North Carolina TASC Clinical Series Training Module Thirteen: Care Management

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 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

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

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

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 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

Identification, Screening and Assessment Prerequisites Competence DSM-IV Criteria SASSI Sources ASI/ASAM PPC-2 Program Acceptability Mental Health Violence Substance Abuse Identification and Resources Available 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

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 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

Care Planning Prerequisites Competence Relapse Signs and Symptoms Interventions Community Resources Goals of Program Standardize Process for Documentation Counseling Theories 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

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 Link client to appropriate resources Identify barriers to needed services and methods to overcome barriers Ensure transition time is planned Realistic expectations Appropriate services

Linkage Prerequisites Competence Community Resources Statewide Resources Access Protocol and Barriers ASAM PPC-2 Levels Program Content to Ensure Service Match Needs 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

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 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

Advocacy Prerequisites Competence Who the client is or group of clients are Who to advocate to When to advocate Substance abuse expertise 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

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 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

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 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

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 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

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 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

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

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 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

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 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

Monitoring Prerequisites Competence ASAM PPC-2 Continued Stay Criteria Program Required Contacts Transition Criteria Program Success Criteria/Rates Sentencing Criteria TASC Jeopardy and Termination Criteria 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