Support Systems, Inc. provides substance abuse case management services that are person-centered, individualized, culturally and linguistically appropriate to adults and their families in order to assist them in accessing needed medical, psychiatric, psychological, social, educational, vocational, recovery, and other supports essential to their supporting success in recovery and helping to meet basic needs. 

Services will be designed to provide the following:

• Enabling individuals to achieve and maintain community stability and enhancing community living skills and increasing independence in the most appropriate and least restrictive environment

• Developing a substance use case management individualized treatment plan through extensive comprehensive needs assessment

• Education and assistance with utilizing community resources and increasing community access

• Assisting the member with developing a support system which includes significant others and family members which will be coordinated and implemented through collateral contacts through authorized releases. 

• Linking the member to community supports and services and maintaining constant and consistent collaboration and coordination of these and providing supports to ensure and promote personal rehabilitative and rehabilitative recovery and the reaching of life goals as outlined on the ISP.

• Monitoring service delivery through consistent contacts with members receiving services and service providers including site and home visits to assess the quality of care and satisfaction of the member

• Facilitating a professional therapeutic relationship with the member that provides follow-up instruction, education, and counseling to guide the member and promotes the ISP

• Advocating for the member regarding their needs and rights within services and/or supports, ensuring that they member is treated fairly and with positive regard and respect.

• Providing consistent monitoring of the member's health status, any medical conditions, medications and potential side effects, and assisting the member in accessing primary care and other medical services, as needed

• Understanding the capabilities of services to meet the member's identified needs and preferences and to serve the member without placing the member, other participants, or staff at risk of serious harm.

• A focus on helping the individual with a substance use disorder acquire needed resources that reinforces treatment goals and provides ongoing support as they move through the recovery continuum.

• Enhancing community integration by contacting other entities to arrange community access and involvement, including opportunities to learn community living skills, and use vocational, civic, and recreational services;

• Making collateral contacts with the individuals' significant others to promote implementation of the service plan and community adjustments

• The case manager will assist each client who is diagnosed with a substance use disorder to move between accurate and appropriate levels of care to ensure the best possible chance of recovery and progress.

Type and Role of Staff/Schedule of staffing pattern:

Services are provided by a minimum of a Qualified Mental Health Professional who has at least 1 year of experience working with the substance use population. Staff will also have a combination of a Bachelors level education and one or more years of experience in the field of mental health services in order to provide case management to individuals who have a dual diagnosis.  Supervision is ongoing both by a monthly clinical and written supervision and daily interaction with supervisors. Clinical supervision and oversight will be provided by either licensed or licensed eligible mental health professionals or individuals who have a CSAC in the state of Virginia.  

Licensed Mental Health Professionals shall provide ongoing assessment and evaluation, quarterly ISP reviews, documentation of continued need of services, coordination of services and overall clinical supervision. LMHP or CSAC staff will also ensure that individuals are receiving appropriate and effective treatment based on level of care.

Support Systems, Inc. case management staff knowledge and characteristics:

• Possess particular knowledge, skills, and attitudes that are appropriate and provide non-judgmental and supportive services.

• Understand various models and theories of addiction and other problems related to substance abuse

• Have the ability to describe the philosophies, practices, policies, and outcomes of the most generally accepted and scientifically supported models of treatment, recovery, relapse prevention, and continuing care for addiction and other substance-related problems

• Have the ability to recognize the importance of family, social networks, community systems, and self-help groups in the treatment and recovery process

• Understand the variety of insurance and health maintenance options available and the importance of helping clients access and navigate those benefits

• Understand diverse cultures and incorporate the relevant needs of culturally diverse groups, as well as people with disabilities, into case management practice

• Understand the value of an interdisciplinary approach to addiction treatment

• Will involve and encourage participation for each client in own specific treatment and care. Clients will be involved in treatment planning and ensure that goals and objective match their specific needs and wants for the program.

• Staff will be trained and able to effectively and accurately utilize Person Centered theory and treatment for best possible progress and in order to ensure that each client is committed to their own recovery.

• Staff will ensure that they develop trust, rapport and a therapeutic relationship with each client who they serve.

• Staff will utilize empathy, unconditional positive regard, support, encouragement, motivation, challenging, providing a safe space and congruence to ensure the client has best possible chance at recovery, as well.

Admission Criteria and Characteristics and needs of the population served:

The Medicaid eligible member shall meet the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for substance use disorder. Tobacco-related disorders, caffeine related disorders and non-substance-related disorders shall not be covered. If a member has co-occurring mental health and substance use disorders, the case manager shall include activities to address both the mental health and substance use disorders and also ensure that the client is referred to all appropriate and beneficial services and will utilize an accurate level of care. The case manager will also assist the client with moving from one level of care to another as necessary.

Population served will include: individuals who are 18 years of age and above, individuals diagnosed with a substance use disorder, and individuals who have co-occurring disorders of mental health and substance use. Support Systems, Inc. will not exclude individuals who have a Power of Attorney or a Guardian. Support Systems, Inc. staff will work to collaborate with this individual to ensure that the needs of the client are being met appropriately. Support Systems, Inc. will include women who are pregnant in case management services. The staff will ensure that each woman who is pregnant will receive appropriate care and in a timely manner for overall mental and physical health throughout pregnancy while the client is in services. Support Systems, Inc. staff will also ensure appropriate referrals for all populations served upon discharge.

Specific Services Provided:

Substance use case management shall include an active individual service plan (ISP) which requires:

• A minimum of two substance use case management service activities each month, that consist of two separate and distinct case management activities occurring on different days with the member, and

• At least one face-to-face contact, separate from the two distinct activities per month minimum, with the member at least every 90 calendar days

• Consistent effort to ensure that clients are referred to other services that are necessary to help manage symptoms and increase stability, such as: psychiatry, counseling, and community based services to encourage wrap around care for best possible functioning and progress.

Based on the regulations listed above, Support Systems, Inc. staff will work to provide at least two face to face contacts with each client in case management services.  Support Systems, Inc. staff members will also put forth effort to make contact with each client in case management services once per week by phone call to ensure their needs are being met, follow up on progress and help assess appropriate level of care consistently.

Continued Stay

To receive Substance Abuse Case Management Services with Support Systems, the client must be an active client, which means an assessment has been completed by a Licensed mental health professional which documents the need prior to initiation of the services and has an active plan of care in effect at the time services are rendered. 

An active client for case management shall mean an individual for whom an individualized ISP has been developed and is in effect which requires regular direct or client-related contacts or communication or activity with the client, family, service providers, significant others and others deemed necessary.  Substance Abuse Case Management authorizations are required prior to services beginning.

There are no maximum service limits for SA Case Management services.

Exclusion Criteria

Individuals who have a history of violence or aggression- Violence or aggression will be identified based on a history of physical aggression or violence toward mental health providers or other professionals. Support Systems, Inc. recognizes that individuals who have a diagnosis of a substance use disorder and/or mental health disorder may have tendencies toward verbal aggression or anger outbursts. Staff will be trained to manage this and provide support toward de-escalation.

Individuals who reside in any domiciliary care facilities or institutions for mental disease including, but not limited to group homes, or nursing facilities are not eligible for this service.

Individuals who are residents of Psychiatric Residential Treatment Centers—Level C facilities except for assessment code H0032/U8 in the 7 days prior to discharge

Individuals who have organic disorders, such as delirium, dementia or other cognitive disorders of this nature unless a physician issues a signed and dated statement indicating that this service would benefit the individual.

Termination of Treatment and Discharge Criteria

Successful termination of treatment is based on goal attainment as noted on the plan of care. Joint decisions with the client and Support Systems staff are made as to the appropriate reauthorization or termination of services.

Termination of treatment criteria may include the following:

• The maximum allowable units have been billed or authorization for services is denied. 

• When the client reaches treatment objectives, or has achieved a minimum of 90 percent of treatment goals and is capable of functioning independently without outside community interventions. 

• When the client has stated that he or she no longer wishes to receive services, or;

• When the client withdraws from services, moves away or passes away.

• Support Systems staff collaborates with the client regarding appropriate discharge, referrals, and/ or needs.

The ISP shall include discharge goals that will enable the individual/client to achieve and maintain community stability and independence.  Reauthorizations for service shall only be granted when Support Systems’ staff and the client are able to demonstrate that the individual is benefitting from the service as evidenced by updates and modifications to the ISP that demonstrate progress toward ISP goals and objectives.  Support Systems, Inc. will work to ensure that each client is a part of his or her treatment planning process and also discharge process (as often as possible).

Transition Criteria

 Transitions to other programs/services will occur when required.  This decision is to be made by the active case manager.  Support Systems will provide support as needed to ensure successful transition.  This will include communication collaboration and other reasonable requests by the case manager or the client.  Transition to any other needed or requested services shall include appropriate discharge including maintaining contact, setting up appointment dates and times with providers and appropriate and consented collaboration with referral partners.