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Outreach, aftercare and referral

Your service can take steps to improve the experience of clients with complex needs while they are part of your program. But for long-lasting effects you also need to follow effective outreach, aftercare and referral practices for these clients.

Outreach and aftercare

Post-treatment outreach and aftercare services benefit all drug and alcohol clients. They provide the opportunity for transitional support back into the community and to consolidate skills learnt in the treatment setting, including relapse prevention, problem-solving, harm-reduction and self-help skills. People with complex needs have an increased chance of experiencing setbacks, so post-treatment follow-up can be key to helping them maintain healthy treatment outcomes.

Best practice indicates that people who participate in follow-up or aftercare after exiting a service do have better long-term outcomes. Structured aftercare programs can help provide additional support for people during the transition from treatment into the community. Assertive follow-up for those who miss appointments can help by providing the opportunity to reschedule, to identify and discuss any problems, and to remain engaged.

People with complex needs such as a cognitive impairment may require more assertive aftercare service provision. Service-directed follow-up can support the person to remain engaged. This may require a person keeping a diary, receiving reminders via phone, and having transport available to get them to their aftercare appointments.

Services that can't provide aftercare or outreach support should refer people with complex needs to other service providers post treatment. When supporting people with complex needs to make this transition, allow time to take them to the new service and have transitional meetings, as people with complex needs may need extra time to feel comfortable with different or multiple service providers. Family, carers or other support people in the person's life should be involved in aftercare planning and treatment where possible.

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As noted above, when working with a person with complex needs you may need to refer them to another service. Recent research suggests that successful engagement with appropriate services largely depends on the person's capacity to navigate the sector, recognise when interventions are not appropriate for their needs, and find more effective services (Flaherty et al 2010). Referrals by workers, and the referral process, therefore, can be particularly influential in facilitating the person's engagement and retention with appropriate care.

Referrals may occur at the initial assessment stage when you and the person determine that another service may be more effective in meeting their needs. It may be while the person is participating in your program and needs specialist support, or it may be at the end of your program as part of their aftercare plan to meet their ongoing needs.

While many people may only be given a service name and number, i.e. a 'cold' referral, "the research suggests that people with complex needs may require more intensive support" (Clarke & Forrell 2007) - in other words, a 'warm' referral.

Cold and warm referrals

Referrals can be categorised as either 'cold' or 'warm'.

A 'cold referral' [involves] providing information about another agency or service so that the client can contact them [while a] 'warm referral' involves contacting another service on the client's behalf and may also involve writing a report or case history on the client for the legal service and/or attending the service with the client. (Clarke & Forell 2007)

Turn cold referrals into warm referrals for people with complex needs by:

  • Speaking directly to the service you are referring the person to and checking it's appropriate for them
  • Introducing yourself and the person to the referring agency and providing a verbal and/or written handover (with the person's consent)
  • Developing a referral pathways list for your service that identifies and shares useful contacts
  • Developing shared assessment or referral tools and processes for services that you regularly refer to (and those that regularly refer to you)
  • Setting up joint meetings with the person and the new service for initial appointments
  • Following up with the person to see how the referral is working out
  • Getting support from colleagues to help identify appropriate services for referrals in particular locations or for specific issues.

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