PS377 Unit 3 Service Coordination Paper Example

Five Appointments, Four Agencies and One Bus Pass: A PS377 Unit 3 Service Coordination Paper

[Student Name]

Purdue University Global

PS377: Models of Peer Recovery

Unit 3 Service Coordination Paper

[Instructor Name]

[Date]

The writer, the center, the participant, the agencies and every detail are composite and illustrative; the articles cited are real.

Tasha's First Two Weeks

Tasha is thirty-one, has a seven-year-old daughter and has been on methadone for opioid use disorder for three months. She also lives with HIV, diagnosed two years ago. She came to our Louisville recovery community center because her methadone counselor thought a peer specialist could help her manage everything else. In her first two weeks with us, she had five appointments: methadone dosing every morning, her counselor, her HIV clinic, a housing caseworker and a school meeting about her daughter. They were run by four agencies across three bus routes, and she had missed two appointments the month before.

Eddie et al. (2019) reviewed research on peer recovery support services and recovery coaching. They described common peer roles, including helping people find their way through services, linking them to treatment and community resources, and supporting them through transitions, and found evidence of benefits such as improved treatment retention and reduced substance use, though study designs varied widely. Coordination is one of the most practical of those roles.

Intake and Screening

At intake, I used the center's standard forms with Tasha: contact information, current services, goals in her own words and a brief screen of recovery strengths and needs, covering housing, income, transportation, health, family, legal issues and supports. The screen is not a diagnosis; it helps us see where she is strong and where she needs help. Her strengths included her daughter, her methadone counselor, whom she trusted, and a cousin who drove her to appointments on weekends. Her needs were transportation, unstable housing and keeping track of appointments.

A Shared Service Plan

Tasha and I wrote a one-page service plan together. It listed her three goals, "keep my daughter," "stay on my meds" and "get my own place," and under each, the services involved, the next step, who would do it and by when. For example, under "stay on my meds," the next step was to get her HIV clinic and methadone clinic to coordinate so that she could get both medications without two separate trips on clinic days.

The plan fit on one page because Tasha needed to read it at a bus stop.

Coordinating Across Agencies

The practical work was ordinary and constant. I helped Tasha build a single paper calendar with every appointment, color coded by agency. I applied for a monthly bus pass through a program for people in treatment. I asked the HIV clinic whether her appointments could be scheduled right after her methadone dose, since both were near the same bus line, and the clinic agreed. I sat with her during the school meeting, at her request, to take notes.

A review of barriers in the continuum of care found that people in recovery often fall through gaps between services, and that peer support can help by accompanying people across those gaps (Stanojlović & Davidson, 2021). Bassuk et al. (2016) found that peer-delivered services were generally associated with positive outcomes, including retention in treatment. For Tasha, missed appointments were the gap; in her first month with us, she missed none.

When the Plan Changed

Service plans are working documents. In week three, Tasha's housing caseworker called to say a unit might open at a family housing program, but the application required a letter from her methadone counselor and proof of income within five days. That one call changed the plan's priorities. With Tasha's consent already on file, I let her counselor know a letter was needed, and Tasha and I spent an afternoon at the center gathering pay stubs and her daughter's school enrollment form. We updated the one-page plan that evening, moving "get my own place" to the top and adding the five-day deadline in red. The application went in on day four. Keeping the plan current, rather than writing it once and filing it, is what turned it from paperwork into a tool Tasha used.

Measuring Coordination

The center tracks a few simple measures for every participant: appointments scheduled, appointments kept, and the number of services the participant is connected to. For Tasha, I also tracked missed medication doses, since both of her medications depend on daily attendance. These numbers go into my notes each week and into the center's monthly report, which helps my supervisor see whether coordination is working.

Consent and Confidentiality

Coordination requires sharing information, and sharing information about substance use treatment has strict rules. Under federal rules, a program treating substance use cannot release a person's records without written consent that names each recipient and purpose. Tasha signed separate consent forms for her methadone clinic, her HIV clinic and her housing caseworker, each naming what could be shared. She declined consent for the school, so I shared nothing there; at the school meeting, she spoke for herself.

Documentation

Peer documentation records what happened, not what the peer thinks it means. After each contact, I write a short note: the date, the type of contact, what Tasha said in her own words, what we did and the next step. I record observations, such as "Tasha arrived fifteen minutes late and said the bus was delayed," not opinions, such as "Tasha seemed unmotivated." I avoid clinical terms I am not qualified to use. My supervisor reviews my notes weekly and corrected me twice in the first month for language that sounded like judgment.

What Coordination Is Not

Coordination is not case management in the clinical sense, and it is not counseling. I do not make treatment decisions, change Tasha's plan with her providers or interpret her medical results. When she asked me whether her HIV viral load was good, I told her to ask her clinic nurse and helped her write the question down.

Early Results

In her first six weeks with the center, Tasha kept every scheduled appointment, received both medications without missing a dose and was approved for a housing program waitlist. She said the calendar was the most useful thing we made.

Conclusion

Five appointments at four agencies became manageable with a one-page plan, a single calendar, a bus pass and coordinated scheduling. Eddie and colleagues' review and Bassuk and colleagues' review support peer roles in navigation and retention, and a review of barriers explains why the gaps between services matter. Consent rules shaped what could be shared, and documentation recorded observations rather than judgments.

References

Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M., & Laudet, A. (2016). Peer-delivered recovery support services for addictions in the United States: A systematic review. Journal of Substance Abuse Treatment, 63, 1-9. https://doi.org/10.1016/j.jsat.2016.01.003

Eddie, D., Hoffman, L., Vilsaint, C., Abry, A., Bergman, B., Hoeppner, B., Weinstein, C., & Kelly, J. F. (2019). Lived experience in new models of care for substance use disorder: A systematic review of peer recovery support services and recovery coaching. Frontiers in Psychology, 10, Article 1052. https://doi.org/10.3389/fpsyg.2019.01052

Stanojlović, M., & Davidson, L. (2021). Targeting the barriers in the substance use disorder continuum of care with peer recovery support. Substance Abuse: Research and Treatment, 15. https://doi.org/10.1177/1178221820976988