Navigating Community – Based Care

In this section, you’ll learn about strategies you can use to successfully link individuals to services and recovery supports in your community. Once you have completed this section, you should be able to:

  • Describe best practices to link individuals to service and supports
  • Explain key elements of a warm handoff

The Role of Peers

A key function of peer specialists is connecting individuals to other services, supports and people that help them maintain recovery. It is important for peer specialists become familiar with the resources available in the community.

People encounter many barriers to recovery supports that may help them begin or sustain their recovery pathway. For example, they may not know programs exist, the eligibility requirements, or how to deal with the forms they have to complete. People may need identification documents they don’t have, especially if they are re-entering the community. Additionally, they might not have transportation to get where they need to go.

As a peer, linking individuals to services is likely to be a key part of your role. Key strategies are to:

  1. Know available programs and requirements
  2. Conduct warm handoffs

Know the Available Programs and Requirements

Peers need to know the different types of services and supports in the community.

These services may meet a wide range of needs, including:

  • Access to safe housing
  • Employment
  • Job skills/Education
  • Life skills
  • Recovery skills
  • Legal support
  • Healthcare and wellness
  • Support networks
  • Treatment

Sometimes peer support staff work within these programs or, they may work in peer-run recovery community organizations. The different types of programs and organizations include:

  • Publicly funded programs that meet basic needs by providing cash assistance, food, housing assistance, supported employment, healthcare services, and mental health or substance use treatment. These are sometimes called safety-net services.
  • Community-based organizations may run food banks, provide spiritual support, legal support, shelters for individuals experiencing homelessness or intimate partner violence, supported employment, and educational programs.
  • Peer-led recovery community organizations provide holistic recovery support services and programs that focus on maintaining and enhance recovery supports that meet individual needs.
  • Peer-led support groups are often a critical to recovery success and are generally available at no cost. They are not as accessible in some communities but are increasingly available online.  Some groups use a specific recovery framework, such as Alcoholics Anonymous, or a specific curriculum, such as Wellness Recovery Action Plans (WRAP).

Links to Publicly Funded Programs in California

Key Strategy: Conduct Warm Handoffs

Warm handoffs are a process where the peer specialist helps support an individual during the transition to another service, support, or treatment provider.

Visit agencies or providers so you know the location of the building and the office where the person needs to go

“When you arrive, you’ll need to go to the office on the 2nd floor. The name is on a sign above the door right after you get off the elevator. You’ll first speak to a receptionist at the front desk. Let her know you have a 2pm counseling appointment with Linda, and then she will give you paperwork to fill out.”

Try to have a contact you can refer to by name

​​​​​​​“I’ve met Linda before and she has been a really great counselor for some other people who I’ve worked with.”

Remind individuals to take needed documents

​​​​​​​“Remember to take your ID and your insurance information. That will help with filling out the paperwork.”

Go to the first visit with them, if possible

“Would it help you if I meet you at the office and help you with the paperwork before your appointment with Linda?”

Check in to ensure that services are taking place and helping as expected.

After a few days or weeks send a text to check in: “How are the counseling sessions with Linda going?”