Who Supports the Patient Between Appointments?

Individuals experiencing alcohol and other drug (AOD) problems frequently engage with psychiatrists, psychologists, withdrawal services, rehabilitation programs, peer support groups and primary care providers. While these services provide valuable episodes of treatment, many individuals experience prolonged periods between appointments, during service transitions, or following discharge from structured treatment. These gaps can contribute to relapse, disengagement from care, and avoidable readmissions.

This presentation describes an emerging Clinical Nurse Specialist-led model developed to strengthen continuity of care between formal treatment episodes. The model was established in response to a recognised service gap for individuals requiring more support than traditional outpatient follow-up can provide, but who do not require intensive case management or inpatient treatment.

The service provides rapid access to appointments, support across all stages of change, family education and involvement, telehealth and video-link accessibility, proactive weekend text check-ins, relapse prevention planning, harm reduction interventions, and ongoing liaison with psychiatrists, general practitioners, psychologists and other treatment providers. A key feature of the model is its emphasis on accessibility, responsiveness, and maintaining engagement during periods of increased vulnerability.

The presentation will explore how proactive follow-up, collaborative care, and regular therapeutic contact can support recovery outcomes and strengthen treatment continuity. Clinical experience within this model suggests that accessible support, proactive engagement, and coordinated communication between providers may assist individuals to remain connected to treatment goals, strengthen accountability, and maintain engagement during periods where relapse risk is elevated. Particular attention will be given to transitions into and out of withdrawal services, rehabilitation programs, inpatient admissions, and other treatment episodes where the risk of disengagement is often greatest.

The model aligns closely with the Western Australian Mental Health and Alcohol and Other Drugs Strategy 2026-2031, which emphasises prevention, early intervention, integrated care, and opportunities for people to achieve their wellbeing goals through accessible, community-based support. By providing flexible clinical recovery support, proactive engagement, and coordinated care between treatment providers, this model reflects the Strategy’s vision of services that are accessible, integrated, easy to navigate, and focused on helping people remain well within their communities. This presentation invites discussion regarding the role of Clinical Nurse Specialists in strengthening continuity of care and contributing to more connected, recovery-oriented systems of support.