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This program provides case management to assist individuals with Serious Mental Health Disorder (MHD) or Co-occurring Disorders (MHD Substance Use) with maintaining community-based placement, enhancing quality of life, and achieving recovery. Case management is a collaborative process of assessment, planning, facilitation, care coordination, and advocacy. Case Management ensures that services are accessible for eligible consumers and designed to meet individual needs. Case management activities are diverse and include:

• Identifying potential users of the service
• Assessing needs and planning services
• Linking the individual to services and supports
• Assisting the individual directly to locate, develop, or obtain needed services and resources
• Coordinating services with other providers; enhancing community integration
• Making collateral contacts; monitoring service delivery
• Discharge planning, and
• Advocating for individuals in response to their changing needs.

Case management is instrumental in assisting individuals with mental illness to navigate through a complex service system and access resources. Services are provided in a welcoming, safe, and recovery-oriented manner. Individuals are supported in reaching their goals and obtaining optimal levels of wellness and functional capability.

Services Provided

Included in the Case Management Program are the following services:

• Assessing needs and planning services, including the development of a case management Individual Service Plan (ISP)
• Linking individuals to services and supports that are identified in the ISP to assist them with attaining their life goals
• Assisting individuals to locate, develop, or obtain needed services, resources, and appropriate public benefits
• Making collateral contacts and monitoring service delivery
• Enhancing community integration
• Coordinating services with other providers and agencies
• Advocating for individuals in response to their changing needs
• Providing follow-up instruction, education and supportive counseling to guide individuals.
• Develop a supportive relationship that promotes the achievement of the goals identified in the ISP
• Developing wellness plans that include the individual's preferences regarding treatment in emergency situations
• Planning for transitions in individual's lives
• Assisting individuals with accessing primary care and other medical services, as needed

Program of Assertive Community Treatment (PACT)

The Norfolk CSB's Program of Assertive Community Treatment, known as PACT, is a community-based program that provides intensive mental health services to adults with severe and persistent mental illnesses.  These individuals have difficulty with maintaining stability, and often resist or avoid involvement with mental health services as a result of their mental health symptoms. In their adult role functioning, these symptoms cause them to experience significant distress, impairment, and functional limitations that are not effectively remedied by other available treatments. 

The three primary components of the PACT Program are: (1) Treatment, (2) Rehabilitation, and (3) Support Services. The program's goal is to increase community stability and promote recovery. This improves the quality of life and reduces the risk of hospitalization, incarceration, and/or homelessness for individuals served. There is an emphasis on outreach; relationship building; continuity of caregivers over time; service provision in natural settings; and individualization of services.

PACT is designed to provide services through an interdisciplinary team of mental health professionals, to include: a designated psychiatrist, nursing staff, case managers, substance abuse counselors, and vocational and peer specialists. The interdisciplinary team provides the majority of services and minimally refers to outside service providers, other than for medical care. Services are provided daily, including evenings, weekends, and holidays.

Services Provided

Specific services provided under the PACT umbrella are as follows:

• Assessment of symptoms and needs
• Psycho-pharmacological treatment, medication administration, and monitoring
• Nursing Services
• Case Management
• Supportive counseling
• Skills training in activities of daily living, social skills, and interpersonal relationships
• Collaboration with families, providers, and other involved parties in the consumer's treatment
• Assistance with maintaining physical health
• Work-related services to help find and maintain employment; support for resuming education
• Forensic Services
• Substance abuse treatment
• Peer counseling and recovery training
• Direct support and advocacy to help individuals access community resources
• Mobile crisis assessment and intervention; collaboration with Emergency Services and hospitals

Mental Health Skill-Building Services

This program includes training and support to help individuals achieve and maintain stability and independence within the community. Support services are rendered in the least restrictive environment based on the identified needs of the individual.  

The goal of the program is to increase the quality of life for those receiving Support Services, thus keeping the person in the community. This can be accomplished by being responsive to individuals needs and increasing their abilities and skills to live in the community. Services are generally provided in the home to offer training, education and supports in the natural setting where the individual will utilize the skill.  Services are individualized and are based on a clinical assessment of the individual's needs. The individual, family member, the doctor, and the Care Coordinator will all play an active role in the provision of services being implemented. The individual is seen as the key person in their treatment and services in the program and, therefore, encouraged to actively engage and guide services throughout the treatment process.

The program recognizes the need for services to be available to assist individuals while achieving recovery. Some of the components associated with these services include maintaining housing, facilitating individual choices, and structured planned training and supports centered on the needs of the individuals.

Services Provided

Specific services provided in the program include:

• Face to face and 1:1 services
• Skill Building in Personal Hygiene
• Medication Monitoring Diet and Nutrition
• Stress Management
• Housing Stabilization
• Coping Skills
• Boundaries and Ethical Decision Making
• Anger Management
• Social Skill Development
• Symptom Management
• Budgeting
• Health Management
• Peer Support