This phase begins once the member has moved out of the JOH facility into their permanent home, and it lasts as long as the person desires services.

Supporting the member in creating a full and content life for themselves in the community has been the ultimate goal of JOH’s work with the member from Phase 1. Phase 5 builds on the progress made throughout the person’s JOH experience to equip the member with the skills and resources they need to build their own dependable recovery support network independent of JOH services.

The risk of resuming substance use is greatest within the first 90 days after treatment, suggesting that more assertive monitoring may be necessary—at least within this critical timeframe—to help people sustain recovery. For individuals with a history of chronic homelessness who have just transitioned out of residential treatment and into an independent living environment, the risks for relapse following treatment can be even greater.

Goals for this phase are to support the person in embedding practices into their daily life that will help them sustain their recovery, increase their capacity to stay housed, and help them achieve their quality-of-life goals. This will entail working with the member to implement their continuing support plan and to ensure the person has regular, scheduled, and structured meetings with a JOH peer specialist and a JOH case manager.

Why is Phase 5 important?

Phase 5 Goals

Individuals should have developed their continuing support plan in Phase 4. This plan represents the collaborative work of the member and their service team. It documents the type and frequency of support that the member would like from JOH staff. It also describes the kinds of actions that they will take on their own to support their ongoing wellness. In phase 5, members put this plan into action, and make adjustments as needed.

In earlier phases, members worked on identifying and strengthening their support system. In this phase, they are learning how to use their support system in their everyday life. Work in this area will be different for each individual, but it will generally focus on helping them solidify relationships. Work with them to set goals and practice interpersonal skills such as setting appropriate boundaries, increasing their comfort with asking for help and support, learning to identify and enjoy pro-recovery recreational activities, and strengthening their communication skills.

Individuals leaving a JOH residence for their own home will be in various places along the continuum of recovery and wellness. The fact that an individual now has independent housing does not necessarily mean that their substance use disorder is fully treated or that they are positioned to successfully maintain their recovery. It is essential to gradually transition members from JOH services and to assertively connect them to community-based supports, including outpatient treatment services, as needed. Even if members have previously said no to outpatient treatment, raise the issue respectfully in this phase. Motivational interviewing and assertive engagement skills could help the individual identifying what kind of support will help them to achieve their current goals. 

While people can find it helpful to structure their days with a clear schedule of activities, for many this still is not enough to protect their recovery. They need more than a schedule, a place to live, and places to go. Like many of us, they crave a sense of meaning, purpose, connection, and fulfillment in their life. Support members in exploring the kinds of activities that promote these feelings and help them to build these experiences into their routine. 

To stay connected with a JOH member over the long term, take steps to ensure that the amount and type of services you offer meets their changing needs. Typically, you’ll want to increase support when the member is experiencing significant life changes, even when those changes are positive.

An essential point to remember about continuing support is that the responsibility for maintaining contact with a member rests with JOH. The staff providing continuing care services—typically peers and case managers—initiate meetings and check-ins, take the lead in rescheduling missed contacts, and ensure that the member is getting helpful and relevant service from JOH and community resources. If a member disengages or informally leaves the program, JOH staff should try to locate that person, including going out into the community to look for them. Members who return to using should be invited back into the residential program. 

Phase 5 Resources

Circle Of Support Tool

Published 2020

Program Manager

Project Assistant