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Welcome to the Department of Behavioral Health and Intellectual Disabilities Services

Department of Behavioral Health and Intellectual disAbility Services


Guide to Providing Values-Based Support

This phase begins once the member has moved out of the JOH facility into their permanent home, and it lasts as long as the person desires services.

Supporting the member in creating a full and content life for themselves in the community has been the ultimate goal of JOH’s work with the member from Phase 1. Phase 5 builds on the progress made throughout the person’s JOH experience to equip the member with the skills and resources they need to build their own dependable recovery support network independent of JOH services.

The risk of resuming substance use is greatest within the first 90 days after treatment, suggesting that more assertive monitoring may be necessary—at least within this critical timeframe—to help people sustain recovery. For individuals with a history of chronic homelessness who have just transitioned out of residential treatment and into an independent living environment, the risks for relapse following treatment can be even greater.

Goals for this phase are to support the person in embedding practices into their daily life that will help them sustain their recovery, increase their capacity to stay housed, and help them achieve their quality-of-life goals. This will entail working with the member to implement their continuing support plan and to ensure the person has regular, scheduled, and structured meetings with a JOH peer specialist and a JOH case manager.

Why is Phase 5 important?

Phase 5 Goals:

1. Implement the continuing support plan

Individuals should have developed their continuing support plan in Phase 4. This plan represents the collaborative work of the member and their service team. It documents the type and frequency of support that the member would like from JOH staff. It also describes the kinds of actions that they will take on their own to support their ongoing wellness. In phase 5, members put this plan into action, and make adjustments as needed.

Goal 1 strategies:
  • Review the continuing support plan with the member and ensure that the activities in the plan are embedded in the individual’s weekly schedule. There should be a time and a place for all of the desired activities to occur.
  • Create the expectation that the plan will need to be adjusted as they determine what works for them.
  • Establish a review period in which the member “test drives” their continuing care plan after they’re in housing; make changes, as necessary.
  • Troubleshoot issues with implementing the continuing care plan. For instance, if they planned to join the JOH community for dinner two times a week but could not get transportation, work with the member to find a solution.
  • As members achieve their initial goals, work with them to set and achieve new goals.
  • Continue to help the member master common adult living skills, such as managing time, managing stress, reading a nutrition label, managing money, cooking meals, cleaning house, taking transportation, banking, using the library, and so on.

2. Support the individual in expanding their natural support network

In earlier phases, members worked on identifying and strengthening their support system. In this phase, they are learning how to use their support system in their everyday life. Work in this area will be different for each individual, but it will generally focus on helping them solidify relationships. Work with them to set goals and practice interpersonal skills such as setting appropriate boundaries, increasing their comfort with asking for help and support, learning to identify and enjoy pro-recovery recreational activities, and strengthening their communication skills.

Goal 2 strategies:
  • Support members in thinking through how they would like to expand or strengthen their circle of support.
  • Ask members to identify one or two things that they would like to work on that would help strengthen their relationships, then support them in following through with their plan.
  • Support members in exploring who in their life might negatively impact their recovery and how they might minimize their contact with the person.
  • Discuss the kinds of activities that the individual would like to do for fun and who they might invite to join them. Then support them in taking the steps to have their desired experiences.
  • Offer to role-play new or difficult conversations that the individual may anticipate having to have with friends or family members about boundaries that they are trying to set.
  • Support members in having intentional conversations with their trusted friends about the kinds of support they would like in general.
  • Discuss ways the support network would know that the member might be becoming unwell, and what would be helpful during those times.

3. Ensure a strong connection to other community-based treatment services

Individuals leaving a JOH residence for their own home will be in various places along the continuum of recovery and wellness. The fact that an individual now has independent housing does not necessarily mean that their substance use disorder is fully treated or that they are positioned to successfully maintain their recovery. It is essential to gradually transition members from JOH services and to assertively connect them to community-based supports, including outpatient treatment services, as needed. Even if members have previously said no to outpatient treatment, raise the issue respectfully in this phase. Motivational interviewing and assertive engagement skills could help the individual identifying what kind of support will help them to achieve their current goals.

Goal 3 strategies:
  • Now that housing is no longer a concern, support the individual in clarifying what life goals are most important to them at this stage of their life.
  • Spend time supporting people with imagining and describing their updated vision for their life. Ask them to share what their life looks like, who is a part of it, what they are doing, and how they are feeling. Support them in making the vision as clear as possible.
  • Use the clarified vision to help people explore the need and role of treatment in their life. What are the potential risks of not continuing treatment? Will treatment help them move toward or away from their desired life?
  • Offer to accompany them to initial treatment appointments.
  • Identify alternatives to treatment, as needed. If a member chooses not to continue treatment, explore what they will do to support their recovery process instead, and identify how they will know if their chosen activities are working for them.
  • Support the individual in identifying the signs of being unwell and how they would like to be supported if those signs arise.
  • Establish some agreements about how and when you should express any concerns about their recovery status.
  • Obtain their permission to check in on how their plan is working for them. Make this an ongoing part of your conversations together.
  • Don’t simply refer members to treatment or tell them what services are out there. Instead, ensure there is a warm hand-off to these services.

4. Support the individual in creating a sense of meaning and purpose in their life

While people can find it helpful to structure their days with a clear schedule of activities, for many this still is not enough to protect their recovery. They need more than a schedule, a place to live, and places to go. Like many of us, they crave a sense of meaning, purpose, connection, and fulfillment in their life. Support members in exploring the kinds of activities that promote these feelings and help them to build these experiences into their routine.

Goal 4 strategies:
  • Ask people to consider what their sense of purpose or meaning might be. So many individuals have been in survival mode for so long that their purpose has been to get through the day. More than what they want their life to look like, explore with them what they want their life to be about.
  • Ask the individual to identify some past experiences that felt meaningful and explore what was most positive about them.
  • Explore the kinds of activities that the individual may find meaningful today.
  • Encourage members to try new things as a fun part of creating their ideal life. Remind them that not all experiences will be equally rewarding, but that the process of trying them out will help them determine what is most fulfilling for them today.
  • Explore together how having a sense of meaning or purpose can help to support their recovery. For example, although going to treatment or looking for a job may feel burdensome at times, those activities are going to help them feel great about their life and protect their recovery.
  • Based on the person’s interests, help them connect with nonprofit interest groups (such as environmental, animal welfare, and faith organizations) that offer opportunities for volunteer and social activities.
  • Support the member with preparing for and finding employment, volunteer, and social support opportunities that match their interests and skills.
  • Attend community events with the individual to increase their comfort level.

5. Adjust the dose of supports to the member's changing needs

To stay connected with a JOH member over the long term, take steps to ensure that the amount and type of services you offer meets their changing needs. Typically, you’ll want to increase support when the member is experiencing significant life changes, even when those changes are positive.

Goal 5 strategies:
  • Check in frequently with the person about whether the type and level of continuing support you are offering matches their needs, and increase or decrease support as indicated.
  • As the individual increases self-sufficiency and improves their quality of life, reduce the level and frequency of JOH support.
  • Offer less intensive supports, but maintain formal and scheduled check-ins via text messages, email, or videoconference.

6. Practice assertive re-engagement

An essential point to remember about continuing support is that the responsibility for maintaining contact with a member rests with JOH. The staff providing continuing care services—typically peers and case managers—initiate meetings and check-ins, take the lead in rescheduling missed contacts, and ensure that the member is getting helpful and relevant service from JOH and community resources. If a member disengages or informally leaves the program, JOH staff should try to locate that person, including going out into the community to look for them. Members who return to using should be invited back into the residential program.

Goal 6 strategies:
  • Keep the person’s locator form up to date.
  • Update permissions from the member along with the necessary consents to reach out to people named on the contact list to help you locate the member, if needed.
  • If members become disengaged, take an assertive approach to looking for them in their community, beginning with places noted on their locator form.
  • Discuss what the member would find helpful if they experience a slip or a relapse. Think about a variety of supports, such as the use of technology. For example the individual might pre-record a message to themselves about their desired course of action should they experience a slip.

Phase 5 Resources:

Circles of Support Tool

Published 2020

Program Manager: Deanna.Lear@phila.gov

Project Assistant: Tina.Newstead@phila.gov