Overview of a Recovery Oriented
System of Care: Characteristics,
Structure and Development
Ijeoma Achara PsyD
Overview
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Identify the characteristics of a recoveryoriented system of care.
Explore the implications for multiple levels
of the system
Examine frequent concerns
Explain the advantages and limitations
associated with different models of
recovery oriented systems.
What is a ROSC
• Recovery-oriented systems of care
(ROSC) are networks of formal and
informal services developed and
mobilized to sustain long-term recovery
for individuals and families impacted by
severe substance use disorders. The
system in ROSC is not a treatment
agency but a macro level organization
of a community, a state or a nation.
William White
Why Transformation:
A Person’s Perspective
I’ve been struggling with trying to maintain recovery
for fifteen years….I’ve been in other programs, got
some good treatment….but for me, for me this was
the missing ingredient right here. This is what I
needed to not just get clean but stay clean.
Because it helped me to identify and realize what I
need to do with my life after I’m clean. It’s given me
a sense of purpose, you know. I spent all those
years drinking and drugging and it was like, now that
I’m clean what am I going to do with my life?
Barbara, person in recovery, Amistad Village Project
What Helps?
Elements of a ROSC
1.
2.
3.
4.
5.
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7.
8.
9.
Promotes community integration and mobilizes
the community as a resource for healing
Facilitates family inclusion
Facilitates a culture of peer support and
leadership
Values partnership and transparency
Provides holistic, individualized, person
directed tx which supports multiple pathways to
recovery
Creates mechanisms for sustained support
Is informed by data and the experiences of PIR
and families
Promotes hope
Provides services in a strengths-based manner
How is this different?
…and where’s
the manual?
Holistic Approach
Traditional System
•
Focused on symptom
reduction/stabilization
ROSC
• Symptom reduction with a
purpose – a means to an end
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• Other domains are a priority including employment,
housing, recreation,
spirituality etc
Other life domains are
not addressed
A Person’s Perspective
Strategies
System Level
• Partnerships with relevant systems
• Relevant Initiatives
Organizational/Administrative
• Services in non-stigmatized settings
• Mutually beneficial collaborations
– Gospel Fests
– Internships
– Resource
Mapping
Strategies
Programmatic
• Holistic assessments
• Recovery plans versus treatment plans
• Flexible Menu of Services
Recovery Community
• Peer specialists assist others with recovery
planning
• Recovery resource identification/ mobilization
• Facilitating linkages
Attending to Culture
And the village was happy…..
Sustained Recovery Supports
Traditional System
ROSC
• Focus on action stage
of change
• Emphasis is on preaction stages of change
also
• Client is
blamed/discharged for
relapse
• Responsibility is placed
on the service milieu
• Limited Aftercare
• Continued support and
early re-engagement
Perspectives
My clients don’t hit bottom; they live on the bottom.
If we wait for them to hit bottom, they will die. The
obstacle to their engagement in treatment is not an
absence of pain; it is an absence of hope. —
Outreach Worker (Quoted in White, Woll, and Webber
2003)
I got help with the kinds of things that were most
important to me – like getting my daughter back,
and putting food on the table for her. Since they
were willing to help me with that stuff, I figured,
“Hey maybe I should listen to what they’ve been
trying to tell me and try out that program they keep
talking about.” Today I’ve been clean for nine
months…
Davidson et al., 2009
Strategies
System
• Reimbursement of pre-treatment supports
• Peer Group Facilitation Training
• Collaborations with other systems - critical
transitions
• No restrictions for high utilization
Organizational
• Welcoming/comfortable environment
• Address organizational barriers to treatment
• No fail policies
– Barbara, women and children’s programs
Strategies
Programmatic
• Informed consent
• Persistence
• Street outreach
• Multi-media continuing care
– Telephone prompts
Recovery Community
• PIR in critical locales
• Volunteers and employed PIR providing
outreach and continued care
– New Pathways
Community Integration
Traditional System
• intra-psychic
orientation
• Community
supports are
recreated in the
system
• Individual is the unit
of intervention
• Stabilization before
reintegration
ROSC
• inter-psychic
orientation
• Existing community
supports are
accessed
• Individual, family and
community are all
units of intervention
• Life helps to initiate
and sustain recovery
A Person’s Perspective
• If my neighborhood’s tore up, what’s going
to happen to me when I go out there. Some
programs tell you to stay away from people,
places and things that’ll trigger you. I can’t
do that. I live in a sober house. Next door’s
a crack house and across the street is the
package store. This place is tore up! What
am I supposed to do? If my community
don’t get better, I ain’t getting better.
Client in Amistad Village Project,
New Haven, CT
People’s Perspectives
• I just wanted to get back to my life: my family, and my job, and
my church activities. My recovery was important, but it didn’t
matter so long as I didn’t have those things in my life to look
forward to. It was those things that kept me going in my
darkest days
• Nobody wanted anything to do with me before. It was always,
“Come back and see us when you get serious about your
recovery… when you’ve got some clean urines.” But then
this program tried to help me out with getting this job I had
wanted for a really long time. Now, I am working part time
and I’ve finally got a reason to be sober every day.
Davidson et al, 2009
Strategies
System
• Develop initiatives that promote
community integration and
strengthen the community
– Leadership academy
– Community Coalitions
– offsite tx
Organizational
• Reciprocal relationships with other
organizations
• Giving back to the community
• Community based events
Strategies
Programmatic
• Services taking place in the community
• Community asset mapping
• Build competencies
Recovery Community
• Assertively link people to opportunities
• Assisting with life skills
Peer Culture, Support and Leadership
Traditional
• Peer support is limited to
AA/NA groups
ROSC
• Diverse mechanisms for
peer support and
LEADERSHIP exist
• PIR may be in leadership,
but not identified as such
• PIR are in leadership
positions at all levels
• Community based peer
support services are not
connected to the formal tx
system
• Seamless integration of
formal tx system and
peer/community supports
More Perspectives
“I’d been doing drugs for something like 30 to 35 years. When I
came here I was broke, I was using, and I was sick. I was a
broken shell of a woman and thought about dying all the time.
They let me come here everyday and do little things. You
know I felt welcome and I felt a sense of purpose again. But I
started to think that if I could do a little thing, then maybe I
could do a big thing.”
Barbara, person in recovery.
“Once you’ve completed treatment you need to know what to do.
We need to find out how to live after treatment. The peer
services help people figure out how to have a life!!”
Wanda, Peer Specialist, NET
Provider Perspective
Joe Schultz, NET
There’s been a huge turnaround in outcomes.
Consumers do better……We have more people
completing treatment than we’ve ever had!
……..Even when they leave early the peer
specialists are able to reengage a lot of them. That
didn’t happen before. The attendance rate has
gone from 50% to over 75%... And clients…stay
connected. That’s something we never saw
before……now counselors feel they are actually
helping people. They can actually see the results
of all the work they do…
Peer Culture, Support and
Leadership
System Level Strategies
Developing Pathways of Opportunity
Training and Job Fair
Perspectives
Equips people with the skills to effectively share
their recovery story in public settings, including Tx
Gloria
After participating in all of the trainings I began to find power
in sharing my story with others at the Consortium where I was
going to get help for my mental illness issues. Now I am a
presenter for Taking Recovery to the Streets, a two-day
WRAP facilitator, member of Enon Tabernacle Baptist Church,
have a new home, new car. I am employed as a file clerk,
and I am a full-time student at the University of Phoenix
online with a GPA of 4.0 in pursuit of my Associates Degree in
Psychology. I am thankful to God and the Recovery
Foundations (Training). I am “living Life to the Fullest!”
Strategies
Peer Culture and Leadership
It’s more than having peers or per led
services….it’s a cultural thing!
Example: North East Treatment Center
• NET Consumer Council
• Recovery Resource Center
• Monthly Consumer Appreciation Dinner
• Peer Specialists, volunteers
Program Development and Evaluations
– Proyecto Nueva Vida
Strategies
Programmatic
• Assertive Outreach
• Recovery Capital assessment at
individual/family/community levels
• Facilitating linkages
• Recovery Check-ups and early reengagement
• Companionship and modeling of recovery
lifestyle
• Recovery Planning
• PIR led groups
Anticipate Challenges
Robert Martin Peer Specialist
In the beginning it was very degrading at times, it was
very intense between peer support staff and traditional
staff. Their attitude in the beginning was “these people
have these 2 weeks CPS training and who do they think
they are to tell us how to do our jobs.” It was split right
down the middle. It was us vs. them for a minute. Now
the respect is on both sides. We compliment each
other. The therapists learned that the stuff they write on
the paper about what the person needs, we can actually
go out in the community and get those things started….
They don’t have to just be words on a paper anymore…
Organizational Readiness
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Dialogue
Role Ambiguity
Role Conflicts
Supervision – good fit
Valuing the work and the person
Opportunities
A Word about Partnership
Traditional Systems:
ROSC:
• Expert model, hierarchical
• Professionals determine
course of action
• Coaching, collaborative
model
• Professionals support
people in making their own
choices
• Goals and strategies are
determined in partnership
and are directed by the
person in recovery
• Treatment planning goals
and strategies are
determined by the
professional based on the
presenting problems
Implications for Criminal Justice
System
• Recidivism and limited
community
connections
• Connecting to meaning
• Implications of prison
culture
• Innovative practices
• Non-confrontational
approaches
“For someone like me just getting out. The
last thing I wanted to hear was you can’t do
this, you gotta do that. I wasn’t hearin’ all
that. I just been locked up and told when to
get up, when to eat, when to sleep. I didn’t
need that. I woulda been outta here.”
Mike, person in recovery,
How do You Structure a
ROSC?
The Additive Model
The Interactive Model
Where is Your System?
N0! No! and a Thousand Times No!
Top Concerns
1. Don’t P-BRSS approaches devalue the
role of professional intervention?
2. Doesn’t recovery oriented care increase
provider exposure to risk and liability?
3. What’s all the hype about, we’ve been
doing this for years?
4. How will we pay for implementing
recovery oriented care and supports?
NIATx
Founded in 2003, NIATx works with behavioral health treatment
providers to make more efficient use of capacity and develop
strategies to improve access and retention in outpatient services
Purpose: Improve Outcomes in Outpatient Tx
Reduce Waiting Times
Reduce No-Shows
Increase Retention
Increase Admissions
Activities: Implement process improvement strategies
through the use of existing resources, rather than additional
expenditures
Niatx Projects
• Northeast Treatment Center
– Increased peer supports, involvement and
activities
– Up to 70% of new admissions continued
after 30 days in treatment
• Northeast Community Mental Health Center
– Initiated earlier clinical involvement versus
“filling out papers,” which resulted in 80%
returning to the clinic after the first visit
Niatx Projects
CO-MHAR
– Reduced wait time from 6-7 weeks to 2-3
weeks at one site
• Improved same day service including having
50% of clients seen the same day
• Confirmation calls to clients
Casa de Consejeria
– Reduced wait time for first appointment from
19.8 days to 4.5 days
• All staff received training on conducting
intakes
Yearly Additional Revenue from 1
Change Cycle
• CO-MHAR
– $30,000
• Community Council
– $12,000
• Intercommunity Action
– $18,000
• Joseph J. Peters Institute
– $150,000 less
associated costs
• Thomas Jefferson
University
– $84,000 less 1 intake
staff person salary
Cost Neutral Strategies
• Mobilizing the community of people in
recovery
• Holistic assessments
• Recovery planning
• Satisfaction surveys/focus groups
• Reciprocal community partnerships
• Consultation Approach
• Continued Care
Challenge
The need for HOPE at all levels
You can do this, we can help!!
Break
Strategies for Developing
a ROSC
Overview
• Discuss the nature of transformational
change
• Explore the implications for leadership
• Describe a framework to guide the
transformation of systems and
organizations
• Small group discussions
Three Types of Change
Developmental
Transitional
New
Old
State
Transition State
State
Three Types of Change (cont’d.)
Transformational
Wake-Up Calls
Reemergence
Through Visioning and
Learning
Growth
Chaos
Mindset
Forced to Shift
Birth
How Transformational Change is
Different
Transformational change is unique in
three critical ways:
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The future is unknown and only through forging
ahead will it be discovered.
The future state is so different than the traditional
state that a shift of mindset is required to invent it.
The process and the human dynamics are much
more complex, partnership is critical!
What Kind of Leadership is Necessary to
Promote Transformational Change?
Leaders who:
• Establish direction and a vision for the future
• Motivate inspire, and energize people to
overcome challenges
• Promote participatory, inclusive processes
• Tolerate ambiguity, rather than predictability
and control
• Lead by example - live by key values
• Empower the people around them
• Create an organizational culture consistent with
recovery values
Conceptual Framework Guiding the
Transformation Process
• Aligning Concepts:
Changing how we think
• Aligning Practice:
changing how we use
language and practices
at all levels;
implementing values
based change
• Aligning Context:
changing regulatory
environment, policies
and procedures,
community support
Aligning
Practice
Aligning
Concepts
Aligning
Context
Starting the Journey to a ROSC
Where is Your System?
• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance
Corresponding Focus
Stages of
Change
Major Focus of
Alignment
PreContemplation
Conceptual
Contemplation
Conceptual
Preparation
Conceptual and Practice
Action
Practice and Contextual
Maintenance
Practice and Contextual
Strategy One:
Promote Conceptual
Alignment
Conceptual Alignment
1. Set the Context and Establish a Sense of
Urgency
2. Form Powerful Guiding Coalitions
Conceptual Alignment
3. Create a shared vision for change and
over communicate the vision X 10
4. Develop a conceptual framework for
transformation that encompasses all related
initiatives
Conceptual Alignment
5. Develop participatory and transparent
approaches
6. Create forums for knowledge sharing
and exploration of new ideas
7. Address perceived loss and facilitate
engagement
Learning Activity I:
Conceptual Alignment
• What excites you about developing a ROSC?
• What is one of your greatest concerns about
developing a ROSC? What are you confused
about or what don’t you agree with?
• Which recovery values do you think are most
important for this system?
• On a scale of 1 to 10, to what extent do you
believe stakeholders in this system understand
what a ROSC is?
• Based on strategies you heard this morning, or
ideas that were triggered, what do you think can
be done to increase everyone’s understanding
and commitment to this transformation?
Lunch
Strategy Two:
Practice Alignment
Practice Alignment
1. Identify your recovery transformation
priorities
2. Identify initiatives/practices to support
the implementation of each priority
3. Examine the implications of these
priorities for all levels of the
system/organization – (in partnership)
Practice Alignment
4. Invest in the
enhancement/development of model
programs/practices
5. Develop mechanisms for skill building
Tools for
Transformation
Practice Alignment
6. Empower all stakeholders
7. Identify and mobilize the early
adopters
8. Tackle the tough issues (regulatory
changes, fiscal alignment, risk and
liability)
9. Create short-term wins
10. Celebrate the successes
Strategy Three:
Aligning the Context
Aligning the Context
1. Align organizational
structure/processes
2. Learn what the barriers to recovery
oriented care are from your emerging
practices
3. Address policy and fiscal issues for
long-term sustainability
Batten Down the Hatches?
• Maximize existing service capacity
• Achieve savings by interrupting cycle of
repeated crises and acute care admissions
• Reinvest savings into recovery supports
and clinical services
DMHAS, CT
Examples from CT (DMHAS)
1. Focus on community life and natural
supports - development of supportive
housing units for 550 individuals. Over
60% now working or in training and
inpatient costs decreased by 70%.
2. Urban Initiative (Housing) 600%
decrease in ER visits, 375% decrease in
detox days
3. Recovery House – 69% connect to care
versus 39% without recovery house stay
4. Reduced utilization of high end services
and increased utilization of inpatient
services
Aligning the Context
4. Address stigma
5. Strengthen the community and build
Indigenous recovery capital
6. Move beyond the choir – link it to
other political agendas
Challenges along the Way
Stabilization or Transformation?
Let’s go for it!!!
Stakeholder Discussion Groups
Commit to a Next Step
What are the things that YOU will commit to
do/change to help advance recovery
transformation in your system or
organization?