What is an Older Adult Full Service Partnership(FSP)?

Full Service Partnership (FSP) Programs seek to provide client driven services and supports. Clients enrolled in a FSP will work with Personal Service Coordinators (PSCs) who along with an interdisciplinary team will facilitate services to assist in the client’s recovery. Full Service Partnership Programs will recruit a number of Personal Services Coordinators (PSCs) to provide services to older adults. Each PSC will assume responsibility for a small case load ensuring available services and supports for their clients 24 hours a day, 7 days a week, addressing their immediate mental health service needs. PSCs will assist the client/family in developing an individualized plan to achieve short-term and long-term life goals which include appropriate linkages to (or provision of) all needed services or benefits as defined by the client and or family. Examples of FSP Services might include:

• Assistance attaining appropriate physical, mental and emotional health treatment.
• Assistance finding safe and appropriate housing or assistance maintaining currently housing.
• Assistance arranging doctor appointments and help get there.
• Ensuring that individuals attain all the medications that they need to be healthy, monitoring that the medications are being used appropriately and continued education on how to use those medications.
• Transportation that is truly "door through door", ensuring individuals are getting where they need to go and back home again.
• Treatment for harmful addictions such as alcoholism and misuse of prescription medications.
• Assistance getting the financial and health benefits that individuals are entitled to.

Who is appropriate for an Older Adult FSP?

A minimum of 50% of Enrolled FSP clients must meet one or more of the following criteria:

a. Homelessness (e.g., client was homeless a total of 120 days during the last 12 months.)

b. Incarceration (e.g., client was incarcerated on two (2) or more separate occasions that total at least 30 days during the last 12 months and must have documented history of mental illness prior to incarceration.)

c. Hospitalizations (e.g., client was hospitalized two (2) or more times totaling at least 28 days of acute psychiatric hospitalizations in the past 12 months. Not only for physical ailment must show psychiatric reason for hospitalization.)

Additional priority populations include:

d. Imminent risk of homelessness (e.g. at risk of eviction due to code violations) or;

e. Risk of going to jail (e.g. multiple interactions with law enforcement over 6 months or more) or;

f. Imminent risk for placement in a Skilled Nursing Facility (SNF) or Nursing Home or being released from SNF or Nursing Home who, without intensive services would not be able to be maintained/released into the community or;

g. Presence of a Co-occurring Disorder (e.g. Substance Abuse, Developmental, Medical and/or Cognitive Disorder) or

h. Recurrent history or serious risk of abuse or self-neglect, including individuals who are typically isolated (e.g. APS-referred Clients) or;

i. Serious risk of suicide (not imminent) or;

j. Currently in the system who are aging up in the system, e.g., consumers who have suffered from severe mental disorders in earlier years who are now becoming senior citizens, perhaps currently in an “ACT or AB2034–like” intensive service program

How do I refer an Older Adult to a Full Service Partnership?

Follow these Steps:

1. Fill out an Older Adult FSP Referral/Authorization Form and fax it to (213) 351-2493.
2. The Impact Unit Coordinator will conduct an initial screen of the referral to determine if the referral is eligible for FSP services.
3. Those not eligible for Older Adult FSP services will be connected with ACCESS Center or Service Area Navigators to assist with linkage to appropriate services.
4. Those eligible for FSP services will be assessed by a Centralized Impact Unit and assigned to a FSP program that best meets their needs.

What is the Older Adult FSP Centralized Impact Unit (CIU)?

Definition of Older Adult Centralized Impact Unit (CIU):

Consisting of Department of Mental Health Staff members and FSP Providers, the Older Adult CIU is the body responsible for identifying clients who meet criteria in an FSP, and engaging in regular on-going case conferences to review referral and to enroll, monitor and disenroll clients in FSP Programs as appropriate.

1. Membership

1.1 The members of the CIU may fluctuate depending on the circumstances of each individual case. There are core members of the CIU that must be present in order to convene. Core members include:

a. Older Adult Programs Administrator

b. DMH Older Adult FSP Enrollment Coordinator

c. Clinical Expert

d. Representatives from Older Adult FSP Team

1.2 There may be other who attends CIU case conferences as appropriate. Others beside core members who may be in attendance at case conference include:

a. Representative(s) from referring agencies (-cies)

b. Representative(s) of client or family member

2. Responsibility of Membership/CIU

2.1 Enrollment Coordinator: will be responsible for the initial screening of referral. When referral is received that has provided adequate preliminary information (correctly filled out referral form, meets general criteria for FSP, Client has had a clinical evaluation prior to referral) then the Enrollment Coordinator will contact referring party to inform them of client disposition. Enrollment coordinator will coordinate a meeting of the CIU to review case. Enrollment coordinator will ensure the appropriate agency (-ies) representatives are in attendance.

2.2 Older Adult Program Administrator: will be responsible for facilitation of CIU case conferences and will also have the responsibility to provide final approval on client placement in FSP program. This approval is necessary for authorization of FSP provider to begin billing for services provided to Client.

2.3 Clinical Expert: will have clinical expertise for diagnosing and treating Older Adults with a severe mental illness, preferably a licensed Clinical Social Worker (LCSW), Psychologist (PhD) or Geriatrician (MD). The function of the Technical Expert will be to provide their clinical opinion and consultation to the CIU.

2.4 Representatives from FSP Providers: will be responsible to attend each CIU conference to provide information and consultation in the authorization and placement of clients in an appropriate FSP program that most meets the clients needs.

2.5 Possible other members who would attend the CIU conferences including Representative(s) from referring agencies (-cies) Representative(s) of client or family member. Other individuals or agency representatives may be invited to attend the CIU conference to acquire further information about the client pertinent to client’s appropriateness for FSP services and/or special consideration in FSP placement