North Carolina TASC Clinical Series Training

1. North Carolina TASC Clinical Series Training Module Thirteen: Care Management

2. Care Management • Assessing their needs • Helping them see the value in recovery • Helping them identify long-term goals and achieve them through short-term goals • Identifying barriers to success and problem solving to overcome those barriers

3. Care Management Goals To enhance: • Continuity of Care • Accessibility to services • Accountability • Efficiency

4. Key Components • Identification, Screening and Assessment • Care Planning • Linkage and Placement • Advocacy • Monitoring and Evaluation

5. Identification, Screening and Assessment Component • Identify acceptability of client to TASC prerequisites • Identify client’s current and potential strengths and weaknesses • Identify client’s primary needs and resources • Identify client’s ancillary needs • Recognize that this is a continual, on-going process

6. Competence DSM-IV Criteria SASSI Sources ASI/ASAM PPC-2 Program Acceptability Mental Health Violence Substance Abuse Identification and Resources Available Proficiency Counseling Skills Interpret Instrument Results Use of Instruments Communicate Decisions to Appropriate Parties (Client, Judge, Attorney, etc.) Listening Identification, Screening and Assessment Prerequisites

7. Care Planning Components • Individualized • Client-centered • Strength based • Map/guideline for client and care manager • Specific objectives with timelines for completion and review • Realistic and meaningful • Anticipatory, proactive plans • On-going process

8. Competence Relapse Signs and Symptoms Interventions Community Resources Goals of Program Standardize Process for Documentation Counseling Theories Proficiency Write measurable objectives Use short-term goals to meet long-term goals Engage client in the recovery process Develop consulting role with client Teach and coach Care Planning Prerequisites

9. Linkage and Placement Components • Link client to appropriate resources • Identify barriers to needed services and methods to overcome barriers • Ensure transition time is planned • Realistic expectations • Appropriate services

10. Competence Community Resources Statewide Resources Access Protocol and Barriers ASAM PPC-2 Levels Program Content to Ensure Service Match Needs Proficiency ASAM PPC-2 Crosswalk Create equivalent or alternative services if unavailable Match client needs with the appropriate services Negotiate with client, treatment, and justice system Linkage Prerequisites

11. Advocacy Components • Continued education and training of CJS and treatment • Continued education and training to CJS and treatment • For an individual client and/or specific populations • Set up specific systems/services with providers • Filling in service gaps • Maintaining continuity of care throughout service delivery

12. Competence Who the client is or group of clients are Who to advocate to When to advocate Substance abuse expertise Proficiency Communication Knowledge of systems involved Negotiation and access Clinical skills Advocacy Prerequisites

13. Location and Accountability of the Client Monitored by: • Knowing where the client is in the continuum of success • Knowing the client’s involvement and progress in treatment services • Visiting treatment providers • Knowing about and intervening with any problems the client is experiencing • Knowing where and how to contact the client at all times • Maintaining client-related contacts • Documenting and maintaining client files

14. Client’s Condition Monitored by: • Face-to-face meetings with the client • Staying informed of any psychological, medical, or other issues of the client • Accessing ancillary and/or support/wrap-around needs and services • Advocating for support of the client

15. Client’s Condition Monitoring also means understanding specifics about their current condition, including: • Where they are in the stages of change • What to do with the client in each stage to help them advance to the next stage • If the client is in need of crisis intervention • How the client is dealing with withdrawal from the drug • What support systems the client has to assist them in their recovery process

16. Jeopardy Status • Client uses drugs/alcohol in treatment • Client adulterates or refuses to submit to urinalysis • Client fails to comply with treatment requirements • Client fails to comply with service plan • Client fails to attend treatment or TASC appointments • Client is re-arrested

17. TASC Termination Philosophy Stage One: Successful Discharge from Treatment Stage Two: Successful Termination from TASC Stage Three: Successful Completion of Probation

18. TASC Successful Termination Criteria • Successful completion of all treatment • Drug-free status maintained for 90 consecutive days prior to termination from TASC • Legitimate source of income or full-time student status established and stable living environment OR • Discharge of criminal justice requirements

19. TASC Unsuccessful Termination Criteria • Client reaches the third and final jeopardy status • Client is convicted on any subsequent felony charge, which precludes his/her participation in TASC services • Client is not in contact with TASC for 30 calendar days • Client acts violently or threatens violence against another client, TASC staff, or treatment staff • Client is repeatedly in non-compliance with his/her care plan • Client is in possession of a weapon at TASC or treatment program sites • Client is in possession of drugs or alcohol at TASC or treatment program sites • Client withdraws from TASC services

20. Competence ASAM PPC-2 Continued Stay Criteria Program Required Contacts Transition Criteria Program Success Criteria/Rates Sentencing Criteria TASC Jeopardy and Termination Criteria Proficiency Communication with all populations Timely reporting to CJS Foster relationship with healthy boundaries Record data Analyze data for trends Clinical discretion in consequences for clients Monitoring Prerequisites