The Role of Care Coordination in a Recovery Oriented System of Care

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The Role of Care Coordination in a Recovery
Oriented System of Care

• Susan Jenkins December 2012

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What is Recovery?

• Recovery from alcohol and drug addiction is a
  process of change through which individuals
  improve their health and wellness, live a
  self-directed life, and strive to reach their
  full potential.

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What is a Recovery Oriented System of Care?

• Wide spectrum of services
• Supports all stages and pathways of recovery
• Addresses access to services
• Includes treatment, alternatives to treatment,
  and recovery support services
• Coordinates multiple services

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Recovery System
Medical Dental Mental Health Family Therapy
Public Transportation
Community Support Self-Help Groups Social/Recreati
on Building Life Skills
Internet
Evaluation
DSS/DJS
Treatment System
Housing/Supportive and Independent Living
Legal Judges Lawyers Parole/Probation
Outpatient Treatment
Residential Programs
Vocational Educational
Faith Organizations
Senior/Child Day Care
Employment
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Goals of a Recovery Oriented System of Care

• Intervene earlier
• Improve treatment outcomes
• Support sustained recovery

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Goal Intervene Earlier

• Why? As disease progresses, damage is greater
  positive outcomes more likely
• Outreach
• Engagement and Intervention
• Continuity of care

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Goal Improve Treatment Outcomes

• Acute model of care to treat a chronic disease
• Partnership between treatment provider and
  patient
• Integrated care
• More choices for patient

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Goal Support Sustained Recovery

• Continuing Care Recovery Checkups
• Recovery Coaches connect patients with recovery
  community
• Community Development work
• Recovery Support Services

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What are Recovery Support Services?

• Outreach
• Engagement and
• intervention
• Recovery guiding or coaching
• Post treatment monitoring and support

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Recovery Support Services

• Sober or supported housing
• Transportation
• Childcare
• Legal services
• Educational/vocational supports

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Goals of Recovery Support Services

• Remove personal and environmental barriers to
  recovery
• Facilitate participation in the recovery
  community
• Enhance the quality of life of the person in
  recovery

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Elements of a Recovery Oriented System of Care

• Person centered
• Family and other ally involvement
• Individualized and comprehensive services across
  the lifespan
• Anchored in the community
• Continuity of care

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Recovery Oriented System of Care Elements

• Partnership-consultant relationships
• Strength-based
• Culturally responsive
• Responsive to personal belief systems

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Recovery Oriented System of Care Elements

• Commitment to peer recovery support services
• Inclusion of voices of recovering individuals and
  families
• Integrated services

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Recovery OrientedSystem of Care Elements

• System-wide education and training
• Ongoing monitoring and outreach
• Outcomes driven
• Research based
• Adequately and flexibly financed

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• What is Maryland doing to move toward a Recovery
  Oriented System of Care?

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Maryland Implementation Plan

• Goal Assign Responsibility for Guiding
  Transformation
• Goal Engage Stakeholder Groups
• Goal Educate the System
• Goal Define Standards for Services
• Goal Change Funding Priorities
• Goal Collect Data that Measure Recovery Outcomes
• Goal Collaborate with other Agencies

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Implementation of Services

• ADAA now requires that jurisdictions offer
• Continuing Care
• Offered by outpatient programs
• Telephone support
• Includes relapse risk assessment
• Care Coordination
• High risk, high cost patients

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Implementation of Services

• ADAA grant funds may now be used for
• Recovery Housing
• Purchased on fee-for-service basis
• Peer Recovery Coaching
• Recovery Community Center activities

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Peer Recovery Support Specialists

• Development of Peer Support Specialist roles,
  training curriculum, and certification
  requirements
• Provide Peer Recovery Coach training
• Allow ADAA grant funds to pay for Peer Support
  Specialist services

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Recovery Community Centers

• ADAA released funds to provide activities within
  18 Recovery Community Centers across the State
• Services to be determined by the target
  population
• Examples include social/recreational activities,
  life skill groups, recovery coaching, warm
  lines to connect people to services, peer support
  meetings

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Access to Recovery GrantMaryland RecoveryNet

• 3.2 million statewide each year for four years
• Clinical and Recovery Support Services for
  individuals leaving residential treatment
  programs
• Halfway house treatment, marital/family
  counseling, recovery housing, pastoral
  counseling, care coordination, transportation,
  job readiness counseling
• 118 Recovery Houses, and 1160 recipients have
  enrolled in Recovery Housing as of 6/29/12

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Where does care coordination fit ?
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Why do people who need treatment avoid seeking
treatment?Once people are in treatment, why do
they drop out?Once people complete treatment,
why do they relapse?
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Care Coordination Potential

• Care Coordinator assigned at the time of
  assessment
• High risk, high cost patients
• Patients who need multiple services

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Care Coordination Potential

• Dual roles
• Recovery Coach
• Continuing Care
• Engagement Specialist

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Resources

• http//partnersforrecovery.samhsa.gov/docs/Summit-
  Report.pdf Summit Report
• www.glattc.org Click on Recovery Management
  Resources
• http//pfr.samhsa.gov Click on Recovery, then
  Resources. Information about the national
  movement
• http//rcsp.samhsa.gov Recovery Community
  Services Program on CSAT'S website
• www.ct.gov/dmhas/site.default.asp
  Connecticut's Practice Guidelines for
  Recovery-Oriented Behavioral Health Care booklet
  can be accessed on this site
• www.bhrm.org Behavioral Health Recovery
  Management

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Portions of this presentation were adapted from
Building a Unified Vision for Resiliency,
Wellness, and Recovery Michael T. Flaherty,
PhDIRETA/Northeast ATTCApril 2008