Whole Person Care - Los Angeles (WPC-LA)

Mental Health High-risk

Intensive Service Recipient

Overview:
The Intensive Service Recipient (ISR) program provides comprehensive services to eligible patients for approximately 90 days post-discharge from an in-patient fee-for-service (FFS) psychiatric hospital.  Because the target population tends to access services in an episodic and crisis-oriented manner, the program focuses on steering these individuals toward behavioral health, physical health, and other community-based services.  By providing resources, such as intensive after-care transition planning and navigation to housing and transportation, ISR addresses the fundamental needs of the person’s recovery, as well as a more successful transition into the community after in-patient care.  As part of the mental health high-risk target population, individuals who are high-users of mental health acute care services due to serious mental illness (SMI) receive services through WPC ISR for 90 days.  After 90 days, services will transition to the Mental Health Services Act (MHSA) Full Service Partnership (FSP) program or other appropriate level of outpatient care to provide ongoing and comprehensive mental health care and system navigation..

Services Provided:

  • Peer support through community health workers;
  • Outreach and engagement;
  • Ongoing monitoring and follow-up, including home visits;
  • Accompaniment to appointments with physical and mental health and SUD providers;
  • Crisis support services;
  • Transportation;
  • Benefits establishment;
  • Assistance with life skills;
  • Assistance with emergency food, clothing and other basic goods; educational and vocational support; requests for legal documents and legal assistance; navigation to permanent housing; and hand-off to MHSA FSP program after 90 days.

Inclusion Criteria:

  • On a DMH-generated list, or serious mental illness; and
  • At least 2 inpatient psychiatric admissions in the past 12 months.

Length of Service:
The maximum length of service for the ISR program is 3 months.

How to Refer:
For mental health service information or referrals in the Los Angeles County area, please call the ACCESS Center 24/7 Helpline at 1-800-854-7771.

Residential and Bridging Care

Overview:
The Residential and Bridging Care (RBC) program will provide comprehensive services to eligible patients to facilitate appropriate movement out of locked or clinically enriched facilities into community-based placement. The long lengths of stay in inpatient psychiatric facilities, Institutions for Mental Diseases (IMD), and Enriched Residential Settings (ERS) limit capacity and many in need of these services are unable to access them. Evidence suggests that a large proportion of participants can be moved to a more appropriate care setting if they receive transitional services and supports to facilitate their reintegration into the community.

Services Provided:

  • Peer support and support of family involvement;
  • Coordination and communication between institutional teams and community-based providers;
  • Augmentation of existing after-care plans to cover a broader range of service needs;
  • Linkages to community-based resources, residential treatment, physical health and SUD providers, benefits establishment;
  • Assistance with life skills and vocational support; and
  • Navigation to housing and legal services.

Inclusion Criteria:

  • On a DMH-generated list, or serious mental illness; and
  • Currently resides in an Institute of Mental Disease or Enriched Residential Setting or admitted on the inpatient psychiatric ward; and
  • Meets functional independence on Multnomah scale; and
  • No history of epilepsy, blindness, nor hearing impairment

Length of Service:
The average length of service for the RBC program is 2 months.

How to Refer:
Call the Department of Mental Health Countywide Resource Management Referral Line (213) 738-4775 and speak to the “Officer of the Day”

Kin Through Peer

Overview:
The Kin through Peer (KTP) program serves a subset of clients who are eligible for the Los Angeles County Department of Mental Health’s WPC ISR or RBC programs and who lack family or healthy social support systems. These clients suffer from a SMI and languish in the context of extended stays in residential facilities or regular transitioning in and out of psychiatric emergency rooms/hospitals.  While lack of access to housing, as well as chronic medical problems, co-morbid substance use disorders, and a myriad of psychosocial stressors drive these problematic phenomena, a lack of healthy family relations are core to the problem. As such, KTP clients are expected to benefit tremendously with ongoing support from a peer substituting as family to provide a surrogate “kin” function. These clients desperately need longer-term social support through Community Health Workers (CHW) who can provide long-term kinship and serve as surrogate family. The CHWs focus on intense relationship-building and long-term sustainable community reintegration to preserve healthy well-being. KTP staff do not provide clinical or case management services, but rather work closely with mental health services providers to address the client’s needs and promote recovery, facilitate and/or participate in case conferencing with other service providers, conduct home visits, and serve as the client’s support system.

Inclusion Criteria:

  • Meets inclusion criteria for the Intensive Service Recipient and Residential and Bridging Care Program
  • Lack of healthy family relations or significant social isolation

Length of Service:
The maximum length of service for the KTP program is 12 months.

How to Refer:
For mental health service information or referrals in the Los Angeles County area, please call the ACCESS Center 24/7 Helpline at 1-800-854-7771