Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice
Technical Assistance Publication (TAP) Series 21

Section 2: the Professional Practice of Addiction Counseling

IV. Service Coordination

The administrative, clinical, and evaluative activities that bring the client, treatment services, community agencies, and other resources together to focus on issues and needs identified in the treatment plan. Service coordination, which includes case management and client advocacy, establishes a framework of action for the client to achieve specified goals. It involves collaboration with the client and significant others, coordination of treatment and referral services, liaison activities with community resources and managed care systems, client advocacy, and ongoing evaluation of treatment progress and client needs.

 

A. IMPLEMENTING THE TREATMENT PLAN

            1. How to access and transmit information necessary for referral.
            2. Missions, functions, and resources of community service network.
            3. Managed care and other systems affecting the client.
            4. Eligibility criteria for referral to community service providers.
            5. Appropriate confidentiality regulations.
            6. Terminologies appropriate to the referral source.
            1. Using appropriate technology to access, collect, summarize, and transmit referral data on client.
            2. Communicating respect and empathy for cultural and lifestyle differences.
            3. Demonstrating appropriate written and verbal communication.
            4. Establishing trust and rapport with colleagues in the community.
            5. Assessing level and intensity of client care needed.

            Attitudes

            1. Respect for contributions and needs of multiple disciplines to treatment process.
            2. Confidence in using diverse systems and treatment approaches.
            3. Open-mindedness to a variety of treatment approaches.
            4. Willingness to modify or adapt plans.

            2. Obtain, review, and interpret all relevant screening, assessment, and initial treatment-planning information.

            Knowledge

            1. Methods for obtaining relevant screening, assessment, and initial treatment-planning information.
            2. How to interpret information for the purpose of service coordination.
            3. Theory, concepts, and philosophies of screening and assessment tools.
            4. How to define long- and short-term goals of treatment.
            5. Biopsychosocial assessment methods.

            Skills

            1. Using accurate, clear, and concise written and verbal communication.
            2. Interpreting, prioritizing, and using client information.
            3. Soliciting comprehensive and accurate information from numerous sources including the client.
            4. Using appropriate technology to document appropriate information.

            Attitudes

            1. Appreciation for all sources and types of data and their possible treatment implications.
            2. Awareness of personal biases that may impact work with client.
            3. Respect for client self-assessment and reporting.

            3. Confirm the client’s eligibility for admission and continued readiness for treatment and change.

            Knowledge

            1. Philosophies, policies, procedures, and admission protocols for community agencies.
            2. Eligibility criteria for referral to community service providers.
            3. Principles for tailoring treatment to client needs.
            4. Methods of assessing and documenting client change over time.
            5. Federal and State confidentiality regulations.

            Skills

            1. Working with client to select the most appropriate treatment.
            2. Accessing available funding resources.
            3. Using effective communication styles.
            4. Recognizing, documenting, and communicating client change.
            5. Involving family and significant others in treatment planning.

            Attitudes

            1. Recognition of the importance of continued support, encouragement, and optimism.
            2. Willingness to accept the limitations of treatment for some clients.
            3. Appreciation for the goal of self-determination.
            4. Recognition of the importance of family and significant others to treatment planning.
            5. Appreciation of the need for continuing assessment and modifications to the treatment plan.

            4. Complete necessary administrative procedures for admission to treatment.

            Knowledge

            1. Admission criteria and protocols.
            2. Documentation requirements and confidentiality regulations.
            3. Appropriate Federal, State, and local regulations related to admission.
            4. Funding mechanisms, reimbursement protocols, and required documentation.
            5. Protocols required by managed care organizations.

            Skills

            1. Demonstrating accurate, clear, and concise written and verbal communication.
            2. Using language the client will easily understand.
            3. Negotiating with diverse treatment systems.
            4. Advocating for client services.

            Attitudes

            1. Acceptance of the necessity to deal with bureaucratic systems.
            2. Recognition of the importance of cooperation.
            3. Patience and perseverance.

            5. Establish accurate treatment and recovery expectations with the client and involved significant others including, but not limited to:

            - nature of services,

            - program goals,

            - program procedures,

            - rules regarding client conduct,

            - schedule of treatment activities,

            - costs of treatment,

            - factors affecting duration of care,

            - client rights and responsibilities.

            Knowledge

            1. Functions and resources provided by treatment services and managed care systems.
            2. Available community services.
            3. Effective communication styles.
            4. Client rights and responsibilities.
            5. Treatment schedule, time frames, discharge criteria, and costs.
            6. Rules and regulations of the treatment program.
            7. Role and limitations of significant others in treatment.
            8. How to apply confidentiality regulations.

            Skills

            1. Demonstrating clear and concise written and verbal communication.
            2. Establishing appropriate boundaries with client and significant others.

            Attitudes

            1. Respect for the contribution of clients and significant others.

            6. Coordinate all treatment activities with services provided to the client by other resources.

            Knowledge

            1. Methods for determining the client’s treatment status.
            2. Documenting and reporting methods used by community agencies.
            3. Service reimbursement issues and their impact on the treatment plan.
            4. Case presentation techniques and protocols.
            5. Applicable confidentiality regulations.
            6. Terminology and methods used by community agencies.

            Skills

            1. Delivering case presentations.
            2. Using appropriate technology to collect and interpret client treatment information from diverse sources.
            3. Demonstrating accurate, clear, and concise verbal and written communication.
            4. Participating in interdisciplinary team building.
            5. Participating in negotiation, advocacy, conflict-resolution, problem solving, and mediation.

            Attitudes

            1. Willingness to collaborate.

      B. CONSULTING

            1. Summarize client’s personal and cultural background, treatment plan, recovery progress, and problems inhibiting progress for purpose of assuring quality of care, gaining feedback, and planning changes in the course of treatment.

            Knowledge

            1. Methods for assessing client’s past and present biopsychosocial status.
            2. Methods for assessing social systems that may affect the client’s progress.
            3. Methods for continuous assessment and modification of the treatment plan.

            Skills

            1. Demonstrating clear and concise written and verbal communication.
            2. Synthesizing information and developing modified treatment goals and objectives.
            3. Soliciting and interpreting feedback related to the treatment plan.
            4. Prioritizing and documenting relevant client data.
            5. Observing and identifying problems that might impede progress.
            6. Soliciting client satisfaction feedback.

            Attitudes

            1. Respect for the personal nature of the information shared by the client and significant others.
            2. Respect for interdisciplinary work.
            3. Appreciation for incremental changes.
            4. Recognition of relapse as an opportunity for positive change.

            2. Understand terminology, procedures, and roles of other disciplines related to the treatment of substance use disorders.

            Knowledge

            1. Functions and unique terminology of related disciplines.

            Skills

            1. Demonstrating accurate, clear, and concise verbal and written communication.
            2. Participating in interdisciplinary collaboration.
            3. Interpreting written and verbal data from various sources.

            Attitudes

            1. Comfort in asking questions and providing information across disciplines.

            3. Contribute as part of a multidisciplinary treatment team.

            Knowledge

            1. Roles, responsibilities, and areas of expertise of other team members and disciplines.
            2. Confidentiality regulations.
            3. Team dynamics and group process.

            Skills

            1. Demonstrating clear and concise verbal and written communication.
            2. Participating in problem solving, decision making, mediation, and advocacy.
            3. Communicating about confidentiality issues.
            4. Coordinating the client’s treatment with representatives of multiple disciplines.
            5. Participating in team building and group process.

            Attitudes

            1. Interest in cooperation and collaboration with diverse service providers.
            2. Respect and appreciation for other team members and their disciplines.

            4. Apply confidentiality regulations appropriately.

            Knowledge

            1. Federal, State, and local confidentiality regulations.
            2. How to apply confidentiality regulations to documentation and sharing of client information.
            3. Ethical standards related to confidentiality.
            4. Client rights and responsibilities.

            Skills

            1. Explaining and applying confidentiality regulations.
            2. Obtaining informed consent.
            3. Communicating with the client, family and significant others, and with other service providers within the boundaries of existing confidentiality regulations.

            Attitudes

            1. Recognition of the importance of confidentiality regulations.
            2. Respect for a client’s right to privacy.

            5. Demonstrate respect and non-judgmental attitudes toward clients in all contacts with community professionals and agencies.

            Knowledge

            1. Behaviors appropriate to professional collaboration.
            2. Client rights and responsibilities.

            Skills

            1. Establishing and maintaining non-judgmental, respectful relationships with clients and other service providers.
            2. Demonstrating clear, concise, accurate communication with other professionals or agencies.
            3. Applying the confidentiality regulations when communicating with agencies.
            4. Transferring client information to other service providers in a professional manner.

            Attitudes

            1. Willingness to advocate on behalf of the client.
            2. Professional concern for the client.
            3. Commitment to professionalism.

 

            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 client’s goals, treatment plan, and motivational level.
            5. Assessment mechanisms to measure client’s 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 client’s 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. Client’s 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 client’s 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 client’s 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 client’s 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 client’s ability to progress within a continuum of care.
            2. Appreciation for the fair and objective use of placement, continued stay, and discharge criteria.
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