Addiction Recovery

An outpatient approach to treatment services for adults eighteen (18) years or older who require structure and support to achieve and sustain recovery, focusing on early recovery skills; including the negative impact of substances, tools for developing support, and relapse prevention skills. Through the use of a multi-disciplinary team, medical, therapeutic, and recovery supports are provided in a coordinated approach to access and treat individuals with substance use disorders in scheduled sessions, utilizing the identified components of the service guideline. 

This service will be delivered during the day and evening hours to enable individuals to maintain residence in their community, continue work, or go to school. The duration of treatment will vary with the severity of the individual’s illness and response to treatment based on the individualized treatment plan, utilizing the best/evidenced-based practices for the service delivery and support   

Specific to adults with substance use disorders, Addictive Diseases Support Services (ADSS) consist of individualized 1:1 substance use recovery services and supports which build on the strengths and resilience of the individual and are necessary to assist the person in achieving recovery and wellness goals as identified in the Individualized Recovery Plan. The service activities include: 

• Assistance to the person and other identified recovery partners in the facilitation and coordination of the Individual Recovery Plan (IRP) including the use of motivational interviewing and other skills support to promote the person’s self-articulation of personal goals and objectives 

• Relapse Prevention Planning to assist the person in managing and/or preventing crisis and relapse situations with the understanding that when individuals do experience relapse, this support service can help minimize the negative effects through timely re-engagement/intervention and, where appropriate, timely connection to other treatment supports 

• Individualized interventions through all phases of recovery (pre-recovery preparation, initiation of recovery, continuing recovery, and relapse) which shall have as objectives: 

• Identification, with the person, of strengths which may aid him/her in achieving and maintaining recovery from the substance use disorder as well as barriers that impede the development of skills necessary for functioning in work, with peers, and with family/friends 

• Support to facilitate enhanced natural supports (including comprehensive support/assistance in connecting to a recovery community 

• Assistance in the development of interpersonal, community coping and functional skills (which may include adaptation to home, adaptation to work, adaptation to healthy social environments, learning/practicing skills such as personal financial management, medication self-monitoring, symptom self-monitoring, etc. 

• Assistance in the skills training for the person to self-recognize emotional triggers and to self-manage behaviors related to the substance use disorder 

•  Assistance with personal development, work performance, and functioning in social and family environments through teaching skills/strategies to reduce the effects of substance use disorder symptoms; 

• Assistance in enhancing social and coping skills that reduce life stresses resulting from the person’s substance use disorder 

• Facilitating removal of barriers and swift entry to necessary supports and resources. Supports/Resources may include but are not limited to medical services, employment, education, etc. 

• ADSS focuses on building and maintaining a therapeutic relationship with the individual and monitoring, coordinating, and facilitating treatment and recovery goals. 

Case Management services consist of providing environmental support and care coordination considered essential to assist the individual with improving his/her functioning, gaining access to necessary services, and creating an environment that promotes recovery as identified in his/her Individual Recovery Plan (IRP). The focus of interventions includes assisting the individual with:

• Developing natural supports to promote community integration
• Identifying service needs
• Referring and linking to services and resources identified through the service planning process
• Coordinating services identified on the IRP to maximize service integration and minimize service gaps
• Ensuring continued adequacy of the IRP to meet his/her ongoing and changing needs.

The performance outcome expectations for individuals receiving this service include decreased hospitalizations, decreased incarcerations, decreased episodes of homelessness, increased housing stability, increased participation in employment or job-related activities, increased community engagement, and recovery maintenance. Case Management Services shall consist of four (4) major components that cover multiple domains that impact one’s overall wellness including medical, behavioral, wellness, social, educational, vocational, co-occurring, housing, financial, and other service needs of the individual: Engagement & Needs Identification The case manager engages the individual in a recovery-based partnership that promotes personal responsibility and provides support, hope, and encouragement.

The case manager assists the individual with developing a community-based support network to facilitate community integration and maintain housing stability. Through engagement, the case manager partners with the individual to identify and prioritize housing, service and resource needs to be included in the IRP. Care Coordination The case manager coordinates care activities and assists the individual as he/she moves between and among services and supports. Care coordination requires information sharing among the individual, his/her Tier 1 or Tier 2 provider, specialty provider(s), residential provider, primary care physician, and other identified supports in order to:

• Ensure that the individual receives a full range of integrated services necessary to support a life in recovery that includes health, home, purpose, and community
• Ensure that the individual has an adequate and current crisis plan
• Reduce barriers to accessing services and resources
• Minimize disruption, fragmentation, and gaps in service
• Ensure all parties work collaboratively for the common benefit of the individual.

Referral & Linkage The case manager assists the individual with referral and linkage to services and resources identified on the IRP including housing, social supports, family/natural supports, entitlements (SSI/SSDI, Food Stamps, VA), income, transportation, etc. Referral and linkage activities may include assisting the individual to:

• Locate available resources
• Make and keep appointments
• Complete the application process
• Make transportation arrangements when needed

Monitoring and Follow-Up The case manager visits the individual in the community to jointly review progress made toward achievement of IRP goals and to seek input regarding his/her level of satisfaction with treatment and any recommendations for change.

The case manager monitors and follows-up with the individual in order to:

• Determine if services are provided in accordance with the IRP
• Determine if services are adequately and effectively addressing the individual’s needs
• Determine the need for additional or alternative services related to the individual’s changing needs or circumstances
• Notify the treatment team when monitoring indicates the need for IRP reassessment and update.