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Recovery-Oriented System of Care (ROSOC)

  • Need: To serve adults in Mendocino County, California with chronic substance use disorders, mental health diagnoses, and/or complex medical conditions who frequently utilize emergency departments and jail services.
  • Intervention: A safety net organization was formed that works with medical providers and law enforcement to reduce the high cost of caring for frequent utilizers through intensive care coordination activities.
  • Results: Greater overall stability in the lives of clients, with less utilization of low-efficacy, crisis-oriented services, hospitalizations, and incarcerations.


The Recovery-Oriented System of Care (ROSOC) was a collaborative approach to intensively engage adults who have a history of frequent crisis services utilization. These individuals may have chronic substance use disorders or co-occurring disorders, as well as other complex medical conditions.

As of January 2018, the project now continues as a Partnership Healthcare-sponsored program utilizing the basic principles and criteria of the CUSOC and ROSOC programs, but is now referred to as the "Whole Person Care Project" (WPC).

The Mendocino County AIDS/Viral Hepatitis Network (MCAVHN) is no longer the lead agency, but is the senior participant in the project because of the extensive experience in holistic care for co-occurring disorders and co-morbid conditions.

Mendocino Community Health Clinic remains the current partner also involved in original program.

Other current partners include:

The (WPC) operates similarly to the ROSOC program receiving referrals from emergency departments, county-contracted mental health providers, jail medical services, and from other program clients. Individuals were interviewed to determine their interest in changing from a crisis-based approach for care to a more stable and proactive approach to provide consistent care.

As were the goals for ROSOC, the WPC goals include:

  • Participants receive primary and behavioral health care
  • Engage participants in their own care
  • Improve participants' health status, including substance use disorders, and finding the most integrated recovery programs that include concurrent treatment of mental health issues
  • Decrease overall healthcare and other community costs

ROSOC was originally the Chronic Users System of Care (CUSOC), a 2-year pilot project funded by County Medical Services Program's (CMSP) Local Health Connections (LHC). Due to the lack of continued funding, CUSOC ended after the pilot project ran its course. MCAVHN realized the value of the continuation of the program, and adapted CUSOC into ROSOC. Delivery of case management services were continued with funding from multiple private foundation grants, local support of Mendocino County Health and Human Services, and occasional asset forfeiture funds.

Now, WPC is a wider bandwidth around our inland and coastal communities and its funding supports the ROSOC framework: Funding streams changed with subsequent program name changes, but focus remains the same. As of 2018, funding is through a 3-year grant cycle in order to continue the service within Mendocino County.

This video highlights the program's original story and CUSOC impact:

Services offered

Services are based on willingness to participate. Clients do not have to enter the program agreeing to anything but engagement with care managers. Goals are consistent with probation and other legal sanctions, as well as personal recovery goals.

  • Assessment tools to form a biopsychosocial profile of a new participant
  • Assistance in attaining housing, Social Security Disability/Supplemental Security Income, or other income if necessary
  • Frequent contact with case manager
  • Referral and guaranteed linkage to appropriate individualized services
  • Monitoring of all services
  • Support for continued access to all services
  • Collaboration with law enforcement officials to reduce recidivism and to seek alternatives to incarceration when appropriate


The following statistics reflect the original work of the ROSOC program:

  • Of those who were homeless upon entry into program, 76% are permanently or stably housed.
  • Of those who were not engaged in medical care upon entry into the program, 93% are now receiving consistent primary medical care.
  • Of those who needed, but were not engaged in mental/behavioral health services, 77% are now regularly attending behavioral health therapy and/or are receiving psychiatric medications.
  • Of those who were in need of Alcohol and Other Drug (AOD) services upon entry, 76% received AOD treatment services.
  • Of those with no income at entry into services 83% have been connected to financial assistance (through public assistance, SSI/SSDI awards, and/or employment)
  • Of those who repeatedly utilized emergency medical services and/or jail services, 96% have dramatically reduced the use of crisis-oriented services and/or incarcerations (0 to 1 incidents per reporting period).

Very early results from leveraging new WPC grant-funding has:

  • Supported new infrastructure development:
    • Needed multifunction community resource center to serve the more isolated residents in the rural service area, infrastructure that is also serving administrative as well as "social hub" needs.
    • Re-focus for homeless service infrastructure upgrade.

For more information on this program:

2014 National Health Care for the Homeless Council presentation: ROSOC: Recovery-Oriented System of Care, the Metamorphosis of a Multidisciplinary Collaborative Project in Mendocino County, California.

Fall 2018 MCAVHN Newsletter, The Whole Person Care Project.


The greatest and most consistent barrier for ROSOC/WPC clients is housing. Mendocino County, particularly the inland valley portion of the county, has a significant housing shortage. Even though 95% of program participants who were once homeless have obtained a housing subsidy certificate, many are still unable to lease-up during the 120-day time limit. Missing this limit results in a loss of their subsidy, and participants must wait for a waiting list to re-open (this can take several years). Mendocino County has a pronounced lack of 1-bedroom units for single adults, so MCAVHN operates an emergency homeless shelter for ROSOC's vulnerable and chronically homeless individuals.


In order for a program like ROSOC/WPC to work effectively, it requires a great number of partnerships and buy-in from other agencies within local communities. It was immensely important at the beginning of the ROSOC collaboration that all agencies agree on the program's goals at the outset. The same holds true with current funding.

With the current WPC funding, ROSOC's impact continues being offered to a larger client cohort throughout the county.

Contact Information

Libby Guthrie, EdD, MA, CCDS, Executive Director
Mendocino County AIDS/Viral Hepatitis Network (MCAVHN)

Alcohol use
Behavioral health
Care coordination
Criminal justice system
Emergency department and urgent care services
Housing and homelessness
Integrated service delivery
Mental health
Networking and collaboration
Substance abuse

States served

Date added
January 20, 2015

Date updated or reviewed
September 23, 2019

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.