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Collaborative Systems Integration Project

The Collaborative Systems Integration Project, or CSIP, is a program developed between Washington County Mental Health Services (WCMHS) and Central Vermont Substance Abuse Services (CVSAS) through a Vermont Judiciary grant starting April, 2011.  CSIP was designed to provide a wide range of community services through outreach and case management to an unconnected and disenfranchised segment of our community population.  This is a program with the primary goal of reaching out and attempting to engage with the most difficult and marginalized individuals in our community.   In other words, this is an important program doing critical work in our community.  Since its beginnings in 2011, CSIP has evolved into an effective program that is making a real difference for the individuals it serves and also for our central Vermont community as a whole.   Let’s find out a bit more about how this program works.

CSIP staff reach out and seek clients through homeless shelters, community meals, probation offices, motels, homeless ‘tent cities’ and police departments in an effort to connect individuals with mental health services or community supports through community providers.  CSIP collaborates and integrates services with numerous community partners specific to the client’s needs and the services these community partners provide. A majority of CSIP clients are involved in the criminal justice system. Utilizing the Sequential Intercept Model (Griffen and Munetz, National Gains Center, 2009), staff offer supports for those simply “on the radar” or “at risk” through re-entry into the community from prison, on probation and even those who are no longer under any supervision of any kind. Our clients also include a number of Severely Functionally Impaired (SFI) designated individuals. We meet our clients wherever they are located and feel comfortable or secure, whether that is in their home, the community shelters, community meals or prison.

CSIP’s primary outreach staff is the Intensive Outreach Case Manager.  The Intensive Outreach Case Manager has provided the community with a variety of services targeted for individuals currently or at risk of involvement with the Department of Corrections. The main role of the Intensive Outreach Case Manager is to provide therapeutic case management using the APIC model (Osher, Steadman and Barr , 2003) calling for an assessment of clinical and social needs, planning for those needs, identification of programs responses for these services, and finally the coordination of those needs.  When the case manager meets clients in the community or correctional facility, relationships are built and goals are established along with the strategies to meet these goals. Through regular work, the client and case manager work together to establish routines, formal (e.g., referrals to psychiatric, psychological, and substance abuse providers, as well as providers who promote financial stability) and informal connections (e.g., peer support groups), and skills that promote the clients’ mental health and success in the community. Clients are also served where they are located, which may mean they are served in prison preparing for re-entry to the community, at the courthouse or probation offices, their residence, whether a motel or apartment, or even a local coffee shop.  In addition to providing intensive outreach to identified clients, the Intensive Outreach Case Manager also provides a weekly Men’s Discussion group offered to the public with open enrollment.  This group focuses on anger management and stress reduction, and most participants report that the groups help them problem solve in areas that have historically caused them problems.  Many report that the groups also offer a sense of comradery in a healthy setting as well, which can boost mood and simply make participants feel less lonely. 

Another key component to CSIP programming is the Re-entry House.  This is a Washington County Mental Health Services supported program which affords men re-entering the community from prison a 24 hour/per day staff supported housing and treatment opportunity. In a safe and sober pro-social environment with staff support a treatment plan is developed, goals determined and strategies agreed upon to address each clients’ goals. Utilizing a clinical model, the clients’ mental health and substance abuse treatment, employment, future independent housing and daily living skills issues are addressed.  An additional component of CSIP is the ‘Day Program’, which was successfully established in 2016.  This program allows clients residing in the community to meet regularly with Re-entry house staff and address such issues as housing, employment search, school registration, Social Security or other economic issues.  Finally, the Weight Training/Fitness group offers clients a way to get healthy and again bond in a safe and positive group environment, something that is often lacking in their lives. CSIP’s Program Coordinator meets with participating clients, reviews their individual fitness goals, dialogues possible training programs and meets with or transports the client to the Berlin First in Fitness center for their scheduled training sessions.  This variety of positive programming makes a real difference in the lives of individuals served by the CSIP program.

Individuals served by CSIP come from a variety of backgrounds and experience a variety of struggles.  Many have co-occurring challenges, which means that they struggle with both substance use and mental health challenges.  The most recent year that has completed data for CSIP is fiscal year 2016.  During the first half of the 2016 fiscal year, 76 men and women were referred to the CSIP Coordinator, and the Coordinator attempted to connect with everyone.  The Coordinator successfully contacted 66 of those referred.  During the course of fiscal year 2016, CSIP had a total caseload of 41 committed to full engagement to treatment. This number also includes individuals referred during prior fiscal years. 24 of the individuals in full engagement were involved with the Department of Corrections upon intake and 29 had some history with the criminal justice system. Three were veterans. Twelve referrals refused services, many of whom were referred elsewhere. No one who chose to engage in services was denied entry into the program.  The work CSIP does with these individuals often yields positive outcomes, as illustrated in the quote below-

I feel more stable now that I am at CSIP. I feel more motivated now than I have for the past 10 years. I have some of my self-worth back. I have been able to heal some of my relationships, like with my mother and her boyfriend. It feels good to have them actually want me to be around. I glad to give my mother some relief. I feel really good when I go to work out with staff and my case manager. I am eating healthy and exercising. Staff supports me to stay sober, and helps me by making sure that I go to CVSAS meetings, and to see my therapist. The staff at CSIP also helps me to stay sober by giving me positive reinforcement.”

CSIP tracks outcomes in the following categories- housing, employment, income, legal status, mental health, substance issues, health care coverage, disability and community involvement.  In fiscal year 2016, 56% of the clients fully engaged in the CSIP program showed improvement in these areas during the course of their engagement.   As for recidivism, two of the forty-one men and women fully engaged in services during the 2016 fiscal year were incarcerated on new charges. Given the high risk nature of this population, it is well established that recidivism is likely. Despite this fact, less than 5% of the individuals fully engaged in treatment returned to jail for new charges during their engagement. These numbers reflect positive outcomes.

Another central piece of working with clients includes collaborating with a large variety of community service providers. Each of these organizations specializes in a given area of expertise surrounding a client’s need and thus these relationships and referrals prove invaluable to a team oriented approach to treatment. Thus, as an example, if a client identifies substance abuse issues as problematic, we would utilize the services of Central Vermont Substance Abuse Services (CVSAS) in order to address that issue.  CSIP continues to reach out and identify other community service providers and introduce the program to them with the goal of including them in CSIP partnerships and services offered. Recently, CSIP successfully established a relationship with The Greater Barre Community Justice Center and joined a COSA Team, thus expanding the program’s ability to provide yet more services to our clients and the community.

As reviewed, the CSIP project has made a significant contribution to the identification and support of individuals who are involved in the criminal justice system and who also struggle with mental health and substance abuse issues. Indicators of program success include the increasing numbers referred for services, the maintenance of individuals in treatment court, and the numbers of individuals supported in the community who do not recidivate and who are more capable to manage their affairs independently after 6 months.  Collaborative relationships are well developed and locally we have an increasingly well-defined network of providers who work together and understand the needs of this challenging population.   CSIP is a program that provides resources to help individuals get re-established in their community, find wellness for themselves, and take steps to become independent and contributing citizens of central Vermont, and this is a good thing!

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