 Welcome to the Addiction Counselor Exam Review. This presentation is part of the Addiction Counselor Certification training. Go to https.www.allceus.com. slash certificate-tracks to learn more about our specialty certificates starting at $149. Hi everybody and welcome to Case Management and Service Coordination in a Recovery Oriented System of Care. This is a review for the Addiction Counselor Certification Exam. We're going to start out by talking about the Recovery Oriented System of Care and Service Coordination and then we're going to move on from there. So you might be saying, well, what is a Recovery Oriented System of Care? Basically, it's creating instead of a single agency or whatever that serves a few needs of the person, it's creating a system that meets all of the needs of the person. And recognizes that recovery is episodic. People will have problems and then they'll hit a plateau, things will get better, they'll go into remission, whatever you want to call it. And then they may need services again, maybe different types of services. So Recovery Oriented System of Care is one that provides comprehensive services and is there for the lifetime of the person. It's not just, okay, we're here for you for 16 weeks and then good luck. It affirms the real potential for permanent resolution of behavioral health problems. It offers solutions to behavioral health problems on a community and cultural level. So again, it's not just an agency, it's an entire community buying in the social service network, preferably law enforcement as well, getting churches, getting community organizations involved to make sure that we're meeting all of the biopsychosocial needs. And a lot of times communities, you know, social services meets the bio needs, the medical, the food. Well, those are the two big ones and sometimes housing. But in Recovery Oriented System of Care, we also may need childcare, transportation, recreation, other things for people to do so they don't feel isolated. This is one of the reasons that a lot of the elder care drop-in centers have opened in order to create a place where people can go and socialize with people who share some sort of similar aspects. It's a shift away from risk management and relapse prevention toward encouraging clients to self-define goals and take responsibility for achieving them. So instead of going, okay, how can we keep this person from getting depressed again? We're going to say, how can we help this person achieve their highest quality of life? You know, instead of saying, we're going to prevent them from going backwards, we're going to say, how can we propel them forwards? But they need to identify what goals are important and take responsibility for achieving them. And, you know, we're there as that safety net, so to speak, we're there to provide resources, but they need to be the ones to actually do the hard work. And it's a shift away from emergency room and acute care models to one of sustained recovery management, which include wraparound recovery support services. This can include drop-in centers, case management, social service needs, community activities that can be done. The limits, there are very few limits. Respite care, that's another big one in the prevention of child abuse and neglect is to make sure that there are respite care centers where parents can bring their children for even just a few hours to get a breather if they need it. There's an emphasis on post-treatment monitoring. So when people are in treatment, they're symptomatic. We know that or they wouldn't be in treatment. Then when they're not symptomatic anymore or they've achieved their goals, they're discharged from treatment. That's great. But a recovery oriented system of care says, we don't just let them get to the top of the mountain and go, well, good luck. Hope you stay up there and don't fall. A recovery oriented system of care follows them or monitors or provides check-ins after treatment to make sure people aren't starting down towards a relapse, to make sure they're maintaining their health-related behaviors, to help them achieve their goals. One of their goals was symptom remediation. They got that. But remember, we're not just preventing relapse. We're propelling forward towards their highest quality of life. It provides stage-appropriate recovery education. And remember, when we talk about stage-appropriate, we're talking about prochaska and declemente, stages of change, pre-contemplation, contemplation, preparation, action, and maintenance. It provides peer recovery coaching. It's not practical to have a therapist calling and checking in on patients every week for three years after they discharge. You know, number one, we can't bill for it. Number two, I would have so many clients, I would never do anything but follow-ups. So peer recovery coaching and peer support services in the community is where a lot of the post-treatment monitoring happens, as well as primary care physicians who hopefully see their people at least once a year. There's an emphasis on assertive linkages to recovery communities. We want to make sure that people can connect with other people who have similar issues, depression support, anxiety support, grief recovery, divorce support. Early intervention is important if there's a problem or reintervention, as they say. If the person starts to exhibit relapse warning signs or decompensation, we want to be able to get them back into treatment quickly and not go, well, there's a six-week wait. You know, good luck. Hope you can stay stable for that long. So early reintervention says, when we see a problem, we've got intervention-level services. If you look at your ASAM, that's below outpatient, that's like outpatient groups, where we can get people in so they can start connecting with services right away before the problem gets bad. Think about if you have a cut on your arm. Early reintervention, if you will, would be making sure that if after you come home from the hospital and you've gotten stitches and everything, if you look down one morning and it's inflamed and hot and pussy, you can get back into the hospital right away to get it taken care of versus waiting, you know, five days until your doctor can get you in to clean it out. So that keeps the infection from getting worse. Same sort of thing with mental health stuff. And it helps people maintain functional ability in all life activities. Recovery in illness instead of recovery from illness. What does that mean? That means if somebody has major depression, for example, or if somebody has a substance use disorder, okay, that may be something that they may be dealing with for a good deal of their life. But that doesn't mean that they can't have a really high quality of life. So it doesn't mean that you can't recover and you can't have a high quality of life until this is gone. It means, okay, so you've got major depressive disorder. When you get your symptoms under control, when it's in remission, let's help you achieve your highest quality of life. So you're not recovering from it. You're accepting that it might be part of your life for a while and you're recovering despite it, so to speak. The goals are to foster health and resilience activities. Encourage people to get enough sleep, get good nutrition, get good medical care, keep on their medications like they're supposed to, get rest and recreation, work-life balance, all that happy stuff. Increase permanent housing and a sense of home and belonging. So we want to help people find a safe place to stay where it is home. It's not just somewhere that they happen to be sleeping at night. It feels home, which means it feels safe and it feels like they belong there. It ensures gainful employment and access to education to provide a sense of purpose. So we want to make sure we get the Workforce Development Board involved in the recovery-oriented system of care to ensure that people are getting access if they can work to education or to jobs if they're not able to work because of the level of their disability. They have access to volunteer work or supported employment. It enhances communities by increasing the availability of necessary supports from and for peers, family and community. So by bringing the recovery-oriented system of care together, that means we're involving peers, we're involving like others and we're saying, let's help you support one another. You know, there's professionals out here when you need them, but a lot can be done by sharing your own support and sharing your own stories and your own successes. And it reduces barriers to social inclusion. It helps communities see that people with addictions and people with depression are not, you know, problematic or they're not weird or different. They're the same. It helps educate people about how prevalent addiction and anxiety and depression and bipolar and all that stuff really is. And encourages them to see the person who has depression as a person, not as a depressed person. Counselor functions and recovery-oriented systems of care include identifying gaps in services. So, you know, where I am now, there's no public transportation. So that's one gap, you know, getting clients to where they need to go to medical appointments, to counseling appointments, to work can be a problem. Identifying emerging needs and trends. Well, you know, right now in 2018, there is a huge emerging trend in opiate abuse and need for education about opiate addiction and treatment options for opiate abuse. And monitoring system effectiveness, you know, of the people that enter the system, no matter where they come in, they come in through social services or their medical doctor or law enforcement, you know, probation and parole. However they enter the system, are they successful at getting their symptoms to remit and starting to achieve a high quality of life as they define it. Guiding principles of recovery emerge from hope and are person-centered, which include self-efficacy and self-direction. So the client is going to decide their goals. And we are going to help them develop that I can do attitude, you know, to believe that they can accomplish their goals. It's non-linear and occurs via many pathways. Recovery doesn't always, well, it almost never goes in a straight line and always forward. It's two steps forward, one step back, three steps forward, a half step back, you know, it's kind of like this. It's kind of like doing the cha-cha more than a straight line. And sometimes it takes a hard left turn. You know, a client may be on a good course of recovery. I can think of one in particular that I had. She was doing really well in recovery and then she was diagnosed with metastatic breast cancer. Well, that was a hard left turn. So recovery activities that were going to keep going out this way, they got derailed for a little while until she got her cancer and remission and then she circled back around. But the recovery oriented system of care said, all right, we recognize what your needs are right now. So let's figure out what we can do with your treatment plan in order to continue to help you, you know, not go backwards and move forwards at the same time. It's holistic incorporating the mind, body, spirit and community. A lot of times we forget community in there. So we're encouraging people to engage their spirituality. We're encouraging people to engage their community for support and a sense of belonging and a sense of connectedness. It's supported by peers and allies and allies are counselors and caseworkers and all of us professionals that are involved in the process, but it's also supported by peers where peers are out there going, hey, been there, done that. Let me give you a helping hand or let me be a sounding board you can bounce stuff off of. It's supported through relationships and social networks within the family among peers, you know, think about 12 step meetings. Those are a perfect example of peer support and the 12 step meetings and the 12 step. Well, each different 12 step meeting tends to form their own sort of little family you have home groups, where you form sort of your own family. Faith groups are out there to also support these relationships and the community. Hopefully you get some buy-in from the politicians from government to support financially. Some of the resources that need to be there to provide a recovery oriented system of care. It's culturally based and influenced. So what a recovery oriented system of care looks like in, you know, the middle of New York City is going to be different than what one looks like in the middle of Lebanon, Tennessee. And that's okay. It's based on the culture that's here and the resources that are here. It's supported by addressing trauma and based on respective individual family and community strengths and responsibilities. What's important in this community? What's important for people? You know, what does the client thinks important? What is the community thinks is important? And how can we align those goals? How can we make that work for everybody? Three core components of a Rosk recovery oriented system of care. Collaborate collaborative decision making and individual empowerment. We don't do things to or for clients. We talk with them. We empower them to do everything they can and we assist them when needed. Continuity of services and supports. There's no wrong door, which is what I talked about earlier. It doesn't matter if the person, you know, came in contact with law enforcement and that's how they got referred to counseling or through social services or through their medical doctor or the emergency room. However they got here, they're here. You know, we want to make sure that everybody in that safety net knows how to refer to the different agencies so clients can get connected with the appropriate resources easily. Because in a Rosk and in any community, when you start getting 1520 services together, it can get a little bit overwhelming sometimes, especially to someone who is struggling just to deal with life on life's terms. So that's where we step in and we go, all right, let me help you get these referrals and get you on the right path. Once they start making progress forward, they generally feel empowered and take on more of the responsibility themselves. And services are available for as long as needed. It's not a well, you have eight authorized sessions. So let's see what we can do and then you're on your own. It may be you have eight authorized sessions and then I need to refer you somewhere else or to a different program because, you know, a lot of private practitioners can't just do pro bono services and totally get that. But a Rosk allows for opportunities and options. So a person doesn't just kind of hit a wall and drop. And it's also based on service quality and responsiveness services are evidence based, you know, we want to provide things that have their they may not be evidence based best practices, you know, we may not be using every single one of those. But there's research evidence that says this works. And it's available to you. It's developmentally and culturally appropriate gender specific trauma informed family focused and stage appropriate. So for some of these for evidence based, you want to go to tip 42, which will help you look learn about treating persons with co occurring disorders for trauma informed. There is a tip and I can't remember what tip number it is, but there is a treatment improvement protocol through SAMHSA on working with people with trauma and stage appropriate. That's tip 35, which is motivational interviewing, which will walk you through the steps of the different types of interventions that are useful for each stage of change. Recovery management in a recovery oriented system of care treatment doesn't need to be voluntary, but success depends on personal engagement. My first job out of college out of graduate school was working as the liaison to probation and parole. So all of my clients were involuntary. They were there because the judge said they had to be. Well, that's wonderful. But, you know, they weren't going to make much progress if I wasn't able to get them personally engaged. It became a matter of me figuring out how to help them see how this might work for them. One, they wanted to get off probation. Well, in order to do that, they had to complete my program. So that was step one, they would at least show up. But I wanted them to do more than show up. I wanted them to get engaged. What can you get out of this? What can I teach in these groups? Because I had the luxury of being able to, you know, provide a fair amount of different topics in groups. But what types of topics are meaningful? As long as you're paying for counseling, you might as well get something out of it. What can I help you work on? And if they didn't have anything specific, we would work on something general like motivation or coping skills. But we would apply it to their everyday life and say, okay, now how could this improve next week? Full recovery often comes from episodic nonlinear treatment. So remember, get better, leave treatment for a while, be in the community. Something else happens. They may need treatment again, may not be mental health treatment, maybe medical treatment. But we need to make sure that the person is healthy, mind, body, and spirit in order to prevent any sort of relapse. Previous treatment and relapse is not indicative of a poor prognosis. Previous treatment and relapse means we missed something. You know, there was not a adequate support network or we didn't adequately identify all of the presenting issues generally. Relapse is viewed as evidence of the severity of the condition rather than a cause for discharge. So if you're working with a client in outpatient and they relapse, it just breaks my heart, especially if they're an intensive outpatient, but in any program, regardless of the level of intensity. If they relapse, that means that that behavior, whatever they did was more rewarding, serve the purpose, solve the problem better than what we were offering. So we need to back up and go, okay, didn't realize that you were in that much pain or, you know, this wasn't working for you, we need to figure out another way to meet that need. But relapse is a learning opportunity and evidence of the severity of the condition and I know I said that twice, but it's important. Recovery management is a time sustained recovery focused collaboration between consumers and service providers. So we're working together in a team with our clients 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. Some people may experience full recovery, never have another episode, wonderful. Some people get to the point where they're in remission and self-management is possible and then, you know, if they have another episode, then they can reenter the system. Recovery management spans three phases, pre-recovery identification and engagement, recovery initiation and stabilization, and recovery maintenance. So pre-recovery identification and engagement is your outreach and your intervention services where we, you know, the social worker at social services realizes that mom needs to come in and need some assistance with substance abuse or something. So she sends Sally over to be assessed and enrolled in a substance abuse program. So then we get Sally and it's our job to assess and engage. Once she's engaged, then we can initiate treatment and help her get stabilized and then help her in that maintenance period for a little while then discharge and discharge her back to that recovery-oriented system of care to the community where she can maintain her recovery. So all of this in order to make this happen requires a great amount of service coordination and case management. So service coordination is a client-level collaborative process designed to help individuals access needed services because you know how overwhelming it can get for us figuring out who to refer to and stuff. It's even more overwhelming for clients. Select the most appropriate services. We need, as clinicians and case managers, we need to be aware of what the requirements are and what the appropriate referral is for each individual agency. I don't want to refer somebody to a program just to have them get there and the program says, oh, you don't qualify for these services. So it's important that I make good referrals, which means I need to know, I need to be really familiar with the different agencies in my system of care. Facilitate linkage with those services. Now, depending on the client, the severity of their problems, we may assist them in contacting the agency and making the referral. Or we may make it for them and say, okay, you've got an appointment, you know, with Dr. So-and-So on Tuesday at 3 p.m. Whenever possible, it is a lot more empowering and more likely that the client's going to show up if they make the appointment themselves. Sometimes they need to do it when they're in your office because they're intimidated by calling and making an appointment. But whenever possible, we facilitate these linkages. We make sure they get in connection with the right person instead of having to call and go through a switchboard of options going, I don't know if you're the right person to talk to. Facilitating linkages gets them directly to the right extension to the right person to do what they need to do. Case management promotes continued retention and services by monitoring participation. You know, we check in, make sure they're going to their appointments, make sure that this service is helping them. If not, what else needs to happen? We coordinate multiple services when necessary and advocate for continued participation. Sometimes the agency will say, well, our census is full and we've got a waiting list. I need to discharge this person. And as a case manager or a clinician, it may become up to us to advocate for that person to stay in services for another certain period of time in order to prevent relapse. Objectives of case management include maintaining continuity of care. So we're not just discharging and then referring and going, well, I hope that went well. We're making sure that the handoff goes smoothly and that every time a client is referred, the handoff goes smoothly and every organization involved in that client's care knows what every other organization is doing. There's a single point of contact, which is the case manager usually. And we keep good records, so we're not duplicating services and we're not contradicting each other either. Case management establishes relationships with gatekeepers. Like I was talking about, we know what the requirements are at each program, so we know who an appropriate referral would be. We develop contracts or memorandums of understanding, which specify available slots. So for example, I may work with a day treatment drop-in center and I may develop a memorandum of understanding where they ensure me they will always have three slots available for our clients. That way I know I once I reach that three level, then I can't refer there anymore because they have clients coming in from other providers. But they will take up to guarantee that they will have a slot for up to three of my clients at any one time. And MOUs also identify consequences for failure to implement specified activities or procedures. So if I refer Sally over to this drop-in center and she gets there and they say, we can't admit you, we're full right now. And I know that I've only got one patient in that program and they've promised me three slots. Then I have sort of a leg of to stand on, just go back to that organization and go the contract says. Now what the consequences are, are between your CEO and the executives and the legal team. But a lot of times it really benefits people to be in these recovery oriented systems of care to keep their slots full so they don't want to get booted. Case management ensures accountability, following up on the referral with the client and the referral source, measuring outcomes with client satisfaction, client outcomes, and service issue outcomes. Like did involving this client with this service reduce the number of days that they were in residential, you know, that's obviously a good thing. Case management works on the principle of efficiency. Know the system and make it work. Case management is necessary because of poor service coordination, lack of service continuity, and difficulty of clients negotiating the gap between services. Without case management, you have 15 independent organizations operating with their own rules, regulations, and kind of in isolation. And when you have a case manager, it helps coordinate these services to make sure clients are getting the right services at the right time at the right intensity, and making sure that clients are able to access them without getting lost in the mix. The case manager acts as the human link between the client and service providers. We're out there, we're holding the client's hand and we reach out and we grab that agency's hand, and we link them together, and so on and so forth. We develop contracts with providers for identified services, control case management funds, act as a single point of entry for clients, and develop missing service elements. So if you can have a case management organization serving as your single point of entry, that doesn't negate no wrong door. That means if somebody comes in from social services and needs assistance, they will refer to the case management agency. And the case manager will assess this person and say, let's figure out what all your needs are. So I can help you develop a plan and we can figure out how to link you in with things. And case managers also develop missing service elements. If transportation is a missing service element, the case management agency will figure out, you know, is there a way we can work with local churches, for example, that have church buses to facilitate, facilitate transportation, you know, maybe one week a month, one week a month or a quarter. Each church volunteers to do transportation. Service coordination and case management approaches include intensive assertive community treatment, which is comprehensive, multi disciplinary and community based. The fact program, as you may know it, or the fact program, case managers go out into the community, visit clients at their homes, check on their medications, you know, they go to the home, make sure it's clean, make sure, you know, the client is bathing or whatever, count their meds to make sure that they're taking their pills, and check in with them each week, at least, sometimes more often, in order to assure that they're stable and not needing additional services. Clinical case managers can provide counseling and some intervention services. Strengths based case managers, obviously identify clients strengths and help them build on those in order to achieve their highest quality of life. Brokridge case managers coordinate services, but they provide few, if any services. So Brokridge case managers are the people that say, come to me, let me figure out where to refer you to, and they refer out. They don't do any of the case management, they don't do any psychoeducation, none of that stuff. They are a coordinator, and that's it. Integrated case management is family focused and strengths based, and it uses an independent facilitator to bring all relevant people, including providers, family and natural supports to the table. So integrated case management really brings the community and the support systems in, instead of just having the agencies involved, we're bringing everybody to the table. The team then works in partnership with the family to create a safety based comprehensive plan addressing the needs of all family members, recognizing that, you know, mental illness or substance abuse affects everybody in the family. And if somebody else in the family starts to become symptomatic with something, you know, it's going to negatively impact the whole family system. So what does the family need? How can we provide a resilient family to support the identified patient and each other? Case management offers a single point of contact for clients. It's client driven and strengths based, and involves advocacy between services with seemingly contradictory requirements to serve the best interest of the clients. So we want to look at, you know, if you combine law enforcement with counseling, and this is your problem solving courts, for example. Yeah, you know, I would rather my clients didn't go back to jail, but sometimes, you know, we need to work together in order to increase motivation and help clients achieve what they need to achieve. We advocate with agencies, families, legal systems and legislative bodies, and we may recommend sanctions to encourage client compliance and motivation. Case management is community based, for the most part, with the exception of brokerage case management. It's pragmatic. It meets the client where they are. It says, in this point in time, what needs do you have? We're not going to look at over here or back then, what do you need right now? We'll worry about the future in the future. It is anticipatory based on the natural course of the client's presenting issues. So we identify where the client is right now. And then we speculate, you know, if they're needing to go into intensive residential right now for 60 days. Okay, we also know that they're going to get discharged from intensive residential in 60 days, and they're going to need to have somewhere to go after that. So a case manager would start working on that at the beginning, so they were assured that they had something lined up or help the client have something lined up for when they get out of treatment. It's flexible to individual needs and culturally sensitive. The case manager's role is 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 to be a case manager. Can you establish rapport? Are you a good listener? Can you establish a therapeutic alliance? Can you maintain boundaries? And this can be really hard sometimes to maintain boundaries and not try to caretake or parent or, you know, overly, become overly involved in the client's case. So you need to be able to maintain boundaries and say, you need to be empowered to do this. Case managers have to be non-judgmental. Recognize the importance of family, social networks, and community in the process of recovery. Understand the variety of insurance and payment options available, because in order to access all these services, they got to be paid for somehow. So case managers are typically experts on how can we get that funded. They understand culture and respond in a culturally sensitive manner. They understand the value of an interdisciplinary approach to treatment. Case managers, you know, are the first to tell you that generally for somebody to recover, they need multiple different types of services. So we need to look at them from a biopsychosocial environmental perspective. And case managers serve as both facilitator of referrals and an advocate for the client. As a facilitator, the case manager composes the team, figures out what resources are needed, who's going to be on the team. Notifies everybody in the team of meetings, because we all need to get together. Now with, you know, the computer and technology now, we can do virtual meetings so people don't have to haul their butts all the way to one particular place and lose a bunch of billable hours. But they do need to participate in the meetings. The facilitator, the case manager chairs the meeting. They're the one who's coordinating everything. They're not going to tell the doctor what to do and the counselor what to do, but they are going to take all this information and figure out how it all weaves together and help resolve any disputes or whatever between the different agencies. They maintain team focus on the client. You know, this is not about who's going to make the most money or who needs a slot filled. It's about what does this client need at this point in time and ensures clients desires and needs are adequately represented and considered. So it's important for the case manager to stand up and go no Sally said she really didn't want to go to residential or Sally said she was really not ready to discharge from from residential for all these reasons. So we need to stand up and say, this is what the client really wants, ideally empowering the client to write a narrative or at least bullet points about all the reasons that they want this and that it's imperative to their recovery. So we can help them learn how to advocate for themselves, even if they're not in the team meeting, we can present that for them. Service coordination and referral referral is the process of facilitating the client's use of available resources and support systems to meet needs identified in assessment and treatment planning. It involves identifying needs of the clients which cannot be met by the agency, regardless of whether the client is receiving case management services. So if you're a clinician and you don't have a case manager that you can refer to, you still make referrals, we make referrals all the time and referrals are important. Inappropriate referrals may lead to dropout if clients hopes get up, and then they're denied access to services. So again, so important that you know why it's important to go there, and you make sure the handoff goes well. I don't want to refer somebody. I remember my doctor referred me to OBGYN at one point. And I went there and I sat for three and a half hours in the waiting room after my appointment time, and nobody said boo or could tell me when the next, when I was going to get seen. So I finally left. And I was like, no, I'm going to find my own referral source from now on. So it's important to remember, you know, that everybody has to play on the team and the client can't be denied access for services or ignored, you know, inadequate follow up also leads to premature dropout. So we need to follow up with the clients and go, how did that go? Did you feel like this person was able to help you, etc. If not, you know, let me understand what went wrong, and I can give you a different referral. Counselors must know resources in their community, the processes for making the resource, the referral, the limitations, what the cost is, who can access those services, the requirements, you know, if somebody has to be clean, drug free for 30 days, and have transportation or whatever the requirements are to participate in the program. Sometimes programs have requirements of they cannot have certain mental health disorders or beyond certain medications. It's important to know that. And you need to know confidentiality. Counselors should visit referral agencies initially and get to know them and then semi-annually after that. This is not always possible. What we used to do in my clinic was we would divide up the different referral agencies and we would go and each person would visit four of them semi-annually. That was doable. Each person going to all 27 agencies semi-annually was not doable. Potential problems and referrals can arise from differences in agency functioning, differences in eligibility criteria, inadequate data sharing, conflicting treatment plans. And it's important to remember that moving between agencies may interrupt continuity of care. So, for example, one of the biggest eligibility issues, for example, you may have a lot of programs in your community that accept Medicaid, whatever it's called in your state. Here it's called 10 Care in Florida. It's called Medicaid. But there are also a lot of treatment centers that don't accept Medicaid. So, it's important to make sure that even though you both serve clients of a similar socioeconomic status, you know, the treatment center may have state funding dollars to provide services, whereas you provide services that are funded by Medicaid. So, just important to know. Potential referral sources, marriage and family and mental health counselors. Abuse and trauma counseling resources. Primary care, women's health, nutrition, dietetics, holistic practitioners, pain management, legal services. This can include criminal as well as civil, you know, child custody, domestic violence, etc. Financial counseling. Helping people get out of bankruptcy, figure out how to make their bills. Housing. Career counseling and educational planning. We want to make sure we can help them become financially independent. And religious spiritual and faith support. This is not an exhaustive list, but these are some of the big ones that we need to know how to refer clients to in order to meet their biopsychosocial needs. And help them be, think about Maslow's hierarchy. They have to have those biological and safety needs met before they can make much progress with depression or substance abuse. Potential referral sources include also include career counseling and educational planning, LGBTQ support, 12 step meetings. And there are 12 step meetings for depression. There are 12 step meetings for a lot of things, not just alcoholism. The Veterans Administration know what services they provide. People sometimes need referrals for childcare, whether it be all the time childcare or childcare while they're in treatment and transportation. Potential reasons why we might make a referral. If your agency doesn't provide that service and your agency is not going to provide all those services I just listed. The counselor may not be the best person to provide the services. For example, issues of sexual identity issues require special training. Working with small children requires special training. I don't have training in play therapy, so I would make a referral to a play therapist. The counselor believes there might be a conflict of interest. If somebody comes in and you know their husband's brother or something, then you might need to make a referral. When I worked at the clinic that I worked at in Florida, my husband was a full-time law enforcement officer. So whenever law enforcement officers came in, especially ones from his department, but any of them that came in, I generally recused myself from their case, even if they entered one of my programs. The counselor recognizes the need for a different level of care. If you're an outpatient therapist and you recognize your client really needs intensive outpatient or residential, then you're probably going to make a referral. The counselor should explain the rationale for any referrals to facilitate participation. So why is it that you're referring me to this dentist or this doctor or this chiropractor or whatever it is? And generally it's pretty obvious, but we want to make sure that clients understand why it's important and how it will benefit their recovery from their mental health issue. Familiarize the client with the agency to quell their anxieties. What's it going to be like when I walk in there? Is it this big building? Is it this little building? Is it one person? Is it this huge clinic? What should I expect? Contact the referral source in the client's presence or have the client contact the referral source in your presence so you can give them a little support when they're making the appointments. Have the client schedule the actual appointment. This is one of the biggest reasons for client no shows is somebody makes an appointment for them at a time that they find is inconvenient so they don't show up. Give the client the contact name and number and the agency address. So after all this is done, write all the information down and give it to the client. Document the referral and follow up in the client record. You want to make sure to follow up both remember with the client and whoever you referred the client to just to make sure that both of you or everybody's on the same page. 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. Think about somebody who's got chronic pain from fibromyalgia. You know that can lead them to feeling depressed and hopeless which can trigger an addiction relapse. It can also make them overuse painkillers in order to get relief from the pain. So I mean they all interact so a relapse or a problem in any one area could precipitate relapse in all of the areas. Use and withdrawal of substances can both cause mood, social and physical conditions. If you've seen anybody in detox, you know that their mood can get pretty erratic. And they don't feel well and it can impact social relationships. You know their friends who are still using you know it's gonna they're gonna have to figure out how to negotiate that. And they may have alienated some of the people who didn't use and they want to build that backup. But during this period of addiction you know there are mood, social and physical complications. There is a continuum of the disorder you know and all disorders from depression to addiction. In terms of the severity you know you can have mild depression. You can have what we used to call substance abuse but mild substance use disorder to very very severe. It varies in its chronicity. People with major depressive disorder may have one episode every couple of years. Other people may have two or three episodes per year. And the disability or degree of impairment in functioning. So some people in this kind of goes with severity but not always. If you have how much does this impact your ability to work? I mean somebody who has a severe major depressive episode once every three years probably will not have the degree of impairment that someone who has a mild case of depressive disorder or persistent depressive disorder will experience because they're depressed most of the time for extended periods of time which will impact their work differently. So they actually even though the severity is less the chronicity may contribute to significant disability. Treatment plans are designed with the provider to identify treatment objectives necessary to achieve goals. Every single agency is going to have their own version of a service plan or a treatment plan. But the case manager needs to compile all of this and create sort of a master recovery plan or service plan. Service plan is an umbrella document which ties together all of the treatment plans from various providers and the short term goals and objectives. Because if you've got 15 people working or agencies working with this person they're going to have 15 different treatment plans. And they're probably going to be sitting there going I don't know what to do first. There's not enough hours in the day. So the case manager can help them sit down and look and say all right let's figure out what needs to be done first. What's step one, step two, step three and break it down so it's not so overwhelming to the client. The comprehensive service plan provides long term goals. Where do we hope to go? What does a rich and meaningful life look like to you? Current status narrative so we can see where we're starting from and the identification of required services, supports and resources. So this is when the case manager says all right in order to get John from here point A to point B. These are the services, supports and resources he's going to need. And this is the order I'm going to make the referrals. Linkages goes beyond providing a list of resources and involves developing a network of known resources and contacts. So we're not just referring people out going well. There are these three people over here I found on the web. We actually have interacted with these agencies. We're familiar with their services. And we have a contact there so we can link the person. Remember I said it's kind of like holding the client's hand and holding the provider's hand and putting their hands together. We're actually making that linkage. We're not just going here. Good luck. Linking, monitoring and advocacy is the foundation for successful implementation and is based on interdisciplinary team planning effort. And this includes the client. If you're making this treatment plan without the client, then you miss the boat somewhere because they need to be the driving force behind every treatment and service plan. The client will help decide goals and priorities as will the team. The team helps assign responsibilities for each goal because the client's probably not going to do everything by him or herself. And everybody on the team, including the client, reach consensus in the overall approaches and objectives. Service coordination encompasses administrative, clinical and evaluative activities that bring the client, treatment services, community agencies and other resources together to focus on needs in an identified recovery plan. The case manager does service coordination. We're kind of pulling the different strings or if you want to think of it as a big machine in a factory. We're flipping the different switches at different times. Service coordination includes case management, which collaborates with the client and their significant others. Coordination of treatment and referral services to address issues contributing to and caused by addictive behaviors. Liaison activities with community resources, so we're constantly engaging, going, how can we help you? How can you help us? How can we make this process go more smoothly? And ongoing evaluation of treatment progress and client needs. Service coordination in addition to case management also involves client advocacy. The tasks of service coordination include initiating and collaborating with the referral source, creating a warm referral. So I'm not just calling this agency for the first time, going, hey, I'm Dr. Snipes. You know, I know you've never met me before, but I have this client who needs your services. So I'm going to give him your number and let him call you. That's cold. The person doesn't know you and they still don't know anything about the client. A warm referral is, you know, you've already established a connection with the agency. They kind of know who you are and you call up and I have this client obviously within the bounds of HIPAA. I have this client, Sam Smith, who I've referred to your agency. Here are his main presenting issues just so you can open a file and be ready for him. Service coordination also involves obtaining, reviewing and interpreting all relevant screening, assessment and treatment planning information. So again, we're gathering from all the players in the team to figure out exactly what's going on. We confirm client eligibility for admission and continued readiness for change for any of these resources. So we're monitoring their eligibility and their motivation. If we don't think they're ready to do this, if their motivation is waned, they're saying, no, I don't think I need to go there. We're going to let the team know and we're going to adjust the service plan accordingly or hopefully we can increase their motivation. But we want to complete necessary administrative procedures for admission and coordinate all treatment activities with services provided to the client by other resources. So again, we're just making sure that the right switches get flipped at the right time. We establish realistic recovery expectations, including the nature of services. We let them know what it's going to be like. You know, we don't want them to think it's going to be a cakewalk or a vacation, but we don't want them to think it's going to be like jail either. So let them know what this program is going to be like. What are the program goals and procedures? What are the rules regarding client conduct? The client rights and responsibilities? A general schedule of treatment activities? The costs of treatment? And facts impacting their duration of treatment. Now, where I used to work, this was what we did in orientation. But if you've got a case manager who's serving as your single point of contact, they can do this orientation piece for you and make sure that the client is on board with everything before they begin with your program. Types of services that we want to look for? Mental health, physical health, including, you know, people with substance use issues may have liver issues, including hepatitis, brain issues, including alcoholic dementia, as well as cognitive deficits from fetal alcohol issues, HIV, tuberculosis, STDs, the whole range. They need a comprehensive physical evaluation and access to services, job skills, employment opportunities, interpersonal skills, helping them learn how to effectively communicate, assertively communicate, and manage their frustration and either anxiety or aggression. Because sometimes that when people are detoxing or in early recovery, their frustration, their patient's fuse is about that thin or that small. So we want to make sure that they have effective interpersonal skills to get them through even when they're feeling like they're barely getting through the day. Training and education, legal services, housing services, food, childcare, and transportation. Service coordination is essential to prevent clients from falling through the cracks. It fosters a more holistic view of the client as not just a person with an addiction or a person with depression, but a person. So, you know, sometimes in the old way of doing, if the client knows shows because they can't find the sitter, the old way would say, well, they're being non-compliant. The new way would say, you know what, maybe they're being a responsible parent because they're taking care of their kid. And yes, it would have been ideal to have a backup, but if the sitter calls five minutes before they're supposed to be there and says, I've got strep throat, sometimes there's nothing you can do. So we want to view the client in terms of and all the client's behaviors in terms of why did the client do this and what does it possibly mean? And obviously we want to look at, you know, how does this make sense and how was this the best choice that the client saw at that point in time? Challenges to collaboration and service coordination include the use of a different assessment tools at each agency to gather the same information. It can produce a fragmented picture of the client unless it's all integrated because the vocational rehab is going to get different information than mental health is going to get. So they're all getting different bits and pieces. If you use the same instrument or the same instruments, plural, then the client has to tell the same exact thing like 17 different times and that gets frustrating. And a lot of times clients will drop out because they're just like, I can't do this again. Agreeing with which agency or clinician is the lead or primary contact for the client and other agencies is another collaboration issue. Case managers, you know, if you can have a memorandum of understanding that is identifies, for example, the case manager as being the primary point of contact. That can help in order to figure out who's who's lead, who's the one that's, you know, coordinating or directing this. Other challenges can include funding and eligibility barriers. For example, some places will not admit persons with a forcible felony. So you need to know what services are out there. So if you can't refer to this treatment center, because the person has a forcible felony, then what treatment center can you refer to? There may be difficult to treat clients and differing staff credentials where they're arguing over the best way to treat a client. So that can make collaboration a little bit difficult, but ideally the case manager or the, you know, team lead is able to help negotiate these differences. Challenges can occur at three levels, personal challenges, including attitudes and attributes. You know, if you are a psychiatrist and you think that every client needs to have 60 days of clean time in an unrestricted environment before they can be on antidepressants, and then you have a addiction counselor who says, there's no way my client's going to get 60 days of clean time in an unrestricted environment unless he's on antidepressants, then you're going to have difficulty because your attitudes are different about how to treat things and what's necessary. Professionally, you may have different theoretical beliefs or approaches to treatment of addiction. One may be tough love. The other one may be strengths based empowerment. And organizational challenges where different organizations don't recognize the need for a partnership, so they don't want to play with your recovery oriented system of care. They're like, if you need us, refer to us, but I don't have time for all your meetings. Lack of a shared mission, lack of ownership by senior management, and ownership means senior management says, this is my team and I will be responsible for what happens and what my agency does. And I will make sure that we own up to our contracts and facilitate these referrals. A lack of trust between agencies, which often happens after senior management lacks ownership, where agencies have gotten into partnerships before and one has not fulfilled their end of the bargain. So then there's no trust that anything's going to happen, or they've gotten into partnerships before and one agency has demanded to have their way the whole time. Unclear guidelines for collaboration and lack of a process for monitoring and managing the collaborative process. So we need to make sure that just like in a family counseling session, we are regularly checking in with every single team player to make sure that they're getting their needs met, they're getting the resources they need, etc. And we're communicating effectively. So recovery oriented systems of care provide a basically a lifelong safety net for people in order to help them achieve their highest quality of life. The goal is to help people live with, learn how to live with any disorder that they may have and achieve their highest quality of life. We recognize that treatment is not linear. It is episodic and it can go up and down and sometimes it can take a hard left. The recovery oriented system of care has services that are able to meet all of the needs of people. And that includes and services include the involvement of family, community, spiritual leaders, as well as the individual to make sure that, you know, everybody is getting their needs met in an affordable way. Because like I said, we can't provide 24 seven clinical services to everybody who might possibly need some, which is why community support groups and intervention level groups and, you know, community based activities and supports are really, really helpful. Alrighty, I hope this gave you some things to think about for recovery oriented system of care, case management, service coordination and referral for preparing for your addiction counselor certification exam.