What We Do

The Behavioral Health Model for Vulnerable Populations asserts that vulnerability influences a person’s ability and opportunity to use care. The model specifically indicates that substance abuse, mental health problems, limited English proficiency, homelessness, HIV status and birthplace (e.g. mainland United States versus Puerto Rico) are all predisposing factors that influence the ability of vulnerable populations to access and engage in health care services. 

suggests that individuals with serious mental illness, including individuals with co-occurring disorders, benefit from a team-based approach that maintains small caseloads, provides most care within the team, relies on assertive engagement mechanisms, and prioritizes the role of consumers and/or family members on the treatment team. 

Assertive Community Treatment has its basis in both the Chronic Care Model that takes a structured approach to clinical improvement through team-care supported by an organizational and information technology infrastructure, and the Institute of Medicine’s (IOM) report on health equity which highlighted the importance of team based care to ensure that care is safe, effective, patient-centered, timely, efficient, and equitable. 

has its basis in both the Chronic Care Model that takes a structured approach to clinical improvement through team-care supported by an organizational and information technology infrastructure, and the Institute of Medicine’s (IOM) report on health equity which highlighted the importance of team based care to ensure that care is safe, effective, patient-centered, timely, efficient, and equitable.  

• Casa builds and develops multidisciplinary teams focused on outcomes-based Care Management (an organized approach to multidisciplinary assessment, diagnosis, and patient-centered care planning designed to strengthen clinical pathways and outcomes) and Care Coordination to address complex patient needs  
• Delivers co-located addictions, mental health, primary/urgent medical care, and health promotions and recovery support services  
• Treats patients in a holistic and integrated way, addressing each diagnosis as primary  
• Addresses social determinants of health through a wide range of recovery support services

Integrates best available research with clinical expertise and responsiveness to patient needs to develop and deliver best-practices  

Grounded in the interventions and approaches developed in the Integrated Dual Disorder Treatment (IDDT) model developed at Dartmouth University, which includes the following core components:  

• Multidisciplinary Team (medical, mental health, addictions, and recovery support professionals)  
• Stage-Wise Interventions (stages of change, stages of treatment)  
• Access to Comprehensive Services (e.g., clinical stabilization, residential, outpatient, MAT, psychopharm, peer support, employment, etc.)  
• Time-Unlimited Services (relapse, recidivism, and crisis responsive)  
• Assertive Outreach (engaging individuals at home, in community, in correctional and other law enforcement settings, actively staying connected to patients to retain them in care)  
• Motivational Interventions  
• Substance Abuse Counseling  
• Group Treatment  
• Family Psychoeducation  
• Participation in Alcohol & Drug Self-Help Groups (AA, NA, SMART Recovery)  
• Pharmacological Treatment (MAT, Psychopharm, etc.)  
• Interventions to Promote Health (vaccination, HIV/HEP counseling and testing, nutrition support, NRT and other tobacco cessation supports, Illness Management and Recovery, etc.)  
• Secondary Interventions for Treatment of Non-Responders  

Benefits Advocacy & Planning  

• Also draws heavily from other trauma informed approaches, such as Dialectical Behavioral Therapy (DBT) Skills, Seeking Safety, Sanctuary/SELF Model, Mindfulness Based Stress Reduction, and Supported Education/Employment  
• Continuously learning and adding to research through our partnerships with academia (University of Denver, Brandeis University, Boston University) 

• Grounded in our understanding of and responsive to the specific needs of our population  
• Direct-care staff are trained in Relational Cultural Theory, a framework that focuses on the cultural factors that shape individuals’ lives and emphasizes the primacy of relationships as indicators of mental health and wellness.  
• Centered in cultural humility and the Latinx philosophy of personalismo, to ensure that all feel welcome, known, and understood  
• Staff and leadership are reflective of the population we serve  
• Aligned with Culturally and Linguistically Appropriate Services (CLAS) standards, developed in 2001 and enhanced in 2013 by the U.S. Department of Health and Human Services’ Office of Minority Health 

• Responding to the needs of the whole person  
• Partnering with patients as experts in and drivers of their own recovery  
• Empowering patients to build self-management skills and self-efficacy  
• Supporting the economic independence and self-sufficiency of our patients 

• Prioritizes physical, emotional, and psychological safety  
• Builds safety through reducing risk and building resiliency  
• Reduces risks and builds resiliency through a commitment to transparency, self awareness, collaboration, empowerment, humility, and equity  
• Recognizes that staff resiliency is central to building patient resiliency 

This phase focuses on thorough assessment, accurate diagnosing, building and implementing effective/optimized care plans, securing basic needs, and stabilizing on medications. Motivational strategies are used by all MDT members to actively engage patients/participants in planning their own care, including developing initial safety plans. DBT skills are introduced early in this phase to support self-regulation and effective communication about clinical needs. Services targeted to this phase include:  

• Clinical Stabilization Services  
• Open Access/Urgent Care Triage  
• Comprehensive Addictions, Mental Health, Medical Assessment and diagnosis  
• HIV/HCV/STI Counseling and Testing  
• Safety Planning  
• Recovery Skills 1: DBT Emotion Regulation and Distress Tolerance Skills  
• Medication Reconciliation  
• Rapid Induction to Medication Assisted Treatment  
• Assertive Engagement/Reengagement  
• Basic Needs (health insurance, housing, basic income and other benefits)  
• Structured Outpatient Addiction Program (SOAP) *  

This phase focuses on maintaining safety, enhancing self-awareness, identifying triggers, and building recovery skills. Motivational strategies are focused on enhancing patient/participant engagement in both individual and group sessions. Psycho-ed, CBT, DBT, and other evidencebased practices are engaged to help patient/participant learn about their own health status, broaden their knowledge of recovery supports and services available to them (including MAT as appropriate), develop safety and prevention plans, practice self-care routines, and connect to their peers in recovery.

• Residential Addictions and Mental Health Treatment
• Primary Care
• Health Screenings
• Recovery Skills 2: DBT Emotion Regulation, Distress Tolerance, and Mindfulness Skills; Seeking Safety; Anger Management; Safe Relationships/Boundaries; and Relapse Prevention
• Developing and Documenting a Safety & Prevention Plan
• Developing and Documenting Daily Recovery/Self-Care practices
• Life Skills 1: Budget, Daily Chores/Routine
• Illness Management and Recovery/Medication Management Skills
• Parenting Skills (Nurturing Program)
• Health/Wellness Promotions Activities
• Individual and Group Counseling/Psychotherapy
• Housing Supports
• Family Visitation
• CasaCare closed NA Groups

This phase focuses on supporting patients/participants in increasing their independence and confidence in recovery. Motivational strategies focus on engaging patients/participants in self advocacy and self-management while sustaining core recovery practices. Patients/participants begin to spend more time in community and expanding their recovery capital (resources a person has to find and sustain recovery) and supports. Patients/participants are actively engaging in family reunification (as appropriate), education, employment, and other community-based services and supports.  

• Wellness Recovery Action Plan
• Maintaining Daily/Weekly Recovery Practices
• Family Reunification Support
• Recovery Skills 3: Interpersonal Communication (DBT Interpersonal Effectiveness); Conflict Resolution; Self-Management
• Life Skills 2: Preparing for Community Based Living (Balancing Work/School and Social Life, Buying and Preparing Meals, Family Budgeting)
• Engaging Family Supports in the Community
• Self Esteem Support
• Supported Education and Employment
• Supportive Case Management/Supportive Housing
• Individual and Group Counseling/Therapy

This phase focuses on supporting patients/participants in developing leadership skills and taking a leadership role in their community. Motivational strategies focus on engaging patients/participants as leaders of their own recovery and role models for others, and preparing them to sustain their recovery skills through difficult periods. Patients/participants may participate in peer leadership training, Casa’s Consumer Advisory Board, local advocacy efforts, or may find other ways to play a role in a community they care about.  

• Recovery Skills 4: Sustaining Self Care; Building a Community-Based Recovery Support Network; Self-Management and Self-efficacy; Staying Connected
• Life Skills 3: Independent Living
• Sober Social Supports/Activities
• Cultural Activities
• Leadership Training/Recovery Coach Academy
• Consumer Advisory Board
• Peer Leadership/Peer Support
• Advocacy
• Individual and Group Counseling/Therapy