Community Integration Services for Adults (Case Management)

Community Integration (CIW)

Community Integration for adults (adult case management) is a service provided to individuals with a qualifying behavioral health diagnosis. The service is intended to work with individuals who have needs related to their diagnosis. Case Managers assist individuals in creating a treatment plan focused on meeting the specific needs of that person including but not limited to: housing, medication management, therapy, educational/vocational and social.

Advocates for clients’ needs with service providers and other organizations
Develops an individualized service plan with clients and guardians when applicable
Monitors the effectiveness of services, natural supports and resources
Promotes independence in order to maintain the least restrictive environment for adults to be active members of their communities
Identifies and offers referrals and resources to target any needs that the client and/or guardian may have
Builds relationships and forms partnerships to enhance care
Supports clients with obtaining MaineCare when needed
Support and assistance navigating complex systems such as Social Security benefits, housing resources/applications, HEAP, and WRAP applications.
Coordinates transportation to medical/behavioral health appointments

All CIWs are Mental Health Rehabilitation Technician Certified (MHRT) with a minimum of a provisional license if eligible to get a full MHRT-C within two (2) years of hire. In addition to these trainings, case managers are provided with quality clinical supervision and training opportunities intended to build their knowledge of the latest practices in working with adults who have behavioral health challenges.

Eligibility Criteria

Active MaineCare insurance coverage

Veterans insurance

Grant fund for those who qualify and do not have full Mainecare

Private pay

Age 18 or emancipated

Documentation of a qualifying mental health diagnosis that is under one year old and is considered eligible under the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders

For those without an eligible diagnosis of schizophrenia or schizoaffective disorder, a clinical letter attesting to the need for case management due to the following at-risk criteria:

-Homelessless

-Psychiatric hospitalization

-Criminal Justice Involvement

-Residential mental health care placement

We provide Adult Case Management services in Kennebec, Somerset, Lincoln, Knox, Waldo, Sagadahoc, Franklin, Oxford, Penobscot and Cumberland counties.

Daily Living and Skills Development Support Services for Adults

Providing essential assistance, so individuals can
thrive independently in their everyday lives.

Daily Living Support

Our Daily Living Support Specialists help people with mental illness or other disabilities in both basic and instrumental activities of daily living (ADLs and IADLs).

We align our support with each client’s care plan so that they can maintain their independence and quality of life and work toward their goals for personal care, personal health, household management, and community engagement.

Our qualified Daily Living Support Specialist team works closely with guardians and case managers to offer quality services aligned to each client’s individual and specific care plans.

SKILLS Development

The Assistance Plus Skills Development Program works to support clients’ connections with their community resources as a foundation for independent living (i.e. guardians, social networks, educational resources, civic engagement, and cultural participation).

Both programs use individualized treatment planning to support each client’s goals. Field staff focus on supporting the client as they work to achieve those goals and build independence.

Each Assistance Plus Daily Living Support Specialist and SKILLS Development team member is carefully matched to each client. Treatment plans are reviewed and revised quarterly to ensure client progress.

Services Provided

The Assistance Plus Daily Living Support and Skills development team can;

Develop individual plans with client and/or guardians.
Assist with reduction/prevention of psychiatric hospitalization, homelessness, residential treatment, and/or criminal justice involvement.
Develop client-centered goals around Activities of Daily Living

Supervisors and field staff are trained in crisis intervention and CPR/First Aid and receive quality clinical supervision and training focusing on the latest practices in support of adults with mental health challenges.

Individuals with diagnosed mental illness can live more independently
when they have the support they need as they work to meet
their goals to improve their overall quality of life.

Areas of Support:

Side By Side assistance with Instrumental Activities of Daily Living (IADLs):

Meal Preparation: Assisting clients as they plan, prepare, and cook meals and clean up afterwards.
Housekeeping Support: Assisting client as they maintain a clean and organized living space, including tasks like laundry, dusting, and vacuuming.
Medication Support: Assisting clients as they obtain and take prescribed medication, including refills and organization.
Financial Management: Assisting clients as they manage their personal finances, including budgeting, paying bills, and avoiding scams.
Shopping: Assisting clients as they buy groceries, clothing, and other necessities.
Communication and Technology Use: Assisting clients with basic communication skills and their use of technology like phones and computers.

Funding Sources:

Active MaineCare insurance coverage,
Grant funds for those who qualify and do not have full Mainecare.
Private pay.

Eligibility Criteria:

Age 18 or emancipated
Documentation of a qualifying mental health diagnosis that is under one year old and is considered eligible under the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders
For those without an eligible diagnosis of schizophrenia or schizoaffective disorder, a clinical letter attesting to the need for Daily Living Support (DLS) or Skills Development due to the following at-risk criteria: Homelessness, Psychiatric hospitalization, Criminal justice involvement, Residential mental healthcare placement.

Service Regions:

Androscoggin-Leeds, Livermore, Livermore Falls, Turner

Franklin-Avon, Carthage, Chesterville, Farmington, Freeman Township, Industry, Jay, Kingfield, New Sharon, New Vineyard, Phillips, Strong, Temple,Weld, Wilton

Kennebec-Albion, Augusta, Belgrade, Benton, Chelsea, China, Clinton, East Vassalboro, East Winthrop, Farmingdale, Fayette, Gardiner, Hallowell, Kents Hill, Litchfield, Manchester, Monmouth, Mount Vernon, North Monmouth, North Vassalboro, Oakland, Pittston, Randolph, Readfield, Rome, Sidney, South China, Somerville, South Gardiner, Vassalboro, Vienna, Waterville, Wayne, Weeks Mills, West Gardiner, Windsor, Winslow, Winthrop

Oxford-Canton, Dixfield, Hartford, Mexico, Peru, Rumford, Sumner

Penobscot-Corinna, Dexter, Dixmont, Etna, Hampden, Hermon, Newport, Plymouth

Sagadahoc - Richmond, Bowdoinham, Bowdoin, Topsham

Somerset-Anson, Athens, Bingham, Canaan, Cornville, Detroit, Embden, Fairfield, Harmony, Hartland, Hinckley, Madison, Mercer, Moscow, North Anson, North New Portland, Norridgewock, Palmyra, Pittsfield, Pleasant Ridge Plantation, Ripley, Shawmut, Skowhegan, Smithfield, Solon, St Albans, Starks

Waldo-Belfast, Belmont, Brooks, Burnham, Frankfort, Freedom, Jackson, Knox, Liberty, Lincolnville, Monroe, Montville, Morrill, Northport, Palermo, Prospect, Searsmont, Searsport, Stockton Springs, Swanville, Thorndike, Troy, Unity, Waldo, Winterport

Behavioral Health Home for Adults

The Behavioral Health Home (BHH) is a community based service that offers a team based approach to comprehensively address physical health and mental health needs for adults. This service is delivered by a team of qualified professionals that include: medical and psychiatric consultants, health home coordinators (case managers), clinicians, nurses, peer/family supports and frequent collaboration with the member’s primary care provider. The BHH provides a primary emphasis on preventative health and wellness, in addition to community partnering.

Members of our Behavioral Health Home (BHH) receive team based support to comprehensively address physical health and mental health issues. This service is delivered by a team of qualified professionals that include: medical and psychiatric consultation, health home coordinators, a clinical team leader, nursing, peer supports and frequent collaboration with the member’s primary care physician. The BHH provides a primary emphasis on preventative health and wellness, in addition to community partnering.

Ongoing monitoring and advocacy:

Develops individual plans with the member and/or guardians
Participates in ensuring the delivery of crisis intervention and resolution
Assists with alternatives to hospitalization
Coordinates services with physicians and other organizations
Assures continuity of care by assessing for gaps in services and offering referrals and resources
Organizes team meetings to review progress

Eligibility Criteria:

Active MaineCare insurance coverage
Private pay
Age 18 or emancipated
Documentation of a mental health diagnosis that is under one year old and is considered eligible under the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders

We provide Adult Case Management services in Kennebec, Somerset, Lincoln, Knox, Waldo, Sagadahoc, Franklin, Oxford, Penobscot and Cumberland counties.

Intellectual/Developmental Support Services

Our Center-Based, Home Supports, and Shared Living Provider Programs are offered throughout central Maine.

The Assistance Plus Direct Support Professional (DSP) program offers home and center-based services to clients with developmental or intellectual disabilities. In each context, trained and certified DSP staff support each client as they each strive to becoming active members of their own communities.

All clients work on goals developed in the treatment plan, which may include:

Accessing and utilizing community resources
Community integration
Community volunteer opportunities
Cooking and cleaning
Coping skills
Exercise and recreation
Laundry
Maintaining a healthy lifestyle
Medical appointments
Medication management
Money management
Other individualized skills, as determined
Safety
Shopping skills to meet wants and needs
Socialization

Each client is carefully matched with an experienced DSP who supports their individual work on treatment goals.

Direct Support Professionals (DSPs) receive certification through Assistance Plus. All staff are trained in crisis intervention techniques and CPR/First Aid. In addition to these trainings, staff are provided with ongoing one-to-one supervision to assist with their support of the consumers we serve and promote successful working relationships with them and their families.

1:1 | 1:2 | 1:3 Home Supports

Assistance Plus offers home-based and community-based support services to clients with developmental and/or intellectual disabilities and Autism aligned with Section 21 and/or 29 Waivers

DSP staff support each client or small group of clients on a 1:1, 1:2, OR 1:3 ratio as they work to become active household and/or community members.

All clients are supported in alignment with their treatment plans and each person’s individual goals for:

Self-Care/ADLs
Mobility
Medication Administration
Independent Living Skills
Accessing Community Events & Activities
Accessing Community Resources
Job Preparedness
Interpersonal Skills
Safety Skills
Activity & Physical Exercise
Communication
Spiritual / Religious Activities
Personal Development & Learning
Building Unpaid Relationships

Home and Community Support Services are available in Franklin, Somerset, Kennebec, Androscoggin, Oxford, Penobscot, and Waldo Counties.

1:3 Center-Based Community Support Services in Kennebec County located in Waterville.

Center-Based Community Supports

Assistance Plus has a Center-Based Community Supports Program at our Waterville location at 3 Michael Lane. The program is geared towards providing education on-the-job preparedness skills such as cooking, gardening, and general tasks that will help with day-to-day living. The program offers instruction on appropriate social skills to assist with creating lasting relationships with peers, vendors, and other members of the community. Community integration is very important, and through the use of creative and innovative activities, skills can be learned and maintained through consistent practice. This program will also assist in developing and providing additional education in regards to safety skills in the community, at home, and while accessing technology. Discussion times, role play, and activities will be used to assist the participant with becoming better educated on what to do. This program will offer several different opportunities to become more involved in the communities surrounding us by attending local museums, parades, community suppers, trips to the theater, trips to visit our state capital, botanical gardens, and many more fun activities. This program will also offer education on exercise, healthy eating, meal preparation, cleanliness in the kitchen, and how to use the tools that are provided to them to build a meal.

Eligibility: