1. The Alcohol and Drug Abuse Administration State Care Coordination 1

2. 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 2

3. Resources Leslie Woolford: ◦ Leslie.woolford@maryland.gov Leslie.woolford@maryland.gov ◦ 410-402-8673 State/ATR Care Coordination Directory ◦ adaa.dhmh.maryland.gov ◦ State Care Coordination

4. Care Coordination Referral Process Know your agency notification process

5. 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 5

6. Peer Recovery Support Specialist Know who they are Determine specific roles Work together COMMUNICATE

7. 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. 7

8. 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 8

9. Ongoing Planning Informally at every contact When client expresses new or changing needs Review contact information at each meeting 9

10. Linkage Client Care Coordinator Peer Recovery Support Specialist Treatment Program 10

11. Housing Halfway Houses Recovery Housing ◦ Treatment Providers ◦ Be prepared for costs, if applicable ◦ Interview Processes

12. Know Your Community Resources Organization is KEY!! Consult with co-workers and peers Communicate with State Care Coordinators in all regions ◦ Care Coordinator Directory-State and ATR Internet resources Ask friends and family members Ask for referrals from other agencies

13. Community Resources  Name, address & phone number of organization  Programs & services  Hours of operation  Transportation options  Costs  Eligibility criteria 13

14. Community Resources Needed consents Outreach to provider “Warm hand-off” Scheduled initial contact Follow-up 14

15. 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.” 15

16. Client Outcome Measures Survey 16 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.

17. 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.

18. 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.

19. 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.

20. State Care Coordination Transfer 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. 20