IV. SERVICE COORDINATION

C. CONTINUING ASSESSMENT AND TREATMENT PLANNING

 

1. Maintain ongoing contact with client and involved significant others to ensure adherence to the treatment plan.

Knowledge

1. Social, cultural, and family systems.
2. Techniques to engage the client in treatment process.
3. Outreach, follow-up, and aftercare techniques.
4. Methods for determining the clientís goals, treatment plan, and motivational level.
5. Assessment mechanisms to measure clientís progress toward treatment objectives.

Skills

1. Engaging client, family, and significant others in the ongoing treatment process.
2. Assessing client progress toward treatment goals.
3. Helping the client maintain motivation to change.
4. Assessing the comprehension level of the client, family, and significant others.
5. Documenting the clientís adherence to the treatment plan.
6. Recognizing and addressing ambivalence and resistance.
7. Implementing follow-up and aftercare protocols.

Attitudes

1. Professional concern for the client, the family, and significant others.
2. Therapeutic optimism.
3. Recognition of relapse as an opportunity for positive change.
4. Patience and perseverance.

 

2. Understand and recognize stages of change and other signs of treatment progress.   

Knowledge

1. How to recognize incremental progress toward treatment goals.
2. Clientís cultural norms, biases, unique characteristics, and preferences for treatment.
3. Generally accepted treatment outcome measures.
4. Methods for evaluating treatment progress.
5. Methods for assessing clientís motivation and adherence to treatment plans.
6. Theories and principles of the stages of change and recovery.

Skills

1. Identifying and documenting change.
2. Assessing adherence to treatment plans.
3. Applying treatment outcome measures.
4. Communicating with people of other cultures.
5. Reinforcing positive change.

Attitudes

1. Appreciation for cultural issues that impact treatment progress.
2. Respect for individual differences.
3. Therapeutic optimism.

 

3. Assess treatment and recovery progress and, in consultation with the client and significant others, make appropriate changes to the treatment plan to ensure progress toward treatment goals. 

Knowledge

1. Continuum of care.
2. Interviewing techniques.
3. Stages in the treatment and recovery process.
4. Individual differences in the recovery process.
5. Methods for evaluating treatment progress.
6. Methods for re-involving the client in the treatment planning process.

Skills

1. Participating in conflict resolution, problem solving, and mediation.
2. Observing, recognizing, assessing, and documenting client progress.
3. Eliciting client perspectives on progress.
4. Demonstrating clear and concise written and verbal communication.
5. Interviewing individuals, groups, and families.
6. Acquiring and prioritizing relevant treatment information.
7. Assisting the client in maintaining motivation.
8. Maintaining contact with client, referral sources, and significant others.

Attitudes

1. Willingness to be flexible.
2. Respect for the clientís right to self-determination.
3. Appreciation of the role significant others play in the recovery process.
4. Appreciation of individual differences in the recovery process.

 

4. Describe and document treatment process, progress, and outcome.   

Knowledge

1. Treatment modalities.
2. Documentation of process, progress, and outcome.
3. Factors affecting clientís success in treatment.
4. Treatment planning.

Skills

1. Demonstrating clear and concise oral and written communication.
2. Observing and assessing client progress.
3. Engaging client in the treatment process.
4. Applying progress and outcome measures.

Attitudes

1. Appreciation of the importance of accurate documentation.
2. Recognition of the importance of multidisciplinary treatment planning.

 

5. Use accepted treatment outcome measures. 

Knowledge

1. Treatment outcome measures.
2. Understand concepts of validity and reliability of outcome measures.

Skills

1. Using outcome measures in the treatment planning process.

Attitudes

1. Appreciation of the need to measure outcomes.

 

6. Conduct continuing care, relapse prevention, and discharge planning with the client and involved significant others. 

Knowledge

1. Treatment planning process.
2. Continuum of care.
3. Available social and family systems for continuing care.
4. Available community resources for continuing care.
5. Signs and symptoms of relapse.
6. Relapse prevention strategies.
7. Family and social systems theories.
8. Discharge planning process.

Skills

1. Accessing information from referral sources.
2. Demonstrating clear and concise oral and written communication.
3. Assessing and documenting treatment progress.
4. Participating in confrontation, conflict resolution, and problem solving.
5. Collaborating with referral sources.
6. Engaging client and significant others in treatment process and continuing care.
7. Assisting client to develop a relapse prevention plan.

Attitudes

1. Therapeutic optimism.
2. Patience and perseverance.

 

7. Document service coordination activities throughout the continuum of care. 

Knowledge

1. Documentation requirements including, but not limited to: - addiction counseling, - other disciplines, - funding sources, - agencies and service providers.
2. Service coordination role in the treatment process.

Skills

1. Demonstrating clear and concise written communication.
2. Using appropriate technology to report information in an accurate and timely manner within the bounds of confidentiality regulations.

Attitudes

1. Acceptance of documentation as an integral part of the treatment process.
2. Willingness to use appropriate technology.

 

8. Apply placement, continued stay, and discharge criteria for each modality on the continuum of care. 

Knowledge

1. Treatment planning along the continuum of care.
2. Initial and on-going placement criteria.
3. Methods to assess current and on-going client status.
4. Stages of progress associated with treatment modalities.
5. Appropriate discharge indicators.

Skills

1. Observing and assessing client progress.
2. Demonstrating clear and concise written and verbal communication.
3. Participating in conflict resolution, problem solving, mediation, and negotiation.
4. Tailoring treatment to meet client needs.
5. Applying placement, continued stay, and discharge criteria.

Attitudes

1. Confidence in clientís ability to progress within a continuum of care.
   Appreciation for the fair and objective use of placement, continued stay, and discharge criteria.
    

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Email: no@nattc.org | Revised March 1998