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

1. The Role of Care Coordinationin a Recovery Oriented System of Care Susan Jenkins December 2012

2. 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.

3. 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

4. Recovery System Medical Dental Mental Health Family Therapy Public Transportation Community Support Self-Help Groups Social/Recreation 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

5. Goals of a Recovery Oriented System of Care • Intervene earlier • Improve treatment outcomes • Support sustained recovery

6. Goal: Intervene Earlier • Why? – As disease progresses, damage is greater; positive outcomes more likely • Outreach • Engagement and Intervention • Continuity of care

7. 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

8. Goal: Support Sustained Recovery • Continuing Care – Recovery Checkups • Recovery Coaches – connect patients with recovery community • Community Development work • Recovery Support Services

9. What areRecovery Support Services? • Outreach • Engagement and intervention • Recovery guiding or coaching • Post treatment monitoring and support

10. Recovery Support Services • Sober or supported housing • Transportation • Childcare • Legal services • Educational/vocational supports

11. 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

12. 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

13. Recovery Oriented System of Care Elements • Partnership-consultant relationships • Strength-based • Culturally responsive • Responsive to personal belief systems

14. Recovery Oriented System of Care Elements • Commitment to peer recovery support services • Inclusion of voices of recovering individuals and families • Integrated services

15. Recovery OrientedSystem of CareElements • System-wide education and training • Ongoing monitoring and outreach • Outcomes driven • Research based • Adequately and flexibly financed

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Where does care coordination fit ?

24. 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?

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

26. Care Coordination: Potential • Dual roles • Recovery Coach • Continuing Care • Engagement Specialist

27. 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 HealthRecovery Management

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