Whole Person Health Services
OVERVIEW
Community 43 is a comprehensive system of care providing support for people living with serious mental illness in the Phoenix metropolitan area.
Community 43 will increase individuals’ capacities to manage their health and wellness, live a self-directed life, and reach their fullest potential by providing person-centered, recovery-oriented services.
Based on the core principles of peer support, self-empowerment, and functionality within a community setting, Community 43 strives to help members:
• Participate in mainstream employment and educational opportunities
• Find community-based housing
• Join health and wellness activities
• Reduce hospitalizations
• Reduce involvement with the criminal justice system
• Improve social relationships, satisfaction, and quality of life
Community 43 provides psychosocial rehabilitative services to people living with serious mental illness to further their self-empowerment, recovery, health and wellness, and improve their integration into the community.
We assist members with establishing meaningful social roles, including competitive employment. Community 43 provides and sustains a strong social support system for members in a non-institutional environment.
The overall goal is to integrate and assimilate members into the larger community by supporting them to meet their vocational, educational, psychological, and social goals. The program objective is to foster independence for people with serious mental illness to live a self-determined life.
At Community 43, members have the opportunity to engage in meaningful day activities of their choosing, including art, culinary skills, gardening, fitness and wellness and daily operations.
Based on their individual goals and preferences, members select the activities they are most interested in and participate according to a schedule created in concert with Community 43 staff.
Programs are based on assumption that people have individual strengths that can be built on and that meaningful relationships and work are essential; members have the right to choose staff to work with and the kind of work they do.
Whole Person Health
Community 43 is licensed for behavioral health outpatient care. Services are delivered under the supervision of a licensed behavioral health professional using an evidence-based practice model, where staff and members work side-by-side to create a community of support that offers a wide array of services.
These services include:
• Assessment
• Community Support Services (case management)
• Family and Peer Support Services
• Health Promotion
• Supported Education
• Supported Employment
Assessments
Community 43 will conduct assessments, as appropriate, to ensure that members receive the necessary services to support them on their recovery journey. Using a person-centered approach, Community 43 will seek to understand members’ strengths, goals and needs, as they define them and collaborate with the member’s Adult Recovery Team to provide or connect the member to services and supports.
Community 43 will offer a voluntary substance use assessment within the first three months of enrollment by implementing the CAGE-AID or other validated screening tool. Positive screenings will result in referral to supports to address co-occurring needs.
Community Support Services
(Case Management)
Community 43 members will have access to an array of case management services provided by members and staff including connecting members to benefits and supports such as housing resources and advocacy and assisting members to access quality medical, psychological, pharmacological and substance abuse services. Through the delivery of case management services, Community 43 will coordinate services and supports with the member’s Adult Recovery Team, other providers involved in the member’s care and community organizations.
Crisis Prevention Planning
Community 43 will introduce members to the value, development and use of relapse prevention and crisis intervention planning such as Wellness Recovery Action Plans (WRAP) and psychiatric advanced directives.
• Community 43 will offer informational sessions on Crisis Prevention/Intervention Planning three (3) times per year and will document member participation with sign-in sheets kept in a binder on-site, and in member progress notes in case records. Members will have the opportunity to complete a Crisis Prevention/Intervention Plan annually either individually or in a group setting.
• Annually, one staff generalist and one Community 43 member will be given more than basic training in order to build internal capacity to provide informational presentations, facilitate groups and support members’ development of a crisis prevention/intervention plan. Documentation of training completion will be kept on-site in a binder and readily available.
• Wellness Recovery Action Plan (WRAP®) training will be offered every 90 days. A WRAP® is a personalized wellness and recovery system born out of and rooted in the principle of self determination. WRAP® is a wellness and recovery approach that helps people to
1) decrease and prevent intrusive or troubling feelings and behaviors;
2) increase personal empowerment;
3) improve quality of life; and
4) achieve their own life goals and dreams. Working with a WRAP® can help individuals to monitor uncomfortable and distressing feelings and behaviors and,
through planned responses, reduce, modify, or eliminate those feelings. A WRAP® also includes plans for responses from others when an individual cannot make decisions, take care of him/herself, and/or keep him/herself safe.
Family and Peer Support Services
Community 43 will connect participants to peer and family support services as an essential component of our recovery-oriented program. We will offer peer support certification classes to facilitate meaningful employment opportunities for members. Core competencies include:
• Recovery-Oriented: Peer workers hold out hope to those they serve, partnering with them to envision and achieve a meaningful and purposeful life. Peer workers help those they serve identify and build on strengths and empower them to choose for themselves, recognizing that there are multiple pathways to recovery.
• Person-Centered: Peer recovery support services are always directed by the person participating in services. Peer recovery support is personalized to align with the specific hopes, goals, and preferences of the individual served and to respond to specific needs the individual has identified to the peer worker.
• Voluntary: Peer workers are partners or consultants to those they serve. They do not dictate the types of services provided or the elements of recovery plans that will guide their work with peers. Participation in peer recovery support services is always contingent on peer choice.
• Relationship-Focused: The relationship between the peer worker and the peer is the foundation on which peer recovery support services and support are provided. The relationship between the peer worker and peer is respectful, trusting, empathetic, collaborative, and mutual.
• Trauma-Informed: Peer recovery support utilizes a strengths-based framework that emphasizes physical, psychological, and emotional safety and creates opportunities for survivors to rebuild a sense of control and empowerment.
Health Promotion
A wellness program will offer a daily healthy lunch service, nutrition education and will draw from therapeutic modalities used in the horticulture and art communities. The work-day focus and daily routines will integrate wellness programming throughout Community 43. The program will offer Health and Wellness Education and encourage participation in Health and Wellness meetings/inservice/education.
• Smoking Cessation activities will be offered on an ongoing basis. Participation will be documented with sign-in sheets that will be kept in a binder and reflected in member progress notes in case records. An unduplicated list of members who participate in Smoking Cessation activities will be kept on-site in a binder and will be updated regularly and readily available for review. Co-occurring Substance Use and Smoking Cessation activities will be offered on an ongoing basis.
• Community 43 will offer Health and Wellness Education, which focuses on the principles of SAMHSA’s 8 Dimensions of Wellness. The program will institute annually, one (1) time-limited best or evidence-based practice module series pertaining to health and wellness, such as SAMHSA’s Whole Health Action Management (WHAM). Participation in Health and Wellness activities will be documented with sign-in sheets that will be kept in a binder and reflected in
progress notes of member case records.
• Community 43 will support members in learning to self-manage co-occurring chronic health problems such as Diabetes, Hypertension, glucose management, nutritional and dietary approaches to lower and reduce risk of Type II Diabetes such as learning to use their glucose meter and manage stress.
The program will introduce individuals to the principles and tools of Wellness Self-Management and offer individual or group support.
Supported Education
Community 43’s supported education program will assist members with pursuing their educational goals, with a focus on completing formal education. Supported education services will offer members assistance and tutoring in taking the GED, computer tutoring and other individualized supports as needed. Members will have access to computers and other resources to further their education, based on their self-defined goals.
Supported Employment
Community 43 offers an employment system that creates opportunities for paid employment that match each member’s vocational goal and allows for maximum participation in the competitive job market. To achieve this, Community 43 will implement a range of evidence-based strategies that include Transitional, Supported and Independent Employment as defined and accredited by Clubhouse International.
By participating in daily activities at Community 43, members have the opportunity to learn skills that are important for employment such as communication, reliability, teamwork, leadership, adaptability, conflict resolution and problem solving. Based on the members readiness and willingness to work, Community 43 will assist members in accessing meaningful employment through partnerships with local employers and community organizations.
Community 43 is designed to support members with a history of serious mental illness rejoin society and maintain their place in it. We offer services and activities that build on people’s strengths and provide mutual support, along with professional staff support, for members to receive pre-vocational work training, educational opportunities, and social support.
