Recovery-Oriented Community Inclusion Model

The Recovery-Oriented Community Inclusion Treatment Model of individuals in recovery, from serious mental illness, addresses the social, emotional, occupational, and importance of freedom of our clients. ROCI increases opportunities of a client to live a meaningful life in their community that result from community inclusion initiatives enhance general medical, social, cognitive, and mental health and wellness. ROCI is also in accordance the treatment guidelines by the American Psychiatric Association. See Link for APA Treatment Guidelines

In accordance with the U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration, CrossBridge's four recovery goal domains are health, home, purpose, and community. We don't just manage symptoms; instead, we embrace all aspects of care for the individual’s personal health and wellness. We also assist in addressing the need for safe, affordable, and stable as-possible independent living. 

We embrace the goal of helping the individual to find or maintain fulfilling daily life activities including work, school, volunteering, family connections, creative endeavors, and appropriately add new challenges that make life meaningful. We strive to encourage individuals with mental health struggles to engage, as much as possible, into their local community.

The Substance Abuse and Mental Health Services Administration has 10 guiding principles of recovery. (See bottom of page) Many of the principles point to the fact that recovery requires addressing all dimensions of a person’s life including resources provided by the community.

Inclusion means more than just the mere presence of people in recovery in certain settings, such as work and community. It means that they are engaged in valued social roles and integrated into the community. Participation in meaningful activities such as education, occupation, recreation, and spiritual activities is an imperative part of recovering from serve mental illness (Salzer, 2021). There is a need for the establishment, support, and protection of significant roles for people who are at risk of being devalued. 

Understanding the Role of a Mental Health Case Manager

At its core, the role of a Mental Health Case Manager is to ensure that clients receive the necessary services and support they need. CCA utilizes an Assertive Community Treatment (ACT) model in addition to the Recovery-Oriented Community Inclusion Treatment Model.

This often involves coordinating care across multiple providers, such as psychiatrists, psychologists, medical doctors, half-way house managers, schools, and social workers. Case managers monitor and provide guidance to clients throughout the course of treatment.

CCA utilized the Interdisciplinary Integrated Care Team Model as outlined in the Primary Care Behavioral Health and Collaborative Care Model (Collaborative Family Healthcare Association, 2023) for case management and care planning with clients and their families.

The Benefits of Mental Health Case Management Services

Mental health case management services can play a crucial role in helping individuals with mental illness access the resources and support they need to manage their condition and improve their quality of life.

Our Services Include: 

• Clinical Records Review & Needs Assessment
• Treatment Placement & Planning Ongoing Care
  • Coordination and adjunct care with your loved ones' treatment center 
  • Discharge/aftercare planning, including locating housing, transportation, and crisis management
  • Sober transportation, if needed 
• Crisis Response Coordination 24/7 
  • Responses within 3 hours. 
  • Overnight 24/7 staffing, as needed 
  • On-call nursing, as needed 
• Care Advocacy and Expert Independent Guidance 
• Transitional & Supported Living Planning and Placement (i.e., sober living, setting up a client’s apartment)
• Job Placement and Academic Support 
• Ongoing Oversight & Evaluation of Care 
  • Weekly Team meeting with clients and loved ones
• Exposure-Based Therapies
• Sober Meetings (i.e., AA or SMART meeting support)
• Neuropsychological Testing
  • For Diagnostic Clarification
  • For College or Standardized Testing Accommodations

Mental Health Case Management Services Offer Numerous Benefits, Including:

Coordination of Care: Mental health case managers coordinate and manage all aspects of an individual’s mental health care, including connecting them with appropriate mental health services and providers. This helps to ensure that individuals receive a comprehensive and cohesive approach to their treatment and support.

Improved Access to Resources: Mental health case managers have a wealth of knowledge and resources at their disposal. They use this information to help individuals find the services and support they need. This can include everything from finding therapy or counseling services to helping individuals access housing, employment, and financial support.

Ongoing Support: Mental health case managers provide ongoing support and advocacy to individuals, helping them navigate the complexities of the healthcare system. They can help individuals stay on track with their treatment and provide emotional support during difficult times.

Better Treatment Outcomes: With the help of a mental health case manager, individuals with mental illness are more likely to stick to their treatment plan and experience better mental health outcomes. This can result in improved quality of life, increased independence, and reduced hospitalizations or other adverse events.

Cost Savings: Mental health case management services can also be cost-effective, as they help to reduce the need for hospitalization and other expensive forms of care. By providing individuals with the support and resources they need to manage their mental health, case managers can help to reduce the overall cost of care. Often case managers and sober supports are able to see a subtle change in behaviors and moods which indicated oncoming relapse or mood episode. This allows the clinical team to proactively respond before a crisis occurs. 

At Crossbridge Clinical Associates we have a network of male and female case managers to help you and your loved ones navigate the complex world of residential treatment, which can involve a multi-phase step-down process, to outpatient scheduling logistics between providers and ensuring that all providers are working from a single unified treatment methodology. Having a case manager brings simplicity to an otherwise chaotic mental health / medical field.

What is Case Management in Mental Health:

Case management in mental health refers to a holistic, integrative, and coordinated care approach for providing support and services to individuals with mental health / substance abuse recovery needs. Case managers' goals are to ensure that individuals receive the appropriate care, accurate and timely coordination with various treatment providers, and support to maintain their mental well-being and improve their quality of life. 

They often act to ensure the necessary medical information is sent to all relevant providers and the client’s needs are being prioritized. In addition, they facilitate the flow of vial information between providers, family, and the rest of a care team. They advocate for and support the client during periods of chaos and emergency. They can be a power force to bring calm to the storm.

Case managers also assist with finding higher levels of care for eating disorders, substance abuse, and mental health treatment. Higher levels of care can range from an intensive outpatient program (IOP), Partial Hospitalization Program (PHP), Residential Treatment (RTC), and Detox. In the event the client has legal issues which must be considered, the Case Managers can liaison with probation offices, Marchman attorneys, and legal guardians to ensure rapid and open communications. This ensure for a smoother process which is less aggravating and stressful for client and their families.

We work with our clients from as long as needed, though a typical period of engagement is 6-18 months. We monitor the entire process and advocate on behalf of the client and family to ensure care needs are met and the client is able to achieve the highest level of sustainable independence.  Dr. Arthur Chen, PsyD and CrossBridge Clinical Associates has extensive experience working with eating disorders, schizophrenia, substance abuse and recovery, and bipolar disorders.

Assertive Community Treatment (ACT) is a model of service delivery and coordination designed to provide people with SMI with regular access to a multidisciplinary team of providers. The benefits of ACT are that it:

• Helps to reduce repeat hospitalizations and other adverse outcomes.
• Allows for the integration of medication management, case management, and psychosocial interventions.
• Offers more frequent contacts through smaller caseloads and 24-hour access to support.
• Improved overall functioning
• Increased follow-through with medication regimens
• Greater likelihood of independent living arrangements

SAMHSA’s 10 Guiding Principles of Recovery

Recovery emerges from hope: An important principle in recovery is the motivating message that a better future is possible. People must believe they can and will overcome internal and external challenges, barriers, and obstacles.

Recovery is person-driven: Creating personalized goals and encouraging self-determination and self-direction can help people design their unique path which is a foundation of recovery.

Recovery occurs via many pathways: An individual’s pathways to recovery are specific to the person and affected by culture, background, and trauma experiences. An individual’s needs, strengths, preferences, and goals are also taken into consideration. 

Recovery is holistic: Integrated and coordinated services are required to address all aspects of an individual’s life. These aspects are reflected in SAMHSA’s eight dimensions of wellness, which include emotional, spiritual, intellectual, physical, environmental, financial, occupational, and social parts of life.

Recovery is supported by peers and allies: There are programs and services run by and for persons with SMI. Peer support is considered an essential part of recovery-oriented care.

Recovery is supported through relationships and social networks: When others who surround an individual believe in the person’s ability to recover, those people are able to offer hope, support, and encouragement. Those same people can also suggest strategies and resources for change.

Recovery is culturally based and influenced: A person’s unique path to recovery is impacted by aspects of culture and cultural backgrounds that need to be acknowledged and supported, including values, traditions, and beliefs.

Recovery is supported by addressing trauma: It is important for trauma-informed care to be a part of services and support which fosters emotional and physical safety and trust. Trauma-informed care will also promote an individual’s choice, empowerment, and collaboration with the provider.

Recovery involves individual, family, and community strengths and responsibility: A foundation for recovery is found in the strengths and resources provided by individuals, families, and communities.

Recovery is based on respect: It is imperative that people affected by mental health and substance use disorders feel that their community, systems, and society are working to protect their rights and eliminate discrimination. It is important for individuals to feel acceptance and appreciation as they work toward recovery.