Overview of a Recovery Oriented System of Care: Characteristics, Structure and Development

1. Overview of a Recovery Oriented System of Care: Characteristics, Structure and Development Ijeoma Achara PsyD

2. Overview • Identify the characteristics of a recovery-oriented system of care. • Explore the implications for multiple levels of the system • Examine frequent concerns • Explain the advantages and limitations associated with different models of recovery oriented systems.

3. What is a ROSC • Recovery-oriented systems of care (ROSC) are networks of formal and informal services developed and mobilized to sustain long-term recovery for individuals and families impacted by severe substance use disorders. The system in ROSC is not a treatment agency but a macro level organization of a community, a state or a nation. William White

4. Why Transformation:A Person’s Perspective I’ve been struggling with trying to maintain recovery for fifteen years….I’ve been in other programs, got some good treatment….but for me, for me this was the missing ingredient right here. This is what I needed to not just get clean but stay clean. Because it helped me to identify and realize what I need to do with my life after I’m clean. It’s given me a sense of purpose, you know. I spent all those years drinking and drugging and it was like, now that I’m clean what am I going to do with my life? Barbara, person in recovery, Amistad Village Project

5. What Helps?

6. Elements of a ROSC • Promotes community integration and mobilizes the community as a resource for healing • Facilitates family inclusion • Facilitates a culture of peer support and leadership • Values partnership and transparency • Provides holistic, individualized, person directed tx which supports multiple pathways to recovery • Creates mechanisms for sustained support • Is informed by data and the experiences of PIR and families • Promotes hope • Provides services in a strengths-based manner

7. How is this different? …and where’s the manual?

8. Traditional System Focused on symptom reduction/stabilization Other life domains are not addressed ROSC Symptom reduction with a purpose – a means to an end Other domains are a priority - including employment, housing, recreation, spirituality etc Holistic Approach

9. A Person’s Perspective

10. Strategies System Level • Partnerships with relevant systems • Relevant Initiatives Organizational/Administrative • Services in non-stigmatized settings • Mutually beneficial collaborations • Gospel Fests • Internships • Resource Mapping

11. Strategies Programmatic • Holistic assessments • Recovery plans versus treatment plans • Flexible Menu of Services Recovery Community • Peer specialists assist others with recovery planning • Recovery resource identification/ mobilization • Facilitating linkages

12. Attending to Culture

13. And the village was happy…..

14. Traditional System Focus on action stage of change Client is blamed/discharged for relapse Limited Aftercare ROSC Emphasis is on pre-action stages of change also Responsibility is placed on the service milieu Continued support and early re-engagement Sustained Recovery Supports

15. Perspectives My clients don’t hit bottom; they live on the bottom. If we wait for them to hit bottom, they will die. The obstacle to their engagement in treatment is not an absence of pain; it is an absence of hope. — Outreach Worker (Quoted in White, Woll, and Webber 2003) I got help with the kinds of things that were most important to me – like getting my daughter back, and putting food on the table for her. Since they were willing to help me with that stuff, I figured, “Hey maybe I should listen to what they’ve been trying to tell me and try out that program they keep talking about.” Today I’ve been clean for nine months… Davidson et al., 2009

16. Strategies System • Reimbursement of pre-treatment supports • Peer Group Facilitation Training • Collaborations with other systems - critical transitions • No restrictions for high utilization Organizational • Welcoming/comfortable environment • Address organizational barriers to treatment • No fail policies • Barbara, women and children’s programs

17. Strategies Programmatic • Informed consent • Persistence • Street outreach • Multi-media continuing care • Telephone prompts Recovery Community • PIR in critical locales • Volunteers and employed PIR providing outreach and continued care • New Pathways

18. Traditional System intra-psychic orientation Community supports are recreated in the system Individual is the unit of intervention Stabilization before reintegration ROSC inter-psychic orientation Existing community supports are accessed Individual, family and community are all units of intervention Life helps to initiate and sustain recovery Community Integration

19. A Person’s Perspective • If my neighborhood’s tore up, what’s going to happen to me when I go out there. Some programs tell you to stay away from people, places and things that’ll trigger you. I can’t do that. I live in a sober house. Next door’s a crack house and across the street is the package store. This place is tore up! What am I supposed to do? If my community don’t get better, I ain’t getting better. Client in Amistad Village Project, New Haven, CT

20. People’s Perspectives • I just wanted to get back to my life: my family, and my job, and my church activities. My recovery was important, but it didn’t matter so long as I didn’t have those things in my life to look forward to. It was those things that kept me going in my darkest days • Nobody wanted anything to do with me before. It was always, “Come back and see us when you get serious about your recovery… when you’ve got some clean urines.” But then this program tried to help me out with getting this job I had wanted for a really long time. Now, I am working part time and I’ve finally got a reason to be sober every day. Davidson et al, 2009

21. Strategies System • Develop initiatives that promote community integration and strengthen the community • Leadership academy • Community Coalitions • offsite tx Organizational • Reciprocal relationships with other organizations • Giving back to the community • Community based events

22. Strategies Programmatic • Services taking place in the community • Community asset mapping • Build competencies Recovery Community • Assertively link people to opportunities • Assisting with life skills

23. Traditional Peer support is limited to AA/NA groups PIR may be in leadership, but not identified as such Community based peer support services are not connected to the formal tx system ROSC Diverse mechanisms for peer support and LEADERSHIP exist PIR are in leadership positions at all levels Seamless integration of formal tx system and peer/community supports Peer Culture, Support and Leadership

24. More Perspectives “I’d been doing drugs for something like 30 to 35 years. When I came here I was broke, I was using, and I was sick. I was a broken shell of a woman and thought about dying all the time. They let me come here everyday and do little things. You know I felt welcome and I felt a sense of purpose again. But I started to think that if I could do a little thing, then maybe I could do a big thing.” Barbara, person in recovery. “Once you’ve completed treatment you need to know what to do. We need to find out how to live after treatment. The peer services help people figure out how to have a life!!” Wanda, Peer Specialist, NET

25. Provider Perspective Joe Schultz, NET There’s been a huge turnaround in outcomes. Consumers do better……We have more people completing treatment than we’ve ever had! ……..Even when they leave early the peer specialists are able to reengage a lot of them. That didn’t happen before. The attendance rate has gone from 50% to over 75%... And clients…stay connected. That’s something we never saw before……now counselors feel they are actually helping people. They can actually see the results of all the work they do…

26. Peer Culture, Support and Leadership System Level Strategies Developing Pathways of Opportunity Training and Job Fair

27. Perspectives Equips people with the skills to effectively share their recovery story in public settings, including Tx Gloria After participating in all of the trainings I began to find power in sharing my story with others at the Consortium where I was going to get help for my mental illness issues. Now I am a presenter for Taking Recovery to the Streets, a two-day WRAP facilitator, member of Enon Tabernacle Baptist Church, have a new home, new car. I am employed as a file clerk, and I am a full-time student at the University of Phoenix online with a GPA of 4.0 in pursuit of my Associates Degree in Psychology. I am thankful to God and the Recovery Foundations (Training). I am “living Life to the Fullest!”

28. Strategies Peer Culture and Leadership It’s more than having peers or per led services….it’s a cultural thing! Example: North East Treatment Center • NET Consumer Council • Recovery Resource Center • Monthly Consumer Appreciation Dinner • Peer Specialists, volunteers Program Development and Evaluations • Proyecto Nueva Vida

29. Strategies Programmatic • Assertive Outreach • Recovery Capital assessment at individual/family/community levels • Facilitating linkages • Recovery Check-ups and early re-engagement • Companionship and modeling of recovery lifestyle • Recovery Planning • PIR led groups

30. Anticipate Challenges

31. Robert Martin Peer Specialist In the beginning it was very degrading at times, it was very intense between peer support staff and traditional staff. Their attitude in the beginning was “these people have these 2 weeks CPS training and who do they think they are to tell us how to do our jobs.” It was split right down the middle. It was us vs. them for a minute. Now the respect is on both sides. We compliment each other. The therapists learned that the stuff they write on the paper about what the person needs, we can actually go out in the community and get those things started…. They don’t have to just be words on a paper anymore…

32. Organizational Readiness • Dialogue • Role Ambiguity • Role Conflicts • Supervision – good fit • Valuing the work and the person • Opportunities

33. Traditional Systems: Expert model, hierarchical Professionals determine course of action Treatment planning goals and strategies are determined by the professional based on the presenting problems ROSC: Coaching, collaborative model Professionals support people in making their own choices Goals and strategies are determined in partnership and are directed by the person in recovery A Word about Partnership

34. Recidivism and limited community connections Connecting to meaning Implications of prison culture Innovative practices Non-confrontational approaches Implications for Criminal Justice System

35. “For someone like me just getting out. The last thing I wanted to hear was you can’t do this, you gotta do that. I wasn’t hearin’ all that. I just been locked up and told when to get up, when to eat, when to sleep. I didn’t need that. I woulda been outta here.” Mike, person in recovery,

37. How do You Structure a ROSC?

38. The Additive Model

39. The Interactive Model

41. Where is Your System?

42. N0! No! and a Thousand Times No!

43. Top Concerns • Don’t P-BRSS approaches devalue the role of professional intervention? • Doesn’t recovery oriented care increase provider exposure to risk and liability? • What’s all the hype about, we’ve been doing this for years? • How will we pay for implementing recovery oriented care and supports?

44. Reduce Waiting Times Reduce No-Shows Increase Retention Increase Admissions NIATx Founded in 2003, NIATx works with behavioral health treatment providers to make more efficient use of capacity and develop strategies to improve access and retention in outpatient services Purpose: Improve Outcomes in Outpatient Tx Activities: Implement process improvement strategies through the use of existing resources, rather than additional expenditures

45. Niatx Projects • Northeast Treatment Center • Increased peer supports, involvement and activities • Up to 70% of new admissions continued after 30 days in treatment • Northeast Community Mental Health Center • Initiated earlier clinical involvement versus “filling out papers,” which resulted in 80% returning to the clinic after the first visit

46. Niatx Projects CO-MHAR • Reduced wait time from 6-7 weeks to 2-3 weeks at one site • Improved same day service including having 50% of clients seen the same day • Confirmation calls to clients Casa de Consejeria • Reduced wait time for first appointment from 19.8 days to 4.5 days • All staff received training on conducting intakes

47. CO-MHAR $30,000 Community Council $12,000 Intercommunity Action $18,000 Joseph J. Peters Institute $150,000 less associated costs Thomas Jefferson University $84,000 less 1 intake staff person salary Yearly Additional Revenue from 1 Change Cycle

48. Cost Neutral Strategies • Mobilizing the community of people in recovery • Holistic assessments • Recovery planning • Satisfaction surveys/focus groups • Reciprocal community partnerships • Consultation Approach • Continued Care

49. Challenge The need for HOPE at all levels

50. You can do this, we can help!!