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C - Coordinating L - Linking A - Accessing M - Monitoring P - Planning. Care Coordination Overview for Service Providers.

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care coordination overview for service providers

C - Coordinating

L - Linking

A - Accessing

M - Monitoring

P - Planning

Care Coordination Overview for Service Providers

what is atr

Access to Recovery (ATR) is a “high-priority” federal initiative that provides vouchers to individuals to purchase services and supports linked to their recovery from substance use disorders.

  • ATR is a SAMHSA system transformation grant designed to build recovery support networks within communities.
  • ATR emphasizes the expansion of capacity within systems of care.
  • ATR projects involve clients in directing their own care and give them choices among appropriate providers.
What is ATR
atr iii in maryland

Four year Access to Recovery (ATR) grant, Maryland RecoveryNet – awarded by to the Maryland Alcohol and Drug Abuse Administration for approximately $3.2 million per year.

ATR III in Maryland







purpose and goal

Helps individual transition from intensive services (residential) to community recovery

  • Improve recovery outcomes for individuals and for the care system
  • Manage resources for high risk/high cost individuals
  • Promote continuity of care
  • Connect individuals to recovery resources in their community.
Purpose and Goal
scope of service

Meet with clients at their inpatient facility (or via phone if necessary) prior to their release from treatment for the Intake Interview.

Bi-weekly follow-up monitoring via telephone or at locations agreed upon by the Care Coordinator and client.

Review and monitor voucher usage and assist with plan for client accessing services. 

Scope of Service
scope of service1

If the client is uninsured, determine the most appropriate insurance program and assist the client with applying for this benefit. (MA, PAC)

  • Make referrals to other available community-based recovery support services. (i.e. A.A. meetings, Sober Support, etc)
  • Assist clients with obtaining documents if needed.
Scope of Service
scope of service2

Refer and/or schedule appointments for clients to receive primary medical care and mental health services if needed and requested.

Arrange transportation, if needed, in support of access to recovery services and activities.

Assess gaps in goods and services and utilize gap service voucher to meet needs in the recovery plan.

Scope of Service
scope of service3

Maintain an ongoing relationship with the client

Administer and submit GPRA Discharge and 6-Month Follow-up Surveys and Client Satisfaction Survey.

Scope of Service
knowledge and competencies

Ability to build solid relationships based on trust

Understands recovery planning and resources needed/accessed that support the recovery plan

Aware of community resources and able to connect to community resources.

Knowledge of GPRA rules and implementation standards

Ability to encourage and empower individuals

Troubleshoot and problem solve

TRACK and locate ATR clients

Knowledge and Competencies
critical gpra facts

A discharge and a 6 month GPRA are required (Care Coordinator function)

A minimum of 80% enrolled of ATR enrolled clients must complete the 6 month follow-up GPRA

Less than 90% follow-up rate = Technical Assistance and correction plan

6 month Follow-up GPRA must be given 5-8 months after initial enrollment

Discharge GPRA is due after 30 days of voucher inactivity. (Care Coordinator function can be via telephone and/or administrative is client is not located)

Critical GPRA Facts
care coordination intake interview

One time, face-to-face or telephone* interview with ATR client conducted prior to discharge from residential treatment program : (Requires 3-5 days notice from portal)


  • Engage the client in Care Coordination
    • Insure that Care Coordinator has information needed to coordinate care and client understands the program
    • Explain the purpose and process of care coordination
    • Establish contact schedule
    • GPRA 6 month follow-up appointment
  • Unit rate =$100.00
  • Maximum unit = 1
Care Coordination Intake Interview
telephone intake interview type

*More than 20 miles 0r 30 minutes travel time= Telephone intake with client while still in residential treatment.

Less then three -five (business) days notice of client discharge date.

Other: Requires RAC approval

Telephone Intake Interview type
atr intake interview description

Review and verification of:

  • Participant Application for RecoveryNet Services.
  • Orient Client to Care Coordination
  • Recovery Plan
  • Voucher Information
  • Contact information and schedule of contact
  • 6 month GPRA Follow-up survey Appointment
ATR Intake Interview Description
documentation of intake interview

Documents the service in the provider’s records

  • Establish a client file, tracks each encounter (type, date, length), maintains updated contact information, records date of next appointment and GPRA 6 month follow-up.
  • Enters the encounter in the ATR SMART VMS
  • End Intake Interview service
Documentation of Intake Interview
care coordination transportation

Public transportation that supports client recovery activities. Passes are obtained by Care Coordination Provider agency and disseminated to clients. Providers are reimbursed through the SMART VMS. Includes administrative fee :Might be adjusted regionally

  • Public Transportation- Passes
    • Unit rate= $80.00
    • Total Available units= 6 (30 day/ea.)
Care Coordination transportation
transportation by taxi or van

Transportation by taxi, van, or other care coordinator arranged transportation. Care Coordinators are reimbursed for transportation that they approve, arrange and pay for. Transportation must be related to client recovery activity.

Max units=200

Unit= $1.00

Transportation by Taxi or van


  • Client signature verifying receipt of service
  • SMART authorization and documented encounter
  • Documentation in provider’s record
care coordination vital documents

Care Coordination/ Vital Documents -Accessing critical vital documents for clients such as birth certificate, soc. security card, etc, Pays for any fees and administrative costs for obtaining documents. (This service does not pay for any transportation of documents. Includes care coordinator time for task required in document acquisition (cannot charge a unit rate with this))

  • Max. units = 2
  • Unit rate =$50.00
Care Coordination Vital Documents
vital documents


Email to RAC and inform of need

Document purchase with receipt

Document in the provider’s record

Obtain client signature of service/goods

Document in the SMART VMS

Vital documents
care coordination gap services

Goods or services paid for by the Care Coordination Provider and reimbursed at the rate below to the Provider. This is a fund used to supplement client identified needs to temporarily support recovery needs and fill service gaps. Items which are appropriate to voucher include:

  • Clothing/Hygiene
  • Food
  • Medication Gap or Co-pay
  • Medical Appointment Gap or Co-pay
  • Grooming
  • Dental Gap Service or Co-pay
  • Other- Required goods or services that support recovery and are approved by the Regional Manager.
Care Coordination Gap Services
gap services

Unit rate=$1.00 Max= 200


  • Email RAC and inform of need
  • Purchase the item alone for/ or with the client
  • Document purchase with receipt
  • Document in the provider’s record
  • Obtain client signature of service/goods
  • Document in the SMART VMS
Gap Services
gpra follow up interview

One time, face-to-face* meeting with client, conducted 5-8 months following admission to ATR, to assess satisfaction with ATR and to complete GPRA follow-up interview. Also includes obtaining client satisfaction information (Customer Satisfaction Survey mailed to ADAA – 55 Wade Ave. Catonsville, MD 21228) and issuing client $15 gift card. (must be completed within the 5-8 month required window)

Unit =1 session

Total available

Units = 1

Unit Rate =$160

*telephone GPRA Waiver can be requested through the Project Director

GPRA Follow-up Interview
gpra follow up interview1


  • tracking and locating client for face to face interview
  • completing the GPRA Follow-up Interview and entering it in the ATR VMS
  • Administering and submitting to ADAA the Client Satisfaction Survey (mailing to ADAA)
  • giving client $15 gift card (i.e. Wal-Mart or Target) and documenting clients receipt of gift card with signature
  • documenting the service in the provider’s records
  • entering the encounter in the ATR VMS
GPRA Follow-up Interview
what can i bill for

Intake Interview ($100.00)

  • Bi-weekly phone check-in (15 minute units@ $12)
  • Location calls and activities (15 minute units)
  • Any client centered activity (15 minute units)
  • GPRA Discharge (15 minute units)
  • GPRA 6 month follow-up + Client Satisfaction survey ($160.00)
What can I bill for?
relationships in the project
Relationships in the Project

Regional Area Coordinators (RAC) –Manage on Regional level

Client utilizes RecoveryNet resources to enhance and stabilize recovery

Care Coordinators (CC) – Manage on the client level

data measures

What are we looking at?

  • Time interval between referral and intake/length of pending status
  • Number of in-person vs. telephonic intakes
  • Client voucher burn rates
  • Billing patterns
  • Number of closed cases
  • GPRA Discharge report
  • GPRA Follow-up Rates
Data measures
atr care coordinator is

Recovery Champion

Overseer of Recovery Resources

Community Resource Connection

Obstacle Mover

System Changer, and

A GPRA Getter

ATR Care Coordinator is:
atr care coordinator is not

The Clinician

Crisis Intervention

Available 24/7



Mother, or a

Best Friend

ATR Care Coordinator is Not:
questions and more information

Contact Deborah Green, Maryland ATR III Project Director – 410,402,8592


Anita Ray- Regional Coordinator- Region III


Questions? And more Information