ADULT CARE COORDINATION
Adult Care Coordination (mental health services) provides a variety of community-based services such as case management, homeless assistance, supervised housing, and intensive outpatient community assistance.
Assertive Community Treatment
Assertive Community Treatment, or ACT, is a self-contained, interdisciplinary community-based team of medical, behavioral health, and rehabilitative professionals who use a team approach to meet with needs of an individual with severe and persistent mental illness. Admission criteria include severe and persistent mental illness, predominately Schizophrenia, impairments on a continuing or intermittent basis without intensive community support, and high service needs.
ACT provides person-centered services addressing the breadth of individuals' needs and is oriented around the individuals' personal goals. The following services provided are: service coordination, psychiatric assessment and treatment, medication management, substance use services, counseling/therapy, vocational services, mental health support services, peer support, and representative payee services. A fundamental charge of ACT is to be the first-line (and generally sole) provider of all the services that an individual receiving ACT needs. Being the single point of responsibility necessitates a higher frequency and intensity of community based contacts between the team and individual and a very low individual-to-staff ratio. ACT services are flexible. Teams offer personalized levels of care for all individuals, adjusting service levels to reflect needs as they change over time.
The goal of ACT is to lessen or eliminate debilitating symptoms of mental illness each client experiences and to minimize or prevent recurrent episodes of illness, assist clients to meet basic needs and enhance their quality of life, improve functioning in adult social and employment roles and activities, increase stability in community, decrease hospitalizations, and lessen the family's burden of providing care.
Community served: adults 18 and older
Contact Us: 757-788-0473
24/7
State Hospital Discharge Planning
The State Hospital Discharge Planning team provides case management and discharge planning services to individuals admitted to State psychiatric facilities. The team, comprised of Discharge Planners and Case Managers, advocates for individual needs, monitors individuals’ progress with treatment goals, and coordinates optimal transition to the community. The staff serves individuals with serious mental illnesses, intellectual or developmental disabilities, and/or individuals with substance use concerns. Staff also work with individuals on Not Guilty by Reason of Insanity status (NGRI) and closely monitor their progress throughout admission to the hospital. Staff, including the NGRI Coordinator, collaborate with the legal system and mental health providers to develop appropriate discharge plans to assist with individuals’ recovery and reintegration to the community. The HNNCSB State Discharge Planning Team is routinely viewed as one of the best in the State. Staff are compassionate towards individual needs and knowledgeable of community resources.
Community served: adults 18 and older
Contact Us: 757-788-0083
Monday - Friday 8:30 am - 5:00 pm
Reinvestment Case Management
Reinvestment Discharge Planning and Case Management: This program is a function of the Regional Reinvestment Project, which was developed and implemented to reduce the amount of inpatient beds at state psychiatric facilities and to develop community supports. This program funds local psychiatric hospitalizations and has aided in the development of three local Crisis Stabilization Units. The case management staff are assigned individuals that are admitted to a local psychiatric hospital or one of the Crisis Stabilization Units. The staff monitor inpatient treatment, develop discharge plans and provide linkage to community resources upon discharge. The cases are managed short-term, usually less than ninety days, and are linked to the larger CSB service delivery system.
Community served: adults 18 and older
Contact Us: 757-788-0083
Monday - Friday 8:00 am - 5:00 pm
Adult Mental Health Case Management
The Hampton-Newport News Community Services Board Case Management services enable individuals with a Serious Mental Illness, or Serious Mental Illness and Co-occurring Substance Use Disorders, to achieve and maintain optimal functioning in the least restrictive, most normative community setting. We achieve our mission by assessing our individuals’ needs and strengths, linking our individuals with community services and supports, monitoring our individuals’ response to treatment and the quality of care provided, facilitating adjustments to our individuals’ Individual Service Plans in response to changing needs, and ensuring effective crisis stabilization services if needed. All Case Management services are focused on individual needs and are carefully crafted to be sensitive to cultural values and preferences. Case Management serves individuals 18 years and older who have a Serious Mental Illness, or Serious Mental Illness and Co-occurring Substance Use Disorders. Individuals typically served by Case Management have complex behavioral health needs requiring multiple services and supports. Case Management services are provided without regard for sex, race, color, creed, religion, political affiliation, or national origin.
Adult Mental Health Case Management Services assesses the individuals' needs and strengths, linking the individuals with community services and supports, monitoring the individuals' response to treatment and the quality of care provided, facilitating adjustments to the individuals' Individual Service Plans in response to changing needs, coordinating the individuals care amongst service providers, and ensuring effective crisis stabilization services if needed. Adult Mental Health Case Management Services are focused on individual needs and are carefully crafted to be sensitive to cultural values and preferences.
Community served: adults 18 and older
Contact Us 757-788-0053
Monday - Friday 8:00 am - 5:00 pm
Homeless Services
Projects for Assistance in Transition from Homelessness (PATH)
PATH provides services to individuals who are homeless or at imminent risk of becoming homeless and who suffer from serious mental illness (SMI) or SMI and co-occurring substance use disorders (SUDs). PATH provides services and supports to the target population to outreach, identify and engage such persons into services with the end goal of transitioning from homelessness or risk of homelessness into behavioral health, social services and housing in order to promote recovery and self-determination. Outreach is the process of identifying and engaging individuals into treatment who do not access traditional services. Often these individuals heave experienced chronic homelessness and untreated mental illness/substance abuse for many years and are not engaged in services. Outreach results in increased access to and utilization of community services by individuals who are homeless and have SMI and or co-occurring SMI/SUDs.
Community served: adults 18 and older
Contact Us: 757-240-5288
Monday - Friday 8:00 am - 5:00 pm
Homeless Services
Newport News PORT Outreach
NN PORT Outreach provides services to individuals who are homeless or at imminent risk of becoming homeless and who suffer from serious mental illness (SMI) or SMI and co-ccurring substance use disorders (SUDs). NN PORT Outreach provides services and supports to the target population to outreach, identify and engage such persons into services with the end goal of transitioning from homelessness or risk of homelessness into behavioral health, social services and housing in order to promote recovery and self-determination. Outreach is the process of identifying and engaging individuals into treatment who do not access traditional services. Often these individuals heave experienced chronic homelessness and untreated mental illness/substance abuse for many years and are not engaged in services. Outreach results in increased access to and utilization of community services by individuals who are homeless and have SMI and or co-occurring SMI/SUDs.
Community outreach is provided to the cities of Hampton and Newport News. Outreach includes other service sites for homeless individuals such as shelters, day centers and soup kitchens. Outreach is also to remote locations of client's campsites and vacant houses and street sites. The goal is to encourage the client to engage in services. Assistance and engagement often starts with clients basic needs being met. Linkage to additional services are made following ongoing assessment. Outreach workers provide linkage to basic needs as well for food, shelter and clothing. Assistance through outreach services is about six months to a year.
Community served: adults 18 and older
Contact Us: 757-240-5288
Monday - Friday 8:00 am - 5:00 pm
Homeless Services
Safe Harbors
Safe Harbors Program is to reduce homelessness by providing housing first, maximize consumers’ opportunities and independence by providing quality supports, training and individualized services to consumers who are homeless who suffer from serious mental illness (SMI) or SMI and co-ccurring substance use disorders (SUDs). Safe Harbors Program will support consumers in their personal choices and encourage them to engage in services to maximize their independence. Must be 18 years of age or older and a resident of Hampton or Newport News. Must be a single adult who has been homeless for the past year or numerous episodes of homelessness over the years and not currently engaged in any treatment or community services. Documentation of homelessness is required.thing. Assistance through outreach services is about six months to a year.
The Safe Harbors Program is Permanent Supportive Housing which provides housing in local apartments. The individuals are monitored weekly for progress with linkage and engagement into community services, resources and treatment such as: mental health treatment, substance abuse treatment, medical services, benefits, employment, and permanent housing referrals in the community. Safe Harbors Program performs assessment and support services, independent living skills training, medication monitoring, money management training, leisure and social skills training, leasing, maintaining housing, and establishing and maintaining relationships in the community. Services are individualized based on each consumer’s goals, needs, and desires. The goal is to move individuals into independent housing in the community that fits the client's needs and reduces the risk of additional episodes of homelessness. There is no time frame on how long a client can stay in the program.
Community served: adults 18 and older
Contact Us: 757-240-5288
Monday - Friday 8:00 am - 5:00 pm
Service Coordination Team
Service Coordination Team: The team provides crisis support services to individuals identified who could benefit from more intensive outpatient services in the community. The team provides on-going monitoring of safety, coping skills education, recovery tools, and linkages to CSB and community resources. One of the team’s goal is to assist individuals with maintaining stabilization in the community upon discharge from a psychiatric facility. This team assists individuals enrolled in the CSB system and is an excellent support to the Reinvestment Case Management Team, Emergency Services and other CSB programs. The team utilizes case management and peer support staff. The peer support specialist is a vital component to the team; sharing real life recovery experiences which benefit the served individuals on their recovery journey.
Community served: adults 18 and older
Contact Us: 757-788-0083
Monday - Friday 8:00 am - 5:00 pm
Transcend Place
The mission of the MH Regional Supervised Housing Program is to reduce the length of stay in local and state psychiatric facilities by providing a living environment that will maximize the individual’s opportunities and independence by providing quality supports, training and individualized services to individuals with severe mental illness and possible co–occurring substance abuse. The MH Regional Supervised Housing Program will support individuals in their personal choices and will work closely with them to engage them in services to maximize their independence and reduce hospital admissions.
The MH Regional Supervised Housing Program is voluntary with a length of stay dependent upon the individual’s goals, needs, and desires. Staff will work closely with the individual to engage them in treatment such as psychiatric, substance abuse, medical and any other treatment the individual may need. Staff will assist with applications for benefits both financial and medical, assist with obtaining a day activity such as psychosocial day, partial hospitalization, vocational, volunteer or employment, and other community agencies that will meet their needs.
ADMISSION CRITERIA:
Must be 18 years of age or older.
Must be a resident of Hampton Roads / Tidewater area.
The individual has a primary DSM V, psychiatric diagnosis that determines the need for this level of care and it is the focus of intervention.
Individuals will be prioritized based on the following:
First priority: individuals who are from HPRV and on the discharge ready list at ESH or ready for discharge whose needs could be met in a community setting.
Second priority: individuals who are from HPRV and are currently in local psychiatric hospitals pending transfer to ESH.
Third priority: individuals in a Community Expansion program will be considered by the Hampton - Newport News CSB clinical discharge planning team on a case by case basis.
Contact Us: 757-596-4926
24/7
Interested in some general information about Adult Care Coordination?
We want to know your needs exactly so that we can provide the care you need. If you are not sure about which program is best for you, call us at the main number for our ACC programs.