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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

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North carolina tasc clinical series training

North Carolina TASC Clinical Series Training

Module Thirteen: Care Management


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


Care management goals
Care Management Goals

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 component
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


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

Proficiency

Counseling Skills

Interpret Instrument Results

Use of Instruments

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

Listening

Identification, Screening and Assessment Prerequisites


Care planning components
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


Care planning prerequisites

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

Care Planning Prerequisites


Linkage and placement components
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


Linkage prerequisites

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

Linkage Prerequisites


Advocacy components
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


Advocacy prerequisites

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

Advocacy Prerequisites


Location and accountability of the client
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


Client s condition
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


Client s condition1
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


Jeopardy status
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


Tasc termination philosophy
TASC Termination Philosophy

Stage One: Successful Discharge from Treatment

Stage Two: Successful Termination from TASC

Stage Three: Successful Completion of Probation


Tasc successful termination criteria
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


Tasc unsuccessful termination criteria
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


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

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

Monitoring Prerequisites