Project Transition’s Systems of Support Assists TennCare Members with Significant Behavior Challenges

By Carrie Carter

About the Author

Carrie Carter has spent the last 17 years working at Project Transition, working in a variety of positions including direct care, program management, quality, project management, customer care management, program expansion and is now the Director of Marketing and Admissions.  Throughout each role that Carrie had held at Project Transition she had held true to the company’s core values and mission, always putting members first and advocating for them to integrate into the community. Carrie’s most recent accomplishment is establishing the statewide footprint of SOS services across Tennessee.

Our hope is that this weekly blog will offer information you want to know, so if you have a question you want answered about employment for people with disabilities or other mysteries of the world of work, please email me at janet.shouse@vanderbilt.edu. Our hope is that this weekly blog will offer information you want to know, so if you have a question you want answered about employment for people with disabilities or other mysteries of the world of work, please email janet.shouse@vumc.org.

Project Transition, which is based in Pennsylvania, has more than 35 years’ experience working exclusively with society’s most vulnerable members – adults, including emerging young adults, who struggle with serious mental illness, co-occurring substance use disorder and/or a dual diagnosis of intellectual and developmental disabilities and behavioral health challenges.

Last year, Project Transition came to Tennessee. In Tennessee, Project Transition’s Systems of Support Program provides behavioral health crisis prevention, intervention, and stabilization services for TennCare members with IDD and co-occurring mental health and/or behavior disorders while designing for each person a Project Transition Member Centered Toolkit.

One of the goals in the Project Transition Toolkit is to help individuals achieve what is called their “Blue Sky.” A person’s “Blue Sky” is a description of what his or her life would include if everything was just right. For many individuals served by the Systems of Support, their “Blue Sky” includes such things as a boyfriend or girlfriend, a place of their own, and employment. Many say a job is important for them to reach their “Blue Sky.”

The Systems of Support Mission Statement is “Building integrated systems of support through innovative partnerships and collaboration to empower Tennesseans with I/DD to live the lives they want in their communities.”

The Systems of Support Program, which is offered through TennCare’s managed care organizations, has the following elements:

  • Person-centered assessment and crisis prevention planning
  • Development of individualized Crisis Prevention and Intervention Plan (CPIP)
  • Training by the Systems of Support provider for paid and unpaid caregivers
  • Identify and address potential behavioral health crisis situations
  • Development of community linkages with local resources and cross-system supports based on the individualized needs of each member and in accordance with the member’s Crisis Prevention and Intervention Plan
  • 24/7 crisis intervention and stabilization response

Who can receive the service?

  • The program is targeted specifically to persons with IDD who experience challenging behavior that places themselves and others at significant risk of harm.
  • The service is available both to persons enrolled in HCBS waivers and those who do not receive waiver services.
  • Initial participants have been selected by TennCare and MCOs, using criteria that include data pertaining to crisis events, ER/in-patient utilization, service utilization, etc.

The Systems of Support Program started working with Tennessee members in April 2016, and the program now reaches 98% of the counties in Tennessee within 90-minute response time, and 100% within a two-hour response time.

Early data is showing that members who are enrolled in the Systems of Support Program are are able in 90% of crisis situations to avoid ending up in a hospital.

Project Transition accepts referrals from all three managed care organizations in Tennessee.

To refer a TennCare member to the Systems of Support Program, please contact the individual’s MCO—either BlueCare, Amerigroup or United Healthcare.

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