Recovery Oriented Systems of Care in Florida
- Explore substance abuse
- Define Recovery Oriented Systems of Care
- Discuss the 17 Elements of Recovery Oriented Systems of Care
- Self-Assessment Tool
- Explore the Guiding Principles of Recovery
More than 60% of individuals entering addiction treatment in the United States have one or more prior episodes of such treatment. This highlights the revolving door aspect of substance abuse treatment.
Most addiction recovery professionals understand that relapse is not uncommon on the road to long-term recovery. However, for the addicts and their loved ones this leads to shattered families, lost jobs, destroyed friendships and a profound sense of hopelessness, failure and self-loathing.
Addiction has long been recognized as a chronic disease. However, most treatment for addiction has used acute care interventions rather than a disease management approach. For many people seeking recovery, this has created seemingly endless acute treatment episodes. Recognizing this, the substance abuse treatment field is undergoing a shift from an acute care model of treatment to a chronic care approach, known as recovery-oriented systems of care (ROSC).
ROSC is a system transformation initiative initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT), In Florida, where we will focus much of our information, this initiative is being furthered by the Department of Children and Families (DCF). DCF is working to integrate a values-based recovery-oriented system of care where recovery is expected and achieved through meaningful partnerships and shared decision making with individuals, communities and systems.
The Department of Children and Family Services held several summits between September 2016 and January of 2017 to transform Florida’s substance use and mental health system into a recovery-oriented system of care. The summits were held in all regions of the state to flesh out a shared vision for creating this approach.
Recovery-Oriented System of Care (ROSC) is a framework for coordinating multiple systems, services, and supports that are person-centered, self-directed and designed to readily adjust to meet the client’s needs and chosen pathway to recovery.
When we think of a recovery-oriented system of care we might think we are focused on making treatment itself recovery-oriented, but this shift is much more than that. A ROSC is a network of clinical and nonclinical services and supports that are aimed at long-term, community-based recovery.
Research supports that recovery happens as much within the community as within treatment and in order to sustain long-term recovery, the community resources should be a part of the long-term plan. These educational institutions, faith-based organizations, community support groups, and others. Together, behavioral health providers and community support systems form ROSCs to:
- Promote good quality of life, community health, and wellness for all.
- Prevent the development of behavioral health conditions.
- Intervene earlier in the progression of illness.
- Reduce the harm caused by substance use disorders and mental health conditions on individuals, families, and communities.
- Provide the resources to assist people with behavioral health conditions to achieve and sustain their wellness and build meaningful lives for themselves in their communities.
VALUES, FOCUS, GOALS and PRINCIPALS
The central focus is to create an infrastructure or “system of care” with the resources to effectively address the full range of substance use problems within communities including the availability of services, the stigma of treatment, lack of funding, and options for different types of recovery just to name a few.
DCF, through the summits they held, found that when creating this system of care focused on recovery the top five priorities for continuing the efforts include:
- Promoting Collaborative Service Relationships
- Develop Cross-System Partnerships To Achieve Common Goals
- Promote Community Integration
- Promote Community Health and Wellness
- Increase Peer-Based Recovery Support Services
Let’s look at these further.
The need to create a system in which providers and the individuals they served worked as true partners in recovery has been a cornerstone of the initiative making the first goal of promoting a collaborative service relationship a good first step. A collaborative relationship shifts the typical expert–patient hierarchy in which a provider might say, “This is what you must do” to a model that helps individuals assume responsibility for their own wellness and recovery. In such a person-centered model, the provider might ask, “How can I help you?” With more collaboration, assessments and service planning would not be merely medical in nature but would become grounded in the broader life goals that individuals identify for themselves.
The second goal of developing cross-system partnerships to achieve common goals recognizes the importance of working across sectors to achieve common goals. There is value in reaching out to criminal justice, child welfare, housing, public health, education, and transportation systems to identify shared goals and strategically leverage resources.
Promoting community integration helps individuals build meaningful lives in their communities. Supporting people in identifying dreams, goals, and preferences for their lives, and then connecting them to resources that help them develop their own interests, skills, and relationships builds a future helps people stay connected to natural community-based resources and supports the development of a strong recovery community and advocacy organizations.
Promoting community health and wellness places a stronger focus on prevention, early intervention, and community wellness. This will be achieved through increased attention to building recovery capital through targeted community education, strategic partnerships, effective prevention programs, and stronger connections between the behavioral health system and local communities.
When there is an increase in peer-based recovery support services there is a value for the inclusion of people with lived experiences. There are far-reaching benefits from increasing access to peer support services. They valued peers for their ability to relate to individuals using services, increase the involvement of family members and the community in recovery, reduce stigma, and “promote hope and understanding that recovery and change are possible.”
DCF create a plan for 2017-2019 titled the Substance Abuse and Mental Health Plan stating the following strategic initiative goals:
Goal 1.1: Enhance the community-based service array to shift from an acute care model to a recovery-based model of care.
Goal 1.2: Improve access to services in both rural and urban areas.
Goal 2.1: Promote emotional well-being.
Goal 2.2: Prevent and reduce substance use.
Goal 2.3: Reduce the spread of infectious disease.
Goal 2.4: Prevent and reduce attempted and completed suicides.
Goal 2.5: Reduce opioid related overdose deaths.
Goal 3.1: Improve family functioning and child welfare related outcomes through an integrated child welfare and behavioral health treatment-based model.
Goal 4.1: Enhance common registration and unique identification of served.
Goal 4.2: Improve process for reporting and analyzing performance outcome data.
Goal 4.3: Improve accountability of units and of state-funded services provided to state target populations.
Goal 4.4: Develop and implement a uniform, clinically- based scoring system to collect and report data pertaining to individual’s service needs.
Goal 5.1: Decrease the wait time for forensic SMHTF admission and return to court.
As behavioral health systems have begun to move toward more recovery-oriented approaches and this transformation process, while widespread, is challenging systems to make sweeping changes to the structure and function of their services.
At the 2005 National Summit on Recovery, a working definition of recovery, 12 guiding principles of recovery, and 17 elements of recovery-oriented systems of care were proposed to serve as a conceptual framework to guide SAMHSA and other stakeholder groups as the treatment and recovery fields move towards operationalizing recovery-oriented systems.
The 12 principles outlined in SAMHSA’s 2005 National Summit on Recovery: Conference Report to guide the implementation of recovery-oriented systems of care, developing measures, and establishment of evidence-based practices are:
- 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
- Recovery is a reality
The 17 essential elements of a recovery-oriented system identified at the National Summit on Recovery are:
- Family and other ally involvement
- Individualized and comprehensive services across the lifespan
- Systems anchored in the community
- Continuity of care (pre-treatment, treatment, continuing care, and recovery support)
- Partnership/consultant relationship, focusing more on collaboration and less on hierarchy
- Strengths-based (emphasis on individual strengths, assets, and resilience)
- Culturally responsive
- Responsive to personal belief systems
- Commitment to peer recovery support services
- Inclusion of the voices of individuals in recovery and their families
- Integrated services
- System-wide education and training
- Ongoing monitoring and outreach
- Based on research
- Adequately and flexibly financed
SAMHSA convened the National Summit on Mental Health Recovery. Over 110 experts, including people in recovery, family members, practitioners, advocates, researchers and others participated in the summit. They articulated 10 fundamental components of recovery, which overlap with the principles outlined at the National Summit on Recovery. Participants in the summit stated that these fundamental components are expected to infuse services and systems that are recovery oriented.
These fundamental components are:
- Individualized and person-centered
- Peer support
How to move this forward:
Increase community education efforts to combat stigma, expand community allies, and broaden the scope of resources available to people.
Increase community education efforts to combat stigma, expand community allies, and broaden the scope of resources available to people. Community members rarely see the reality and hope of recovery. Targeted community education efforts can broaden the circle of recovery support in communities across the state. Examples include training individuals and family members to tell their recovery story and helping community partners understand what they can do to support recovery.
Support community stakeholders to create regional ROSC-focused coalitions.
Many summit participants expressed interest in starting community-driven planning groups to connect like-minded individuals and coordinate their efforts. DCF can support these groups by offering technical assistance around topics such as getting started, structuring meetings, facilitating community planning efforts, identifying priorities and short-term wins, and leveraging partnerships.
Encourage providers to start peer advisory councils.
These councils help ensure that people with lived experience have genuine opportunities for integration and leadership in their service organizations. Peer advisory councils are organizationally supported, peer-run leadership groups who help to ensure that services are aligned with a recovery-orientation.
Expand the reach of the Statewide Coordinator of Integration and Recovery by increasing the presence of peer leaders in all regions of the state.
Given the size and diversity of the state, to truly integrate peer-based supports and expand peer and family leadership, there will need to be an increase in the number of qualified peer staff who can provide support and technical assistance to agencies and communities across the state.
Incorporate people in recovery and family members into quality assurance activities.
Consistent with ROSC principles, people with lived experience can be incorporated as a part of monitoring teams. These individuals bring a different perspective from other staff.
Provide more opportunities for people in recovery and their families to provide feedback to the system.
Community listening sessions, focus groups, and outreach from the statewide peer organizations can all be effective in increasing the engagement of people receiving services and their family members and shaping the system in ways that are most meaningful to them.
Increase the opportunities for people in recovery and family members both within and across communities to network with and support one another.
Increase the opportunities for conferences, story-telling training opportunities, and other activities.
Sponsor Leadership Academies for people in recovery and family members who are interested in playing active roles in the system’s recovery-focused transformation.
These roles can be for people in recovery and family members who are interested in playing active roles in the system’s recovery-focused transformation.
Create practice guidelines for each of the service priorities identified in the summits.
For example, one priority was the promotion of community integration. What would it take for providers to promote community integration? What does community integration mean for the roles of peers, clinicians, supervisors, and executive staff? What would they do more of, less of, or differently? To bring these principles to life, a deeper dive is needed to explore the implications of the various priorities.
Provide technical assistance to supervisors to promote practice adoption.
Clinical and peer supervisors have some of the most critical roles in the service system, yet they are often too busy to attend ROSC-related events. Web-based learning collaboratives and opportunities for convenient training and technical assistance can help supervisors understand and model ROSC concepts and provide guidance to their staff.
Identify and highlight local centers of excellence and share their promising practices across the system.
Across the state, summit participants described innovative recovery-oriented services that are already underway in Florida.
Conduct an informal training of trainers.
Conduct an informal training of trainers for providers who would like to engage their staff in an organizational recovery transformation process. Typically, only a few staff from any provider organization were able to participate in the summit. It would be helpful if providers were equipped with the tools and resources to conduct their own mini-trainings and facilitate relevant dialogue with their staff to further align their approaches with a recovery-orientation.
Provide training and technical assistance to priority initiatives to ensure that opportunities to deliver recovery-oriented services are maximized.
DCF has already partnered with other systems to develop initiatives that are grounded in recovery-oriented principles, such as the Family Intensive Treatment and Florida Assertive Community Treatment teams and the Care Coordination and Housing initiatives. To supplement existing guidance documents, 7 the staff associated with these initiatives would benefit from more intensive technical assistance to support them in translating recovery-oriented principles into concrete practices.
Provide additional support to providers on how to integrate peer support services.
Although Florida has been working to integrate peer support services for several years, peer staff are still relatively new to the field. During the summits and webinars, participants voiced a range of questions about hiring practices, supervision, reimbursement, role clarity, and other issues concerning how to effectively integrate peers into service settings. Peer staff also raised concerns about how to expand employment opportunities and how to help providers understand their roles. Additional focus groups should be conducted with both providers and peer staff to determine specific areas where technical assistance would be helpful.
Launch a pilot project to demonstrate impact and infuse lessons learned.
While the DCF Central Office works to provide support to stakeholders across the system, the Regional Offices and MEs might also provide intensive technical assistance to smaller groups of early adopters who are interested in participating in pilot projects. This would allow various partners to collaborate and to learn what it takes to operationalize recovery-oriented services and disseminate those promising practices to others in the system. The pilot projects do not need to be new initiatives; they might entail attaching additional technical assistance to existing projects or efforts and studying the outcomes
Begin to incorporate ROSC expectations in provider contracts.
As providers become increasing clear about recovery-oriented approaches, contracts can reflect the state’s commitment to ensuring policies and services are recovery-oriented.
Enhance the capacity of leadership to lead recovery-focused change efforts.
ROSC expansion is a significant, long-term undertaking that requires an array of planning and implementation support. Summit participants were concerned about the leadership support dedicated to this effort. In addition to integrating peer staff in regional offices, all the administrative entities would benefit from increasing their capacity to coordinate, plan, and implement a recovery-focused system transformation effort.
Align monitoring process.
Just as providers are expected to collaborate with individuals, families, and allies in a ROSC, a more collaborative approach to supporting system providers in learning how to increase their recovery-orientation could be adopted. Both the process and products involved with performance measurement could be aligned with recovery-oriented approaches.
Create DCF Unit Transformation Plans.
Just as providers participated in a self-assessment process, DCF and the MEs could also examine their processes and procedures through the lens of ROSC values and principles. They could then devise a transformation plan that supports state goals for ROSC implementation.
Create a Strategic Communications Plan.
Think ahead about the different audiences that need information about the transformation effort, what types of information would be useful for them to have, and how they prefer to receive information. Take steps to ensure that the vision and key messages are thoroughly communicated in communities and systems across the state.
Supporting the Guiding Principles of Recovery
Belief in the process and reality of recovery is vital for struggling individuals to face and cope with their disease or disorder. Each person is ultimately in charge of their own recovery, setting goals and creating a path to achieve them, but they need support in creating and maintaining these goals.
People recovering from substance abuse or mental disorders have different backgrounds and face unique challenges. As a result, the paths that people take toward recovery will vary from person to person. There needs to be varied options from self-help, outpatient, educational, inpatient and long term, residential options. These options must also consider an individual’s unique cultural beliefs, values and traditions.
For long-term recovery to take root, a person must address every aspect of their life, from mental and physical health to income and housing to seeking support and maintaining medication if needed. Having peers that have experienced similar challenges and come through it provides a model for those in recovery to lean on, refer to and receive support from. This is an important element to help the client feel like they are not alone.
An emotional bond with family members, friends and peers that believe in a person’s ability to recover can offer the strength and determination to get through these difficult times.
Sexual assault, domestic violence, emotional abuse and any other trauma must be treated if recovery is to be long lasting and successful. These should be addressed in treatment programs.
Communities have a responsibility to make sure that those in recovery can live free of discrimination and have opportunities to have housing, employment and education. The stigma associated with addiction and psychiatric issues needs to be addressed.
Recovery-oriented systems of care are as complex and dynamic as the process of recovery itself. They are designed to support individuals seeking to overcome substance use problems and disorders across their lifespan. They build on the strengths 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.
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