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Advisory Workgroup participants recommended a Care Coordination Approach in helping youth in transition move forward in their lives. There are several practices across the country that link together services through a care coordination model.

Several states have developed one of the already existing evidenced-based best practice models for adults — Assertive Community Treatment (ACT) Teams. Listed below are highlights from three states that use ACT Teams for YIT including Ohio, Massachusetts and Connecticut.

Based on a review of research and the consensus of experts, the Schizophrenia Patient Outcome Research Team recommended ACT for the treatment of schizophrenia. In federal performance indicators systems developed by SAMSHA, accessibility to ACT services is one of three best-practice measures of the quality of a state’s mental health system.

ACT is a transdisciplinary team of 10 to 12 practitioners who provide services to approximately 100 people. Services are delivered directly by the team as opposed to being brokered by other agencies or providers. Most services are provided in community settings where problems may occur and support is needed rather then in staff offices or clinics. Each person’s status is reviewed daily by the team so that the intensity of services can be adjusted quickly as needs change. ACT services are available on a twenty-four hour basis.

State Models:
Ohio uses the Assertive Community Treatment (ACT) Model to provide transitional services. The Ohio Model is referred to as the Transitional Youth Assertive Community Treatment Team. The team is comprised of a team leader, nurse, peer specialist, vocational specialist, case manager and psychiatrist. (Beech Brooks’s Ohio Transition Community Team 2006)

Massachusetts and Connecticut
Massachusetts and Connecticut both use ACT Teams for YIT (GAO Report). These teams are comprised of a multidisciplinary group of individuals dedicated to providing the most appropriate individualized services with small case loads. Connecticut includes foster care kids and juvenile justice as part of their ACT outreach.

Vermont created Case Management Teams. The Intensive Case Managers work with YIT to provide access to mental health services, roommate services, and vocational and adult services. (Guideposts)

The case managers work with youth in helping them to prepare for life on their own. Based on their assessments, the youth receive life skills instruction and support to pursue housing, health care, employment and community services.

Pennsylvania Mental Health and Substance Abuse Services created a Transition Coordinator Position and a Transition Coordinating Council. (Ohio Report)

The Transition Coordinating Council is part of the Youth Housing workgroup in which transition age youth, family members, providers and stakeholders develop specific recommendations around needs of youth related to housing. These recommendations are provided to the larger advisory committee and consolidated into the state’s housing plan.

Our Town
The Our Town program in Indiana supports young adults with psychiatric disabilities to build upon their interest and ability to live in the community. The case management program provides early intervention and psychosocial intervention to transition aged youth. Their goal is to improve quality of life through employment, education, housing and mental health services.

Experts Recommendations:
GAO Report
The Report recommendation is to use wrap-around models with case managers and involving families in a participatory process and develop an individualized plan focusing on individual and family strategies in multiple domains. Also urge case managers to commit to working collaboratively across systems.

Maine White Paper
Maine 2008 Task Force recommends transition facilitators who are trained to work with issues surrounding this population. (A facilitator would be assigned to each child.)

Oregon White Paper
Oregon has recommended development of the position of Specialist Care Coordinators who help to bridge the gap between adult and children’s mental health services as well as ACT models for youth.

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Table of Contents

Overview of Literature Search
Best Practices

I)      Access and Linkages
A. Cross Systems Approach
B. Care Coordination
C. Family Links
D. Workforce

II)     Population
A. Eligibility
B. Diverse Populations Involved with Youth in Transition
C. Schools (Screenings and Assessments)

III)   Services
         A. Overarching Service Needs
B. Employment
C. Education Services
D. Self-Determination and Empowerment
E. Youth Mentors
F. Clinical Services
G. Individualized and Person Centered Planning
H. Cultural Competence
I. Adult Skills Training

IV)   Financing
A. Overarching Funding including Blended Models
B. Youth Oriented Services
C. Employment and Education
             (Subset of Youth-Oriented Services)
D. Clinical Services

V)     Housing
A. Various Housing Options for Youth in Transition
B. YIT Services Linked to Housing
C. Housing Model Funding

VI)   Transition to Independence Process System (TIP)
        (Emerging Best Practice)



Literature Search: End Notes

Advisory Group Members