Mental Health Recovery Oriented Care and Methods of Service Delivery       

 At the end of this course material you will be able to:

Discuss four concepts of person centered planning and its relation to recovery.

Identify and describe at least five cultural factors that must be taken into account in any planning and service delivery.

Describe at least three barriers to implementing person centered planning and discuss the reasons why these must be overcome prior to implementing the process

Identify the five steps that make up the person centered process and discuss the essential components of each

Describe at least three practices to facilitate true person centered planning         

 
Are you looking for resources on resiliency and recovery-oriented systems of care (ROSC)?  Further, have you been reading the headlines concerning national health care reform and wondering how it will impact programs and services within a ROSC? This guide, which contains information from the Substance Abuse and Mental Health Services Administration (SAMHSA), and your colleagues around the country, will assist you with answers to these questions. State and local policy makers responsible for substance use programming, as well as providers of treatment and recovery support services, can look to this guide for information to enhance prevention, treatment, and recovery services as the changes in health care evolve in their communities. 

The purpose of this resource guide is to share an overview of ROSC and illustrate how these systems are an integral part of the new health care environment. This guide will align the tenets of health care reform to the benefits, framework, and history of ROSC, and the steps for planning and implementing ROSC.  Following each section of the guide’s narrative, you will find websites to direct you to specific resources that will assist you in conceptualizing and developing ROSC. The resources in this guide include research studies, white papers, conference presentations, manuals, practice guides, check lists, regulations and a number of other documents that have been prepared in response to the need for systems reform.  

  The establishment of ROSC is a relatively new concept in the substance use disorder field.  The structure of ROSC will likely evolve as these systems mature and are evaluated.  However, as States and communities are creating and implementing ROSC, they can learn from one another. At the same time that they are developing ROSC, they must also consider the changes that are occurring as a result of health care reform.  Some policy makers and providers have begun to assess their community strengths and needs in this regard and formulate ROSC plans that are compatible with the tenets of national health care reform.  We hope this resource guide will assist with that process.

One of the most important elements of national health care reform is the expansion of coverage for those with substance use and mental health disorders. The law also requires parity or that group health insurance plans that provide coverage for mental health and substance use disorders be equal to coverage provided for other medical and surgical benefits.  These sweeping changes form the foundation for the new health care environment.  Ingrained in health care reform is a public health model that supports ROSC through its vision of prevention, screening and early intervention, treatment, and recovery, integrated with primary health care.  Complex developments that include new benefit packages and financing strategies, greater use of technology, promotion of evidence-based practices, and the very important linkage with primary care all present opportunities and challenges that will be addressed in months and years to come.  For this reason, this resource guide will be a very fluid product.  As information on new initiatives and findings becomes available, it will be incorporated into the resource guide to further illuminate this new environment.

The goal of this guide is to arm you with sufficient information to leverage resources that will create the most favorable outcomes for individuals, families and communities. 

ROSC in the New Health Care Environment

 A ROSC is a coordinated network of community-based services and supports that is person-centered and builds on the strengths and resiliencies of individuals, families, and communities to achieve abstinence and improved health, wellness, and quality of life for those with or at risk of alcohol and drug problems.

The central focus of a ROSC is to create an infrastructure or system of care with the resources to effectively address the full range of substance use problems within communities.  The specialty substance use disorder field provides the full continuum of care (prevention, early intervention, treatment, continuing care and recovery) in partnership with other disciplines, such as mental health and primary care, in a ROSC. A ROSC encompasses a menu of individualized, personcentered, and strength-based services within a self-defined network.  By design, a ROSC provides individuals and families with more options with which to make informed decisions regarding their care. Services are designed to be accessible, welcoming, and easy to navigate. A fundamental value of a ROSC is the involvement of people in recovery, their families, and the community to continually improve access to and quality of services. The table below further illustrates the range of recovery-oriented services that may be offered in a ROSC. 
Examples of Recovery-Oriented Activities


 
Examples of
Recovery-
Oriented
Activities

Prevention

Intervention

Treatment

Post-Treatment

  • Early screening before onset
  • Collaborate with other systems, e.g., Child welfare, VA.
  • Stigma reduction activities
  • Refer to intervention treatment services
  • Screening
  • Early intervention
  • Pre-treatment
  • Recovery support services Outreach services
  • Menu of treatment services
  • Recovery Support services
  • Alternative services and therapies
  • Prevention for families and siblings of individuals in treatment
  • Continuing care
  • Recovery support services
  • Check-ups
  • Self-monitoring

 
Traditionally, recovery-oriented services have been viewed as long-term recovery related activities that occur after a formal substance use treatment episode. However, recovery-oriented activities and approaches are also part of the full continuum of care available to persons within a ROSC.  Substance use problems are preventable, but left untreated can progress into more serious conditions and can become chronic. A ROSC provides a network of services and supports to address the full spectrum of substance use problems, from harmful use to chronic conditions.  Through education, communities are strengthened by recovery-oriented activities that can prevent inappropriate substance use before it occurs.  Education also raises awareness about the disease, dispels myths that foster stigma and discrimination, and provides early intervention for those at risk of developing substance use conditions. 

A ROSC supports the premise that there are many pathways to recovery.  Recovery-oriented activities include providing a menu of traditional treatment services and alternative therapies, including peer recovery coaching, acupuncture, meditation, and music and art therapy.   Recovery support services, including employment assistance, child care, care management and housing support, may enhance the engagement of individuals and their families in achieving and sustaining recovery.  

Like other chronic health conditions, substance use disorders typically require long-term involvement with the health care system and parallel informal networks. Recovery-oriented services and supports include provision of continuing care following treatment, education regarding self-care, regular check-ups and linkage to community resources.        

Increasingly, technology is being used in a ROSC to improve access to services through e-therapy, to assist with information sharing, to increase quality and efficiency through use of electronic health records, and to support recovery through social networks. Proficiency with technology will become all the more critical as health care reform is implemented and integration with primary care occurs. A multi-disciplinary workforce is also viewed as critical to delivering quality care in a ROSC. The workforce may include prevention staff, treatment counselors, nurses, doctors, a marriage and family therapist, a psychologist, peer coaches, etc.  In a ROSC, organizations are guided by a set of values, goals, elements, core functions, and outcomes to achieve the ROSC’s mission.  To promote the health of individuals, families and communities, a public health approach is adopted.  Substance use disorders are biopsychosocial conditions.  These conditions are influenced by various social determinants of health—for example, the social and physical environment, income, education, and life skills. Only by understanding these determinants and applying strategies to influence them can the disease be impacted. 

A public health approach focuses on prevention of substance use problems in the general population, and addresses symptoms when they first emerge, rather than when they become acute or chronic.  A public health approach also uses data to monitor health problems and evaluate the effectiveness of services, and relies on interdisciplinary methods and partnerships. 

The diagram pictured illustrates a ROSC framework that includes the mission, values, goals, system elements, core functions, and outcomes of the systems. The principles of a ROSC and health care are closely aligned —for example, invest in prevention and wellness, expand coverage, guarantee choice, and improve quality of care.  A major component of a ROSC is implementing the provisions of health care reform to provide high-quality substance use services.  To achieve reform, integration of substance use services will need to occur within primary care settings. Primary care providers will likely require additional education and training on how to screen and intervene with at-risk populations, and on how to refer individuals with more severe conditions to specialty settings.  Additionally, specialty providers may be required to establish new partnerships, enhance technology, establish quality improvement systems, expand capacity, recruit and train staff, and work with health insurance plans. 

 Implementation of ROSC continues to evolve today, and the passage of national health care reform has opened another potential door in support of ROSC.  As more of the public responds to the integration of ROSC within the public health model, there will be additional lessons learned and further development of tools to enhance efforts and sustain health and human services systems at multiple levels.

Thus far, a number of factors at the Federal, State, and local levels have converged to initiate and support the development of ROSC. They include advances in research and technology, release of influential reports (i.e., the Institute of Medicine Quality Chasm Series), growth of the recovery community, an increased focus on collaboration and accountability, and implementation of successful local, State and Federal initiatives.  In 2005, key policy makers, prevention and treatment professionals, families impacted by substance use disorders, persons in recovery, and Federal, State, and local officials were brought together at SAMHSA’s Center for Substance Abuse Treatment (CSAT) National Summit on Recovery.  Their charge was to: 
  • Develop ideas to transform policy, services, and systems that provide a recoveryoriented response for family members, as well as the persons seeking recovery.
  • Articulate guiding principles and measures of recovery that are adaptable across services and programs while supporting system improvements, data sharing, and program coordination.
  • Generate ideas that advance ROSC in multiple settings and systems, and for specific populations.

Participants successfully reached a consensus on the guiding principles of recovery and elements of recovery-oriented systems of care.  This effort provided the framework for additional discussions and engagement by persons in communities across the country.

Opportunities for ROSC abound, as systems are integrated and transformed through coordination, communication, and linkage.  SAMHSA and the substance use disorder field have begun to conceptualize the magnitude of this paradigm shift.  The history of ROSC continues to be written as the focus of health care reform broadly encompasses the continuum of care for substance use disorders.

 Each of the partners in a ROSC can play a role in the provision of recovery support services.  When RSS are provided across the continuum of care, they support resiliency, open doors to service access and engagement, and support long-term recovery.  Person-centered supports bolster successful individual and family outcomes. 

Recovery support services are non-clinical services that assist individuals and families working towards recovery from substance use disorders.  They incorporate a full range of social, legal, and other resources that facilitate recovery and wellness to reduce or eliminate environmental or personal barriers to recovery.  RSS include social supports, linkage to and coordination among allied service providers, and other resources to improve quality of life for people in and seeking recovery and their families.  RSS are provided by professionals and peers and are delivered through a variety of community and faith-based groups, treatment providers, and RSS providers.  Provision of RSS is based upon the needs in a person’s individualized recovery plan.

While typically viewed as available post-treatment, recovery support services within the construct of ROSC can be offered before, during, or even in lieu of treatment. This approach and its supports are inclusive of pre-treatment, as well as promotion of resiliency in prevention and early or brief interventions. These are tenets that also form the basis of a public health model and are aligned with the principles of health care reform.

Child care and transportation are two of the most commonly recognized support services, but States and providers must leverage other systems to assemble a broader menu of resources as they implement ROSC.  By looking across the entire continuum and addressing supports specific to the individual, ROSC can identify a myriad of resources that may be used to foster recovery.  Housing, life skills training, help with employment readiness, and legal consultation are examples of support that may be beyond what a ROSC currently provides, but which are often important to supporting recovery.  Wellness checks, which support healthy lifestyles, are currently used in primary care settings for persons who have chronic conditions such as diabetes or heart disease.  This same practice can be replicated for persons with substance use disorders.

In addition to tangible resources like housing and transportation, there is a human element that is equally valuable in the provision of RSS.  A peer mentor or recovery coach can be very effective in providing motivation and support as an individual seeks a recovery lifestyle. 

When an established frame of reference reflects their own recovery process, peer mentors and recovery coaches are valuable assets in recovery support.  They can bring significant interpersonal skills to their work with individuals engaged in or contemplating recovery. As a ROSC moves further into the implementation phase, peer-driven supports will become a part of the fabric of recovery that cannot be replicated by other resources.  

Beyond the RSS functions that often require certification, States will be challenged to develop core competencies or minimal guidelines for persons and organizations who deliver these services.  Although health care reform and parity legislation will enable some service billing through insurance carriers for RSS, they may have more-stringent requirements related to service delivery for RSS than for conventional medical treatment.  When peer-driven services are initiated, consideration should be given to a reasonable match of gender, education, ethnicity and recovery philosophy, as well as defined core competencies. 
As a ROSC implements RSS, a few key steps can guide the process:  

  • Secure a broad range of supports through leverage with all partner systems. 
  • Focus on the specific needs of the individuals and families. 
  • Engage peer recovery coaches who have a personal recovery focus. 
  • Define competency guidelines.  (Competency guidelines should reflect requirements of third- party insurance carriers if possible.) Resources found below can assist States and providers to achieve these steps. 
  • Ethical Guidelines for the Delivery of Peer-based Recovery Support Services
  • Manual for Recovery Coaching and Personal Recovery Plan
  • Center for Substance Abuse Treatment: What are Peer Recovery Support Services

 
Within the framework of a ROSC, recovery management provides treatment and recovery supports to individuals with severe substance use disorders. This targeted approach to a specific population differs from the overarching role of a ROSC.  As has been described, a ROSC serves those with or at risk for substance use problems. The persons served within a ROSC encompass the general population, at-risk populations, harmful users of alcohol and drugs, those with dependence, and those with chronic dependence. 

Recovery management is often described as typifying the shift from an acute care model, which treats medical conditions in an intensive short-term manner, to a chronic care approach reflecting a service commitment to long-term supports and wellness.  A ROSC provides a full spectrum of services based on individual need.  These may include early intervention service (i.e., Screening, Brief Intervention and Referral to Treatment), acute care services (i.e., medically managed detoxification), and chronic care services (i.e., continuing care followed by recovery checkups, otherwise known as Recovery Management).
                 
The public health community has long practiced recovery management when treating chronic diseases such as diabetes, asthma, and hypertension.  While public health care providers may use different terminology, recovery management is a tool embedded in their approach to practice.  Public health principles address health promotion through comprehensive prevention strategies, screening, early intervention, treatment, and reinforcement of healthy lifestyles.  Sound familiar?  This model is also found in ROSC, and one that is the cornerstone of the new health care environment.  

Recovery management engages individuals with chronic substance use conditions and assists the person in managing efforts to achieve long-term recovery.  Individuals and their families are empowered to seek supports specific to meet the needs of the person.  There is no formula or set of rote practices that serve everyone.  Different persons require different resources.  It is the role of recovery management to coordinate access to resources and foster engagement.  ROSC coordinate the layers of multiple systems that can produce those resources.  As a result of the collaborative work done by a ROSC, these systems—including criminal justice, education, child welfare, and primary care—can provide the supports necessary to sustain recovery management activities.

At the 2005 National Summit on Recovery, a recommendation was made to hold a series of regional meetings to assist States and communities in planning and implementing ROSC.  Following the Summit’s recommendation, the Center for Substance Abuse Treatment’s (CSAT’s) Partners for Recovery (PFR) Initiative hosted five regional meetings in 2007 and early 2008 to support ROSC planning and  implementation at the State and community levels. Teams from 49 States, the District of Columbia, and Puerto Rico participated.

At that time, the stages of ROSC implementation across the country ranged from active planning and systemic re-engineering to very preliminary consideration of the ROSC concept.  Of those States attending the regional meetings, 10 percent (5 States) were engaged in active planning and implementation of ROSC, 35 percent (18 States) were implementing system elements and had begun planning for ROSC, 43 percent (22 States) had implemented one or more system elements, and 12 percent (6 States) were considering implementing ROSC.  

As a part of the work done during the regional meetings, State teams were asked to envision a ROSC that reflected their own locale’s unique environment, inclusive of challenges and creative solutions to work within existing systems.  They were then asked to develop an action plan to identify steps that have been taken, and what steps need to be taken to facilitate implementation of ROSC. 

After the regional meetings, a number of States moved forward in implementing a recovery oriented framework.  These states have cultivated partnerships with the medical community, among other systems, and are poised to further implement the tenets of health care reform in their alcohol and drug programming.  Following are examples of State ROSC activities:

California

In 2006, the California Department of Alcohol and Drug Programs (CADP) began a multi-year process to support system evolution from an acute care model to one of chronic care.  Established by CADP, the Continuum of Services System Re-Engineering Task Force have led this effort through engagement of stakeholders, development of core principles and goals, and creation of a website containing their presentations, findings, and other materials that reflect the principles of ROSC.   As with most States, resources have diminished, but California remains committed to supporting a client- centered chronic care system that is inclusive of prevention, treatment, and recovery.

North Carolina  

A task force, convened at the direction of the North Carolina General Assembly and led by the North Carolina Institute of Medicine, has steered the State’s efforts to plan and implement ROSC.  In addressing the full continuum of care, the task force published a comprehensive report that provided significant recommendations for a system redesign that reflects the principles of ROSC.  Their work was taken a step further by the legislature when this model was embedded in State statutes.  Today, much of the activity centers around training and a public campaign called ‚Recovery North Carolina.‛  The campaign has successfully engaged an advisory board, as well as volunteers and community members throughout the State.

North Carolina also redirected funds through an RFP process to allow provider flexibility in establishing services to support ROSC.  The challenges that remain in North Carolina are primarily lack of funding and lack of a data system to support the success of evidence-based practices.

Vermont

Prior to the regional meetings, Vermont had begun to construct a framework for recovery activities, called Friends of Recovery – VT. Following the CSAT-sponsored meetings, and with technical assistance from their ATTC, Vermont began to formalize ROSC through the establishment of a strategic plan and mission statement.  The plan ensured that all stakeholders understood the principles and concept of ROSC.  In addition, a State initiative, the Vermont Blueprint for Health, provided a statewide structure and a vehicle to more effectively manage chronic diseases using a public health model in tandem with ROSC.  With the strategic plan, mission, and Friends of Recovery – VT in place, the State initiated a series of provider trainings with the assistance of NIATx.  Incentives planning grants and monthly learning calls have further bolstered Vermont’s efforts to implement ROSC.  

Steps have been taken to ensure that the prevention community is part of the overall continuum, and that a strong family focus and resiliency are integral to ROSC.  Vermont has termed their systems change approach a Resiliency and Recovery-Oriented Systems of Care (RROSC). Vermont has instituted telephone recovery checkups, fostered peer support, and strengthened an integrated approach to RROSC.  

  • Access to Recovery (ATR) Approaches to Recovery-Oriented Systems of Care: Three Case Studies
  • Provider Approaches to Recovery-Oriented Systems of Care: Four Case Studies
  • Approaches to Recovery-Oriented Systems of Care at the State and Local Levels: Three

Case Studies                                                               

Creating a ROSC requires thoughtful and strategic planning, particularly as policymakers, providers, the recovery community, and the general public negotiate systems changes that involve the integration of substance use services within the general health care system.   This evolution is ongoing, so be mindful of its implications as you plan and implement ROSC within your State or community.   Identifying where you are in the ROSC planning and implementation process, while being cognizant of the new health care environment, will guide you in determining priorities and next steps.  


The diagram below reflects the steps that are integral to establishing a systems change process.  Each will be further described in this resource guide.
 
 
A Readiness Assessment should examine your willingness and ability to establish a platform for a ROSC.  A coalition of stakeholders should be engaged to consider important questions that examine the level of commitment and feasibility for the effort.  That dialogue may prompt divergent opinions before you reach a consensus.  However, that is to be expected, given the time and effort needed to construct a functional ROSC.  A facilitator with no vested interested in the outcome can play a key role in keeping the discussion moving and maintaining a record of the proceedings.


In assessing readiness, there are core questions that, when answered, will drive the consideration for systems change.  The following table can be used to frame that discussion.


ASSESSING READINESS: Core Considerations in Preparing for Change


Initial Consideration

Further Considerations

1. Can you build a compelling case for change?


What is the compelling case for creating a ROSC at this time? 
What problems will be solved? 

 

What value will be added to the system? 

 

What currently is being done in your community to address substance use problems and disorders? 

 

How effective are the current interventions?

 

Will change be better than business as usual?

2. Are the anticipated results compelling enough to initiate and sustain the change process?



What are the desired results from adopting a ROSC?
Results for your community? 
Results for families and involved others?

 

Results for persons in or seeking recovery?

 

By when do you expect to see these results?

 

What measures will you use to assess progress and impact?

3. Are the essential stakeholders willing and able to commit to and champion ROSC over time? 


Who will be the sponsors and advocates of a ROSC change initiative in your community?
Are the sponsors able to initiate and sustain support for the process?

4. Are the potential benefits of change, and the consequences of
"business as usual,‛ sufficient for community stakeholders to support
ROSC implementation?



What are the consequences of continuing systems as they currently exist?
For the key stakeholders, what are the rewards associated with supporting and participating in the ROSC initiative?
 What are their incentives for sustained engagement?

5. Are there sufficient systems and resources in your community to support implementation of ROSC?


How much will it cost to adopt a ROSC?
Are stakeholders willing and able to assure the systems and resources necessary to fully sustain a ROSC over time?

You may also wish to use the resource below to further aid in the assessment process.

The next step in the assessment readiness process is to establish a Conceptual Framework.  Use of focus groups and key participant interviews can ensure input from a broad spectrum of the community.  Participation by persons in recovery, as well as family members and other allies, can provide valuable insights as stakeholders develop a vision for a system of care, clearly articulate values for how services should be delivered,  and determine the desired outcomes for individuals, families and communities.  Some of the questions posed to the stakeholder group during the assessment readiness exercise may help structure the conceptual framework.  In addition, other important questions are:

  • What is your definition of recovery?
  • What should a ROSC look like in your community?
  • Why is a change needed?
  • What outcomes do you hope to achieve through a ROSC?

A discussion and consideration of these issues should result in a common vision, and in common values, system elements, outcomes, and definitions.  Without general agreement on the conceptual framework for the ROSC, the process cannot successfully move forward. 

Completion of a Needs Assessment is another key step in developing an informed ROSC plan.  Stakeholders must understand the extent of substance use problems, the populations affected, gaps in services and supports, and services and systems that require quality improvements.  This information will allow you to target and maximize resources.  Identifying community and organizational strengths is equally important, as they provide a strong foundation upon which to build.  This identification can strengthen discussion among ROSC partners, and provide a path for support in your implementation plan.  Stakeholders should also examine policies and practices to assess their alignment with ROSC elements, in order to determine what changes a

 The needs assessment process has identified the strengths as well as gaps in services within the current systems.  It should now be translated into a plan to enhance the capacity of your system where needed.  Capacity Building is an integral part of successful systems change implementation.  Does your ROSC have capacity at all levels, the staff or volunteer level, the organizational level, the broader systems level?  
Each systems element should reflect a comprehensive, person-centered, and individualized approach to service provision.  It is understandable that all systems may not initially align with this operational philosophy, but it’s important to determine what your capacity needs are so that they can be addressed.  In addition to workforce capacity, technology and other resources should be considered. 

 The next step in ROSC planning and implementation is development of a Strategic Planning Process.  After you have assembled a planning team that represents stakeholder interests, articulated a vision, conducted a needs assessment, and constructed a capacity building plan,  it’s time to develop a strategic plan including specific ROSC goals.  A critical step at this juncture is, once again, to ensure sufficient community representation, inclusive of individuals in recovery, family members and other allies. 


Following that, the planning team should be charged with identifying measureable objectives for each goal, as well as strategies to support achievement of each goal. Other tasks that should be completed in order to reinforce a strategic planning process are: 

  • Developing action steps,
  • Identifying timelines and parties responsible for completing each strategy,           Creating a resource plan, and          Documenting the entire plan.

 

 Now that the planning is well underway, it’s time to begin assembling the resources for Implementation.  Engagement of the community at large, as well as individuals in recovery, their families, and other allied members, will strengthen efforts to identify and garner resources for a ROSC.  Implementation of ROSC will require changes to a number of institutional practices and processes.   Trying to affect change in multiple levels of systems that interact with other multiple levels of systems can be overwhelming.  You may initially focus on workforce development, financing, policy enhancement, technology changes to support data tracking and billing, or one of many other topics that will come into play when putting your plan into practice.  Due to the complexity and challenges inherent in a major systems change, it may be wise to implement ROSC incrementally.   

California Access to Recovery (CARE) Recovery Support Services

As States and communities move toward implementation of ROSC, Financing may become a primary concern.  However, broad consideration must be given to all viable funding sources to encourage creative and flexible financing.   An initial review of funding resources may focus on Medicaid and the Substance Abuse Prevention and Treatment Block Grant (SAPT BG), but other streams may be leveraged when States are able to braid dollars and access funding from multiple systems.  There is great diversity across the country regarding financing of systems of care, and there is not one funding solution that will adequately meet the needs of every community.  The key is sufficient flexibility to achieve the best outcomes for individuals, families, and communities.

Flexible funding will enable a ROSC to offer individualized and comprehensive services for each person in a manner that best meets their needs.  Funding tied to specific program models and approaches that are ‚one size fits all‛ is inconsistent with the person-centered focus of a ROSC.  A ROSC that exercises creative financing strategies to offer an array of services tailored to an individual’s needs will encourage more successful outcomes. Offering financial incentives to offset systems improvement costs and providing start-up funds to initiate systems change are successful strategies that have been used in States and localities. 

While States have historically relied on Medicaid, the SAPT BG, and State general revenue dollars to fund prevention, treatment, and recovery services, those who are planning and implementing ROSC are also accessing resources provided through other systems.  Changes resulting from implementation of parity and national health care reform initiatives will open additional doors to service provision.  

Some States have already forged a successful collaboration with the justice system, at both the local and Federal levels, to garner funding support for ROSC services.  The education community and its prevention resources provide another avenue to enhance ROSC activities and funding.  Local environmental strategies shape school prevention initiatives that are broadly supported and funded.
Partnering with school systems ensures the inclusion of prevention as a part of ROSC.  Seeking support and building a ROSC framework with multiple partners will bolster resources to sustain the most comprehensive system.

Financing opportunities may also be available from the private sector.  As systems collaborate and identify common goals and activities supporting ROSC on a local level, foundation grants and private partner donations can be accessed to fund specific services.  This can be achieved by designing a flexible system that satisfies the requirements of the funder while meeting the specific needs of individuals and families. Another source of financing ROSC changes may be through Federal grant opportunities.  An ROSC may secure ‚seed money‛ through grant awards to begin or further progress its systems changes.  Once those innovations are realized, cost offsets from the previous system structure may be realized and applied to the ROSC operation. 

 Having the necessary Policies and Regulations in place is critical to successful implementation of a ROSC. A thorough inventory of existing policies and regulations will determine which require amendment or modification.  This process should also include identification and subsequent development of new policies and regulations that further support the framework for ROSC implementation and ongoing operation.  A successful ROSC is made up of multiple stakeholders, representing multiple systems.   Thus, the inventory must include a broad range of policies and regulations.  These policies exist at the State level and local provider level, and will further unfold at the Federal level as national health care reform is realized.

Within the inventory will be State statutes.  Significant changes may be required at the State level to ensure that enabling legislation is in place that reflects the fundamentals of ROSC.  In addition to statutes related to the functions of the Single State Agencies (SSA) for Alcohol and other Drugs, language embedded in criminal justice statutes, primary health care statutes and child welfare may require amendment.  Following statutory changes, States will develop or amend their Administrative Rules, and issue policy guidelines and interpretations to reflect ROSC fundamentals.  Providers and other ROSC partners must also incorporate ROSC-related policies and procedures into their operational directives at the

In order to fund a portion of ROSC services through Medicaid, State Medicaid Plans may require amendment and approval by the Federal Centers for Medicare and Medicaid Services.  As national health care reforms crystallize, additional policies and regulations will need to be developed at multiple levels within a ROSC.


The breadth in policy and regulatory changes required to implement a ROSC may seem daunting. 
But once again, an incremental approach and prioritization of steps to implementation will enable States and providers to move forward in establishing a comprehensive ROSC.  

 Evaluation is integral to a systems change process.  It can promote sustainability of effective policies, programs, and practices. It can inform funding decisions, guide clinicians and other service providers when they are working with patients, assist in patient decision making, and educate peers. Evaluation approaches typically look at the processes as well as the outcomes, ranging from short- to long-term goals and objectives.
As component partners within a ROSC begin to forge their resources through collaboration, it is important to consider data collection.  Without a mechanism to collect administrative data, it may be difficult to make assumptions concerning performance improvements.  Surveys, focus groups, and key informant interviews are also evaluation tools that can be used to strengthen evaluation findings.  Stakeholder partners should be encouraged to provide input into the development of these tools in order to increase commitment, broaden their knowledge of the process, and increase the practicality of the evaluation findings. Through ongoing data collection and establishing performance measures you can capture meaningful and immediate response to your ROSC transformation activities.    
An effective evaluation systemically tells us:

  • How well does the planning process reflect the identified needs, priorities and resources? 
  • What is implemented—what programs, strategies, activities—and by whom?
  • What can we say about ‚implementation fidelity‛?
  • What changes were made along the way and why?
  • Where are the successes?
  • Where are needed improvements? 

Thus far, little evaluation has been conducted on ROSC. This dearth of information highlights the importance of evaluating your recovery-oriented system to improvement them and to more effectively serve your community. Process improvement models are valuable resources to assist you with enhancing your change processes and outcomes. They offer practical approaches to guide and test your work in real-life settings for the purpose of continuous quality improvement.
 

 The information and materials provided in this guide will continue to be updated and disseminated for use as the movement to ROSC and national health care solidifies policies and provides further guidance to stakeholders, providers, and policymakers vested in the substance use disorders field.  As this evolution occurs, you may be just beginning to conceptualize ROSC for your community, while others are tackling implementation issues and beyond.  Regardless of your stage in the planning and implementation process of ROSC, please use this resource guide as a tool to encourage discussion and strengthen the infrastructure of ROSC in your community.

 
Acknowledgement


This technical assistance resource guide was prepared for the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Partners for Recovery (PFR) Initiative by Melanie Whitter and Donna J. Hillman of Abt Associates Inc. and Peggie Powers, consultant to Abt Associates Inc.  Shannon B. Taitt, M.P.A., served as the Government Project Officer.
Disclaimer
The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of the Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment (SAMHSA/CSAT).

Provider Approaches to Recovery-Oriented Systems of Care: Four Case Studies

Background

The basis of the Substance Abuse and Mental health concept of recovery lies at the core Health Services Administration’s (SAMHSA) mission, and fostering the development of recovery-oriented systems of care is a Center for Substance Abuse

Treatment


(CSAT) priority.  In support of that commitment, in 2005, SAMHSA/CSAT convened a National Summit on Recovery.  Participants at the Summit represented a broad population of stakeholders, policymakers, advocates, consumers, clinicians and administrators from diverse ethnic and professional backgrounds.  Although the substance use disorder treatment and recovery field has discussed and lived recovery for decades, the Summit represented the first broad-based, national effort to reach a common understanding of recovery guiding principles, elements of recovery-oriented systems of care, and a definition of recovery. 
 
Through a multi-stage process, key stakeholders formulated guiding principles of recovery and key elements of a recovery-oriented system of care.  Summit participants then further refined the guiding principles and key elements in response to two questions:  1) What principles of recovery should guide the field in the future? and 2) What ideas could help make the field more recovery oriented?  
 
A working definition of recovery, 12 guiding principles of recovery, and 17 elements of recovery-oriented systems of care emerged from the Summit process.  These principles and elements can now provide a philosophical and conceptual framework to guide SAMHSA/CSAT and other stakeholder groups, and offer a shared language for dialogue among stakeholders.
 
Summit participants agreed on the following working definition of recovery:
 
Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life.  
 
The guiding principles that emerged from the Summit are broad and overarching; they are intended to give general direction to
SAMHSA/CSAT and other stakeholder groups as the treatment and recovery field moves toward operationalizing recovery-oriented systems of care and developing core measures, promising approaches, and evidence-based practices.  The principles also helped Summit participants define the elements of recoveryoriented systems of care and served as a foundation for the recommendations to the field contained in Part III of the National Summit on Recovery Conference Report.
 
Following are the 12 guiding principles identified by participants (for a complete definition of each of the guiding principles, see the National Summit on Recovery Conference Report):

  • There are many pathways to recovery;
  • Recovery is self-directed and empowering;
  • Recovery involves a personal recognition of the need for change and transformation;
  • Recovery is holistic;
  • Recovery has cultural dimensions;
  • Recovery exists on a continuum of improved health and wellness;
  • Recovery emerges from hope and gratitude;
  • Recovery involves a process of healing and self-redefinition;
  • Recovery involves addressing discrimination and transcending shame and stigma;
  • Recovery is supported by peers and allies;  
  • Recovery involves (re)joining and (re)building a life in the community; and
  • Recovery is a reality.

 
Participants at the Summit agreed that recoveryoriented systems of care are as complex and dynamic as the process of recovery itself.  Recovery-oriented systems of care are designed to support individuals seeking to overcome substance use disorders across the lifespan.  Participants at the Summit declared, “There will be no wrong door to recovery” and also recognized that recovery-oriented systems of care need to provide “genuine, free and independent choice” (SAMHSA, 2004) among an array of treatment and recovery support options.  Services should optimally be provided in flexible, unbundled packages that evolve over time to meet the changing needs of recovering individuals.  Individuals should also be able to access a comprehensive array of services that are fully coordinated to support individuals throughout their unique journeys to sustained recovery.  
 
Participants identified the following 17 elements as what recovery-oriented systems of care should be (for a complete definition of each of the elements, see the National Summit
on Recovery Conference Report): 

  • Person-centered; 
  • Family and other ally involvement;  
  • Individualized and comprehensive services across the lifespan; 
  • Systems anchored in the community; 
  • Continuity of care; 
  • Partnership-consultant relationships; 
  • Strength-based; 
  • Culturally responsive; 
  • Responsiveness to personal belief systems; 
  • Commitment to peer recovery support services; 
  • Inclusion of the voices and experiences of recovering individuals and their families; 
  • Integrated services; 
  • System-wide education and training; 
  • Ongoing monitoring and outreach; 
  • Outcomes driven; 
  • Research based; and 
  • Adequately and flexibly financed.  

Purpose Statement 

The resource for States, organizations, and  his white paper has been developed as a communities embarking on or strengthening systems change efforts to develop recovery-oriented systems of care.  Each State, organization, and community will create a unique design and implementation strategy for recovery oriented systems of care. The lessons learned by several organizations that have already begun this process are captured in this paper and can serve as an invaluable resource throughout the design and implementation phase.  
 
Developing and implementing recovery oriented systems of care are a rewarding, difficult and complex process.  This process is relatively new to the addictions treatment and recovery field and minimal information is available to guide States, communities, and organizations wishing to develop recoveryoriented systems of care.  The case studies presented in this document provide examples, of recovery-oriented approaches within several communities/settings for diverse populations.   By providing a range of examples, States and communities can explore approaches best suited to their circumstance. None provides a complete template or roadmap, since each State and community is unique, and since the development of recovery-oriented systems of care is a continuous process of systems and services improvement.    
 
Using the principles and elements as the framework, this white paper will highlight the activities and operations of provider organizations that have taken steps toward the development of such systems.  This paper will present four case studies describing:

  • The approach used;
  • Funding mechanisms used or developed that support the recoveryoriented system;
  • Workforce and training issues encountered;
  • Research used to inform the structure and programmatic requirements;
  • Motivating factors contributing to systems change;
  • Challenges or barriers to systemschange efforts; and 
  • Other elements critical to each agency’s implementation of a recovery-oriented system of care.  

 
Agencies used as case studies are Fayette Companies (Peoria, Illinois), and the Behavioral Health Recovery Management Project; White Bison, Inc. and the Wellbriety Movement; the Sheridan Correctional Center Drug Treatment Prison and Re-entry Program and TASC Illinois’ role in the project; and the Citizens Planning and Housing Association (CPHA) of Baltimore, Maryland, and their efforts to expand supportive housing in Baltimore.
  
  

Behavioral Health Recovery Management Project

 
An individualized care acute care model principles of disease management but plans based on treats intense, sudden shifts the focus from the disease to the clinical guidelines afflictions with short- management to building a life in individuals with term, time-limited recovery.  Recovery management treatable chronic intensive care, and approaches also place greater emphasis diseases.  The results in discharge on family and community supports that patient/physician with minimal to no can be capitalized on to enhance partnership allows follow up or ongoing the individual to recovery initiation and maintenance. support.  However, engage actively insubstance use employ disease management strategies in the General Assembly in 1999.  


Illinois Administrative Rule 2060 to include recovery planning.  The recovery management concept would also come to influence systems change efforts in organizations and State systems across the country. 
 

Behavioral Health Recovery Management Project

The idea of recovery management flowed logically from the disease management concept.  Recovery management uses the same approaches that are most prevalent today.  It encompasses social and recreational activities, employment, education, housing, and life meaning and purpose.  In a recovery management approach, recovery should strive to be an enjoyable and positive experience. 
 

The BHRM model recognizes that recovery is an incremental process in which an individual moves through a series of five zones of personal experience and that there is an “ebb and flow” through and across each of the five zones.  The zones of personal experience are and spiritual.  The recovery management model uses “progress in one zone to prime improvement in other zones.”2  Additionally, recovery management recognizes three stages in the recovery process: 1) engagement and recovery priming (pre-recovery/treatment), 2) recovery initiation and stabilization (recovery activities/treatment), and 3) recovery maintenance (post-treatment recovery support services).3
 
Within a BHRM model, treatment becomes one of many ways in which an individual can achieve recovery.  When treatment is necessary, particularly in cases where an individual is experiencing highly severe, multiple co-occurring problems, evidencebased treatment practices are used.4  
 
According to the BHRM project staff, recovery management differs from traditional treatment by:
 

  1. Lowering the threshold of service entry for individuals and families impacted by behavioral health disorders, such as working with the existing level and sources of motivation for change, even if the individual or family is not ready to engage in services the clinician would otherwise recommend; 
  2. Redefining the role of the person in recovery from “patient” to full partner in the recovery management process;
  3. Redefining the role of the professional from expert who treats behavioral health disorders to consultant and ally who remains engaged with the individual or family over an extended period of time;
  4. Viewing treatment as a multi-tiered intervention designed, operated, and evaluated in collaboration with individuals and families in recovery that also addresses stigma and destructive stereotypes that constitute barriers to treatment and community integration;
  5. Shifting the service emphasis from crisis stabilization to promoting the identification and achievement of goals consistent with the developmental needs of the individual and the family;
Re-engineering assessment to achieve a process that is global rather than categorical,
  1. and continual rather than a service intake function; 
  2. Emphasizing sustained monitoring, selfmanagement, stage-appropriate recovery education and recovery support services, linkage to the natural resources of communities of recovery, and, if necessary, early re-intervention;
  3. Assessing recovery as a multidimensional process of personal growth, self-management, empowerment, and self-determination that transcends the biomedical dimensions of recovery;
  4. Evaluating service events based not on their short-term effects but on their combined effects on the course of the individual and family’s recovery career; and
  5. Evaluating recovery programs in terms of a dynamic interaction among persons and families in recovery, service providers, and the community over time.5
Implementation of Recovery Management at Fayette Companies: A Shift in Philosophy and Practice

For clinicians who had been trained in and practiced acute care treatment models, the shift to a recovery management approach required training and a conscious effort to accept a significant philosophical change.  To facilitate adoption of the approach, Fayette project staff initiated a series of “brown bag” lunch discussions designed to elicit dialogue among project staff and clinicians in the addictions and mental health programs.  Many of the discussion topics addressed ingrained philosophies stemming from treatment approaches modeled after acute care interventions.  Discussions focused on the chronic and relapsing nature of addictions and psychiatric disorders; others addressed the “power-control” scenarios that are often present in an acute care model.  Project leaders outlined the project expectations, core attitudes, values, knowledge and skills in written documents, and also made it very clear to staff that the system and philosophies were going to change.  Staff could accept the change and remain with the organization or move on to an organization in which they were more comfortable.  Most staff accepted the change. 
 
A comprehensive training plan also played a key role in the cultural shift within the organization.  Ken Minkoff conducted a oneday training designed to motivate the staff on treating co-occurring disorders.  His training was followed by a series of evidence-based trainings on both substance use disorders and mental health.  Training on motivational interviewing resulted in the most significant cultural shift within the organization for both substance abuse and mental health practitioners.  Motivational interviewing changed the culture of confrontation and blame that had previously existed in the service units, to one of acceptance, respect, and understanding.  It became acceptable for individuals to be ambivalent about their treatment and honest about why they were there -- for example, whether it was because they were court-mandated to treatment or because a child welfare worker said they needed to go to treatment if they hoped to get their children back.
 
Staff was also trained in the community reinforcement approach, contingency management, strengths-based approaches, illness management and recovery, and supportive employment by experts in these areas including, Bob Myers, Nancy Petry, Leigh Steiner, Kim Mueser, and Pat Corrigan and Associates.  Collectively, these trainings moved the organization and its staff toward evidencebased practices and a stronger orientation to recovery.  They also helped to move the organization toward a person-centered approach in which clinical staff relinquished control over decision-making in the treatment and recovery process, recognizing that the individual or family serve as the ultimate experts and decision-makers in the recovery process.  Individuals therefore became partners and active collaborators in the pursuit of recovery, rather than passive responders.  
 
Recovery partnerships became a cornerstone of the recovery management model and reflected the strength-based approach advocated by researchers in the mental health field.  The message conveyed to individuals is that the clinician is a partner in the process and is there to help the individual achieve his or her life goals beyond any treatment goals that may exist.  
 
The BHRM project made significant changes in what has traditionally been called discharge and treatment planning.  Historically, individuals were discharged because they violated rules or because clinicians determined they were not ready for change.  
 
In the context of residential treatment, Fayette eliminated rules that had little to do with recovery.  These included prohibitions on using the telephone or having visitors for a period of time at the beginning of treatment.  This blackout period was implemented out of fear that an individual would get homesick, or hear the “call of the streets” and leave.  Once the blackout period was eliminated and individuals were able to have contact with their support network outside of the facility, they remained in the program, and the number of people leaving against medical advice declined.  Today, when individuals for whom residential treatment would otherwise be recommended decline admission or are unable to participate, they are offered services at a lower level of care.  This supports the philosophy of client choice that is so important to recovery-oriented approaches. 
 

The BHRM project found a way to eliminate discharge plans, replacing them with personal recovery plans.  In the beginning, Fayette project staff requested a rule exception to replace discharge planning with treatment planning and personal recovery plans.  The State later changed the administrative rule permitting treatment planning and personal recovery planning, eliminating the need for a rule exception.  Fayette staff started with a treatment plan that transitioned to a personal recovery plan as an individual neared completion of structured treatment and began the transition to community support.  Recently, the Fayette staff has developed recovery planning guidelines that can be used from the time of initial intake.  They believe these plans meet all administrative rule requirements while still supporting a recovery-oriented system of care.  They are awaiting confirmation of this from the State.


Integrated Services

A key principle of recovery-oriented approaches is integrated services.  Many individuals served in addictions treatment have co-occurring physical health problems and needs.  Many of the addictions treatment clients test positive for hepatitis or HIV.  Some are diagnosed with AIDS.  The BHRM project works closely with a Federally qualified health center (FQHC) in the Peoria area.  Individuals in the addictions program are connected with the FQHC or are linked with other primary health care providers.  Facilitating connections to primary health care services as a part of the recovery planning process ensures that the whole person is treated, decreasing potential for relapse that can be triggered by challenges associated with physical health.  Recovery support services play an important role in ensuring connections to primary health care and other critical services in the community. 
 

Recovery Support 

BHRM is piloting providing recovery support services utilizing recovery coaches to assist women leaving the residential addictions treatment program.  Four to six weeks prior to treatment completion, women are offered an opportunity to work with a recovery coach who will assist them in developing a personalized recovery plan.  Recovery coaches provide ongoing post-discharge support in eight domains:
 

  • Recovery from substance abuse;
  • Living and financial independence;
  • Employment and education; 
  • Relationships and social supports; 
  • Medical and physical health; 
  • Leisure and recreation; 
  • Independence from legal problems and institutions; and 
  • Mental wellness, spirituality and meaning in life. 

 
The recovery plan is developed prior to discharge.  Recovery coaches are available to women even if they leave treatment against medical advice.  Recovery coaches assist women with their transition to the community and provide support related to the recovery plan.  They also assist women in locating safe shelter or housing conducive to recovery, attending to primary health care needs, and support them in working toward a variety of goals, including education and employment.  
 

Financing Recovery Management

The BHRM project continues to receive the majority of its funding from the Illinois Department of Human Services (DHS).  Once the initial three years of the project were completed, DHS extended the project for two years and then moved the project from the grant mechanism that had sustained it to the standard fee-for-service contract between the State Department of Human Services and Fayette Companies.  Recovery coach services are now billed to either the Division of Alcoholism and Substance Abuse or the Division of Mental Health as case management services.  (Medicaid in Illinois covers case management for mental health services but not for substance abuse.  Thus, when billed to the Division of Mental Health, recovery coach services are Medicaid reimbursable, whereas when billed to the Division of Alcoholism and Substance Abuse, they are reimbursed using State or Federal block grant funding.)  Project staff believe that future funding will rely heavily on demonstrating the effectiveness of recovery management through ongoing data collection.  Initial data appear very positive, and the anecdotal evidence also supports the effectiveness of BHRM.  
 

Barriers and Challenges

Initial challenges included rule and financing issues that were resolved through State changes.  However, separate funding streams at the State and Federal levels, and the absence of funding streams that support recovery-oriented services remain ongoing challenges.  Internal challenges included staff ambivalence and organizational inertia, as well as a belief that staff time was too limited to provide ongoing monitoring and support after discharge.  
 
An unexpected external challenge arose in the form of the attitudes among referral sources for the BHRM project.  For example, judges wanted to mandate residential treatment for all referred offenders, regardless of assessed need.  Other commonly encountered external challenges of organizations attempting to implement this approach may include:
 

  • The lack of capacity to provide a holistic intervention that treats people, not diseases; 
  • The resistance to providing services in the community, rather than in traditional addictions treatment programs; 
  • The lack of systems to blend treatment with services outside the traditional realm of addictions treatment (e.g., vocational, housing, and educational services); 
  • The lack of coordination between systems,  particularly the criminal justice system and mental health; and 
  • The ongoing problem of getting families and allies involved in the treatment and recovery process.  

 
Two other challenges were raised in providing holistic services.  They are addressing trauma concurrently with substance use disorders and viewing substance use disorders from a public health perspective.  Viewing substance use disorders from a public health perspective would involve taking a total health approach, providing preventative services, early intervention, and treatment for not only the substance use disorders, but for other health conditions.   
 

Lessons Learned

Based on experience gained in implementing recovery management, the BHRM staff believes the following recommendations will support the Movement toward recoveryoriented systems of care:  
 

  • Collect data on the cost of the current system and the cost of diverting individuals to less expensive forms of treatment and recovery supports;
  • Track people rather than episodes of treatment and see what factors contribute to recovery and recidivism;
  • Promote the benefits of integrated substance use treatment (promote addictions treatment the way education is promoted; for example, it takes a village to raise a child, and it takes a community to help an individual recover);
  • Modify State and local policies, rules, and practices that are not congruent with the development of recoveryoriented systems of care (including evidence-based programs);
  • Modify addictions training programs at local community colleges and universities to include recoveryoriented approaches and to emphasize compatible evidence-based practices, such as motivational interviewing and community reinforcement approach;
  • Integrate criminal justice and behavioral health services (e.g., promote jail diversion policies and continuity of care);
  • Promote community-based programs and services that can reduce the need for detoxification, hospitalization, and residential treatment;
  • Mandate assessment for trauma in all behavioral health programs and modify treatment programs that lead to high dropout rates for individuals with trauma;
  • Connect funding to improving treatment processes and outcomes;
  • Track and report outcomes that promote recovery over time (employment, education, stable housing); and
  • Promote the growth of housing programs rather than residential treatment (help clients access affordable housing, child-care services, vocational and educational services while receiving outpatient treatment).
Summary

The BHRM project is an example of an innovative recovery-oriented systems of care change effort within an organization.  This project is based on the implementation of a specific approach called Recovery Management.   
 
The BHRM project generally reflects several of the elements of recovery-oriented systems of care developed through the National Summit on Recovery.  However, there are areas where the convergence between the project’s work and the Summit’s elements is particularly marked.  They include:
 

  • Person-centered through a focus on individual goals and plans for recovery.  In recovery management, individuals are supported in making decisions that best meet their own recovery goals.
  • Family and other ally involvement through family and other support from the beginning of formalized treatment/recovery planning.  Family and ally supports are an important part of recovery planning. 
  • Individualized and comprehensive services across the lifespan through the configuration of systems and services to flexibly respond to the needs of the individual.  Traditionally, the individual was expected to adapt to the norms, requirements, and expectations of the program.  
  • Systems anchored in the community through recovery coaches and other community organizations, BHRM provides ongoing support for the individual in recovery. 
  • Continuity of care through the development of a recovery plan and the assignment of a recovery coach who will support continuity of care for women post-discharge.  
Partnership-consultant relationships through the development of the recovery plan. 
  • The recovery coach serves as a consultant who partners with the individual in treatment and following treatment to clarify goals and strategies related to the recovery plan.
  • Strength-based because recovery management focuses on the strengths

and resources individuals can bring to bear on their own recovery, not on the deficits of the disease.  

  • Integrated services by providing an approach for integrated treatment of co-occurring substance use and mental health services disorders and by integrating behavioral health and primary health care.  Recovery planning also reflects integrated services by looking at the needs of the whole person and linking with a variety of community-based services in support of recovery. 
  • System-wide education and training by conducting comprehensive strengthbased training for the staff at the outset of the systems change effort. 
  • Ongoing monitoring and outreach through support over time and continuity from initial engagement through treatment completion through the transition and integration within the community.
  • Research based through the ongoing involvement of some of the field’s leading researchers in recovery management and through the adoption of evidence-based practices such as Motivational Interviewing, Community Reinforcement Approach and contingency management.  Research is also ongoing and continues to inform the evolution of the system.

The Wellbriety Movement:  A Natural Evolution of the Recovery Process

Native American elders point to the years following World War II and the return of Native American soldiers to the reservations as the turning point for the rise of alcoholism in their communities.  The elders believe this trend was strengthened in the early 1950s, when policies moved a significant number of Indians from the reservations to major cities to find work.6  The move often resulted in isolation and loss of cultural connection, contributing to the increase in alcoholism in Native American communities.
 
In response to this rise in alcoholism rates, as well as a rebirth of Native pride across the United States in the 1960s and 1970s, the Indian sobriety movement gained momentum.  The sobriety movement capitalized on the Native American history of resistance to the dangers of alcoholism, dating back to the first recorded Native American in recovery, Handsome Lake, a Seneca religious leader (1735-1815).  By the late 1980s, the sobriety movement that had begun in the 60s and 70s had become visible, and the groundwork for the Wellbriety Movement was laid.  
 
The Native American population recognized the importance of health and healing, as well as the need to address sobriety and wellness through a “holistic way of life involving the family and the community as well as the individual.”7  While some Native Americans did follow the traditional 12-step Alcoholics Anonymous (AA) model, many found the 12step process culturally inappropriate.  
 
However, Don Coyhis, Mohican Nation, the founder of White Bison, Inc., and one of the founders of the Wellbriety Movement, knew from his own AA recovery experience that there was great benefit to be gained from 12step programs.  He became determined to combine his own healing experience in the 12-step process with Native American cultural and spiritual ways to reach his own people more effectively than 12-step programs alone.8  By the mid-90s, with the Native American recovery movement fully active, Coyhis and his staff at White Bison recognized that many Native Americans who were seeking healing and wellness “wanted to find sobriety and recovery from alcohol and drugs, and then go on to live lives of wellness and wholeness rooted both in their own tribal cultures and in the mainstream world.”9  It was at this point that White Bison helped to initiate the transition from the sobriety movement to the Wellbriety Movement. 
 
What is Wellbriety?

The term Wellbriety means to be both sober and well.  For the American Indian and Native Alaskan populations, the term Wellbriety describes a natural evolution of the recovery process10 and combines Native American cultural values with the traditional 12-step programs of AA.  Wellbriety is a state of well-being in which the nations can be well only if the tribes and groups are well.  Tribes and groups recover only when the families are well.  Families can be well only when each individual person is physically, mentally, and spiritually fit.
 
“Wellbriety means to have come through recovery from chemical dependency and to be a recovered person who is going beyond survival to thriving in his or her life and in the life of the community.  To be well is to live the healthy parts of the principles, laws, and values of traditional culture.  It means to heal from dysfunctional behaviors other than chemical dependency, as well as chemical dependency itself.  This includes codependency [adult child of alcoholics] behavior, domestic or family violence, gambling, and other shortcomings of character.”11 Wellbriety is a state of wellbeing in which the nations can be well, only if the tribes and groups are well.  Tribes and groups recover only when the families are well. Families can be well only when each individual person is physically, mentally, and
spiritually fit.12   
 

Wellbriety:  A Recovery-Oriented Approach

Relying largely on the cultural teachings of the Native American elders, Wellbriety is based in the Four Laws of Change for Native American community development.  The Four Laws involve family and other allies in a personcentered approach to recovery and are a vital part of every Wellbriety event, resource, and program.  The Four Laws are strongly anchored in the community, ensuring that the community remains a centerpiece and ongoing support network for individuals and families seeking recovery.  They also demand a level of community accountability, recognizing that the community as a whole cannot disassociate itself from one of its own who is not healthy. 
 
The First Law, “change is from within,” “means that human beings must change their thinking, values, beliefs and attitudes before the community can gain lasting healing and a positive direction.”13 
 
The Second Law, “development must be preceded by a vision,” “means that community self-determination is most effective when the community participates in a visioning process to guide its own future.”  The visioning process asks the question, “what would the community look like if it were healthy and working?”14   
 
The Third Law, “A great learning must take place,” “means that all parts of the cycle of life—baby, youth, adults, and elder—in a community must participate in a simultaneous learning experience for the community to get well.”15   
 
The Fourth Law, “You must create a healthy forest,” “means that the entire community needs to be part of the healing process from alcohol and drug problems so that the community itself may recover and individuals may become well persons.”16  
 
The Four Laws of Change provide a culturally specific view of healing and recovery that is expressed in the American Indian Medicine Wheel.  For the very spiritual Native American population, the Medicine Wheel represents the wheel of life which is forever evolving and bringing new lessons and truths to those walking the path.  The Earthwalk is based on the understanding that at one point or another, everyone must stand many times on every spoke of the great wheel of life.  Until one has walked the path of another or stood on his spoke of the wheel, one cannot truly know another’s heart.  The medicine wheel teaches that all lessons are equal, as are all talents and abilities.  It is a pathway to truth, peace, and harmony, and the circle is never ending, life without end.  Within the Medicine Wheel are the Four Cardinal Directions.  Each of the four directions represents something different, in the east is success and triumph, in the north is defeat and trouble, in the west is death, and in the south is peace and happiness.  

In Coyhis’ own recovery, he combined the traditional teachings of AA and 12-step programs with the cultural teachings of the Medicine Wheel.  Coyhis placed what he identified as the key principles of 12-step programs on the Medicine Wheel—in the East is healing, in the North is the power to forgive the unforgivable, in the West is unity, and in the South is hope. As can be seen in the Medicine Wheel graphic, 3 of the 12-steps of Alcoholics Anonymous are associated with each of the four directions.  Steps one through three, which mark the beginning of the recovery journey through 12step programs are in the East, which coincides with the dawn and early childhood.  The recovery process, the journey around the Medicine Wheel, begins in the East with the first three steps.  This helped to provide a culturally appropriate, spiritually familiar context for the 12-step process.  A principle of the Medicine Wheel is interconnectedness—all aspects of life are connected, related and involved with other

The Medicine Wheel Teachings:

  • Harmony
  • Balance
  • Polarity
  • Conflict precedes clarity
  • The Seen and the Unseen worlds
  • All things are interconnected
  • The honor of one is the honor of all

  (White Bison, 2007)

 
This idea of using the Medicine Wheel teachings to communicate the 12-step concepts eventually evolved into the Medicine Wheel and 12-step program that was piloted in an Idaho prison with incarcerated males in the early 90s.  This approach allowed incarcerated Native Americans males an opportunity to benefit from the effectiveness of 12-step programs expressed in a culturally familiar context.  The Medicine Wheel and 12-step programs developed for men gave rise to the Medicine Wheel and 12-step programs for women which were also effectively piloted in an Idaho women’s prison.  
 
Between 1999 and 2003, Wellbriety supporters traveled across the United States a total of four times, carrying the teachings of the Medicine Wheel and 12-step programs, and the concept of the Wellbriety Movement to tribes, tribal colleges, and Native American communities.  In 1999, the Firestarters program was introduced, becoming a cornerstone for the Native American grassroots recovery movement.  Firestarters are trained to work the Medicine Wheel and 12-step programs and commit to continue with the program for four years.  Once Firestarters are far enough along in their own recovery, many go on to facilitate their own peer support services, ensuring that the voices and experiences of recovering individuals are included in helping others in their recovery.  
 
Many other programs have evolved from the Wellbriety Movement in response to the needs of different populations within the Native American community.  These additional programs are individualized and provide comprehensive services across the lifespan. 

The Creator designed the universe Mother Earth to function as a system of circles and cycles. Therefore, to heal we must understand and live by the cycle and circle system in every area of our lives. spring summer fall winter baby youth adult elder individual family community nation recognize acknowledge forgive change In order to heal, we must follow the natural order of healing (White Bison, 2007).

 The Wellbriety for prisons program has grown to serve incarcerated Native American populations in several State and Federal prisons.  Additionally, two programs, a series of trainings and the Coalition Building program, have arisen out of the feedback from individuals who are familiar with the Medicine Wheel and 12-step program and other Wellbriety Movement initiatives.  The trainings series brings together in one place several target populations.  The trainings are conducted simultaneously and address the needs of every member of a tribe that is impacted by alcoholism. The trainings and target populations are: 
 

  • Firestarters (The Medicine Wheel and 12-step programs) for men and women; 
  • Firestarters (The Medicine Wheel and 12-step programs) for spouses;
  • Sons of Tradition and Daughters of Tradition programs (gender-specific substance abuse prevention programs for youth ages 13-17);  
  • Strengthening our Families (for family healing); and 
  • Children of Alcoholics (for youth whose families are affected by alcohol abuse).18

The Coalition Building, conducted by Community Anti-Drug Coalitions of America (CADCA), teaches Native American tribes how to build coalitions.  What the tribe members discovered, however, was that they already understood the idea of coalitions, but for them coalitions were called clans.  Tribe members would attend the CADCA trainings during the day, but then in the evening would sit together and transfer the CADCA coalition information to ideas and concepts more readily understood by the clans.  The coalition building training program ensures that the system is anchored in the community by teaching, “communities in healing have to band together as coalitions in order to be more effective in accessing healing resources for their communities.  It teaches them how to act in unity for the benefit of all.”19
 
The most recent addition to the Wellbriety list of program services is called Warrior Down.  Warrior Down is a relapse prevention program targeting individuals returning to the community from incarceration or treatment.  Warrior Down creates and trains a network of healthy people to support individuals returning home at a critical and often very difficult time in their recovery. 

The Movement and its ideas have also begun to spread to other cultures.  An African American group is working on their own culturally specific book inspired by the Red Road to Wellbriety, the Native American version of the Big Book.  The Red Road is also eing translated into Spanish.  The Daughters of Tradition material is being translated into Spanish and Spanish Braille.  A sign-language version of the video for the Medicine Wheel and 12-step programs has been recorded.  The Medicine Wheel and 12-step programs are also being taught overseas in Australia and other foreign countries. 

     

Barriers

Initially, the barriers were internal and existed within Native American communities that were resistant to change.  But now a greater barrier exists in the fact that the Wellbriety Movement is not grounded in evidence-based science.  This has precluded Wellbriety followers from receiving grants from funders that restrict funding to evidence-based practices.  Additionally, continued cultural differences plague communications between the Movement’s supporters and local, State, and Federal agencies.  
 

Lessons Learned 

The most important lesson learned by the founders of the Wellbriety Movement is the need for evaluation from the start of the Movement.  White Bison was initially funded by a Center for Substance Abuse Treatment (CSAT) Recovery Community Services Program (RCSP) grant.  The organizers chose to spend their grant funds in the communities rather than on evaluation.  Now, several years later, the Movement is just beginning to collect the data that can demonstrate, scientifically, that the work they are doing has been effective.  
 

Summary

The Wellbriety Movement is an example of a culturally responsive, culturally literate, recovery-oriented approach.  Wellbriety Movement founders saw a need to adapt a culturally inappropriate and ineffective approach to recovery support into something that met the cultural and spiritual needs of the Native American population, demonstrating the flexibility of recovery-oriented approaches to meet the needs of very diverse populations.  
 
The Wellbriety Movement generally reflects several of the elements of recovery-oriented systems of care developed through the National Summit on Recovery.  However, there are areas where the convergence between the Movement’s work and the Summit’s elements is particularly marked. 
They include:
 

  • Person-centered by providing stage and age-appropriate support services for individuals.  
  • Family and other ally involvement by recognizing that recovery requires healing the community including the family, other support networks, and the tribal elders.  
  • Individualized and comprehensive services across the lifespan by addressing the needs of the entire life cycle from birth to elder.  The Wellbriety programs have evolved since their inception to meet the needs of all members of the community.  
  • Systems anchored in the community through the Four Laws of Change and the Coalition Building trainings. The Wellbriety Movement anchors recovery in the community and also holds the community accountable for healing itself and its members.
  • Continuity of care through support for those coming out of treatment, as well as addressing the needs of the family and the community.  The Wellbriety Movement offers services appropriate to every stage of the recovery process, including new efforts to spiritually prepare individuals in need of treatment for methamphetamine addictions prior to their participation in a treatment program.  Wellbriety does not provide direct treatment services, though individuals can receive assistance in locating treatment resources. 
  • Partnership-consultant relationships by encouraging individuals and families to seek their own spiritual pathways to recovery and by offering the support services necessary to help them do that. 
  • Culturally responsive through the evolution of the entire Wellbriety Movement.  In response to cultural needs, Wellbriety has developed training materials in Spanish, Braille, and sign language.
  • Responsiveness to personal belief systems through the inclusion of Native American spiritual culture into the 12-step concept to create the Medicine Wheel and 12-step program. 
  • Commitment to peer recovery support services through Firestarter groups that are peer-led.
  • Inclusion of the voices and experiences of recovering individuals and their families through peer and community supports as well as Firestarter groups. 
  • System-wide education and training through annual Wellbriety conferences that bring together the Movement’s supporters from tribes all over the United States.  Ongoing training for Firestarters also ensures that those involved in the program are able to continue to provide peer support. 
  • Ongoing monitoring and outreach by making the community accountable.  Individuals publicly commit to their recovery in a variety of Native American ceremonies.  The community also commits to taking care of one of its own and will return an individual to treatment or to a group if he or she relapses.  
 

The Sheridan Correctional Center:  A Drug Treatment Prison and Re-entry Program 


Background designed to holistically address the needs of the entire while they were in prison and programs in and provide services in outside the Institution that the community upon person including mental are designed to help them release.  Continuity of health and primary healthcare manage and maintain care through case services, and education and recovery and restore management and linkage employment goals. citizenship.  The focus on to community supports for restoring citizenship individuals released from requires that the services within the Sheridan. Sheridan Correctional Center were intended to sustain and reinforce the treatment and recovery experience.  What evolved is a system of care that serves the criminal justice population utilizing recovery-oriented approaches. 
 

The Design 

Identification of individuals appropriate for the Sheridan program takes place at the system go beyond substance use disorder treatment.  To fully support re-entry and the recovery process, services must be designed to holistically address the needs of the entire person including mental health and primary healthcare services, and education and employment goals.
 
The Sheridan program is also committed to peer recovery support services.  These are offered in the prison through a peer-led support group known as the Inner Circle.  Inner Circle is intended to support incarcerated individuals who wish to enter recovery and to stay crime free following their release.  This group meets weekly inside Sheridan and provides opportunities for individuals to share concerns and support and to help each other develop plans for returning to the community.  Upon release, Inner Circle participants join a Winners’ Circle group, which serves a similar function in the community.  This ongoing peer recovery support is a critical component of the Sheridan model. 
 
Winners’ Circle is a peer-led, peer-driven support group designed to address the special needs of formerly incarcerated individuals. Membership is open to formerly incarcerated individuals, as well as their families, friends, and allies.  Participants must express a desire to participate in their own healing and recovery.  They must also be committed to assisting others through encouragement and support.  Winners’ Circle events provide a positive, social setting in which participants can explore and develop new life skills in a relaxed and non-judgmental setting.23  

Return to the Community: The Need for Linkages and Community Supports

 
Because individuals take part in treatment for six to nine months, over half return to the community and are able to “step-down” into a supportive living arrangement.  This can include transitional housing, halfway houses, or recovery homes.  Many parolees require employment and education support services as a part of their re-entry plan. The continuity of care from incarceration to release allows continued access to services that will help them meet their employment and education goals.   
 

TASC and the parole system work closely together to support an individual’s re-entry in to the community.  TASC provides clinical re-entry case management, intensive case management services specially designed for offenders returning to the community,24 and the parole system provides supervision and enforcement.  Unique to the parole system, TASC and the parole staff devise creative strategies to provide incentives and sanctions in support of the parolee recovery and successful re-entry.  Historically, when a releasee relapsed or stopped attending mandated treatment, he or she would be deemed in violation of parole and sent back to the correctional system.  This resulted in high recidivism rates and reflected a failure to recognize the chronic and relapsing nature of addictions.  With clinical re-entry case management, sanctions do not include an automatic return to prison for an individual.  When relapse occurs or potential relapse issues are identified, a group consisting of the parolee, family members, TASC, a member of parole, other community-service providers, and the treatment provider develop a plan to address the relapse and to respond to factors that may have contributed to the relapse episode, such as continued unemployment, lack of adequate housing, or lack of child care.  Then together, in a client-centered, community support process, the group identifies strategies to resolve those issues.  However, while case management and creative sanctions and incentives play an important role in decreasing recidivism and supporting individuals seeking recovery, the parolee’s return to family and community is stressful and may lead to relapse.  Multiple studies suggest that the point of return to family and/or community is a critical juncture of vulnerability to relapse and consequently, re-incarceration.  Communities often reject individuals returning from incarceration out of mistrust

Financing Re-entry and Recovery Following Incarceration

A critical system element of recovery oriented systems of care is that they be adequately and flexibly financed.  The Sheridan project is funded through IDOC, which has woven together a creative funding strategy that has been essential to the success of the program.  A blended funding stream and fear that the parolee will re-offend.   
 
Key stakeholders in the Sheridan project brainstormed a way to address this juncture of vulnerability in a manner that built support capacity in the community.  Their solution was to create Community Support Advisory Councils (CSACs), which are intended to assist recovering parolees in (re)joining the community and (re)building a life in it.  CSACs are composed of individuals who live and work in high-impact communities and include community service providers, employers, and faith-based organizations of a variety of denominations.  They engage offenders prior to release to ensure continuity of support.  CSACs adopt a client-centered approach and strive to serve as the face of reentry for the recovering parolees returning to the community.  CSACs also serve as a buffer between an often unsupportive or hostile community and the parolee.  
 
 
The program pays for most of the services that an individual receives upon release from incarceration, including mental health care and housing.  The multiple funding streams afford parolees access to a variety of services critical to successful re-entry and recovery. However, the flexible funding comes with its own set of challenges.  Each of the blended funding streams entails separate reporting requirements, application processes, and timelines, making record keeping, reporting, and fiscal management challenging, though not insurmountable.  
 

Other Challenges

Collaborations, though highly effective, are difficult to maintain.  The collaboration essential to Sheridan’s success experienced a number of challenges, many of which had to do with conflicting regulations, procedures, and priorities across systems.  However, strong leadership from the Governor’s staff helped to overcome many of the crosssystem challenges.  In addition, giving key not move the individual or he would be in violation of his parole. Recovery-oriented approach to support incarcerated individuals is an important step towards eliminating the continuing cycle of drug related offenses.  Building recoveryoriented systems of care for parolees has the potential to reduce recidivism, saving tax payers money.  It also contributes to the health and safety of the community.  
 
 The Sheridan Project generally reflects several of the elements of recovery-oriented systems of care developed through the National Summit on Recovery.  However, there are areas where the convergence between the Project’s work and the Summit’s elements is particularly marked.  They include:
 

  • Family and other ally involvement through support services offered for both the family and the parolee in coordination with the CSACs, TASC and parole.
  • Systems anchored in the community through the ongoing community advocacy work of the CSACs.  The CSACs provide an anchor to community support services for returning individuals and their families.  TASC and other support providers also connect individuals to communitybased support services including treatment, and education and employment programs.
  • Continuity of care through case management services that begin prior to release from incarceration as well as through the work of the CSACs that reach into the Institution and connect with individuals prior to their release.  
  • Commitment to peer recovery support services through Inner Circles inside the Institution and Winners’ Circles within the community following release.  Both of these groups rely on peers to support individuals throughout the incarceration, release, and recovery process. 
  • Inclusion of the voices and experiences of recovering individuals and their families through the use of Winners’ Circles and CSACs in supporting individuals in their recovery. 
  • Integrated services through an array of community support services.  The needs of individuals returning to the community are broad and include housing, employment, education, transportation, and child care.  These services are integrated through the ongoing communication and advocacy of the CSACs and community support providers. 
  • Ongoing monitoring and outreach through continued and coordinated case management services provided by TASC.  
  • Adequately and flexibly financed by creatively blending multiple funding streams to access services that traditionally have not been financed by the Department of Corrections. 

 

Background

Efforts in many communities across the acilitating and sustaining recovery country is dependent upon safe and secure housing.  Upon completion of substance use treatment, many individuals need supportive housing and have few available housing options.  Like many cities, the City of Baltimore lacked safe affordable housing.  For those without housing, the primary housing alternative was often living in crowded community shelters or returning to their former living environments that contributed to their addiction, thus starting the cycle of addiction all over again.   In 2005, a small group of community organizers working at the Citizens Planning and Housing Association (CPHA) of Baltimore launched a plan to address the housing situation for recovering individuals.    
 
CPHA is a community organizing citizen action organization with a sixty year history of facilitating citizen action around neighborhood stabilization, leadership development, public transportation, and capacity building.  They also helped craft some of the first fair housing legislation in the country.  CPHA assists grassroots neighborhood organizations, fostering collaboration and coordinated action to achieve shared goals.  Composed of an executive director, a lead organizer, five special interest organizers, two support staff and student interns from the University of Maryland School of Social Work, CPHA spearheaded their supportive housing recovery initiative. 
 

Supportive Housing

These group living arrangements provide residents with housing and support commonly found in a family unit.  Residents adhere to house rules and participate in similar activities, e.g., meal preparation, house and property maintenance and gainful employment when possible.  The supportive housing model also serves as a bridge for family reunification, encouraging residents to address past problems that have been neglected, e.g., children in foster care, unpaid child support, and damaged family relationships.  Utilizing the Twelve-Step model, residents of supportive housing programs begin repairing relationships with family and significant others.   Most supportive houses have designated times (usually weekends) for family visits.  Supportive housing is not subject to State licensure or certification, because services which require licensure are not provided.25 
 
In Baltimore, Maryland, supportive housing was needed to support the recovery process where there was a scarcity of affordable housing and insufficient residential treatment beds in the City’s existing addictions continuum of care.  Preliminary research estimated 18,000-20,000 treatment admissions annually in Baltimore with only 450 available city residential treatment beds.  Historically, there had been widespread community-level opposition to the placement of supportive housing and addictions treatment facilities in neighborhoods.  Frequently, such dwellings were denied building permits or forced out of communities where they were already operating.   
 

The Process of Building Support 

While the addictions treatment system in Baltimore had begun to recognize the need for more recovery-oriented approaches to care, widespread stigma remained an obstacle to the development of services in the community, including housing.   Aware of misperceptions and stigma associated with supportive housing in the City, CPHA decided to address the communication gap and the resistance to placement of supportive housing and treatment programs in local neighborhoods.  The lack of communication and collaboration among treatment providers, supportive housing operators, and community stakeholders was having a detrimental affect on the community, and CPHA hoped to bridge the communication disconnect that divided these groups.  
 
Multiple issues needed to be addressed for collaboration to occur.   Community residents were concerned about the lack of State and local regulatory oversight of certain kinds, “unlicensed recovery homes” of supportive housing.  Reports circulated about overcrowding, inappropriate activities, and public incidents/disturbances involving supportive housing residents.   
 
As was stated, supportive housing is not licensed in Maryland, and staff who work in the homes are not credentialed.  This created a belief by many treatment providers that supportive housing did not effectively support recovering individuals.   Finally, there was the perceived unwillingness of the supportive housing operators, who embraced an abstinence-based philosophy, to accommodate individuals receiving methadone or participating in other medically-assisted treatment approaches.  Many of the supportive housing operators were in recovery themselves and at odds with different pathways to recovery.    
 

Initiating Dialogue

Beginning in July 2004, the CPHA Drug Treatment Committee began a series of “Hot Topics” educational forums targeting treatment and zoning reform.  Treatment providers, community stakeholders, supportive housing operators, and key city officials were invited as guest speakers to these forums.  
 
Participants represented the Mayor’s Office of Neighborhoods, the City Planning Department, Baltimore Substance Abuse Systems (BSAS), the University of Maryland Drug Policy Clinic, members of The Baltimore City Council and Community Housing Association members.  Over 80 participants attended the initial meeting held at the University of Maryland Law School.  While the agenda included bills before the City Council regarding licensed group homes and outpatient treatment facilities, unlicensed group “recovery homes” (as they were called at the time) dominated the discussions.  The outgrowth of the forums was the creation of a more common vision among the various stakeholder groups regarding the value of group recovery homes and their designation as supportive housing.   For purposes of this report, we will refer to supportive homes for residents in recovery as “supportive recovery homes/housing.”
 
In late 2004, Baltimore City Council adopted Bill 04-1555 for the purpose of establishing a Supportive Housing Task Force to study the operations and code enforcement of the homes to ensure safe conditions for supportive housing residents and the neighborhoods that surrounded them.  Composed of four subcommittees, legal, funding, best practices, operations and enforcement, the Task Force met regularly from December 2004, through February 2005, and developed an increased understanding related to supportive “recovery” homes.  
 
Another important outcome was a proposal with three core recommendations:

  • Development and dissemination of  educational materials pertaining to supportive housing;
  • Development of a one-stop system for “problem” properties;
  • Funding for an organizer to create an umbrella organization of supportive recovery homes.

 
In 2003, the Common Ground Process was also created by CPHA in collaboration with neighborhood leaders and treatment providers.  The process was a tool for promoting positive dialogue, interactions, and accountability among communities and treatment providers.  The tool assisted with creating a memorandum of understanding (MOU), or “good neighbor agreement” between the community and providers, and was subsequently utilized by CPHA in garnering support for the supportive recovery housing initiative in Baltimore.  
 

The Baltimore City Drug Court, also aware of the longstanding housing needs of drug offenders, informally advocated for an investigation of supportive housing conditions and the identification of reputable, safe supportive houses in local neighborhoods.  The CPHA Director of Drug Treatment and Community Outreach assisted in this process.
 
In response to a growing need for safe housing, CPHA submitted an application to the Abell Foundation for a grant to fund an organizer and the development of voluntary standards and a peer review process.  The Abell Foundation funds non-profit organizations located in Maryland with over 95 percent of their grants awarded to Baltimore metropolitan area organizations.      
 
Through its efforts, the CPHA and partners had successfully created a forum for dialogue among all stakeholders.   At the same time, the supportive recovery housing operators demonstrated a desire to be part of the addictions continuum within the community. 
Some examples include: 
 

  • Joining neighborhood associations;
  • Modeling for supportive housing residents the role of a good neighbor, e.g., keeping their houses and yards in good order; 
  • Creating opportunities for neighborhood residents to become involved with the supportive houses; and
  • Participating in the Hot Topics forums and the Supportive Housing Task Force with other stakeholders. 

 
Supportive recovery housing residents also played a role in helping break down some of the barriers, stereotypes, and stigma associated with existing supportive houses by volunteering to shovel snow during the winter months, and mowing grass and painting houses in the summer months.  By increasing involvement in the community, residents and housing operators helped change how they were perceived by stakeholders.    

Bridging the Gap: Setting Standards for Supportive Housing

In 2005, CPHA was awarded an $80,000 Abell Foundation grant that funded an organizer who developed voluntary standards and guidelines for management of supportive recovery housing.  Additionally, based on the recommendation of the Task Force, CPHA created the Baltimore Area Association for Supportive Housing (BAASH).  BAASH is an association of supportive housing operators who work together to conduct peer reviews of housing programs and monitor supportive recovery housing standards.   The standards do not address day-to-day operations of the supportive recovery homes, but outline basic life safety codes and other standards modeled closely on the State of Maryland’s treatment program regulations.  The creation and monitoring of these standards served to enhance the overall reputations of supportive recovery homes.   
 

Supportive Housing:  Holistically Addressing the Needs of Residents

Because of the sheer volume of people seeking treatment in the City, there is often minimal case management or follow up once an individual completes treatment and moves into a supportive recovery home.  Out of necessity, housing operators have taken on the role of case managers, helping residents maintain their recovery.  Operators have encouraged residents to seek employment and provided informal assistance to residents in their job search.  Many house operators have familiarized themselves with local employment offices, credit bureaus, child welfare offices, and other local services important to residents.  Many are also familiar with local case managers and help residents’ access services when feasible.  Thus, supportive housing operators, through informal networks, are often able to assist with a wide variety of recovery support resources needed by residents.  In addition BAASH has successfully utilized the Common Ground process by establishing MOU’s with groups such as the Jericho Exoffender program increasing referrals to BAASH members.
 
To further the effectiveness of supportive recovery housing, CPHA has provided clinical training focusing on relapse risk identification and relapse prevention.  CPHA also coordinated a day-long training that brought together methadone providers and supportive housing operators in a successful effort to break down the barriers for individuals participating in methadone maintenance treatment.  CPHA continues to provide or coordinate training on a variety of topics for BAASH and neighborhood stakeholders.  Discussion and training topics are determined during monthly BAASH meetings.  Examples of training sessions include: “Supportive Housing Operators 101” and “A Legal Framework for Supportive Housing.”   
 

Barriers

Funding continues to be a barrier for the supportive recovery housing programs in Baltimore primarily because most operators prefer their autonomy and remain reticent about becoming licensed facilities.  Licensure is required for many funding sources.  However, 15 -20 percent of supportive recovery housing operators are licensed halfway house operators. The primary difference between half-way houses and supportive homes are that treatment is customary in halfway houses.  Operators who are certified addictions counselors or licensed social workers were more likely to pursue half-way house licensure and can provide counseling services to residents.  Some operators believed that licensure would facilitate access to BSAS funding as well as strengthen support for grant applications.  To date, however, foundations have provided most of the funding for supportive recovery housing initiatives in the City of Baltimore.  
 
The lack of data on the efficacy of supportive housing is a limitation in receiving additional funding.  The City is currently developing a plan for evaluating the supportive recovery housing programs.  Lastly, although progress has been made, stigma associated with addictions continues to be a barrier.  

Lessons Learned 

By bringing key stakeholders to the table for frank and open discussions, CPHA and its partners have successfully changed perceptions about supportive recovery housing.  Supportive housing is an essential element for many individuals completing treatment and in need of safe living environments in which to continue their recovery.   Engaging recovery housing operators and residents in the Changing attitudes is a process that takes time.  The experience CPHA has had with the supportive recovery housing process is a testament to the fact that attitudes can be changed.   Community is critical to overcoming fear and decreasing mistrust of neighborhood residents.  Finally, data are needed to substantiate supportive recovery housing as a viable housing alternative, as well as critical to supporting those in recovery.   
 

Summary

The work of CPHA in assisting supportive recovery housing gained credence in the community and is an example of how a community resource can support recoveryoriented systems of care.  Though there is still work to be done in the supportive housing community and in the larger system, the work of CPHA on this issue has helped to initiate systems change.  Outcomes include:
 

  • Decreased community opposition toward supportive recovery housing in neighborhoods; 
  • Increased interest and buy-in from supportive recovery housing operators  (e.g., membership in BAASH increased from 15 members to nearly 50 members) and neighborhood residents;
  • Increased accountability with  voluntary standards and submission to peer review  inspections that are criteria for membership in BAASH;
Increased credibility of supportive recovery housing programs and funding
  • opportunities, and community support;
  • Increased collaborations, (e.g., among BAASH and Baltimore City Drug Court and the Jericho Ex-offender program) through MOU’s resulting also in increased referrals to BAASH members.

 
The work of CPHA generally reflects several of the elements of recovery-oriented systems of care developed through the National Summit on Recovery.  However, there are areas where the convergence between the Association’s work and the Summit’s elements is particularly marked.  They include:
 

  • Family and other ally involvement  through BAASH family reunification efforts, resident counseling, and regular family visits that help mend damaged relationships with spouses and children.
  • Systems anchored in the community through the provision of communitybased housing.  Supportive recovery homes are located within local neighborhoods providing residents with safe housing and access to community services.  Community reintegration provides individuals an opportunity to recover and “give back” to the community.
  • Continuity of care by providing essential recovery support following discharge from treatment and through linkages with available community resources and networks.  
  • Strength-based by building on the natural qualities of the residents, and their family and friends.  Additionally, the housing operators (BAASH) demonstrate resilience by modeling successful recovery for their residents. 
  • Commitment to peer recovery support through employing peers as supportive housing operators in supportive recovery homes.
  • Inclusion of the voices and experiences of recovering individuals and their families by gaining buy-in from stakeholders, including people in recovery (e.g., BAASH), and supportive housing residents and their families/significant others. BBS Approved Mental Health Recovery Oriented Care and Methods of Service Delivery for out of state licensure. Online Course, Board of Behavioral Science CEU Credit.
Conclusion 

Each organization approached systems change differently, some as a part of a larger coalition, others as the lead organization creating internal change.  Moreover, the motivating factors influencing systems change varied.  For example, Fayette Companies was motivated to develop and pilot the Behavioral Health Recovery Management project because the staff observed that the organization’s clinical and business practices were not only ineffective but potentially damaging to the long-term recovery prospects of those they served.  The State of Illinois, through the Sheridan Treatment and Re-entry Program, responded to unprecedented recidivism rates that were clearly linked to drug and alcohol use and ineffective approaches to re-entry.  White Bison on the other hand, saw that an existing recovery support service, AA, while effective in some cultural settings, was of much more limited value in the Native American cultural context.  In response, the Wellbriety Movement was created, integrating key elements of AA and Native American culture.  Lastly, CPHA brought together a coalition to provide a critical recovery support service (housing) and community resource.  In doing so, they addressed issues of stigma, funding, and housing standards in response to individual and community needs. 
 
Several key themes emerge from each of the case studies.  The need for strong leadership was consistently found to be a critical element in successful systems change efforts.  Articulating a clear vision and the goals of the systems change process, as well as an effective strategy for communicating them to all parties involved, was also important.  Serious consideration must also be given to which key stakeholders from the community or State are included in systems-change planning and implementation.  Once the key players are identified, ongoing communication is essential.  Evaluation was identified as an important element that should be included from the beginning of the process.  Benchmarks, outcomes, and evaluation guidelines must be established at the outset to effectively monitor performance and to demonstrate program/organizational effectiveness to potential funding sources.  Finally, providers consistently stated that systems change efforts are far from easy and must be undertaken with an understanding that the process requires a long-term commitment on the part of all stakeholders involved.  
 
In conclusion, the providers stressed that systems change is an effort that must be undertaken to improve the current weaknesses in the systems, thereby providing quality services and maximizing limited resources.  The providers believe that efforts towards systems change will ultimately benefit policymakers, advocates, clinicians, the community, and most importantly, the individuals with substance use disorders and their families.


Required Reading


Reframing Psychology for the Emerging Health Care Environment

 

 

CEUs Home | CEUs Courses |Provider Approved | CEUs Contact Us | Ceus Logon | Ceus Questions |