3.6 Case Management and Service Coordination in Peer Practice
Key Takeaways
Case management and service coordination are required NCPRSS education areas; peers contribute navigation, accompaniment, follow-up, and advocacy from a non-clinical stance.
Core case management functions are assessing needs, planning, linkage, monitoring, and advocacy.
SAMHSA's TIP 27 describes brokerage/generalist, strengths-based, Assertive Community Treatment (ACT), and clinical/rehabilitation case management models.
Outside emergencies, information is shared with other providers, including probation officers, only with the person's written consent (42 CFR § 2.31; Code II-22).
Closed-loop referrals and planned support at transitions such as hospital discharge or jail release prevent people from falling through gaps.
3.6 Case Management and Service Coordination in Peer Practice
Note
Quick Answer: Case management is a collaborative process of assessing needs, planning, linking people to services, monitoring progress, and advocating so that services fit the whole person. Service coordination is the work of keeping multiple providers and supports pointed in the same direction, with the person's consent. Both are required NCPRSS education areas. Peers contribute navigation, accompaniment, follow-up, and advocacy from a non-clinical, person-directed stance, while respecting consent rules (42 CFR Part 2; Code II-10, II-22) and avoiding the role drift of becoming a compliance monitor.
Case Management: Definition and Core Functions
The Case Management Society of America describes case management as a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet a person's comprehensive health needs. In addiction services, SAMHSA's Treatment Improvement Protocol (TIP) 27, Comprehensive Case Management for Substance Abuse Treatment, frames it as connecting people with the full range of services they need, not only treatment.
| Core function | What it means | Peer contribution |
|---|---|---|
| Assessment of needs | Identify needs and strengths across life areas | Recovery capital conversations, immediate-needs screening (Section 3.4) |
| Planning | Set goals and steps with the person | Person-directed recovery planning (Section 8.1) |
| Linkage | Connect to services and supports | Warm handoffs, accompaniment, transportation planning |
| Monitoring | Check whether services are working | Regular check-ins and follow-up on every referral |
| Advocacy | Remove barriers and protect rights | Coaching self-advocacy, speaking up in team meetings with consent |
Case Management Models (SAMHSA TIP 27)
| Model | Key features |
|---|---|
| Brokerage/generalist | Identifies needs and arranges services; limited ongoing contact |
| Strengths-based | Builds on the person's strengths and self-direction; uses natural community resources; often outreach-oriented |
| Assertive Community Treatment (ACT) | Multidisciplinary team with small shared caseloads that delivers services directly in the community, often around the clock |
| Clinical/rehabilitation | Combines clinical care and case management in one provider relationship |
Peer support fits most naturally with the strengths-based approach, and many ACT teams now include peer specialists.
Peer Specialist vs. Case Manager
| Dimension | Case manager | Peer specialist |
|---|---|---|
| Basis of role | Professional training (often social work, nursing, or human services) | Lived experience of recovery plus peer training and credential |
| Typical tasks | Eligibility determinations, benefit applications, formal service plans, utilization tracking | Engagement, hope, navigation, accompaniment, self-advocacy coaching |
| Relationship | Professional coordinator | Mutual, non-hierarchical partner |
| Overlap | Both link, follow up, and advocate | Both link, follow up, and advocate |
Some agencies employ "peer navigators" or "peer case managers." Whatever the title, Principle X still applies: the NCPRSS works under supervision, stays within the scope of their training, and explains their role clearly (Principle X introduction; X-III-1).
Service Coordination: Keeping the System Connected
People in recovery often juggle a prescriber, a counselor, a primary care clinic, a housing program, probation, child welfare, and benefits offices, each with its own appointments and rules. Coordination prevents duplicated paperwork, conflicting instructions, and dropped handoffs.
Coordination Practices
- One shared plan, led by the person. Use the person's own goals as the organizing frame.
- Consent first. Outside a true emergency, share information only with written consent naming who will receive it and why (42 CFR § 2.31). The Code bars releasing information to physicians, psychiatrists, or probation and parole officers without written consent (II-22).
- Transparency about the team. When the peer is part of a multidisciplinary team, the person is told, and they may ask who is on the team and what is being shared (II-10).
- Closed-loop referrals. Track each referral until you know whether the person connected: date made, who it was with, whether they attended, barriers, and next step.
- Transitions of care. Hospital discharge, release from jail, and leaving residential treatment are high-risk moments. Meet the person before or at the transition, have naloxone and appointments ready, and check in within 24 to 48 hours.
- Benefits and practical supports. Help with Medicaid, SNAP, identification documents, transportation, and disability applications (for example, through SOAR, Section 3.3).
Useful Navigation Tools
- FindTreatment.gov, SAMHSA's locator for substance use and mental health treatment, including providers that offer medications for opioid use disorder.
- 988 for mental health and substance use crises.
- 2-1-1, a free referral line for local social services in most of the United States.
- The agency's own resource directory, kept current by calling providers to confirm hours and intake rules.
Avoiding Role Drift in Coordination Work
| Coordination task | Within the peer role | Drift to avoid |
|---|---|---|
| Sharing progress with probation | Sharing only what the person consented to, ideally with them present | Reporting cravings or minor slips to probation without consent |
| Team meetings | Bringing the person's voice and goals into the room | Becoming the team's eyes and ears for rule enforcement |
| Benefit applications | Helping the person gather documents and practice interviews | Completing forms for the person without involving them |
| Appointment reminders | Supportive reminders the person asked for | Tracking attendance to justify sanctions |
Warning
Coordination is not surveillance. If a team asks a peer to report information the person has not agreed to share, the peer explains the consent requirement, involves the supervisor, and offers to ask the person whether they want to share it.
A Coordination Example
Malik is leaving a 28-day residential program. With his consent, his peer specialist:
- Confirms his buprenorphine appointment for the day after discharge and walks him to the pharmacy to fill the prescription.
- Calls the recovery residence with Malik on speakerphone to confirm move-in.
- Helps him bring his discharge papers and ID to the Medicaid office.
- Logs each referral and checks in at 24 hours and 72 hours.
When Malik misses his first counseling appointment, the peer does not report it as non-compliance. She calls Malik, learns the bus route changed, and helps him reschedule with a transit plan.
At an interdisciplinary team meeting, a probation officer asks the peer specialist whether a participant has mentioned any cravings this month. The participant has not signed a consent naming the probation officer. What should the peer do?
Share the information briefly, because probation is part of the participant's care team and needs to know about cravings to keep the community safe.
Decline to share, explain the consent requirement, and offer to ask the participant what they want shared.
Share only a general impression, such as "things are going fine," since a general comment does not count as a disclosure under federal rules.
Leave the meeting without comment, then tell the participant afterward that the probation officer is trying to catch them using again.
A peer specialist refers a participant to a dental clinic and an outpatient counselor. Which practice best reflects closed-loop referral?
Giving the participant the two phone numbers and assuming they will call if they still want the services after thinking it over.
Logging both referrals, confirming whether each connection happened, and following up on any barriers.
Calling both providers weekly to collect detailed reports on the participant's progress without asking the participant first.
Closing both referrals in the record as soon as they are made, since the peer's part of the task is complete once the numbers are given.
Which case management model uses a multidisciplinary team with small, shared caseloads that delivers services directly in the community, often around the clock?
The brokerage/generalist model, in which a single worker arranges services and keeps only limited ongoing contact with the person.
The clinical/rehabilitation model, in which one provider combines therapy and case management in the same relationship.
The strengths-based model, which builds on the person's strengths and natural supports, usually through a single case manager.
Assertive Community Treatment (ACT).
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