Organization Profile: North Central Mental Health Services (North Central) is a comprehensive community-based mental health and substance abuse recovery agency. North Central provides short- and long-term services for all age groups in Franklin County, Ohio. Incorporated in 1973, North Central’s main facility is located in Columbus with satellite offices in several nearby communities. The agency also operates a number of residential programs across the county. North Central’s mission is to provide an array of clinically excellent, culturally competent, and user-satisfying mental health and recovery services that promote personal growth and independence while improving the quality of life for children, adults, and families affected by mental illness, emotional distress, or chemical dependency. Working with people in many ways to carry out its mission, North Central emphasizes self direction and resilience, personal responsibility, personal and social empowerment, and hope (i.e., the belief that each person can progress and grow).
North Central operates as a community not-for-profit agency affiliated with the Alcohol, Drug, and Mental Health Board (ADAMH) of Franklin County. The major mental health services offered by North Central include elder focus, family focus, recovery support, suicide prevention, prevention and education, and psychiatry.
Program Structure/Design: The Transitional Community Treatment Team (TCTT)was established in 1990 and was one of the first community treatment teams for transition-age youth in the U.S. As Ohio was closing its state psychiatric hospitals in the late 1980s, the Alcohol, Drug, and Mental Health (ADAMH) Board of Franklin County and North Central used start-up funding from the Robert Wood Johnson Foundation to design and implement a program of community treatment teams for adults with severe mental illness. When the Ohio children’s psychiatric hospital also closed, its youth began ending up in jails and adult inpatient wards. As a result, momentum grew to develop a better way to meet these youths’ mental health needs, resulting in the establishment of the first adolescent treatment team for youth ages 16-22, TCTT, in 1990. After several years, a second team was added to serve adolescents ages 14-15. Since its inception, the TCTT program has worked with more than a thousand youth ages 14-22, providing treatment services for multiple mental health needs and coordinating involvement with multiple service systems, including mental health, education, child welfare, and juvenile court.
TCTT’s mission is to help adolescents and young adults with mental illness move into adulthood; assist them with recovery and enhance their resilience; help them achieve employment, independent living, and stable social relationships; and become integrated into the local community. This transitional program is customized to meet each individual’s needs and emphasizes that young people can do well despite facing adversity in their lives. It offers a bridge for youth most in need of assistance by providing a connection between the two large systems of child mental health and adult mental health.
The target population for the TCTT program is youth ages 14-22 who have had: (1) a diagnosis of a severe emotional disturbance or severe mental illness; (2) a previous psychiatric hospitalization (including residential treatment); and (3) multi-agency involvement (e.g., with special education, child welfare, and/or the juvenile justice system). These young people have been described as high-need youth who in the past would have been in state psychiatric hospitals.
TCTT’s design is based on an adaptation of the Program for Assertive Community Treatment (PACT) model, an evidence-based intervention developed for adults with severe mental illness who are transitioning from state psychiatric hospitals to the community. The PACT model emphasizes employment as a long-term approach to treatment and recovery. The model includes individualized assessment, employment placement, follow-along services, and reassessment. PACT programming integrates clinical and rehabilitative services within a continuous or assertive community treatment team, such as TCTT. While the original PACT model team was comprised of case managers and nursing staff, the current TCTT interdisciplinary team includes a team leader, case managers, a psychiatrist, therapists, and an outreach nurse.
Defining features of the TCTT program include the following:
- A well-coordinated, multidisciplinary approach based on PACT principles, with teams that include a psychiatrist, nurse, team leader, team counselor, case managers, an education/vocational specialist, and wrap-around staff or case aides. Case managers assume specialist responsibilities in areas such as housing, child welfare, benefits, and juvenile justice liaison.
- A younger staff, most of whom are in their 20s and capable of relating to an adolescent and young adult population.
- Appropriately trained staff who are knowledgeable about adolescent development and adolescent treatment strategies.
- A program that is flexible and understands both the youth and adult social service systems, with well-established program linkages to, and relationships with, each system.
- A philosophy that is balanced between a youth-system orientation (encompassing the person- and family-centered approach) and a young-adult approach (emphasizing adolescent empowerment, responsibility, and developmental autonomy).
- Location within an adult-oriented treatment facility to help ensure that program graduates move seamlessly into appropriate adult services, as required.
- Delivery of services within the larger community and natural settings, to promote “normalization.”
- Use of highly individualized county-based wrap-around supports that can meet the needs of the most at-risk young people.
- Team meetings three mornings per week to ensure close communication and coordination of care.
- Flexible staff scheduling to meet individual youth needs, including 24-hour-a-day crisis support.
- Group treatment and life skills instruction to advance the development necessary for illness management and successful emancipation.
- Transition and emancipation of adolescents into safe, affordable housing arrangements.
Since initial funding support for the TCTT program from the Robert Wood Johnson Foundation ended, Franklin County funds and Medicaid reimbursements have primarily sustained the program. In Ohio, all mental health funding is distributed through local government agencies. In the case of TCTT, North Central bills the county for each individual service using established Medicaid fee-for-service procedures. This billing is largely for medical, psychiatric, and case management services and does not include rehabilitation services, since these are not covered under Ohio’s Medicaid plan.
In 2007, North Central entered into a contract with the Child Welfare system to work with an additional 100 youth who had a mental illness and were emancipating from Franklin County’s Children’s Services. This TRAC (Transition, Resilience, Ability, Courage) component of the TCTT program has an additional funding stream from the Franklin County ADAMH Board of Franklin County, Franklin County Children’s Services, and federal John H. Chafee Foster Care Independence Program.
North Central has four full-time independently licensed intake workers for the entire agency. Intake to the TCTT program generally occurs with the family coming to North Central, but if the youth is in a hospital, an intake worker will go there for the process. Within 24 hours after the intake, the intake worker meets with the North Central associate director who assigns all new clients to the appropriate service. If the young adult is assigned to TCTT, the clinical director meets with the youth and the family to explain the TCTT services. Referral, intake, assessment, and delivery of the first services all usually occur within a week’s time.
Once the youth and family have been assigned to a team, a case manager is paired with them and individualized service planning begins. TCTT utilizes a structured individualized service plan that addresses multiple life domains. All enrolled youth must work on clinical recovery and, if they have a drug or alcohol problem, this must also be addressed in the plan. Other life domain components are addressed in accordance with young adults’ priorities and include personal empowerment, social empowerment, community integration, education and career technical (i.e., vocational) training, and general health. Partner agencies generally do not participate in developing the individualized service plan, but do participate in its implementation as appropriate.
The young adults are central to designing their own plan. If they are 18 or older, family participation is not required but is encouraged. For youth ages 14-17, family participation is required. Parents (or child welfare for those who are in their custody) are required to sign the plans and the youth to co-sign. The plans are very structured and designed to guide participants through the process.
States of Operation: OH
ODEP Funded: No
School-Based Preparatory Experiences: Youth entering the TCTT program are often high school dropouts or in a secondary special education program. A significant number of TCTT program participants have individualized education programs (IEPs) that were developed as part of their schooling, and in these instances, the program’s mental health plan is attached to the IEP (as required by state regulation). There appears to be a consensus among TCTT program managers and staff that this coordination with the local schools works well if TCTT is able to get involved early. One of the reasons the program expanded eligibility to age 14 was to reach adolescents before they dropped out of school.
For youth who are eligible to earn a high school diploma, the goal may be to reconnect them to secondary school. Alternatively, the objective may be to (1) facilitate attainment of a GED certificate; (2) encourage enrollment in an appropriate career technical training program, such as the Center for Vocational Alternatives (COVA); or (3) assist them with career assessment and a job search. Depending on an individual’s goals and prior attainment, some older youth may also be assisted to apply to Columbus State Community College, a local community college that provides extensive support for youth with disabilities. It is the responsibility of each individual youth and his or her case manager to help determine which pathway is best.
Career Preparation and Work-Based Learning Experiences: Young adults are referred to the Franklin County COVA for career preparation services and exposure to career options or career pathways. COVA provides vocational assessments, career technical training, referrals, on-site computer classes, job coaching, and independent employment options. COVA has well-established relationships with employers who work with adults with mental illness.
For youth who do not opt for the COVA route, case managers will walk them through the job search process and provide more informal job coaching, guiding them through the competitive employment process. Case managers frequently facilitate work-based experiences, including job shadowing, internships, and community service. They also may communicate directly with employers, but this type of activity is limited. TCTT also refers individuals to the Ohio Bureau of Vocational Rehabilitation (BVR) for job matching services, occupational skills training, and supported employment.
Connecting Activities: The TCTT program provides intensive independent-living skills training. This training is delivered both individually and in groups, and includes areas such as medication management, financial planning, benefits management, and travel planning.
North Central is frequently the representative payee for youth who receive Supplemental Security Income (SSI) disability benefits and/or Social Security Disability Insurance (SSDI) benefits, but they also instruct youth on how to become their own payees.
Case managers do considerable training in conflict resolution, self-advocacy, and empowerment, and provide youth numerous opportunities for building leadership skills and self-esteem. The program also instructs young adults on daily living skills, hygiene, practice for job interviews, and job seeking. At present, however, formal mentoring activities are limited.
The TCTT program has trained staff on-site to assess mental health needs and provide mental health treatment. For youth receiving services from TCTT, all of the case management provided is intensive. North Central also has certified staff on-site who can provide substance abuse treatment, and young adults with significant substance abuse treatment needs can receive services through North Central’s Integrated Dual Disorders Treatment team.
TCTT also coordinates with, and refers youth to, school-based day treatment when needed. While mental health services are provided directly, TCTT refers adolescents and young adults off-site for general health services. TCTT provides transportation when needed. TCTT also helps young adults obtain housing services, personal documentation (e.g., library cards, voter registration, birth certificates), medical records, and child care if needed.
Housing is a particularly critical need for this population. TCTT provides support to help its young adults find housing. For example, it works with the Community Housing Network (funded by ADAMH), which helps people with mental illness find subsidized housing. TCTT also works with young adults who qualify for public housing. Additionally, in 2008, North Central purchased a multi-unit apartment complex that transition-age youth may use. This facility provides a supervised, safe, and secure apartment living environment for youth with mental illness.
EVIDENCE OF SUCCESS (INFORMATION AND ANALYSIS)
Systems Change: The TCTT program definition includes the following indicators of success: (1) fewer hospitalizations, (2) more youth employed, (3) more youth living independently, (4) more high school completions or GED attainments, and (5) less intensive services needed going forward. In 2010, the TCTT program director summarized the meaning of “success” for the program as follows: “Success in this program is determined by successful transitions to adulthood, increased levels of independence, and linkages by the team to the most appropriate community resources.”
Over the past 20 years, the TCTT program has had many young adults move from needing intensive case management services to requiring less intensive services, such as mental health counseling. North Central and TCTT both further define success as a client’s ability to enjoy a better quality of life without discrimination based on mental illness. They help clients better understand their illness, continually move through a lifelong recovery process, and appreciate their uniqueness and work with that in their recovery. To facilitate these objectives, the Transitional Team is extensively involved with community psychiatric hospitals, local schools, juvenile courts, and child welfare.
As part of its ongoing self-evaluation, the TCTT program looks at the history of each youth at admission and again at discharge to help benchmark individual progress and program effectiveness. TCTT also conducts satisfaction surveys on a regular basis, administering them at the time of admission, at three months, at six months, and annually to assess and reassess outcomes. Outcomes are also monitored through treatment planning and termination summaries that address the goals attained and not attained. Termination summaries are also examined—that is, where the young adults go after they leave TCTT. In addition, the ADAMH Board calls a random sample of clients to assess their satisfaction with program services.
Respondents to a 2008 stakeholder survey indicated that the TCTT program’s most important achievements are all of the young adults who have successfully transitioned to adulthood and been diverted from a chronic course of illness. A Franklin County Children’s Services (FCCS) representative stated that the program has been extremely successful, thus far, both financially and clinically: “The youth are being well-served, gaining skills towards independence and at great savings.” For example, the first 20 youths in TRAC cost an average of $450 per day to house in their various residential placements before referral to TCTT (i.e., $270,000 per month or $3,240,000 per year). By comparison, TCTT was budgeted for $450,000 to serve 40 youth in the same time period. While FCCS incurred some costs for these youth after referral and billing for some Medicaid services through North Central, the net savings in placement and service costs were considered very impressive.
Respondents to the 2008 survey also felt that a definite strength of TCTT was that the program is part of and located in the overall North Central Community Health Services Center. While acknowledging that being located in the Center was initially a challenge to engaging youth, they came to believe that being in proximity to the adult center was an advantage, since a proportion of these youth are likely to need some adult services, even if less intensive, and will already be familiar with the adult mental health center and system.
North Central also has come to appreciate the collaboration that exists between the TCTT program and Franklin County Children’s Services. This collaboration has resulted in building strong professional relationships that are a benefit to both organizations on behalf of the citizens of Columbus and Franklin County.
Because TCTT was among the first programs of its kind, it has provided consultations locally, regionally, and throughout the U.S. and Canada. TCTT has helped raise sensitivity to the special needs of the youth population in adult mental health programs. The TCTT program has shown that youth with mental illness can be treated successfully and that there is a great need for this type of program. TCTT’s future plans include opening a drug and alcohol program for minors and supported housing resources for the transition-age population.
Organization Name: North Central Mental Health Services
Organization Director: Kim Yates
Program Name: Transitional Community Treatment Team (TCTT)
Street Address: 1301 North High Street
Phone Number: (614) 299-6600
Phone Extension: 2048
Contact E-mail: firstname.lastname@example.org