ROSC

1. Case Management and Service
Coordination in a Recovery
Oriented System of Care
(ROSC)
Instructor: Dr. Dawn-Elise Snipes
Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery & The
Addiction Counselor Exam Review
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2. Objectives
 Define a Recovery Oriented System of Care
 Identify the goals and counselor functions in a ROSC
 Explore the ROSC belief about recovery management
 Define referral and service coordination within the
context of case management
 Explore why CM is necessary
 Identify the different approaches to case
management
 Identify the CM role in service coordination
 Define service planning
 Identify challenges and solutions to collaboration
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3. Recovery Oriented Systems of Care
 Affirms the real potential for permanent resolution of
behavioral health problems
 Offers solutions to behavioral health problems on a
community and cultural level
 Shift away from risk management and relapse
prevention toward encouraging clients to self-define
goals and take responsibility for achieving them
 A shift from emergency room/acute care model to
one of sustained recovery management which include
wrap-around recovery support services
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4. Recovery Oriented Systems of Care
 Emphasis on
 Post-treatment monitoring
 Stage-appropriate recovery education
 Peer recovery coaching
 Assertive linkages to recovery communities
 Early re-intervention
 Maintaining functional ability in all life activities
Recovery in illness instead of recovery from illness
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5. Recovery Oriented Systems of Care
 Goals
 Foster health and resilience activities
 Increase permanent housing and sense home/belonging
 Ensure gainful employment and access to education to
provide a sense of purpose
 Enhance communities by increasing availability of necessary
supports from and for peers/family/community
 Reduce barriers to social inclusion
 Additional Counselor Functions
 Identify gaps in services
 Identifying emerging trends and needs
 Monitor system effectiveness
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6. Recovery Oriented Systems of Care
 Guiding principles of Recovery emerge from hope and
are…
 Person-centered - self-efficacy, self-direction
 Non-linear, and occurs via many pathways (methods)
 Holistic – mind, body, spirit, community
 Supported by peers and allies (counselors/case workers)
 Supported through relationships and social networks (family,
peers, faith groups, community)
 Culturally based and influenced
 Supported by addressing trauma
 Based on respect of individual, family and community
strengths and responsibilities
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7. Recovery Oriented Systems of Care
 3 core components
 Collaborative decision making /individual empowerment
 Continuity of services and supports
 No wrong door
 Services available as long as needed
 Service quality and responsiveness
 Evidence based
 Developmentally and culturally appropriate
 Gender specific
 Trauma informed
 Family focused
 Stage appropriate
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8. Recovery Management
 Treatment does not need to be voluntary, but success depends
on personal engagement
 Full recovery often comes from episodic, nonlinear treatment
 Previous treatment and relapse is not indicative of poor
prognosis
 Relapse is viewed as evidence of the severity of the condition
rather than a cause for discharge
 Recovery management is a time-sustained, recovery focused
collaboration between consumers and service providers with
the goal of stabilizing and managing the ebb and flow of co-
occurring disorders until full recovery is achieved or self-
management is possible.
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9. Recovery Management
 Spans 3 phases
 Prerecovery identification and engagement
 Recovery initiation and stabilization
 Recovery maintenance
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10. Case Management
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11. Service Coordination: Case Management
 A client-level collaborative process designed to:
 Help individuals access needed services
 Select the most appropriate services
 Facilitate linkage with those services
 Promote continued retention in services by monitoring
participation
 Coordination of multiple services when necessary
 Advocate for continued participation
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12. Service Coordination: Case Management
 Objectives of case management
 Continuity of care
 Accessibility:
 Establish relationships with “gatekeepers”
 Develop contracts or MOUs which specify
 Available “slots”
 Consequences for failure to implement specified activities/procedures
 Accountability
 Following up on the referral with client and referral resource
 Measuring outcomes with
 Client satisfaction
 Client outcomes
 Service system outcomes (i.e. reduction in cost to treat)
 Efficiency “Know the system and make it work”
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12

13. Service Coordination: Case Management
 Necessary because of poor service coordination, lack
of service continuity and difficulty of clients
negotiating the gap between services
 Structure
 Case manager who acts as the human link between the
client and service providers
 Core agency
 Develops contracts with providers for identified services
 Controls case management funds
 Acts as a single point of entry for clients
 Develops missing service elements
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14. Service Coordination: Case Management
 Approaches
 Intensive/Assertive Community Treatment
 Comprehensive, multidisciplinary, community based
 Growth
 Paternalism
 Clinical
 Case manager provides many services including counseling
 Stabilization
 Strengths based
 Focus on strengths and empowerment
 Growth
 Empowerment
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15. Service Coordination: Case Management
 Approaches
 Brokerage
 Coordinates services and provides few, if any services
 Stabilization
 Empowerment
 Integrated
 Family-focused, strength-based program that uses an
independent facilitator to coordinate all relevant people,
including providers, family and natural supports.
 This team then works in partnership with the family to create a
safety-based comprehensive plan addressing the needs of all
family members.
 Growth
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16. Service Coordination: Case Management Principles
 Offers a single point of contact for clients
 Client-driven and strengths based
 Involves advocacy
 Between services with seemingly contradictory requirements to serve
the best interests of the client
 With agencies, families, legal systems and legislative bodies
 May involve the recommendation of sanctions to encourage client
compliance and motivation
 Community based
 Pragmatic “Where the client is”
 Anticipatory based on the natural course of the client’s
presenting issues
 Flexible to individual needs
 Culturally sensitive
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17. Service Coordination: Case Manager’s Role
 To coordinate, manage, link, advocate and support clients
in their quest to maximize their quality of life and achieve
as much independence as possible
 Basic Prerequisites and Competencies
 Ability to establish rapport
 Awareness of how to maintain boundaries
 Willingness to be nonjudgmental
 Recognize the importance of family, social networks and
community in the process
 Understand the variety of insurance and payment options available
 Understand culture and respond in a culturally sensitive manner
 Understand the value of an interdisciplinary approach to
treatment
 Serve as both facilitator of referrals and advocate
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18. Service Coordination: Case Manager’s Role
 Facilitator Duties
 Composing the team
 Notifying participants of meetings
 Chairing the meeting
 Maintaining team focus on the client
 Ensuring clients’ desires and needs are adequately
represented and considered
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19. Service Coordination: Referral
 Referral is the process of facilitating the client’s use
of available services and support systems to meet the
needs identified in assessment or treatment planning
 Involves identifying needs of the clients which cannot
be met by the agency (regardless of whether client is
receiving case management services)
 Inappropriate referrals may lead to dropout if clients
hopes get up then they are denied access to services
 Inadequate follow up also often leads to premature
drop-out
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20. Service Coordination: Referral
 Counselors must know resources in their community
 Processes
 Limitations
 Requirements
 Confidentiality
 Counselors should visit the referral agencies
 Initially
 Semi-annually
 Potential problems in referrals
 Differences in agency functioning
 Differences in eligibility
 Inadequate data sharing
 Conflicting treatment plans
 Moving between agencies may interrupt continuity of care
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21. Service Coordination: Referral
 Potential referral resources
 Marriage and family & mental health counselors
 Abuse and trauma counseling resources
 Health:
 Primary care
 Women’s health
 Nutrition
 Holistic practitioners
 Pain management
 Legal
 Financial counseling
 Housing
 Career counseling/educational planning
 Religious/spiritual/faith support
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22. Service Coordination: Referral
 Potential referral resources
 Career counseling/educational planning
 Religious/spiritual/faith support
 LGBTQ Support
 12-step meetings—variety and locations
 Veterans Administration
 Childcare
 Transportation
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23. Service Coordination: Referral
 Potential reasons
 Counselor’s agency does not provide that service
 Counselor may not be the best person to provide the
service (i.e. sexual identity issues)
 Counselor believes there might be a conflict of interest
 Counselor recognizes the need for a different level of
care
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24. Service Coordination: Referrals
 Counselor should
 Explain the rationale for any referrals to facilitate
participation
 Familiarize the client with the agency to quell anxieties
 Contact the referral source in the client’s presence
 Have client schedule the actual appointment
 Give the client
 Contact name and number
 Agency address
 Document the referral and follow (with client AND provider)
up in the client record
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25. Service Coordination: Referral
 Dual-diagnosis or co-occurring disorders indicates the
presence of both mental health and addiction issues.
 People with co-occurring issues often experience more
severe emotional, social and physical problems than
someone with only one issue
 Medical, Mental health and Addictive disorders all
influence each other
 Use and withdrawal can both cause mood, social and
physical conditions
 Continuum: Disorders vary in terms of…
 Severity
 Chronicity
 Disability/degree of impairment in functioning
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26. Service Coordination: Service Planning
 Treatment plans are designed with the provider to
identify treatment objectives necessary to achieve
goals
 Service plans is an umbrella document which ties
together all of the
 Treatment plans from the various providers
 Short term goals and objectives
 Structure of the Comprehensive Service Plan
 Long Term Goals
 Current status narrative
 Required services, supports and resources
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27. Service Coordination: Linking, Monitoring, Advocacy
 Linkages
 goes beyond providing a list of resources
 Involves developing a network of known resources and
contacts
 Foundation for successful implementation is based
upon interdisciplinary team planning effort
(including the client)
 Decides goal priorities
 Assigns responsibilities for each goal
 Reaches consensus in overall approaches
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28. Service Coordination
 Encompasses administrative, clinical and evaluative
activities that bring the client , treatment services,
community agencies and other resources together to
focus on needs identified in the recovery plan
 Service coordination includes:
 Case management
 Collaboration with client and SOs
 Coordination of treatment and referral services to address
issues contributing to and caused by addictive behaviors
 Liaison activities with community resources
 Ongoing evaluation of treatment progress and client needs
 Client Advocacy
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29. Service Coordination
 Tasks
 Initiating and collaborating with referral source “warm
referral”
 Obtain, review and interpret all relevant screening,
assessment and treatment planning information
 Confirm client eligibility for admission and continued
readiness for change
 Completing necessary administrative procedures for
admission
 Coordinating all treatment activities with services provided
to the client by other resources
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30. Service Coordination
 Tasks
 Establishing realistic recovery expectations including
Nature of services (IOP, Residential etc.)
Program goals
Program procedures (schedule, services offered)
Rules regarding client conduct
Client rights and responsibilities
Schedule of treatment activities
Costs of treatment
Facts impacting duration of treatment
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31. Service Coordination
 Types of services
 Mental health
 Physical health (liver (including hepatitis), brain, HIV, tuberculosis,
STDs etc)
 Job skills
 Employment opportunities
 Interpersonal skills
 Training/education
 Legal services
 Housing services
 Food
 Childcare
 Transportation
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32. Service Coordination: Collaboration
 Service coordination is essential to
 Prevent clients from falling through the cracks
 Foster a more holistic view of the client…not just a
person with an addiction
Client no-show because cant find sitter. Noncompliance
or responsible parent?
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33. Service Coordination: Collaboration
 Challenges
 Use of different assessment tools at each agency to gather
same information
 Produces a fragmented picture of the client (unless integrated)
 Creates frustration for the client. (Didn’t I just do this?)
 Agreeing which agency or clinician is “lead” or primary
contact for the client and other agencies
 Lead agency uses holistic assessment that meets the needs of
all associated agencies
 Funding/eligibility barriers (i.e. services for persons with a
felony)
 Difficult to treat clients
 Differing staff credentials
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34. Service Coordination
 Challenges to collaboration/service coordination
 Can occur at 3 levels
 Personal: Attitudes and attributes
 Professional: Differing theoretical beliefs/approaches to
treatment of addiction, and “jargon”
 Organizational
 Not recognizing the need for partnership
 Lack of a shared mission
 Lack of ownership by senior management
 Lack of trust between agencies
 Unclear guidelines for collaboration
 Lack of a process for monitoring and managing collaboration
process
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35. Summary
 A Recovery Oriented System of Care is a comprehensive system
designed to support growth through multiple episodes of
treatment
 The goals in a ROSC include fostering resilience activities and
enhancing communities by increasing availability of necessary
supports from and for peers/family/community
 Define referral and service coordination within the context of
case management
 Case management is necessary because of poor service
coordination, lack of service continuity and difficulty of clients
negotiating the gap between services
 There are many CM models ranging from brokerage to clinical
 Case managers are charged with developing the comprehensive
service plan to ensure client needs are met
 Collaboration challenges can often be addressed through
effective communication, creativity and negotiation
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