Process improvement for behavioral health

Map Out Continuing Care


Clients do not know that recovery continues beyond the current level of care.


Introduce a “roadmap to recovery” at regular intervals to show the treatment choices the client will have to make in order to continue their recovery.

Featured Stories

The Partnership for Advancing Recovery in Kentucky (PARK) used a Roadmap to Recovery to show clients the decisions they will face as they move through recovery. The roadmap is introduced early in treatment to help communicate realistic expectations, including that treatment will need to continue even after they complete the program they have just begun. For more information about this change and all of the changes implemented by PARK, see the PARK Continuum of Care.

Fayette Companies in Peoria, Illinois explains to everyone admitted to detox that continued treatment is expected even after they leave detox.

Lessons Learned

  • Map out the need for continuing care to clients early in treatment and again just prior to discharge.

Tracking Measures

Cycle Measure

Percentage of referred clients who were admitted

Data Collection Form



  • 1. Select one referral source.
  • 2. Create a roadmap of continuing treatment that can be explained to clients and decide when to present it – e.g., when they are referred to treatment and/or before they are discharged from treatment and referred to the next level of care.
  • 3. Collect baseline data for the percentage of referred clients who were admitted.


  • 4. Test use of the roadmap by presenting it to a few clients at the designated point–e.g., when the referral is made and/or before discharge.
  • 5. For the clients who were exposed to the roadmap, track the percentage of referred clients that are admitted.


  • 6. Check the fidelity of the change. Was the change implemented as planned?
  • 7. Evaluate the change:
    • How did the clients react to learning about the entire roadmap to recovery?
    • For clients who were exposed to the roadmap, did the percentage of referred clients who were admitted increase?


  • 8. If this change was an improvement:
    • Adopt this change or adapt the content and/or timing and frequency of introducing the roadmap for more improvement and re-test it.
    • Expand the use of the roadmap by referrers.
    • Document the processes that resulted in an improvement so that you can continue to use them efficiently.
    • Test other, related promising practices that apply to your setting.

If this change was not an improvement and you can’t make it work, abandon this practice and test other promising practices that might be more successful in your setting.