of flexibility and works to engage young people through relationship development, person-centered planning, and a focus on the young person’s future.  Services and supports are tailored to be accessible, appealing, non-stigmatizing, and developmentally appropriate, and will build upon strengths to support the young people in pursuing their goals across the five transition domains.  Personal choice and social responsibility are acknowledged and developed, and personal competencies will be enhanced to support the young people in greater self-sufficiency and confidence.  TIP will work to ensure that a safety net of support to include informal and formal key players in the young person’s life will be in place.  TIP will maintain an outcome focus and will involve young people, parents, and community partners at the practice, program, and community levels.  TIP provides frequent contact with the youth, typically weekly.

More information can be found at www.TipStars.org.

Eligibility

Adolescents and young adults ages 16-26 with emotional and/or behavioral health needs, who have a mental health disorder and medical assistance will be eligible. 

Anyone can make a referral on behalf of the young person utilizing the TIP Referral Form.  It is encouraged that the referral be discussed with the young person to ensure that they are interested in exploring TIP services.

TIP works collaboratively with all other key players involved in the young person’s life.  Certain services, including Case Management (Recovery Coaching, BCM, D&A ICM), High Fidelity Wraparound, RTF, Therapeutic Foster Care, Family Based Services, ACT, and MST are considered a duplication of services with TIP.  However, each young person’s needs will be evaluated, and exceptions may be made based on those needs.

Referral

Contact Central to get set up with a TIP facilitator at our Child & Young Adult Services office.

Location

Child & Young Adult Services

Intensive Outpatient Program (IOP)

The Intensive Outpatient Program is a group therapy program for people with persistent or recurrent co-occurring disorders that require a more intensive level of care due to symptoms. This could be due to an acute phase of the disorder and/or crisis or transition from an inpatient facility to a community setting. The program is tailored to meet the unique needs of each individual, especially those with co-occurring challenges (behavioral health issues and substance use/abuse history). In an effort to target the various needs of our diverse population of individuals, we have developed several IOP tracks. These tracks are General Adult Population, Life Skills Enhancement, and Co-occurring IOP and includes group therapy topics that were developed to help those identified individuals move closer towards their identified goals. A consumer can choose to attend one group per week or attend a three hour session several times per week, based on one’s current needs. The goal of the IOP is to empower participants to support their own recovery, cope more effectively, prevent relapse and strengthen social relationships through group therapy and community forum to eventually integrate into the community.

Our program offers a wide array of group therapy topics such as Trauma groups, Co-Occurring groups, Music Therapy, Creative Expressions, and Wellness groups. We provide a “Women’s Group” or a “Men’s group” for individuals who may have a preference to work through more difficult, sensitive issues with peers of the same gender. In addition, we offer a Grief and Loss group, 12-Step Group, Goals group, Emotional regulation group, Personal issues group, Understanding mental health group, and more!

Referrals

Individuals  (18 years of age and older) living in central and eastern Montgomery County who are interested in joining the Intensive Outpatient Program (IOP) and attending one or more of the groups they have available can call to schedule an intake at our Outpatient department. Contact an intake worker at our Outpatient & Intake Services building. If the individual is currently receiving other services from Central, you can schedule an IOP intake by calling Central's Main Office.

Location

Central's Main Office

Certified Peer Specialist (CPS)

At Central, we offer peer support services to individuals who qualify and live within the boundaries of Central and Eastern Montgomery County. We provide CPS services to individuals with many different needs that can benefit from extra support and guidance. A CPS offers assistance and resources and are able to relate their experiences while walking side by side with people that are on a path of recovery. In addition, CPS’s are able to support individuals with co-occurring substance use disorders that may interfere with whole health recovery.

Our CPS Engagement Specialist for Project Connect engages and works closely with participants who are inpatient at MCES and other inpatient facilities. The goal of this service is to connect, engage, or re-engage individuals who have a serious mental illness and are reluctant to engage with formal supports to link to needed services.

The CPS Generalist offers individuals support with a general goal oriented recovery plan. This may include maintaining ongoing recovery, community activities, integration, socialization, or extending guidance to someone towards the direction of other services. The CPS Generalist instills hope for recovery, encourages self-advocacy, peer choice and personal responsibility.

Our CPS Career Specialists support individuals preparing to return to the workforce and seek employment.  This includes support for building a resume, completing online applications, preparing for an interview connecting the applicant with current employers who are hiring, and understanding how future employment will affect current benefits. The career peer specialist can support the individual with managing their health and wellness to secure and maintain employment. They can discuss the advantages to gaining a job and how to utilize educational resources to further enhance career choices.

The Older Adult CPS provides community based supports for Older Adults (60 years and older) to help create a network of natural supports and to decrease isolation.  This CPS service can foster hoper for an older adult by helping to create meaning in a person’s life.

Referrals

Individuals eligible for peer support services have a serious mental illness with moderate to severe functional impairments in those areas supported by the team as indicated above. Their treatment history will indicate past hospitalization(s), past encounters with the mobile crisis unit, a history of attending community mental health or prison psychiatric services, and/or difficulty maintaining consistency in previous behavioral health treatment. Referrals can be initiated by another behavioral health professional, however, a physician, psychiatrist or licensed psychologist will review and recommend this service for the individual.

Location

Central’s Main Office

Abington Area Services