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Recovery Oriented System of Care and Service Coordination
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
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
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
~ Counselor functions
~ Identify gaps in services
~ Identifying emerging trends and needs
~ Monitor system effectiveness
Recovery Oriented Systems of Care
~ Guiding principles of Recovery emerges from hope and is…
~ 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

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

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.
Recovery Management
~ Spans 3 phases
~ Prerecovery identification and engagement
~ Recovery initiation and stabilization
~ Recovery maintenance
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

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

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

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

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?
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

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