7.10 Continuing care

A Family Guide to Concurrent Disorders - Part III: Treatment

People with concurrent disorders should be entitled to a team of resource workers that take an ongoing, respectful and proactive interest in supporting them and their families. Continuing care does not necessarily mean that the client and counsellor must continue to meet regularly, but that, from the counsellor's perspective, the door is always open and the client is welcome, even if the last contact was some time ago.

The long-term goal is a stable recovery and transition out of treatment. Because concurrent disorders are often complex, recovery may include several transitions between levels of care (e.g., between inpatient and outpatient care; between outpatient and community care). Treatment providers should take responsibility for managing the transition and for following up to ensure that the new arrangement works. However, we know that this co-ordination is sometimes left to the family and the client.

Transition or discharge planning should begin when the client enters care. You and your relative need to be involved. You should make sure that the treatment team understands how much care you can provide for your relative, and that services are put in place to fill any gaps. A transition plan should include a full array of services:

• case management
• child care
• financial support
• housing
• physical health needs
• a support network.

When your relative leaves treatment, you need to be clear about how to reconnect with the service, if necessary.

Questions to ask about a transition or discharge plan

• Has a follow-up session been scheduled? (If so, make sure you know the date and time, location, contact name and telephone number.)
• What medications have been prescribed? What are they for? What is the dosage of each prescription? When should they be taken?
• Have relapse risk factors/triggers been identified?

If your relative isn't living with you:

• What arrangements have been made for housing?
• Have resources been identified to help the person reconnect to employment, school or vocational training?

It takes a lot of effort and commitment to make the mental health and substance use systems work for your relative. You should be recognized as a partner in organizing and delivering the care your relative needs, so educate yourself about concurrent disorders and treatment options, be persistent, ask questions—and keep asking them until you get the information you need.

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