DISCHARGE
PLANNING
PACKET
MIAMI-DADE
AND
MONROE
COUNTIES
Figure
AAAAU
JUL July 2015
[Type text]
This packet can be downloaded from:
[Type
text]
www.sfbhn.org
[Type text]
Contents
SFBHN/DCF Overview ............................................................................................................................................................. 3
Stable Housing ........................................................................................................................................................................ 5
Community Mental Health Centers – ..................................................................................................................................... 6
Private and Public Receiving Facilities – Circuit 11 & 16......................................................................................................... 7
Addiction Receiving Facilities (ARF) and Juvenile Addiction Receiving Facility (JARF) ........................................................... 8
ARF/JARF Facilities .............................................................................................................................................................. 8
Lead Case Manager Supervisors – Community Mental Health Centers ................................................................................. 9
FACT Description ................................................................................................................................................................... 10
FACT – Referral form ......................................................................................................................................................... 11
STAR – Short Term Residential Treatment Facility ............................................................................................................... 12
STAR SRT Referral form ..................................................................................................................................................... 13
Residential Level II Description – Substance Use.................................................................................................................. 14
Residential Providers Screening/Assessment ................................................................................................................... 15
Residential Level II Description – Mental Health .................................................................................................................. 16
Residential Level II Referral............................................................................................................................................... 17
Consent Forms ...................................................................................................................................................................... 18
English ........................................................................................................................................................................... 18
Spanish .......................................................................................................................................................................... 19
Creole ............................................................................................................................................................................ 20
Consumer and Family Resource Manual .............................................................................................................................. 21
Housing Directory ................................................................................................................................................................. 22
Page 2 of 22
SFBHN/DCF Overview
The Department of Children and Families (DCF) Program Office is the Substance Abuse and Mental Health
(SAMH) authority that regulates the SAMH prevention and treatment practices and ensures that providers of
services comply with Florida laws, rules and regulations protecting the welfare of Florida’s most vulnerable
consumers of services. The Southern Region’s DCF SAMH Program Office contracts with South Florida Behavioral
Health Network, Inc. (SFBHN) to manage the SAMH system of care, ensuring quality and best practices are
provided to consumers and families seeking services. SFBHN provides the administration, management, and
oversight of a consumer-centered and family-focused comprehensive coordinated system of care as a managing
entity. The contract requires the managing entity to subcontract with qualified, direct service, community-based
network providers who will provide services for adults and children with behavioral health issues as authorized in
section 394.9082, F.S. and which are consistent with the approved Regional Plan.
What We Do
SFBHN helps individuals and families in Miami-Dade and Monroe County that have a mental illness and/or
substance use disorder by allocating public funding to purchase a system of care to meet their needs. There are six
Community Mental Health Centers (CMHC) in Miami-Dade County and one in Monroe County that comprise the
system of care (See page 6 for a list of the CMHCs). A CMHC is a publicly funded, not-for-profit center which
contracts with SFBHN for the provision of inpatient, outpatient, day treatment, or emergency services.
Purpose
The purpose of this manual is to provide resources to assist in the discharge planning of consumers from a receiving
facility to community-based services. When a consumer has reached significant gains and retention at a receiving
facility is no longer appropriate, a consumer may be discharged to community placements. Before discharging a
consumer from the facility, the consumer shall be encouraged to participate in treatment and discharge planning
activities. As stated in the 2014 Baker Act Reference Guide, discharge planning activities shall include and document
consideration of the following:
a) The person’s transportation resources;
b) The person’s access to stable living arrangements;
c) How assistance in securing needed living arrangements or shelter will be provided to individuals who are at
risk of re-admission within the next 3 weeks due to homelessness or transient status and prior to discharge
shall request a commitment from a shelter provider that assistance will be rendered;
Page 3 of 22
d) Assistance in obtaining a timely aftercare appointment for needed services, including continuation of
prescribed psychotropic medications. Aftercare appointments for psychotropic medication and case
management shall be requested to occur not later than 7 days after the expected date of discharge; if the
discharge is delayed, the facility will notify the aftercare provider. The facility shall coordinate with the
aftercare service provider and shall document the aftercare planning;
e) To ensure a person’s safety and provide continuity of essential psychotropic medications, such prescribed
psychotropic medications, prescriptions, or multiple partial prescriptions for psychotropic medications, or a
combination thereof, shall be provided to a person when discharged to cover the intervening days until the
first scheduled psychotropic medication aftercare appointment, or for a period of up to 21 calendar days,
whichever occurs first. Discharge planning shall address the availability of and access to prescribed
psychotropic medications in the community;
f) The person shall be provided education and written information about his or her illness and psychotropic
medications including other prescribed and over-the-counter medications, the common side-effects of any
medications prescribed and any adverse clinically significant drug-to-drug interactions common between
that medication and other commonly available prescribed and over-the-counter medications;
g) The person shall be provided contact and program information about and referral to any community-based
peer support services in the community;
h) The person shall be provided contact and program information about and referral to any needed community
resources;
i) Referral to substance use treatment programs, trauma or abuse recovery-focused programs, or other selfhelp groups, if indicated by assessments; and
j) The person shall be provided information about advance directives, including how to prepare and use the
advance directives.
It is recommended that a receiving facility provide written information on the above, including the name of the
CMHC, address, and phone number, appointment information and SFBHN’s Consumer Hotline phone number:
1-888-248-3111.
This Discharge Planning Packet provides information on available resources in the community and instructions on
how to access them. For further assistance with any of the following programs, please communicate with the “point
of contact” identified and/or (305) 858-3335 to speak to an Adult System of Care Specialist.
Page 4 of 22
Stable Housing
Affordable and safe housing is important to the well-being and health of individuals and families. Without adequate
housing, individuals have trouble managing their daily lives. When this happens, their health suffers. Stable housing
may help individuals living with chronic illnesses to better maintain their treatment regimens and seek medical care
more frequently.
A stable living environment includes the following settings:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Independent living – alone
Independent living – with relatives
Independent living – with non-relatives
Dependent living – with relatives
Dependent living – with non-relatives
Assisted Living Facility (ALF) with a Limited Mental Health License (LMHL)
Foster Care/Home
Group Home
Nursing Home
Supported Housing
If the individual needs ALF placement, please verify potential facilities on www.FloridaHealthFinder.gov prior to
placement, to assure that they are operating with a Limited Mental Health License (LMHL).
Page 5 of 22
Community Mental Health Centers –
SOUTHERN REGION COMMUNITY MENTAL HEALTH CENTERS (CMHC)
A CMHC is a publicly funded, not-for-profit center which contracts with South Florida Behavioral Health Network, Inc. (SFBHN) for
the provision of inpatient, outpatient, day treatment, or emergency services.
1.
Jackson CMHC
Adult Outpatient
(786) 466-2800
15055 NW 27th Avenue
Opalocka, FL 33054
Jackson CMHC
20201 NW 37th Avenue
Administration/Children’s Services
Miami Gardens, FL 33056
(786) 466-2700
Service Zip Codes: 33054, 33055, 33056, 33160, 33162, 33169, 33179, 33180
2.
Citrus Health Network, Inc.
4175 West 20th Avenue
(305) 825-0300
Hialeah, FL 33012
Service Zip Codes: 33010, 33011, 33012, 33013, 33014, 33015, 33016, 33018, 33122, 33166, 33172, 33178, 33182, 33192
3.
New Horizons CMHC
1469 NW 36th Street
(305) 635-7444
Miami, FL 33142
Service Zip Codes: 33109, 33127, 33132, 33136, 33137, 33138 33142, 33147
4.
Douglas Gardens CMHC
(305) 531-5341
1680 Meridian Avenue, 5th floor
Miami Beach, FL 33139
(305) 403-0654
1150 NE 125th Street
North Miami, FL 33139
Service Zip Codes: 33138 (north of 79th Street), 33139, 33140, 33141, 33147 (north of 79th Street), 33150, 33154, 33161, 33167,
33168, 33169, 33181
5.
Banyan Health Systems
3850 West Flagler Street
(305) 774-3300
Miami, FL 33134
Service Zip Codes: 33125, 33126, 33128, 33129, 33130, 33131, 33133, 33134, 33135, 33136, 33144, 33145, 33146, 33149, 33155,
33165, 33172, 33174, 33175, 33182, 33184, 33185, 33192, 33194
6.
Community Health of South Florida, Inc. (CHI)
10300 SW 216th Street
(305) 252-4840
Miami, FL 33190
Service Zip Codes: 33030, 33031, 33032, 33033, 33034, 33035, 33039, 33143, 33156, 33157, 33158, 33170, 33173, 33176, 33177,
33183, 33186, 33187, 33190, 33193, 33196
7.
Guidance Care Center (Monroe County)
(305)434-7660
*same phone number for all locations
Upper Keys
99198 Overseas Hwy., Ste 5
Key Largo, FL 33037
Middle Keys
3000 41st St., Ocean
Marathon, FL 33050
Lower Keys
1205 Fourth St.
Key West, FL 33040
Service Zip Codes: 33001, 33036, 33037, 33040, 33041, 33042, 33043, 33044, 33045, 33050, 33051, 33052, 33070
Page 6 of 22
Private and Public Receiving Facilities – Circuit 11 & 16
Aventura Hospital and Medical Center
20900 Biscayne Boulevard
Aventura, Florida 33180
(305) 682-7000 (Main)
(305)682-7241 (Baker Act/Crisis)
Citrus Health Network, Inc.
ACSU and CCSU
4175 West 20th Avenue
Hialeah, FL 33012
(305) 825-0300 (Main)
(305) 825-0300 X11205 (Children Baker Act/Crisis)
(305) 825-0300 X11305 (Adult Baker Act/Crisis)
Guidance/ Care-Center, Inc.
3000 41 Street Ocean
Marathon, FL 33050
(305) 434-7660 X31202 (Main)
(305) 434-7660 X31123 (Baker Act/Crisis)
Jackson CMHC
15055 NW 27 Avenue
Opa-Locka, FL 33055
(786) 466-2800 (Main)
(786) 466-2834 (Baker Act/Crisis)
Kendall Regional Medical Center
11750 SW 40th Street
Miami, Florida 33175
(305) 223-3000 (Main)
(786) 315-5901 (Baker Act/Crisis)
Lower FL Keys Health System (DePoo Hospital)
1200 Kennedy Drive
Key West, Florida 33040
(305) 294-5531 (Main)
(305) 294-5531 X8330 (Baker Act/Crisis)
Mount Sinai Medical Center
4300 Alton Road
Miami Beach, Florida 33139
(305) 674-2000 (Main)
(305) 298-6365 (Baker Act/Crisis)
Nicklaus Children’s Hospital
3100 SW 62nd Avenue
Miami, Florida 33155
(305) 666-6511 (Main)
(305) 663-2363 (Baker Act/Crisis)
Palmetto General Hospital
2001 West 68th Street
Hialeah, Florida 33016
(305) 823-5000 X2050 (Main)
(305) 823-5000 X2060 (Baker Act/Crisis)
University of Miami Hospital
1400 NW 12th Avenue
Miami, Florida 33136
(305) 689-5511 (Main)
(305) 689-5077 (Baker Act/Crisis)
Banyan Health Systems
3800 West Flagler Street
Miami, FL 33134
(305) 757-0602 (Main)
(305) 774-3616 (Baker Act/Crisis)
Community Health of South Florida, Inc. (CHI)
10300 SW 216 Street
Miami, FL 33190
(305) 253-5100 (Main)
(305) 252-4865 (Baker Act/Crisis)
Jackson Behavioral Health Hospital
1695 NW 9th Avenue
Miami, Florida 33136
(305) 355-7777 (Main)
(305) 355-7332 or (305) 355-7334 (Baker Act/Crisis)
Jackson South Community Hospital
9333 SW 152nd Street
Miami, Florida 33157
(305) 251-2500 (Main)
(305)256-5310 (Baker Act/Crisis)
Larkin Community Hospital
7031 SW 62nd Avenue
Miami, Florida 33143
(305) 284-7500 (Main)
(305) 284-7575 (Baker Act/Crisis)
Mercy Hospital, a Campus of Plantation General Hospital
3663 South Miami Avenue
Miami, FL 33133
(305) 854-4400 (Main)
(305) 285-2240 (Baker Act/Crisis)
Mount Sinai Aventura Emergency Room
2845 Aventura Boulevard
Aventura, 33180
(305) 932-2099 (Main)
North Shore Medical Center
1100 NW 95th Street
Miami, Florida 33150
(305) 835-6000 (Main)
(305) 835-6122 (Baker Act/Crisis)
Southern Winds Hospital
4225 West 20th Avenue
Hialeah, Florida 33012
(305) 558-9700 (Main/Crisis)
Westchester General Hospital
2500 SW 75th Avenue
Miami, Florida 33155
(305) 264-5252 (Main)
(305) 264-5252 ext. 1111 (Baker Act/Crisis)
Page 7 of 22
Addiction Receiving Facilities (ARF) and Juvenile Addiction Receiving Facility (JARF)
Adults and minors in need of medical assistance to withdraw from drug and alcohol abuse or dependence,
detoxification and addiction receiving facilities are available in Miami-Dade and Monroe County.
Addiction Receiving Facility (ARF) –state contracted and designated secure acute care residential facility providing
intensive level of care capable of handling aggressive behavior and deter elopements for persons meeting
involuntary assessment / treatment.
Juvenile Addiction Receiving Facility (JARF) - state contracted and designated secure acute care residential facility
providing intensive level of care capable of handling aggressive behavior and deter elopements for minors meeting
involuntary assessment / treatment.
ARF/JARF Facilities
Community Health of South Florida (CHI) (Inpatient Detox)
10300 SW 216th St, Miami
305-252-4865
Citrus Health Network (JARF)
4175 West 20th Ave, Hialeah,
305-825-0300 x12353
Jackson CMHC (ARF & Inpatient Detox)
15055 NW 27th Ave, Opa-Locka
786-466-2834
Banyan Community Health Center (ARF)
3850 West Flagler St, Miami
305-774-3600
Guidance Care Center (ARF & Inpatient Detox)
3000 41 Street Ocean, Marathon
305-434-7660
Page 8 of 22
Lead Case Manager Supervisors – Community Mental Health Centers
Provider
Name
Phone
E-Mail
Community Health of
South Florida Inc. (CHI)
Jennifer Weaver
305-252-4407
JWeaver@chisouthfl.org
Henry Swedlaw
305-252-4892
HSwedlaw@chisouthfl.org
Jackson CMHC
Diane Luly
786-466-1315
DLuly@jhsmiami.org
Douglas Gardens CMHC
Eleanor Lanser
305-531-5341
ELanser@dgcmhc.org/tastolfo@dgcmhc.org.
Banyan Health CMHC
Sarai Martin
786-230-4652
SMartin@banyanhealth.org
New Horizons CMHC
Cherie Harden
305-370-2417
charden@nhcmhc.org
Citrus CMHC
Rosario Morffy
305-424-3112
rosariom@citrushealth.com
Guidance Care Center
Lisa Menard
305-587-8455
Lisa.menard@westcare.com
Maureen Kempa
305-434-7660
ext. 31221
Maureen.kempa@westcare.com
Page 9 of 22
FACT Description
Florida Assertive Community Treatment (FACT) Teams provide intensive, assertive community-based treatment
that includes rehabilitation and support services for persons with psychiatric disabilities. These disabilities typically
include schizophrenia, other psychotic disorders (e.g., schizoaffective disorder), mood disorders, such as bipolar
disorders and major depression, personality disorders, such as borderline personality disorder, obsessivecompulsive disorder, posttraumatic stress disorder, anorexia nervosa, and dissociative identity disorders.
Individuals must first meet the definition of mental illness as defined in Chapter 394, F.S., and be in one of the
target groups included under the auspices of the Departmental performance measures as required by the
Government Performance and Accountability Act of 1994.
PURPOSE: To describe the eligibility, admission and criteria for provision of services by a FACT team as outlined in
Assertive Community Treatment (ACT) Start-Up Manual published by The National Alliance on Mental Illness
(NAMI).
PROCEDURE:
I.
Admission Criteria: An applicant may be admitted to the FACT program if they meet the following criteria:
A. Has repeated crisis stabilization admissions(>3 admissions within the past year) AND
B. Either:
1. Demonstrates a high risk for hospital admission or readmission OR
2.Presents with a history of prolonged inpatient length of stays (>90 days)
AND
C. The applicant must meet at least THREE of the following six characteristics:
1. Unable to consistently perform the range of Activities of Daily Living (ADLs) tasks except
with significant support or assistance from others.
2.Unable to engage in regular productive activity such as employment, volunteer work, school,
or homemaker responsibilities.
3.Unable to retain permanent housing due to repeated evictions or loss of housing.
4.Presents with a co-occurring Substance Use disorder of significant duration.
5. Exhibits destructive behavior to self or others.
D. Demonstrates high risk for legal involvement or has a recent legal history
E. The person has been referred to outpatient mental health services and has either failed to benefit or
has been non-adherent.
POINT OF CONTACT:
Pam Ford, Peer Services Manager
Email: pford@sfbhn.org
Direct: 786-507-7472
Main: 305-858-3335
Fax: 305-860-4869
*** Please submit a consent form with the referral form.
Page 10 of 22
FACT – Referral form
Please send referrals to Pam Ford, Peer Services Manager
Double click on the table to open PDF
Page 11 of 22
STAR – Short Term Residential Treatment Facility
Citrus Health Network Safe Transition and Access to Recovery (STAR) Program
A Short-term Residential Treatment (SRT) Program is a state-supported acute care 24-hour-per-day, 7-days per
week residential alternative service, typically with lengths of stay of 90 days or less, and is an integrated part of a
designated public receiving facility and receiving state mental health funds under the authority of Chapter 394, F.S.
The purpose of an SRT is to provide intensive short-term treatment to individuals who are temporarily in need of a
24-hour-a-day structured therapeutic setting in a less restrictive, but longer-stay alternative to hospitalization.
PURPOSE: To describe admission criteria and the SFBHN management functions related to SRT.
PROCEDURE:
I.
Admission Criteria: For admission to an SRT, the individual must meet the following criteria:
a. Individual must be at least 18 years old and diagnosed with a severe and persistent mental illness,
with or without co-occurring disorders
b. Individual is at risk of institutionalization or incarceration for mental health reasons
c. Individual shall be admitted pursuant to Chapter 394 (voluntary or involuntary), Part I, F.S., and
Chapter 65E-5, F.A.C., and only on the order of a physician.
d. Individual must present as acutely mentally ill and in need of intensive staff supervision, support and
assistance, as documented in a psychiatric or psychological evaluation.
e. Individual must be continent, ambulatory or capable of self-transfer.
POINT OF CONTACT:
Carol Caraballo, Adult System of Care Manager
Email: ccaraballo@sfbhn.org
Direct: 786-507-7468
Main: 305-858-3335
Fax: 305-860-4869
*** Please submit a consent form with the referral form.
Page 12 of 22
STAR SRT Referral form
Please send referrals to Carol Caraballo, Adult System of Care Manager
Double click on the table to open PDF
Page 13 of 22
Residential Level II Description – Substance Use
Residential substance use treatment is provided 24 hours-per-day, 7 days-per-week, and is intended for consumers
who meet the placement criteria for this level of care.
PURPOSE: To describe the eligibility, admission and criteria for provision of services for adult residential substance
use.
Residential Level II:
Level II programs include those that are referred to as therapeutic communities or some variation of therapeutic
communities. This level is appropriate for persons characterized as having chaotic and often abusive interpersonal
relationships, extensive criminal justice histories, prior treatment episodes in less restrictive levels of care,
inconsistent work histories and educational experiences, and anti-social behavior. In addition to clinical services,
considerable emphasis is placed on services that address the consumer’s educational and vocational needs, socially
dysfunctional behavior, and need for stable housing upon discharge. It also includes services that assist the
consumer in remaining abstinent upon returning to the community.
For level II, each consumer shall receive services each week in accordance with subsection 65D-30.007(3), F.A.C.,
including at least 10 hours of counseling per week.
PROCEDURE:
I.
Assessment Procedure:
Consumers who may require residential Level II substance abuse treatment and who are eligible for Department of
Children and Families (DCF) funds are required to receive the following assessments prior to placement on the
circuit centralized wait list and placement into a DCF funded bed. To schedule a screening/assessment, please
contact the residential providers listed on page 15.
a. Screening: Adult Screening Tool (AST)
b. Admission: Clinical Assessment Tool (CAT)
II.
Obtaining Consent: Prior to conducting the above outlined screening/assessment, provider agencies are
required to obtain consent from consumers. The consent form used is provided by South Florida Behavioral Health
Network (SFBHN). The consent shall include authorization for sharing the information gathered in the assessment
with the Department, SFBHN and any other entities requiring access to ensure coordinated quality care. All entities
privileged to access the assessment are identified on the consent form appendix. The consent form is available in the
‘Forms’ section of this manual.
POINT OF CONTACT:
Carol Caraballo, Adult System of Care Manager
Email: ccaraballo@sfbhn.org
Direct: 786-507-7468
Main: 305-858-3335
Fax: 305-860-4869
Page 14 of 22
Residential Providers Screening/Assessment – Available with appointment
Central Intake – No Appointment Needed
M-F 8 a.m. – 4 p.m.
3140 NW 76 St., Miami
786-466-3020
South Florida Jail Ministries, Inc. d/b/a Agape
Family Ministry
22790 SW 112th Ave., Miami
305-235-2616
Betterway of Miami
800 NW 28th St., Miami
305-634-3409
Camillus House
726 NE 1st Ave., Miami
305-374-1065
Catholic Charities: St. Luke’s Recovery
7707 NW 2nd Ave., Miami
305-795-0077
Concept House
162 NE 49th St., Miami
305-751-6501
Here’s Help, Inc.
15100 NW 27th Ave. Opa Locka
305-685-8201
Jessie Trice Community Health Center
2985 NW 54 Street; Miami
305-685-8201
Banyan Community Health Center:
Casa
Nueva Vida
1560 SW 1st St., Miami
305-644-2667
Banyan Community Health Center: Dade
Chase
140 NW 59 St., Miami
305-759-8888
Miami Dade Office of Rehabilitation Services:
New Directions
3140 NW 76 St., Miami
305-693-3251
The Village South
3180 Biscayne Blvd. Miami
305-341-1718
Page 15 of 22
Residential Level II Description – Mental Health
A Level II residential treatment facility provides a structured group treatment setting with 24- hour per day, 7 days
per week supervision for five or more residents who range from those who have significant deficits in independent
living skills and need extensive supervision, support and assistance to those who have achieved a limited capacity for
independent living, but who require frequent supervision, support and assistance.
PURPOSE: To describe the eligibility, admission and criteria for provision of services for adult mental health
residential treatment facilities.
DESCRIPTION: Level II Mental Health Residential Treatment Facilities provide a long term, residential
environment that provides care, support, assistance and limited supervision in daily living to adults diagnosed with
a serious and persistent major mental illness who do not have another primary residence. A residential treatment
facility under 65E-4.016 must sustain a 60- day average or greater length of stay of residents.
For level II, each consumer shall receive services each week in accordance with subsection 65E-4.016(c) F.A.C.
PROCEDURE:
I.
Assessment Procedure: Consumers seeking Adult Residential Level II Mental Health Treatment, and who
are eligible for Department of Children and Families (DCF) funds, are required to receive an assessment
prior to placement on the circuit centralized wait list and placement into a DCF funded bed. A referral is
required, including referral form, recent psychiatric evaluation and any other clinical information if
available.
Obtaining Consent: Prior to conducting the assessment described above, provider agencies are required to obtain
consent from consumers. The consent form used is provided by DCF and South Florida Behavioral Health Network
(SFBHN). The consent shall include authorization for sharing the information gathered in the assessment with
DCF, SFBHN and any other entities requiring access to ensure coordinated quality care. All entities privileged to
access the assessment are identified on the consent form appendix. The consent form is available in the ‘Forms’
section of this manual
POINT OF CONTACT:
Carol Caraballo, Adult System of Care Manager
Email: ccaraballo@sfbhn.org
Direct: 786-507-7468
Main: 305-858-3335
Fax: 305-860-4869
*** Please submit a consent form with the referral form.
Page 16 of 22
Residential Level II Referral
Please send referrals to Carol Caraballo Adult System of Care Manager
Double click on the table to open PDF
Page 17 of 22
Consent Forms
Please submit a consent form with each referral form.
English
Double click on the table to open PDF
Page 18 of 22
Spanish
Double click on the table to open PDF
Page 19 of 22
Creole
Double click on the table to open PDF
Page 20 of 22
Consumer and Family Resource Manual
Double click on the table to open PDF
Page 21 of 22
Housing Directory
Double click on the table to open PDF
Page 22 of 22