North Carolina TASC Clinical Series Training

North Carolina TASC Clinical Series Training

Module Thirteen: Care Management

Care ManagementCare 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 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 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 ComponentIdentification, 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 PrerequisitesIdentification, Screening and Assessment PrerequisitesCompetence

• 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

Proficiency

• Counseling Skills

• Interpret Instrument Results

• Use of Instruments

• Communicate Decisions to Appropriate Parties (Client, Judge, Attorney, etc.)

• Listening

Care Planning ComponentsCare 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 PrerequisitesCare 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

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 ComponentsLinkage 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 PrerequisitesLinkage PrerequisitesCompetence

• 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

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 ComponentsAdvocacy 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 PrerequisitesAdvocacy 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

Proficiency

• Communication

• Knowledge of systems involved

• Negotiation and access

• Clinical skills

Location and Accountability of the ClientLocation and Accountability of the ClientMonitored 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 ConditionClient’s ConditionMonitored 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 ConditionClient’s ConditionMonitoring 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 StatusJeopardy 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 PhilosophyTASC Termination PhilosophyStage 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 CriteriaTASC 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 CriteriaTASC 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 PrerequisitesMonitoring 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

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