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The Alcohol and Drug Abuse AdministrationState Care Coordination

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State CC Referral: Eligibility

State Funded III.3, III.5 and III.7 Residential Treatment

And other jurisdictional targeted populations

Detention centers Intensive Outpatient Outpatient

ResourcesLeslie Woolford:

◦Leslie.woolford@maryland.gov◦410-402-8673

State/ATR Care Coordination Directory◦ adaa.dhmh.maryland.gov◦ State Care Coordination

Care Coordination Referral Process

Know your agency notification process

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Initial Planning

Communicate with the treatment program clinician to discuss the recommended level of care after discharge

Meet with the client to establish/confirm contact information & plan for regular meetings/contacts

Explore all areas of need with your client◦ Recovery Plan◦ Health◦ Housing◦ Employment◦ Legal◦ Other requested services/supports

Peer Recovery Support Specialist

Know who they areDetermine specific rolesWork togetherCOMMUNICATE

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Health Needs

1. Determine insurance benefits Assist with application Identify needed documents

2. After health insurance confirmed Provide education on options & benefits Assist with enrollment into MCO Assist with selection of primary care doc Assist in scheduling appointments for primary medical

care or mental health services, as needed.

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Broad Needs Assessment

◦ Review treatment recovery plan◦ Ask open questions – not yes/no◦ Ask non-judgmental questions◦ Cover a wide range of subjects

Housing situation Current source of income Health insurance Food for you and your family Childcare needs Emotional/mental health concerns Other concerns or needs

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Ongoing Planning

Informally at every contact

When client expresses new or changing needs

Review contact information at each meeting

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Linkage

Client Care CoordinatorPeer Recovery Support

SpecialistTreatment Program

Housing

Halfway HousesRecovery Housing

◦Treatment Providers◦Be prepared for costs, if applicable◦Interview Processes

Know Your Community Resources

Organization is KEY!!Consult with co-workers and peersCommunicate with State Care

Coordinators in all regions◦Care Coordinator Directory-State and ATR

Internet resourcesAsk friends and family membersAsk for referrals from other agencies

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Community Resources

Name, address & phone number of organization

Programs & servicesHours of operationTransportation optionsCostsEligibility criteria

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Community ResourcesNeeded consents

Outreach to provider

“Warm hand-off”

Scheduled initial contact

Follow-up

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Client Outcome Measures Survey

Mandatory for ALL State Care Coordinators.

COMS will be required data entry for all State Care Coordinators as a condition of award.

“The grantee shall provide the ADAA with data as required by the Administration for all ADAA funded care coordination, recovery housing services, recovery community center services, and peer recovery support specialist activities.”

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Client Outcome Measures Survey• Purpose of the COMS is to collect data that

demonstrates the effectiveness of Care Coordination on specific measures of improved wellness and recovery status

• New clients enrolled into state care coordination are required to have an initial COMS completed at enrollment. Clients previously enrolled into State Care Coordination are required to receive the COMS at 6 month intervals.

• SMART will cue you on records that require a COM Survey.

• Clients enrolled in State Care Coordination for less than 6 months are only required to have the enrollment COMS.

Client Outcome Measures Survey

Successful COMS completion tips:

◦ COMS begins at initial enrollment of State Care Coordination◦ Incorporate COMS into your regular care coordination practices◦ Keep a good tracking record◦ Stay organized and know your priorities◦ Review client contact information at each meeting◦ Encourage OP treatment and transitioning into a lower level of care◦ Stay in touch◦ Communication is KEY◦ If you have Peer Recovery Support Specialists within your

jurisdiction, know who they are and how their role can enhance care coordination.

SMART Recovery Plan

The SMART Recovery Plan is NOT mandated by ADAA. The Recovery Plan is for you and your client’s focus on recovery.

From the first point of contact, promoting and utilizing positive goals and objectives should be an upfront aspect of recovery.

Recovery plans should address motivation for change.

SMART Recovery Plan

The recovery plan is where information gathered is used to put recovery into practice. The recovery plan is a map designed to meet your client’s specific needs during their journey of abstinence from substance use.

The plan’s focus is on where the client needs to be, and how they can best use available resources (personal, program-based, or criminal justice) to get there.

At a minimum, the recovery plan serves as a basis of shared understanding between the client and care coordinator.

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State Care CoordinationTransfer Rules

Clients enrolled in State Care Coordination must remain under the care of the State Care Coordinator in their home county

Clients enrolled in State Care Coordination in their county of residence cannot be transferred to other State Care Coordinators in other jurisdictions

State Care Coordination dollars are not transferable

Communication is KEY when caring for a client enrolled in State Care Coordination.