Cenpatico Integrated Care

Guidance Document


Transition to Adulthood

Developed by

Cenpatico Integrated Care

Effective Date: [November 2016]

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TITLE

Transition to Adulthood

GOAL/WHAT DO WE WANT TO ACHIEVE THROUGH THE USE OF THIS TOOL?

To strengthen practice within the Cenpatico system and promote continuity of care through collaborative planning by:

supporting individuals transitioning into early adulthood in ways that reinforce their recovery process;

ensuring a smooth and seamless transition from the children’s behavioral health service system to the adult service system; and

fostering an understanding that becoming a self-sufficient adult is a process that occurs over time and can extend beyond the age of eighteen.

TARGET POPULATION(S)

All adolescents enrolled with Cenpatico Integrated Care who will be experiencing transition at the age of 18. All young adults up to age 22 enrolled who have transitionedto adulthood.

PRACTICE GUIDANCE

Youth should be encouraged to remain enrolled in the system upon turning 18 so that providers can assist them in achieving their transition goals.

ICC Agencies who serve both children and adults are encouraged to develop blended teams, comprised of recovery coaches that are skilled and able to work with youth during their entire transition period.

ICC Agencies are encouraged to administer the Casey Life Skills Assessment (CLSA) within 6 months of the member’s 16th birthday to assess the member’s current understanding of life skills, then annually thereafter until the member turns 18. Staff are encouraged to utilize areas of need to develop treatment goals.

Recovery Coaches are encouraged to complete Cenpatico-IC Provider Manual Form 4.1.2 Transition to Adulthood Checklist to assist the youth in coordinating, identifying and completing various transition-related tasks which should result in the development of a plan for transitioning to adulthood.

Youth should be encouraged to co-facilitate CFT meetings and should assist in completing their Transition to Adulthood Checklist (Provider Manual Form 4.1.2)

For youth transitioning to another ICC Agency at age 18, it is encouraged that a DRC/RC must attend and be a part of the monthly Child and Family Team (CFT) meetings no later than the youth turning 17.5 years of age.

In conjunction with other involved family members, caregivers, or guardians, ICC Agencies are encouraged to support the member and clinical team upon request to retain his/her/their current CFT until the youth turns 21.

TRAINING AND SUPERVISION RECOMMENDATIONS

It is recommended that all staff working with members ages 16 through 22 complete the Transition Age Youth Curriculumin Relias. It is recommended that staff working with Transition Age Youth have knowledge of both child and adult systems of care and are able to assist youth with natural and community support wrap around services.

ANTICIPATED OUTCOMES

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It is anticipated that:

  • Services and identification of service providers that are indicated as needed to assist the member will result in achieving independence in various areas of transition.
  • There will be improved self -advocacy in transition age youth.
  • Increased engagement and collaboration of members, families, and support systems in the transition planning process
  • Transition Age Youth will have stable housing.
  • Transition Age Youth will have employment or involvement in education or training
  • Decreased involvement in crisis system.
  • Youth will have knowledge of accessing their own medical care and have regular medical follow up.
  • Youth will demonstrate skills to manage finances, health, nutrition and self-advocacy.
  • Increase in natural and community supports.
  • There will be an increased awareness and utilization of early psychosis interventions.
  • There will be further exploration of developing an integrated program.
  • A Youth Center will be opened to provide a safe place for TAY and it will be a location where they can learn living skills.
  • There will be an increase of direct support and family support to assist youth, young adults and their family members.
  • Additional blended teams will be developed to maintain stable housing, maintain school attendance, and increase employment rates.

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