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TLC Programs Access To Recovery Access & Care Coordination

Access & Care Coordination


Rocky Mountain Tribal Access to Recovery

ATR Care Coordination

What Does Care Coordination Mean to ATR?

ATR Care Coordination is the thread that holds the fabric of the ATR program together. Consistent supportive contact with an identified Care Coordinator leads to higher retention in services, and better treatment outcomes.

What is ATR Care Coordination Based On?

ATR Care Coordination is a strengths-based approach:  the two principals of this model are 1) providing clients support for asserting direct control over the search for resources and 2) examining the client’s own strengths and assets as the vehicle for resource acquisition. This model:

  • encourages the use of informal helping networks,
  • promotes the importance of the client/care coordinator relationship, and
  • provides active forms of outreach.

This model has been used with the substance abuse population because of

  1. the usefulness of helping the client access resources for recovery,
  2. the strong advocacy component and
  3. the emphasis on helping clients identify their strengths, assets and abilities (Treatment Technical Advisory-03; Issued October 1, 2006, ODCP).


The ATR Care Coordination model uses local paraprofessionals who serve as a bridge between people experiencing life problems, (who may have identified the connection of these problems with their alcohol/drug use), with traditional Native American mentors, and both Native and non-Native service providers. Care coordination has been shown to improve outreach, enhance client access to treatment and recovery support, increase family engagement and enhance the ability of treatment programs to incorporate cultural healing practices. Utilizing local people, especially people in recovery, to advocate and coordinate services for ATR clients can greatly expand the network of recovery support resources and enhance the client’s chances for sustained recovery.

The Care Coordinator should be someone from the tribal or urban community who is

  • knowledgeable about community supports,
  • knowledgeable about where the local resources are located and
  • knows who the clinical treatment and recovery support network providers are in the area.


This person should understand cultural values and beliefs, both formal and informal.  He or she will recognize the Soul Wound of Native people and help to build a healthy forest for them to flourish and grow in. He or she works peer to peer with clients to bring about an understanding and an ability to relate. Care Coordination sites will provide a place people can trust and be comfortable with.  Care coordination sites may use Medicine Wheel teachings in addressing emotional, mental, physical, and spiritual aspects in a recovery person’s life.

What Does an ATR Care Coordinator Do?

Basic functions of the Care Coordinator:  To work with the client as an advocate for his/her recovery path; including recovery support assessment, planning, providing services, evaluating services and outcomes, and monitoring treatment and recovery services from a variety of resources.

  1. The ATR Tribal Access and Care Coordination Site assign a Care Coordinator when the client enters the ATR system. The Care Coordinator should stay with the client throughout their participation in the program. At Intake, the Care Coordinator identifies barriers to recovery in the client’s own words. The client’s goals and perceptions are used to guide the recovery process.
  2. The Care Coordinator advocates for the client, helps the client navigate the system, requests services using the Voucher Management System.
  3. The Care Coordinator stays in regular contact with the client by phone and in person and will check on progress with the client’s Treatment and Recovery Management Plan.


As an advocate, the Care Coordinator networks with community resources, and interfaces on behalf of the ATR client.  The Access and Care Coordination site may assign the Care Coordinator to recruit recovery support providers based on the needs of the clients.

The Care Coordinator works with the clinical treatment and recovery support providers to make sure the client is accessing services and to ensure appropriate updates are made to the treatment and recovery plans.  In the case of “no shows” the Case Coordinator can follow-up with a call or visit; discuss concerns regarding absences and determine the need for additional support services to ensure continued participation.

The Care Coordinator acts as the primary contact for access to Recovery Support services, especially once the client has completed clinical treatment and is using the recovery support resources available to them.  The Care Coordinator may complete a Recovery Support Assessment with the client and work with the client to develop and then implement a Recovery Management Plan.

The Care Coordinator ensures that the grant requirements for participation in the Rocky Mountain Tribal Access to Recovery Program are met. This includes working with the client and the primary treatment provider to complete a GPRA interview at three points:  initial Intake, five to six months after the Intake and at the point where the client stops receiving ATR services and is discharged from the program.  These GPRA interviews are a grant-mandated requirement: an 80% completion rate for 6 month follow-up interviews is mandated in order to receive federal funding.

For more information please contact:

Nell Eby – Project Manager – (office) 406-252-2550 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it '; document.write( '' ); document.write( addy_text13418 ); document.write( '<\/a>' ); //--> This e-mail address is being protected from spambots. You need JavaScript enabled to view it


Karla Two Two – Recovery Support coordinator – (office) 406-252-2550 This e-mail address is being protected from spambots. You need JavaScript enabled to view it