During Services. 1. Provide services to the target population who are concurrently admitted to substance use disorder treatment programs as long as services are coordinated and sequenced to avoid duplication of service and case manage for transitional assistance in discharge from treatment setting.
2. Ensure all program participants being unsuccessfully discharged or disengaging from treatment, due to non-attendance or non-compliance, are referred to the Linkage Specialist for follow up Motivational Interviewing attempts and/or future attempts in the community.
3. Develop and implement a policy and procedure for prior to discharge requirements as non-completer for System Agency review.
4. Provide appropriate referrals and referral follow ups to participants based on the Substance Use Disorder (SUD) assessment that include referrals and referral follow ups to this Contract.
5. Provide ongoing, weekly coordinated case management activities that promote engagement, re-engagement, and retention/maintenance in medical care, asappropriate.
6. Ensure co-case management is not a duplication of service, but rather a set of agreed upon, joint, and coordinated activities that clearly delineate the unique and separate roles of case managers who work jointly and collaboratively with the individual’s knowledge and consent to partialize and prioritize goals to effectively achieve individual’s treatment and/or personal goals.
7. Ensure access to appropriate primary medical care, including prenatal care and reproductive health services.
8. Assist eligible individuals with obtaining eligible community assistance/support.
9. Ensure access to appropriate pediatric medical care, including well-child visits and developmental screenings.
10. Coordinate with Child Protective Services, and/or court system, and other child placement situations, to increase access to child(ren) not residing with pregnant women and/or women with dependent children.
11. Ensure the following recovery-oriented values and principles in the organization’s service delivery:
a. Choice and Self-Determination;
b. Community Integration;
c. Peer Culture;
d. Family Orientation;
e. Continuity of Care;
f. Partnership-Counselor Relationship;
g. Culturally and Linguistically Competent; and
h. Promote Recovery Coach Self-Care.
12. Provide, as needed, family-based services to participants.
