Provide recovery education for every phase of the recovery journey from pre-recovery engagement, recovery initiation, recovery stabilization, and sustained recovery maintenance. Provide a model for both people in recovery and staff by demonstrating that recovery is possible. Assist recovering persons to identify their personal interests, goals, strengths and weaknesses regarding recovery. Assist/coach recovering persons develop their own plan for advancing their recovery; for “getting the life they want” and doing so on the path of recovery that is right for them (abstinence, MOUD, 12 Step, etc.) Actively identify and support linkages to community resources (communities of recovery, MOUD, educational, vocational, social, cultural, spiritual resources, mutual self- help groups, professional services, etc.) that support the recovering person’s goals and interests. This will involve a collaborative effort including the recovering person, agency staff and other relevant stakeholders. Link individuals to appropriate professional resources (including MOUD). Provide vision-driven hope and encouragement for opportunities at varying levels of involvement in community based activities (e.g., work, school, relationships, physical activity, self-directed hobbies, etc.). Develop relationships with community groups/agencies in partnership with others in the agency. Identify barriers (internal and external) to full participation in CORE and/or community resources and develop strategies to overcome those barriers. Maintain contact either in-person, by phone and/or e-mail with recovering person for 12 months once they engage in CORE to ensure ongoing success and to provide re-engagement support in partnership with others in the agency if needed.

The CRS will meet with patient at least monthly to assess compliance, address patient needs and gain insight into unmet needs. Coordinate information and patient needs (social service, health and medication) with appropriate interdisciplinary provider: PCP, social work, MOUD provider, D&A provider, etc. Serve as an essential link between patients and all other care providers. CRS is responsible for interacting with patient service representatives to expedite scheduling for follow-up and acute care appointments within UPHS. Facilitate appointments for consults and support services within established service standards, including behavioral health clinicians, social workers, physician, community agencies, etc. Coordinate multidisciplinary team meetings; develop concise patient progress summaries for use by the care team, and document recommendations made utilizing standardized care protocols in accordance with state/nationally recognized care guidelines. Monitors and evaluates the delivery of care through documentation and tracking of needs addressed, track outcomes and support strategic planning through CORE data collection in accordance with all state requirements. Follow patients throughout the care continuum, including inpatient admissions, discharges from all levels of care, and collaborate with inpatient care management resources. Adhere to established productivity benchmarks.