Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Comprehensive
Case Management
for Substance Abuse
Treatment
Treatment Improvement Protocol (TIP) Series
27
Comprehensive
Case
Management
for
Substance
Abuse
Treatment
Treatment Improvement Protocol (TIP) Series
27
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration Center for
Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20857
Acknowledgments
This publication was produced under contract
number 270-95-0013 for the Substance Abuse
and Mental Health Services Administration
(SAMHSA), U.S. Department of Health and
Human Services (HHS). Sandra Clunies, M.S.,
ICADC, served as the Government Project
Officer.
Disclaimer
The opinions expressed herein are the views of
the consensus panel members and do not
necessarily reflect the official position of
SAMHSA or HHS. No official support of or
endorsement by SAMHSA or HHS for these
opinions or for the instruments or resources
described are intended or should be inferred.
The guidelines presented should not be
considered substitutes for individualized client
care and treatment decisions.
Public Domain Notice
All materials appearing in this volume except
those taken directly from copyrighted sources
are in the public domain and may be
reproduced or copied without permission from
SAMHSA or the authors. Citation of the source
is appreciated. However, this publication may
not be reproduced or distributed for a fee
without the specific, written authorization of the
Office of Communications, SAMHSA, HHS.
Electronic Access and Printed Copies
This publication may be ordered from or
downloaded from SAMHSA’s Publications
Ordering Web page at http://store.samhsa.gov.
Or, please call SAMHSA at 1-877-SAMHSA-7 (1
877-726-4727) (English and Español).
Recommended Citation
Center for Substance Abuse Treatment.
Comprehensive Case Management for Substance
Abuse Treatment. Treatment Improvement
Protocol (TIP) Series, No. 27. HHS Publication
No. (SMA) 15-4215. Rockville, MD: Center for
Substance Abuse Treatment, 2000.
Originating Office
Quality Improvement and Workforce
Development Branch, Division of Services
Improvement, Center for Substance Abuse
Treatment, Substance Abuse and Mental Health
Services Administration, 1 Choke Cherry Road,
Rockville, MD 20857.
HHS Publication No. (SMA) 15-4215
Printed 2000
Revised 2002, 2003, 2006, 2008, 2010, 2012, and
2015
ii
Contents
What Is a TIP?............................................................................................................................................................ v
Editorial Advisory Board....................................................................................................................................... vii
Consensus Panel ...................................................................................................................................................... ix
Foreword.................................................................................................................................................................... xi
Executive Summary............................................................................................................................................... xiii
Case Management and Substance Abuse Treatment...................................................................................xiii
Interagency Case Management....................................................................................................................... xiv
Evaluation and Quality Assurance of Case Management Services ............................................................ xv
Case Management for Clients With Special Needs.....................................................................................xvii
Funding Under Managed Care.....................................................................................................................xviii
Chapter 1—Substance Abuse and Case Management: An Introduction.........................................................1
Why Case Management .......................................................................................................................................2
Case Management—A Brief History..................................................................................................................4
Definitions and Functions....................................................................................................................................5
Models of Case Management with Substance Abusers...................................................................................6
Chapter 2—Applying Case Management to Substance Abuse Treatment ...................................................13
Case Management Principles ............................................................................................................................13
Case Management Practice—Knowledge, Skills, and Attitudes ..................................................................15
The Substance Abuse Treatment Continuum and Functions of Case Management .................................17
Chapter 3—Case Management in the Community Context: An Interagency Perspective .........................29
Characteristics of the Three Models .................................................................................................................30
Forging the Linkages..........................................................................................................................................33
Identifying Potential Partners ...........................................................................................................................35
The Agency Environment..................................................................................................................................36
Potential Conflicts...............................................................................................................................................39
Chapter 4—Evaluation and Quality Assurance of Case Management Services ..........................................41
A Brief Overview of the Research Literature ..................................................................................................41
iii
Contents
Evaluating Case Management Programs.........................................................................................................43
Future Research...................................................................................................................................................49
Chapter 5—Case Management for Clients With Special Needs .....................................................................51
Minority Clients ..................................................................................................................................................51
Clients With HIV Infection and AIDS..............................................................................................................52
Clients With Mental Illness................................................................................................................................53
Homeless Clients.................................................................................................................................................54
Women With Substance Abuse Problems .......................................................................................................55
Adolescent Substance Abusers .........................................................................................................................57
Clients in Criminal Justice Settings ..................................................................................................................57
Clients With Physical Disabilities.....................................................................................................................62
Gay, Lesbian, Transgendered, and Bisexual Clients ......................................................................................63
Case Management in Rural Areas ....................................................................................................................64
Chapter 6—Funding Case Management in a Managed Care Environment..................................................65
Funding Case Management in a Managed Care World ................................................................................65
Preparing a Program for Managed Care..........................................................................................................68
Future Directions ................................................................................................................................................71
Appendix A—Bibliography...................................................................................................................................73
Appendix B—Practice Dimensions ......................................................................................................................87
Referral .................................................................................................................................................................87
Service Coordination ..........................................................................................................................................90
Appendix C—Managed Healthcare Organizational Readiness Guide and Checklist: Special Report...99
Introduction .........................................................................................................................................................99
Goals and Objectives ........................................................................................................................................100
Background........................................................................................................................................................100
Ways To Use the Guide and Checklist...........................................................................................................100
Managed Healthcare Organizational Readiness Checklist .........................................................................104
Summary of Answers.......................................................................................................................................111
Common Questions and Answers..................................................................................................................112
How Can We Design an Action Program for Change? ...............................................................................113
Summary and Conclusion ...............................................................................................................................113
References ..........................................................................................................................................................114
Appendix D—Resource Panel.............................................................................................................................115
Appendix E—Field Reviewers ............................................................................................................................117
iv
v
What Is a TIP?
Although each consensus-based TIP strives to
include an evidence base for the practices it
recommends, SAMHSA recognizes that behavioral
health is continually evolving, and research
frequently lags behind the innovations pioneered in
the field. A major goal of each TIP is to convey
"front-line" information quickly but responsibly. If
research supports a particular approach, citations are
provided. When no citation is provided, the
information is based on the collective clinical
knowledge and experience of the consensus panel.
T
reatment Improvement Protocols (TIPs) are
developed by the Substance Abuse and
Mental Health Services Administration
(SAMHSA) within the U.S. Department of Health
and Human Services (HHS). Each TIP involves the
development of topic-specific best-practice
guidelines for the prevention and treatment of
substance use and mental disorders. TIPs draw on the
experience and knowledge of clinical, research, and
administrative experts of various forms of treatment
and prevention. TIPs are distributed to facilities and
individuals across the country. Published TIPs can be
accessed via the Internet at http://store.samhsa.gov.
vii
Editorial Advisory Board
Note: The info
rmation given indicates each participant's affiliation during the time the board was convened and may no
longer reflect the individual's current affiliation.
Karen Allen, Ph.D., R.N., C.A.R.N.
President
National Nurses Society on Addictions
Associate Professor
Department of Psychiatry, Community Health,
and Adult Primary Care
University of Maryland, Baltimore
Baltimore, Maryland
Richard L
. Brown, M.D., M.P.H.
Associate Professor Department of
Family Medicine
University of Wisconsin School of Medicine
Madison, Wisconsin
Dorynne C
zechowicz, M.D. Associate
Director Medical/Professional
Affairs Treatment Research
Branch
Division of Clinical and Services Research
National Institute on Drug Abuse Rockville,
Maryland
Linda S. Foley, M.A. Former
Director
Project for Addiction Counselor Training
National Association of State Alcohol and
Drug Counselors Director
Treatment Improvement Exchange Health
Systems Research, Inc.
Washington, D.C.
Wa
yde A. Glover, MIS, NCAC II Director
Commonwealth Addictions Consultants and Trainers
Richmond, Virginia
Pedro J
. Greer, M.D.
Assistant Dean for Homeless Education
University of Miami School of Medicine
Miami, Florida
Thomas W. H
ester, M.D. Former
State Director Substance
Abuse Services
Division of Mental Health, Mental
Retardation and Substance Abuse
Georgia Department of Human Resources Atlanta,
Georgia
Gil Hill
Director
Office of Substance Abuse American
Psychological Association Washington,
D.C.
Douglas B. Kamerow, M.D., M.P.H.
Director
Center for Practice and Technology
Assessment
Agency for Health Care Policy and Research
Rockville, Maryland
viii
Editorial Advisory Board
Stephen W. Long
Director
Office of Policy Analysis
National Institute on Alcohol Abuse and
Alcoholism
Rockville, Maryland
Richard A. Rawson, Ph.D.
Executive Director
Matrix Center
Los Angeles, California
Ellen A. Renz, Ph.D.
Former Vice President of Clinical Systems
MEDCO Behavioral Care Corporation
Kamuela, Hawaii
Richard K. Ries, M.D.
Director and Associate Professor
Outpatient Mental Health Services and Dual
Disorder Programs
Harborview Medical Center
Seattle, Washington
Sidney H. Schnoll, M.D., Ph.D.
Chairman
Division of Substance Abuse Medicine
Medical College of Virginia
Richmond, Virginia
ix
Consensus Panel
Note: The infor
mation given indicates each participant's affiliation during the time the panel was convened
and may no longer reflect the individual's current affiliation.
Chair
Harvey A. Siegal, Ph.D.
Professor and Director
Substance Abuse Intervention Programs School
of Medicine
Wright State University Dayton,
Ohio
Workgroup Leaders
James A. Hall, Ph.D.
Associate Professor
School of Social Work
University of Iowa Iowa
City, Iowa
Howard Isenberg, M.A.
Division Director
Outpatient Treatment Services
Northeast Treatment Centers
Wilmington, Delaware
Mary Nakashian
Vic
e President and Director of Program
Demonstration
National Center on Addiction and Substance
Abuse at Columbia University (CASA)
New York, New York
Richard C. Rapp, M.S.W.
Co-Investigator, Assistant Professor Substance
Abuse Intervention Programs School of Medicine
Wright State University Dayton,
Ohio
M. Susan Ridgely, M.S.W., J.D.
Associate Professor
Department of Mental Health Law and Policy
Florida Mental Health Institute
University of South Florida Tampa,
Florida
Patrick Sullivan, Ph.D
. Division
Director Division of Mental
Health
Family and Social Services Administration
Indianapolis, Indiana
Panelists
Kathleen Andolina, R.N., M.S., C.S. Consultant
Center for Case Management Natick,
Massachusetts
Barbara A. Blakeney, M.S., R.N., C.S., A.N.P.
Principal Public Health Nurse
Long Island Shelter
Homeless Services and Addiction Services Public
Health Commission
Boston, Massachusetts
Elizabeth Garcia, M.
S.W. Director
Managed Care
Pinal Gila Behavioral Health Association Apache
Junction, Arizona
Consensus Panel
Margaret E. Hanna, M.Ed.
Executive Director
Bucks County Drug and Alcohol
Commission
New Britain, Pennsylvania
Albert Hasson, M.S.W.
Administrative Director
Matrix Institute on Addictions
Pizarro Treatment Center
Los Angeles, California
Judith Levy, Ph.D.
Associate Professor
School of Public Health
University of Illinois
Chicago, Illinois
Duane C. McBride, Ph.D.
Director of Research
Behavioral Science Department
Andrews University
Berin Springs, Michigan
Sylvia M. Ryan, M.A., B.A.
Program Director
Rocky Boy Health Board
Rocky Boy Chemical Dependency Program
Box Elder, Montana
Anne C. Sowell, A.C.S.W., L.I.S.W.
Coordinator of Community Projects
Miracle Village
MetroHealth Medical Center
Cleveland, Ohio
x
xi
Foreword
Federal clinical researchers, clinicians, program
administrators, and patient advocates debates and
discusses their particular area of expertise until they
reach a consensus on best practices. Field reviewers
then review and critique this panel’s work.
The talent, dedication, and hard work that TIPs
panelists and reviewers bring to this highly
participatory process have helped bridge the gap
between the promise of research and the needs of
practicing clinicians and administrators to serve, in the
most scientifically sound and effective ways, people in
need of behavioral health services. We are grateful to
all who have joined with us to contribute to advances in
the behavioral health field.
Pamela S. Hyde, J.D.
Administrator
Substance Abuse and Mental Health Services Administration
Daryl W. Kade
Acting Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
T
he Substance Abuse and Mental Health
Services Administration (SAMHSA) is the
agency within the U.S. Department of Health
and Human Services that leads public health efforts to
advance the behavioral health of the nation.
SAMHSA’s mission is to reduce the impact of
substance abuse and mental illness on America’s
communities.
The Treatment Improvement Protocol (TIP) series
f
ulfills SAMHSA’s mission to reduce the impact of
substance abuse and mental illness on America's
communities by providing evidence-based and best
practices guidance to clinicians, program
administrators, and payers. TIPs are the result of
careful consideration of all relevant clinical and health
services research findings, demonstration experience,
and implementation requirements. A panel of non-
Executive Summary
C
ase management has been variously
classified as a skill group, a core
function, service coordination, or a
network of “friendly neighbors.” Although it
defies precise definition, case management
generally can be described as a coordinated
approach to the delivery of health, substance
abuse, mental health, and social services, linking
clients with appropriate services to address
specific needs and achieve stated goals. The
Consensus Panel that developed this TIP
believes that case management lends itself to the
treatment of substance abuse, particularly for
clients with other disorders and conditions who
require multiple services over extended periods
of time and who face difficulty in gaining access
to those services. This document details the
factors that programs should consider as they
decide to implement case management or
modify their current case management activities.
This summary is excerpted from the main text,
in which references to the research appear.
Research suggests two reasons why case
management is effective as an adjunct to
substance abuse treatment. First, retention in
treatment is associated with better outcomes,
and a principal goal of case management is to
keep clients engaged in treatment and moving
toward recovery. Second, treatment may be
more likely to succeed when a client’s other
problems are addressed concurrently with
substance abuse. Case management focuses on
the whole individual and stresses
comprehensive assessment, service planning,
and service coordination to address multiple
aspects of a client’s life. Comprehensive
substance abuse treatment often requires that
clients move to different levels of care or
systems; case management facilitates such
movement.
Any definition of case management will be
contextual, depending on who is implementing
the program. Perhaps a more helpful way to
understand it is to examine the functions that
generally comprise case management: (1)
assessment, (2) planning, (3) linkage, (4)
monitoring, and (5) advocacy.
Case Management and
Substance Abuse
Treatment
When implemented to its fullest, case
management will enhance the scope of
addictions treatment and the recovery
continuum. A treatment professional utilizing
case management will
Provide the client a single point of contact for
multiple health and social services systems
Advocate for the client
Be flexible, community-based, and client-
oriented
Assist the client with needs generally
thought to be outside the realm of substance
abuse treatment
xiii
Executive Summary
To provide optimal services for clients, a
treatment professional should
possess particular
knowledge, skills, and attitudes including
are distinct goal
s and treatment activities at each
point on the continuum, rarely do clients’ needs
fit neatly into any one area at a given time; case
Understanding various models and theories
of addiction and other problems related to
substance abuse
Ability to describe the philosophies,
practices, policies, and outcomes of the most
generally accepted and scientifically
supported models of treatment, recovery,
relapse prevention, and continuing care for
addiction and other substance-related
problems
Ability to recognize the importance of family,
social networks, community systems, and
self-help groups in the treatment and
recovery process
Understanding the variety of insurance and
health maintenance options available and the
importance of helping clients access those
benefits
Understanding diverse cultures and
incorporating the relevant needs of culturally
diverse groups, as well as people with
disabilities, into clinical practice
Understanding the value of an
interdisciplinary approach to addiction
treatment
In addition to the above competencies,
treatment professionals must have skills relating
to interagency functioning, negotiating, and
advocacy. CSAT’s Addiction Technology
Transfer Centers classify referral and service
coordination—basic case management
functions—as core competencies for substance
abuse treatment providers.
The Substance Abuse Treatment
Continuum and Functions of Case
Management
The continuum of substance abuse treatment
ranges from case finding and pretreatment to
primary treatment to aftercare. Although there
management serves to span client needs and
program structure. Substance abuse treatment
and case management functions differ in that
treatment involves activities that help substance
abusers recognize their problems, acquire the
motivation and tools to stay abstinent, and use
the acquired tools; case management focuses on
helping the substance abuser acquire needed
resources. Case management supports a client
as he moves through the recovery continuum
and reinforces treatment goals.
Interagency Case
Management
The goal of interagency case management is to
expand the network of services available to
clients. All organizations have boundaries to
what they can do, and case managers or
“boundary spanners” transcend them to
facilitate interactions among agencies. In the
field of substance abuse, three interagency
models have been identified. In the single agency
model, the case manager personally establishes
a series of distinct relationships on an as-needed
basis with counterparts in other agencies. In the
informal partnership model, staff members from
several agencies work as a collaborative team,
often constituted case by case; the formal
consortium binds case managers and service
providers through formal written agreements.
Clearly defined roles are essential to all three
models to ensure that services are coordinated
and relevant gaps addressed.
Although informal exchange or “social
service bartering” among different agencies is
intrinsic to case management, a more formalized
connection among agencies sometimes may be
required. Examples include memoranda of
understanding and interagency agreements and
contracts; each of these methods for formalizing
xiv
Executive Summary
expectations can
be used in single agency
models, informal partnerships, and formal
consortia.
To be successful, a case management plan
must thoroughly and critically examine
community resources to determine what forms
of assistance are available and how case
management efforts can help clients attain
necessary assistance. Many communities have
published directories of social, health, welfare,
housing, vocational, and other service
organizations to help case management
programs identify resources, possible provider
linkages, and potential gaps in services for their
clients. Although such directories are a good
starting point, it is important to follow up on the
listings to ensure they are still accurate and will
be of use to the client.
The Environmental Assessment
Exploring the environment in which an agency
operates is crucial to determining the feasibility
of an interagency effort. Analysis of the
community environment will enhance
understanding of the changes that occur among
clients, within the program, and in the
community. Case management takes place
within a dynamic social service environment in
which agencies are in constant flux. Programs
considering interagency efforts must devise
strategies to respond to change while providing
continuity for the client. Regular reevaluation
helps ensure continued relevance; community
service provider networks or consortia are
particularly effective in sharing information
about changes and developments.
Potential Conflicts
Whenever agencies or service providers work
together, the potential for conflict exists. Areas
of tension may be present from the very onset of
the collaboration. For example, a new project
may be viewed by established social service
agencies as competition for scarce resources.
Sometimes social pressures or the need to
maximize resources can force public agencies
into joint ventures even if they do not mesh well
or have a history of being service competitors.
Tensions can also develop in the course of
delivering services; for example, interagency
collaboration may result in a client having two
case managers. Recognizing potential triggers
for conflict is a necessary first step in developing
a system to handle them. When problems do
arise, case managers and other agency personnel
can use both informal and formal
communication to clarify issues, regain
perspective, and refocus the interagency case
management process.
Evaluation and Quality
Assurance of Case
Management Services
Substance abuse treatment programs, including
those that receive public funding, are
increasingly operating in a managed care
environment. In such an environment, policy
and clinical decisionmaking rely on outcome
data that traditionally describe the impact of
case management and substance abuse
treatment interventions in the context of services
used and money spent. An additional demand
for data comes from public and private payers
who want services linked to specific outcomes.
To gauge the effectiveness of case
management, indicators of “success” must be
defined by the substance abuse program and its
stakeholders (including funding and regulatory
agencies). In documenting a case management
effort, it is necessary to establish benchmarks to
measure the case management process, for
example, recording how often a client shows up
at treatment. Once the benchmarks are defined
in measurable terms, the next step is to develop
and implement a method for measuring
practice; that is, to answer the questions, “What
are case managers doing, and how does their
xv
Executive Summary
practice conform to the benchmarks?” Methods
of such documentation include
Maintenance of a simple staff log procedure
that measures case managers’ activities by
contact
Reviews of case manager client records to
evaluate how service planning and referrals
adhere to benchmarks
Interviews or surveys of case managers or
clients and their family members to collect
information on activities in which case
managers engage, to identify how clients’
and case managers’ views of case
management activities differ
Analysis of data from the agency’s
management information system (to examine
patterns on type, number, and duration of
case manager contacts with different target
populations).
Measuring System Outcomes
System outcomes are particularly important in a
managed care environment, where overall use
of expensive services such as hospitalization and
residential treatment is strictly monitored.
System outcomes can measure cost savings and
quality of care: For example, continuity of care is
an appropriate measure for a client at risk for
relapse after detoxification and before entry into
outpatient treatment. Tracking clients within a
comprehensive service agency or analyzing data
on costs and encounters within a network of
agencies are two methods for measuring system
outcomes. For such analyses, a computerized
management information system (MIS) is
essential.
Measuring Client Outcomes
Although “evaluation” is generally considered
worthwhile, there is little agreement about the
measurement and documentation of specific
outcomes for individual clients. Some view a
single measure such as sobriety to be the only
meaningful indicator of success; others believe
success should be gauged against a range of
factors, including reduced substance use,
improved family functioning, and fewer
encounters with the criminal justice system.
Until the debate is resolved, programs should
identify treatment objectives and extrapolate
from them the outcome variables they want to
measure.
Anticipating Quality Assurance
Data Needs
The types of data required for an evaluation of
case management, how the data are collected,
and the manner in which data are put to use
vary among different stakeholders. It is
important to understand the types of data that
various stakeholders need to evaluate the
program. Structured feedback loops should be
established to ensure that the gathered data are
returned to various stakeholders in some
meaningful way so that they have an impact on
shaping future program development (and
future data needs). One of the benefits of the
case management approach is that it can be
adapted to meet the sometimes contradictory
needs of the various stakeholders.
Management Information Systems
A management information system contains all
of the case management services information
and allows stakeholders to access it. In
evaluating a MIS, local programs should
Determine how to use data already routinely
collected by a statewide MIS or a managed
care company-based MIS, saving the
program from duplicating primary data
collection
Develop or enhance a program-level MIS
that tracks data the program needs locally
Integrate with other computer-based or
paper-based systems
Supply data required by third party payer
and governmental bodies
xvi
All staff members of a specific program
should be stakeholders in the MIS, which
increases both system accuracy and the
likelihood that a broad array of staff members
will use it. If an agency does not have the
resources to develop a sophisticated system, it
should be able to automate at least a minimum
amount of client information through
commercially available software. When
designing today’s MIS, the data requirements of
managed care organizations must be addressed.
Future Research
Research centered on case management and the
substance abuse field is limited, thus offering
local substance abuse programs the opportunity
to make significant contributions to the field.
Suggested directions for future research include
the following:
Key ingredients of successful programs,
especially for hard-to-reach populations
Relative cost-effectiveness of particular case
management models, including cost outcome
results within systems incorporating full
parity of substance abuse with other health
care; outcome results when a full continuum
of care is available to patients; and outcome
results associated with use of standardized
guidelines for placement, continued stay,
and discharge for substance abuse patients
Improved methodology to investigate
research questions in “real world” settings
Development of brief versions of valid and
reliable research outcome instrumentation
The effect of particular forms of case
management on societal costs of substance
abuse and its treatment
Cost shifting among health, behavioral
health, criminal justice, and other systems
that can be accessed by the target population
Creative ways to use secondary data sets
(such as Medicaid and Medicare) to
determine trends and patterns of care
Executive
Summary
Research questions from broader sociological
or multidisciplinary perspectives
Case Management for
Clients With Special
Needs
Case management is especially appropriate for
substance abusers with special treatment needs,
related to such issues as HIV infection or AIDS,
mental illness, chronic and acute health
problems, poverty, homelessness, responsibility
for parenting young children, social and
developmental problems associated with
adolescence and advanced age, involvement
with illegal activities, physical disabilities, and
sexual orientation. Ideally, a case manager will
possess all the expertise and skills needed to
treat the many special needs she confronts, but
this is unlikely—understanding the
ramifications of even one special need can be a
staggering task. In the absence of such
comprehensive knowledge, a case manager
should have a basic foundation of attitudes and
skills for delivering services to “special needs
clients.” The case manager should
Make every effort to be competent in the
special circumstances that affect clients
typically referred to a particular substance
abuse treatment program
Understand the range of clients’ reactions to
the challenges associated with particular
special circumstances
Remain aware of the limits of his own
knowledge and expertise
Evaluate personal beliefs and biases about
clients who have special problems or needs
Maintain an open attitude toward seeking
and accepting assistance on behalf of a client
Know where additional information on
special problems can be accessed
xvii
Executive Summary
Funding Under Managed
Care
Whatever treatment providers’ attitudes toward
managed care, they will have to accept that it is
the new paradigm for health care. Well over
one-half of the States are currently in the process
of adopting some form of managed care for
providing public-sector behavioral health care
services. Many have already received Federal
waivers to implement Medicaid managed
behavioral health programs, and other waivers
are planned or pending. Managed care has
changed the context in which substance abuse
treatment services are delivered, and substance
abuse programs must prepare to function within
this new environment if case management is to
survive.
Treatment providers using case management
may not only survive but actually thrive under
managed care. Many managed care
organizations (MCOs) reimburse for case
management, so it behooves providers to prove
that their brand of case management should be
covered. The program should develop a
comprehensive case management system with
the flexibility and resources necessary to
eventually show tangible savings.
To adapt to this new way of doing business,
treatment programs must assess how they use
case management and appraise their readiness
to operate in a managed care environment. One
way providers can thrive under managed care is
to position themselves and their case
management services in a competitive market
by identifying market niches, such as clients
with HIV/AIDS, criminal justice clients, or older
clients.
As MCOs increasingly reimburse for case
management, licensing requirements are
becoming stricter. The trend is toward case
managers who have advanced degrees.
Accreditation standards will also tighten under
managed care.
In short, there are many reasons for
substance abuse treatment providers to adopt
case management or to formalize their existing
case management activities. This will not
necessarily mean an upheaval, as many
programs are already helping clients navigate
their other, non-substance abuse problems. This
TIP equips providers with the knowledge they
need to fully serve their clients at the same time
they conform to the changing health care
system.
xviii
1 Substance Abuse and Case
Management: An Introduction
T
he term case management has appeared in
social services literature more than 600
times in the last 30 years, referring to
everything from the routing of court dockets
through the judicial system to the medical
management of a hospitalized patient’s care.
This TIP uses the term to refer to interventions
designed to help substance abusers access
needed social services.
Support for the use of case management in
this setting developed from both clinical practice
and empirical observation suggesting that
substance abusers who seek treatment have
significant problems in addition to using
psychoactive substances. Alcohol or other drug
use often damages many aspects of an
individual’s life, including housing,
employment, and relationships (Oppenheimer et
al., 1988; Westermeyer, 1989). Clients in
substance abuse treatment programs,
particularly publicly funded treatment
programs, present a variety of associated
problems. Many use multiple substances and
may be poly-addicted. Many suffer from related
health disorders, either caused by their
substance abuse—such as liver disease and
organic brain disorders—or exacerbated by
neglect of health and lack of preventive health
care. In addition, some diseases—including
HIV/AIDS, tuberculosis, and some strains of
hepatitis—are transmitted by substance abuse,
either directly or indirectly.
Substance abusers also have a higher
incidence of mental health disorders than the
general population. Up to 70 percent of
individuals treated for substance abuse have a
lifetime history of depression (Mirin et al., 1988).
Between 23 and 56 percent of individuals with
diagnosable Axis I mental disorders also have a
substance abuse or dependence disorder (Regier
et al., 1990).
Substance abuse clients often arrive in
treatment programs with numerous social
problems as well. Many are unemployed or
under-employed, lacking job skills or work
experience. Many in publicly funded treatment
programs do not have a high school diploma.
Some are homeless, and those who have been
incarcerated may face significant barriers in
accessing safe and affordable housing. Many
substance abuse clients have alienated their
families and friends or have peer affiliations
only with other substance abusers. Women in
treatment have often been victims of domestic
violence, including sexual abuse; some women
in treatment may be living with an abuser.
Achieving and maintaining abstinence and
recovery nearly always requires forming new,
healthy peer associations.
1
Chapter 1
A significant number of clients in treatment
are also under some form of control by the
criminal justice system. Criminal justice
substance abuse clients represent more than half
of all clients in treatment in many state and local
jurisdictions. Although those afflicted by
chemical addiction are found among all
socioeconomic groups, persons already plagued
by poverty, disease, and unemployment are
over-represented (CSAT, 1994). Particularly in
publicly funded treatment programs, substance
abuse clients have limited resources and may
lack health insurance. Many are eligible for
publicly supported health and social benefits,
including Medicare, food stamps, or welfare.
Data suggest that substance abusers who
receive professional attention for these
additional problems will see improvements in
occupational and family functioning and a
lessening of psychiatric symptoms (McLellan et
al., 1993; McLellan et al., 1982; Moos et al., 1990;
Siegal et al., 1995). Clinicians who develop a
"helping alliance" with substance abusers have
been shown to produce better treatment
outcomes than those who do not (Luborsky et
al., 1985).
Why Case Management
Because addiction affects so many facets of the
addicted person’s life, a comprehensive
continuum of services promotes recovery and
enables the substance abuse client to fully
integrate into society as a healthy, substance-free
individual. The continuum must be designed to
provide engagement and motivation, primary
treatment services at the appropriate intensity
and level, and support services that will enable
the individual to maintain long-term sobriety
while managing life in the community.
Treatment must be structured to ensure smooth
transitions to the next level of care, avoid gaps
in service, and respond rapidly to the threat of
relapse. Case management can help accomplish
all of the above.
Case management is needed because, in most
jurisdictions, services are fragmented and
inadequate to meet the needs of the substance-
abusing population. This lack of coordinated
services results from a variety of factors,
including
Different funding streams. Substance abuse
treatment is funded from a variety of
sources—block grants, competitive grants,
state and local funding, criminal justice
funding, and others. The different
requirements or goals of these sources can
result in a piecemeal approach to
programming
A focus on program funding rather than
system funding
Funding focused on single modalities rather
than a continuum of care
Inadequate funding created by missing
pieces in the continuum
Waiting lists caused by inadequate funding
Barriers between systems (e.g., mental health
vs. substance abuse, criminal justice vs.
mental health and substance abuse)
Lack of incentives geared to client outcome;
programs rewarded for process measures,
not outcome measures
Eligibility/admission criteria that exclude
certain clients
Lack of agreement on priority for
admission/treatment
Lack of incentives for programs to work
together
Due to the fragmentation of services, the
accompanying inefficiency, and a growing
scarcity of resources, some form of case
management is used with virtually every
population that routinely seeks social services.
The variability in social services system
configurations has led to many different
implementations of case management, resulting
2
Introduction
in conceptual
disagreements about case
management and difficulty in assessing its
value. Inevitably, many of the same issues will
arise in the substance abuse setting. This TIP is
designed to establish a common starting point
for case management work with substance
abusers. To address at least some of those
conceptual disagreements, the TIP makes
several assumptions, including
1. Case management is a set of social service
functions that helps clients access the
resources they need to recover from a
substance abuse problem. The functions that
comprise case management—assessment,
planning, linkage, monitoring, and
advocacy—must always be adapted to fit the
particular needs of a treatment or agency
setting. The resources an individual seeks
may be external in nature (e.g., housing and
education) or internal (e.g., identifying and
developing skills).
2. Advocacy is one of case management’s
hallmarks. While a professional conducting
therapy may speak out on behalf of a client,
case management is dedicated to making
services fit clients, rather than making clients
fit services.
3. Case management may be implemented by
an individual dedicated solely to helping the
client access needed resourcesa case
manageror by a professional who has this
responsibility along with therapeutic or
counseling functions. This TIP stresses the
intervention rather than the intervener’s
profession.
4. The primary difference between case
management and therapy is that the former
stresses resource acquisition, while the latter
focuses on facilitating intra- and
interpersonal change. However, case
management and therapy are not
incompatible. Indeed, both are generally
called for in addressing the needs of a
majority of substance abuse clients.
5. When
implemented to its fullest, case
management challenges the addiction
treatment continuum of pretreatment,
primary treatment, and aftercare (discussed
further in Chapter 2). This occurs because of
the advocacy function of case management;
the need for case managers to be flexible,
community-based, and community-oriented;
and the need for case managers to be the
primary figures in planning work with the
client.
These assumptions are all affected by the
setting in which case management is practiced.
Practitioners who work with substance abusers
do so in methadone maintenance clinics,
hospital- and community-based addiction
programs, local social service departments,
family preservation programs, and storefront
community outreach programs. These physical
settings are in turn influenced by numerous
other factors, including the source(s) of an
agency’s funding; the agency’s mission; staff
orientation, education, and training; the
agency’s treatment philosophy; and the makeup
of other social services in a particular
geographical area.
Complicating the implementation of case
management with substance abusers are three
trends that will alter the current manner in
which substance abuse treatment and case
management are implemented: Managed care,
treatment provided in the criminal justice
system, and diminishing social services and
resources. Managed care uses case management
to restrict access to services as well as to facilitate
access to services. In addition to the issue of
cost containment, the movement of a great deal
of substance abuse treatment (and thereby case
management) into criminal justice venues is
significant. The potential conflicts between
coerced involvement in treatment and case
management will test the limits of advocacy and
client-driven aspects of the intervention.
Finally, unlike the early period of case
3
Chapter 1
management, clients and professionals
practicing case management now negotiate a
drastically constricted menu of services. Each of
these contemporary conditions makes
implementation and evaluation an increasingly
difficult task.
Case Management – A
Brief History
More than 70 years ago when Mary Richmond
envisioned a cadre of “friendly neighbors”
helping others in their struggles with real world
needs (Richmond, 1922), she created not only
the field of social work, but case management as
well. While she applied the term social casework
to the activities that affected the adjustment
between an individual and the social
environment, she could well have been
describing the key functions that now comprise
case management.
One of the first legislative embodiments of
case management occurred in the 1963 Federal
Community Mental Health Center Act
(Intagliata, 1982) in anticipation of
deinstitutionalization, in which persons in long
term psychiatric care were moved into
community settings. The expectation that these
individuals would need services previously
provided in the institution led to the rapid
expansion of community-based social services.
Unfortunately, these services were often created
independently of one another and, coupled with
the categorical nature of the eligibility for
services, led to difficulties for persons used to
having these services provided in institutions.
The Community Support System developed by
the National Institutes of Mental Health in 1977
envisioned case management as a mechanism
for helping clients navigate this fragmented
social service system. Accessing these resources
would thus enable them to live and function
adequately in their communities (Intagliata,
1982; Stein and Test, 1980; Test, 1981; Turner and
TenHoor, 1978).
Substance abusers historically were never
institutionalized as often as were persons with
chronic mental illness and so were not directly
impacted by deinstitutionalization legislation.
Substance abusers were not generally targeted
for the development of categorical systems of
service delivery and were not generally
recipients of case management services.
However, case management-like services were
provided to substance abusers under other titles,
such as “mission work,” and frequently
delivered by the clergy or others in skid row
missions, detoxification centers, and ad hoc
halfway houses. Jails and county work farms
were generally the institutions of choice in
dealing with this population. Only after
substance abuse began to be decriminalized and
defined as a disease were substance abusers
referred to various social services.
Policymakers in Canada were among the first
to translate many generic case management
functions into the field of substance abuse
treatment, outlining the essential elements of a
union of case management and substance abuse
treatment (Graham and Birchmore-Timney,
1990; Ogborne and Rush, 1983; Rush and
Ekdahl, 1990). Case management for substance
abusers initially gained attention in the United
States through the Treatment Alternatives for
Safe Communities (TASC) program (formerly
known as Treatment Alternatives to Street
Crime), which began linking the criminal justice
system with the drug abuse treatment system in
1972 and has grown to over 185 programs
(Cook, 1992) today.
A 1987 National Institute of Mental Health
initiative funded 13 demonstration projects
targeted at young adults with coexisting mental
health and substance use problems. Of these 13
projects, 10 identified some form of case
management as a primary service and provided
a general description of the case management
4
Introduction
intervention
(Teague et al., 1990). Initiatives
undertaken by both the National Institute on
Drug Abuse (NIDA) and National Institute on
Alcohol Abuse and Alcoholism (NIAAA)
resulted in numerous projects that used case
management to enhance treatment (Bonham et
al., 1990; Conrad et al., 1993; Cox et al., 1993;
Inciardi et al., 1993; Fletcher et al., 1994; Mejta et
al., 1994). Case management in these projects
was designed to increase retention in the
treatment continuum and to improve treatment
outcomes.
Definitions and Functions
Any definition of case management today is
inevitably contextual, based on the needs of a
particular organizational structure,
environmental reality, and prior training of the
individuals who are implementing it, whether
they are social workers, nurses, or case
management specialists. Nonetheless, there is
relatively widespread agreement on the basic
definition, as illustrated in Figure1-1.
While definitions are useful in guiding
general discussions, functions are a more helpful
way to approach case management as it is
actually practiced. As with definitions, there is a
high degree of consensus about a core group of
functions. One widely accepted set of functions
comprises (1) assessment, (2) planning, (3)
linkage, (4) monitoring, and (5) advocacy (Joint
Commission on Accreditation of Healthcare
Organizations, 1979). The National Association
of Social Workers’ standards for social work
case management include assessing, arranging,
coordinating, monitoring, evaluating, and
advocacy (National Association of Social
Workers, 1992).
Figure 1-1
Definitions of Case Management
Case management is
“planning and coordinating a package of health and social services that is individualized to meet a
particular client’s needs” (Moore, 1990, p. 444)
“[a] process or method for ensuring that consumers are provided with whatever services they need in
a coordinated, effective, and efficient manner” (Intagliata, 1981)
“helping people whose lives are unsatisfying or unproductive due to the presence of many problems
which require assistance from several helpers at once” (Ballew and Mink, 1996, p. 3)
“monitoring, tracking and providing support to a client, throughout the course of his/her treatment
and after” (Ogborne and Rush, 1983, p. 136)
“assisting the patient in re-establishing an awareness of internal resources such as intelligence,
competence, and problem solving abilities; establishing and negotiating lines of operation and
communication between the patient and external resources; and advocating with those external
resources in order to enhance the continuity, accessibility, accountability, and efficiency of those
resources” (Rapp et al., 1992, p. 83)
“assess[ing] the needs of the client and the client’s family, when appropriate, and arranges,
coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific
client’s complex needs.” (National Association of Social Workers, 1992, p. 5)
5
Chapter 1
There is also general agreement about case
management functions in the specific context of
substance abuse treatment. Case management is
one of eight counseling skills identified by the
National Association of Alcoholism and Drug
Abuse Counselors (National Association of
Alcoholism and Drug Abuse Counselors, 1986)
and one of five performance domains developed
in the Role Delineation Study (International
Certification and Reciprocity Consortium, 1993).
Another framework is supplied by the
Addiction Technology Transfer Centers
(ATTCs), established by CSAT to transmit
current information on treatment to providers in
the field. The essential elements of case
management are laid out in their publication
Addiction Counseling Competencies: The Knowledge,
Skills, and Attitudes of Professional Practice (CSAT,
1998). That document has been endorsed by
many leading addiction organizations.
Referral and service coordination are two of
eight practice dimensions the ATTCs deem
essential to the effective practice of addiction
counseling. Activities considered part of those
two dimensions include engagement;
assessment; planning, goal-setting, and
implementation; linking, monitoring, and
advocacy; and disengagement. The document
defines service coordination as:
“The administrative, clinical, and evaluative
activities that bring the client, treatment
services, community agencies, and other
resources together to focus on issues and needs
identified in the treatment plan. Service
coordination, which includes case management
and client advocacy, establishes a framework of
action for the client to achieve specified goals. It
involves collaboration with the client and
significant others, coordination of treatment and
referral services, liaison activities with
community resources and managed care
systems, client advocacy, and ongoing
evaluation of treatment progress and client
needs” (CSAT, 1998, p. 53).
Addiction Counseling Competencies describes
the knowledge, skills, and attitudes required for
all eight practice dimensions. Those supporting
referral and service coordination are reproduced
in full in Appendix B.
Models of Case
Management With
Substance Abusers
Case management models, like the definitions of
case management, vary with the context. Some
models focus on delivering social services,
others on coordinating the delivery of services
by other providers. Some provide both. The
models result as much from the needs of specific
client populations and service settings as they
do from distinct theoretical differences about
what case management should be. Four models
from the mental illness field have been adapted
for the field of substance abuse treatment. Each
of these models—broker/generalist, strengths-
based, assertive community treatment, and
clinical/rehabilitation—has proved valuable in
treating substance abusers in a particular
setting.
For example, the strengths-based approach
was adapted to work with crack cocaine users.
This approach was chosen not only for its focus
on resource acquisition but also because it helps
clients see their own assets as a valuable part of
recovery (Siegal and Rapp, 1996). Assertive
community treatment was implemented to
provide parolees a wide range of integrated
services, including drug treatment, skills
building, and resource acquisition.
Figure 1-2 compares the four models across
11 activities of case management and specifies
which models are appropriate for particular
substance abuse populations. Implementation of
these models may vary with other populations
and from setting to setting.
6
Figure 1-2
Models of Case Management
Conducts outreach
and case finding
Not usually Depends on
agency mission &
structure
Depends on
agency mission &
structure
Depends on
agency mission &
structure
Provides assessment
and ongoing
reassessment
Specific to
immediate
resource
acquisition
needs
Strengths-based,
applicable to any
of client life areas
Broad-based, part
of a
comprehensive
(biopsychosocial)
assessment
Broad-based, part
of a
comprehensive
(biopsychosocial)
assessment
Assists in goal
planning
Generally brief,
related to
acquiring
resources, possibly
informal
Client-driven,
teaches specific
process on how to
set goals and
objectives, goals
may include any
of client life areas
Comprehensive,
goals may include
any of client life
areas
Comprehensive,
goals may include
any of client life
areas
Makes referral to
needed resources
Case manager may
initiate contact or
have client make
contact on own
As negotiated with
client, may contact
resource,
accompany client,
or client may
contact on own
As needed, many
resources
integrated into
broad package of
case management
services
As negotiated with
client, may contact
resource,
accompany client,
or client may
contact on own
Monitors referrals Follow-up checks
made
Close involvement
in ongoing
relationship
between client and
resource
Close involvement
in ongoing
relationship
between client and
resource
Close involvement
in ongoing
relationship
between client and
resource
Provides therapeutic
services beyond
resource acquisition,
e.g., therapy, skills-
teaching
Referral to other
sources for these
services if
requested
Usually limited to
responding to
client questions
about treatment
issues, education
about how to
identify strengths
and about self-
help resources
Provides many
services within
unified package of
treatment/case
management
services
Provision of
therapeutic
activities central to
the model
Helps develop
informal support
systems
No Development of
informal
resources
— neighbors,
church, family— a
key principle of
the model
Through
implementation of
drop-in
centers
and shelters
Emphasis on
family
and self-
help support
through
therapeutic
activities
Primary Case
Broker/Generalist Str
engths Assertive
Clinical/
Management
Perspective Community
Rehabilitation
Activities
Treatment
Introduction
7
Primary Case
Management
Activities
Broker/Generalist Strengths
Perspective
Assertive
C
ommunity
Treatment
Clinical/
Rehabi
litation
Figure 1-2 Continued
Responds to crisis Responds to crises
related to resource
needs such as
housin
g
Responds to crises
related to both
resource needs
and mental health
concerns; active in
stabilization and
then referral
Responds to crises
related to both
resource needs
and mental health
concerns; active in
stabilization and
then referral
Responds to crises
related to both
resource needs
and mental health
concerns; will
stabilize crisis
situation and
provide further
therapeutic
intervention
Engages in advocacy
on behalf of
individual client
Usually only at
level of line staff
Assertive
advocacy, will
pursue multiple
administrative
levels within
agency
Assertive
advocacy, will
pursue multiple
administrative
levels within
agency
Assertive
advocacy, will
pursue multiple
administrative
levels within
agency
Engages advocacy in
support of resource
development
Not usually Usually in context
of specific client
needs
Either advocates
for needed
resources or may
create resources as
part of case
management
services
Usually in context
of specific client
needs
Provides direct
services related to
resource acquisition
as part of case
management, e.g.,
drop-in center,
employment
counseling
Referral to
resources that
provide direct
services
Provides services
crucial to
preparing client
for resource
acquisition
activities, e.g., role
playing,
accompanying
client to
interviews
Provides many
direct services
within unified
package of
treatment/case
management
Provides services
that are part of
rehabilitation
services plan;
skill-teaching
Appropriate for the following substance abuse populations
Injectable drug
users; HIV positive
and at-risk
substance abusers
Male crack
cocaine users;
female
polysubstance
abusers
Chronic public
inebriates;
parolees with
substance abuse
problems; dually
diagnosed clients
Dually diagnosed
clients; female
polysubstance
abusers
Chapter 1
8
Introduction
Brokerage/Generalist
Brokerage/generalist models seek to identify
clients’ needs and help clients access identified
resources. Planning may be limited to the
client’s early contacts with the case manager
rather than an intensive long-term relationship.
Ongoing monitoring, if provided at all, is
relatively brief and does not include active
advocacy.
Brokerage/generalist models are sometimes
disparaged in discussions of case management
because of the limited nature of the client–case
manager relationship and the absence of
advocacy. Nonetheless, this approach shares the
basic foundations of case management and has
proved useful in selected situations. The
relatively limited nature of the relationship in
this model allows the case manager to provide
services to more clients. This approach is also
appropriate in instances where treatment and
social services in a particular area are relatively
integrated and the need for monitoring and
advocacy is minimal. The model works best
with clients who are not economically deprived,
who have significant intent and sufficient
resources, or who are not in late-stage addiction.
Small agencies or agencies that offer narrowly
defined services may be in an ideal position to
offer brokerage-only services.
Two creative uses of a brokerage model
involved clients who were infected with the
human immunodeficiency virus (HIV) or who
were at significant risk of acquiring HIV. In one
program, case managers also served as
educators, delivering cognitive, behaviorally
oriented, educational sessions focusing on
substance abuse and high-risk behaviors (Falck
et al., 1992). The mixing of the educator and
case manager roles was intended to increase
clients’ receptivity to HIV prevention messages
by reducing barriers to services that would
address problems that might divert attention
from those messages. In another variation of the
brokerage model, case managers in a large
metropolitan area conducted extensive
assessments with HIV-infected clients, generally
making at least two referrals during the initial
session. This “quick response” approach was
intended to provide immediate results to clients
and to link them with agencies or services that
would provide ongoing services (Lidz et al.,
1992).
Generalist approaches to working with
substance-abusing clients have taken several
forms. Case managers in the central intake
facility of a large metropolitan area performed
the core functions of case management, linking
clients with area substance abuse treatment and
other human service providers. These case
managers had access to funds for purchasing
treatment services, thereby drastically reducing
waiting periods for these services (Bokos et al.,
1993). Another example of a generalist model is
Providence, Rhode Island’s Project Connect, a
family-centered, community-based intervention
program designed to address the problems of
substance abuse among high-risk families in the
child welfare system. Staff members provide
intensive home-based counseling services and
work with families to obtain other services they
may need, including safe and affordable
housing and adequate health care.
Assertive Community Treatment
The Program of Assertive Community
Treatment (PACT) model, originally developed
in Wisconsin (Stein and Test, 1980), emphasizes
the following components
Making contact with clients in their homes
and natural settings
Focusing on the practical problems of daily
living
Assertive advocacy
Manageable caseload sizes
Frequent contact between a case manager
and client
Team approach with shared caseloads
Long-term commitment to clients
9
Chapter 1
Willenbring and his colleagues were among
the first to adapt a mental health model for
persons with substance abuse problems,
specifically chronic public inebriates
(Willenbring et al., 1990). Following the tenets
of PACT, an individual case manager was
closely supported by a core services team that
together carried the responsibility for providing
services. The model deviated from the usual
approach to dealing with substance abuse
clients in two ways. First, instead of expecting
clients to come to services when they “hit
bottom,” case managers sought out clients
through a process known as “enforced contact.”
Second, case managers and the services team
acknowledged the chronic nature of the client’s
condition and sought to modify the course of the
condition and to alleviate suffering. The clients
were not required to pledge a goal of abstinence.
A derivation of PACT, the Assertive
Community Treatment (ACT) model, was used
with parolees who had histories of injecting
drugs (Martin and Scarpitti, 1993). In this
implementation, case managers provided direct
counseling services and worked with clients to
develop the skills necessary to function
successfully in the community. Case
management staff also provided family
consultations and crisis intervention services
and functioned as group facilitators to provide
skills training in areas such as work skills,
relapse prevention, and education about
HIV/AIDS. Departing from the mental health
tenets of the PACT model, ACT had time limits
and success goals rather than the continuous
care envisioned for the mentally ill.
Achievement of protracted periods of abstinence
and graduation from treatment continuum
components were expected of clients (Martin
and Scarpitti, 1993). Assertive Community
Treatment has been implemented alone and in
conjunction with a therapeutic community
(Martin et al., 1993).
Strengths-Based Perspective
The strengths-based perspective of case
management was originally developed at the
University of Kansas School of Social Welfare to
help a population of persons with persistent
mental illness make the transition from
institutionalized care to independent living
(Rapp and Chamberlain, 1985). The foremost
two principles on which the model rests are (1)
providing clients support for asserting direct
control over their search for resources, such as
housing and employment, and (2) examining
clients’ own strengths and assets as the vehicle
for resource acquisition. To help clients take
control and find their strengths, this model of
case management encourages use of informal
helping networks (as opposed to institutional
networks); promotes the primacy of the
client−case manager relationship; and provides
an active, aggressive form of outreach to clients.
A strengths perspective of case management
has been selected for work with substance
abusers for three reasons. First is case
management’s usefulness in helping them
access the resources they need to support
recovery. Second, the strong advocacy
component that characterizes the strengths
approach counters the widespread belief that
substance abusers are in denial or morally
deficient—perhaps unworthy of needed services
(Bander et al., 1987; Ross and Darke, 1992). Last,
the emphasis on helping clients identify their
strengths, assets, and abilities supplements
treatment models that focus on pathology and
disease. Strengths-based case management has
been implemented with both female (Brindis
and Theidon, 1997) and male substance abusers
(Rapp, 1997; Siegal et al., 1995).
Because of the advocacy component and
client-driven goal planning, a strengths-based
approach can at times cause stress between a
case manager and other members of the
treatment team (Rapp et al., 1994). Despite this,
there is evidence that the approach can be
10
Introduction
integra
ted with the disease model of treatment
and that its presence leads to improved
outcomes for clients. The improved outcomes
include employability, retention in treatment,
and (through retention in treatment) reduced
drug use (Rapp et al., in press; Siegal et al., 1996;
Siegal et al., 1997).
Clinical/Rehabilitation
Clinical/rehabilitation approaches to case
management are those in which clinical
(therapy) and resource acquisition (case
management) activities are joined together and
addressed by the case manager. It has been
suggested that the separation of these two
activities is not feasible over an extended period
of time and that the case manager must be
trained to respond to client-focused, as opposed
to solely environmental issues (Kanter, 1996).
Client-focused services could include providing
psychotherapy to clients, teaching specific skills,
and family therapy. Beyond the usual repertoire
of case management functions (e.g., monitoring),
the case manager should be aware of numerous
issues including transference,
countertransference, how clients internalize
what they observe, and theories of ego
functioning (Harris and Bergman, 1987; Kanter,
1996).
Many substance abuse treatment programs
use a clinical model in which the same treatment
professional provides, or at least coordinates,
both therapy and case management activities.
Such an approach is frequently driven by
staffing considerations: It is more economical to
have one treatment professional provide all
services than to have separate clinical and case
managers deliver them.
One example of combining clinical and case
management activities is found in a program for
women who have substance abuse problems
(Markoff and Cawley, 1996). In Project Second
Beginning, an emphasis on relationships and
empowerment is used both to secure needed
resources and to guide implementation of
therapy activities. This approach is based on the
belief that women have special needs in the
treatment setting—needs that can most
appropriately be addressed through a
therapeutic relationship with a single caregiver.
The clinical/rehabilitation approach has been
widely used in the treatment of persons with
diagnoses of both substance abuse and
psychiatric problems (Anthony and Farkas,
1982; Drake et al., 1993; Drake and Noordsey,
1994; Lehman et al., 1993; Shilony et al., 1993).
11
2 Applying Case Management to
Substance Abuse Treatment
C
ase management is almost infinitely
adaptable, but several broad principles
are true of almost every application.
This chapter will discuss those principles, the
competencies necessary to implement case
management functions, and the relationship
between those functions and the substance
abuse treatment continuum. For the purposes of
discussion, case management and substance
abuse treatment are presented as separate and
distinct aspects of the treatment continuum,
although in reality they are complementary and
at times thoroughly blended.
Case Management
Principles
Case management offers the client a single
point of contact with the health and social
services systems. The strongest rationale for
case management may be that it consolidates to
a single point responsibility for clients who
receive services from multiple agencies. Case
management replaces a haphazard process of
referrals with a single, well-structured service.
In doing so, it offers the client continuity. As the
single point of contact, case managers have
obligations not only to their clients but also to
the members of the systems with whom they
interact. Case managers must familiarize
themselves with protocols and operating
procedures observed by these other
professionals. The case manager must mobilize
needed resources, which requires the ability to
negotiate formal systems, to barter informally
among service providers, and to consistently
pursue informal networks. These include self-
help groups and their members, halfway and
three-quarter-way houses, neighbors, and
numerous other resources that are sometimes
not identified in formal service directories.
Case management is client-driven and
driven by client need. Throughout models of
case management, in the substance abuse field
and elsewhere, there is an overriding belief that
clients must take the lead in identifying needed
resources. The case manager uses her expertise
to identify options for the client, but the client’s
right of self-determination is emphasized. Once
the client chooses from the options identified,
the case manager’s expertise comes into play
again in helping the client access the chosen
services. Case management is grounded in an
understanding of clients’ experiences and the
world they inhabitthe nature of addiction and
the problems it causes, and other problems with
which clients struggle (such as HIV infection,
mental illness, or incarceration). This
understanding forms the context for the case
manager’s work, which focuses on identifying
psychosocial issues and anticipating and
helping the client obtain resources. The aim of
case management is to provide the least
13
Chapter 2
restrictive level of care necessary so that the
client’s life is disrupted as little as possible.
Case management involves advocacy. The
paramount goal when dealing with substance
abuse clients and diverse services with
frequently contradictory requirements is the
need to promote the client’s best interests. Case
managers need to advocate with many systems,
including agencies, families, legal systems, and
legislative bodies. The case manager can
advocate by educating non-treatment service
providers about substance abuse problems in
general and about the specific needs of a given
client. At times the case manager must
negotiate an agency’s rules in order to gain
access or continued involvement on behalf of a
client. Advocacy can be vigorous, such as when
a case manager must force an agency to serve its
clients as required by law or contract. For
criminal justice clients, advocacy may entail the
recommendation of sanctions to encourage
client compliance and motivation.
Case management is community-based. All
case management approaches can be considered
community-based because they help the client
negotiate with community agencies and seek to
integrate formalized services with informal care
resources such as family, friends, self-help
groups, and church. However, the degree of
direct community involvement by the case
manager varies with the agency. Some agencies
mount aggressive community outreach efforts.
In such programs, case managers accompany
clients as they take buses or wait in lines to
register for entitlements. This personal
involvement validates clients’ experiences in a
way that other approaches cannot. It suits the
subculture of addiction because it enables the
case manager to understand the client’s world
better, to learn what streets are safe and where
drug dealing takes place. This familiarity helps
the professional appreciate the realities that
clients face and set more appropriate treatment
goals—and helps the client trust and respect the
case manager. Because it often transcends
facility boundaries, and because the case
manager is more involved in the community
and the client’s life, case management may be
more successful in re-engaging the client in
treatment and the community than agency-
based efforts. For clients who are
institutionalized, case management involves
preparing the client for community-based
treatment and living in the community. Case
management can ensure that transitions are
smooth and that obstacles to timely admissions
into community-based programs are removed.
Case management can also coordinate release
dates to ensure that there are no gaps in service.
The type of relationship described here is likely
at times to stretch the more narrow boundaries
of the traditional therapist-client relationship.
Case management is pragmatic. Case
management begins “where the client is,” by
responding to such tangible needs as food,
shelter, clothing, transportation, or child care.
Entering treatment may not be a client priority;
finding shelter, however, may be. Meeting these
goals helps the case manager develop a
relationship with and effectively engage the
client. This client-centered perspective is
maintained as the client moves through
treatment. At the same time, however, the case
manager must keep in mind the difficulty in
achieving a balance between help that is positive
and help that may impede treatment
engagement. For example, the loss of housing
may provide the impetus for residential
treatment. Teaching clients the day-to-day skills
necessary to live successfully and substance free
in the community is an important part of case
management. These pragmatic skills may be
taught explicitly, or simply modeled during
interactions between case manager and client.
Case management is anticipatory. Case
management requires an ability to understand
the natural course of addiction and recovery, to
foresee a problem, to understand the options
14
available to manage it, and to take appropriate
action. In some instances, the case manager may
intervene directly; in others, the case manager
will take action to ensure that another person on
the care team intervenes as needed. The case
manager, working with the treatment team, lays
the foundation for the next phase of treatment.
Case management must be flexible. Case
management with substance abusers must be
adaptable to variations occasioned by a wide
range of factors, including co-occurring
problems such as AIDS or mental health issues,
agency structure, availability or lack of
particular resources, degree of autonomy and
power granted to the case manager, and many
others. The need for flexibility is largely
responsible for the numerous models of case
management and difficulties in evaluating
interventions.
Case management is culturally sensitive.
Accommodation for diversity, race, gender,
ethnicity, disability, sexual orientation, and life
stage (for example, adolescence or old age),
should be built into the case management
process. Five elements are associated with
becoming culturally competent: (1) valuing
diversity, (2) making a cultural self-assessment,
(3) understanding the dynamics of cultural
interaction, (4) incorporating cultural
knowledge, and (5) adapting practices to the
diversity present in a given setting (Cross et al.,
1989).
Case Management
Practice—Knowledge,
Skills, and Attitudes
All professionals who provide services to
substance abusers, including those specializing
in case management, should possess particular
knowledge, skills, and attitudes, which prepare
them to provide more treatment-specific
services. The basic prerequisites of effective
practice include the ability to establish rapport
Case Management and Treatment
qu
ickly, an awareness of how to maintain
appropriate boundaries in the fluid case
management relationship, the willingness to be
nonjudgmental toward clients, and certain
“transdisciplinary foundations” created by the
Addiction Technology Transfer Centers (ATTCs)
(see page 6). These foundations—
understanding addiction, treatment knowledge,
application to practice, and professional
readiness—are articulated in 23 competencies
and 82 specific points of knowledge and
attitude. Examples of competencies include
Understanding a variety of models and
theories of addiction and other problems
related to substance use
Ability to describe the philosophies,
practices, policies, and outcomes of the most
generally accepted and scientifically
supported models of treatment, recovery,
relapse prevention, and continuing care for
addiction and other substance-related
problems
Recognizing the importance of family, social
networks, and community systems in the
treatment and recovery process
Understanding the variety of insurance and
health maintenance options available and the
importance of helping clients access those
benefits
Understanding diverse cultures and
incorporating the relevant needs of culturally
diverse groups, as well as people with
disabilities, into clinical practice
Understanding the value of an
interdisciplinary approach to addiction
treatment (CSAT, 1998)
Even though case managers have not always
enjoyed the same stature accorded other
specialists in the substance abuse treatment
continuum, they must possess an equally
extensive body of knowledge and master a
complex array of skills in order to provide
optimal services to their clients. Case managers
15
Chapter 2
must not only have many of the same abilities as
other professionals who work with substance
abusers (such as counselors), they must also
possess special abilities relating to such areas as
interagency functioning, negotiating, and
advocacy. In recognition of the specific
competencies applicable to conducting case
management functions, two of the eight core
dimensions—referral and service coordination—
provide critical knowledge, skills, and attitudes
pertinent to case management. Below are the
activities covered under those dimensions.
Referral
Establish and maintain relations with civic
groups, agencies, other professionals,
governmental entities, and the community at
large to ensure appropriate referrals, identify
service gaps, expand community resources,
and help to address unmet needs
Continuously assess and evaluate referral
resources to determine their appropriateness
Differentiate between situations in which it is
more appropriate for the client to self-refer to
a resource and those in which counselor
referral is required
Arrange referrals to other professionals,
agencies, community programs, or other
appropriate resources to meet client needs
Explain in clear and specific language the
necessity for and process of referral to
increase the likelihood of client
understanding and follow-through
Exchange relevant information with the
agency or professional to whom the referral
is being made in a manner consistent with
confidentiality regulations and professional
standards of care
Evaluate the outcome of the referral
Service Coordination
Implement the treatment plan
Initiate collaboration with referral source
Obtain, review, and interpret all relevant
screening, assessment, and initial treatment-
planning information
Confirm the client’s eligibility for admission
and continued readiness for treatment and
change
Complete necessary administrative
procedures for admission to treatment
Establish realistic treatment and recovery
expectations with the client and involved
significant others including, but not limited
to
♦ Nature of services
♦ Program goals
♦ Program procedures
♦ Rules regarding client conduct
♦ Schedule of treatment activities
♦ Costs of treatment
♦ Factors affecting duration of care
♦ Client rights and responsibilities
Coordinate all treatment activities with
services provided to the client by other
resources
Consulting
Summarize the client’s personal and cultural
background, treatment plan, recovery
progress, and problems inhibiting progress
for purpose of ensuring quality of care,
gaining feedback, and planning changes in
the course of treatment
Understand terminology, procedures, and
roles of other disciplines related to the
treatment of substance use disorders
Contribute as part of a multidisciplinary
treatment team
Apply confidentiality regulations
appropriately
Demonstrate respect and nonjudgmental
attitudes toward clients in all contacts with
community professionals and agencies
(CSAT, 1998)
16
Case Management and Treatment
Alm
ost 200 specific knowledge items, skills, and
attitudes are associated with these dimensions:
They can be found in Appendix B.
The Substance Abuse
Treatment Continuum
and Functions of Case
Management
Substance Abuse Continuum of
Care
Substance abuse treatment can be characterized
as a continuum arrayed along a particular
measure, such as the gravity of the substance
abuse problem, level of care—inpatient,
residential, intermediate, or outpatient (Institute
of Medicine, 1990)—or intensity of service
(ASAM, 1997). The continuum in this TIP is
arranged chronologically, moving from case
finding and pretreatment through primary
treatment, either residential or outpatient, and
finally to aftercare. Inclusion of case finding and
pretreatment acknowledges the wide variety of
case management activities that take place
before a client has actually become part of the
formal treatment process.
While distinct goals and treatment activities
are associated with each point on the
continuum, clients’ needs seldom fit neatly into
any one area at a given time. For example, a
client may need residential treatment for a
serious substance abuse problem, but only be
motivated to receive assistance for a housing
problem. Case management is designed to span
client needs and program structure.
Case finding and pretreatment
The case-finding aspect of treatment is generally
of paramount concern to treatment programs
because it generates the flow of clients into
treatment. Pretreatment has changed
enormously in the past five years as programs
have closed, resources have dwindled, and
services available under managed care plans
have been severely curtailed. Many individuals
identified as viable treatment candidates cannot
get through the gate, and pretreatment may in
fact constitute brief intervention therapy.
Treatment programs may undertake case-
finding activities through formal liaisons with
potential referral sources such as employers, law
enforcement authorities, public welfare
agencies, acute emergency medical care
facilities, and managed care companies. Health
maintenance organizations and managed care
companies often require case finding when
hotlines are called. General media campaigns
and word of mouth also lead substance abusers
to contact treatment programs.
Some treatment programs operate aggressive
outreach street programs to identify and engage
clients. Outreach workers contact prospective
clients and offer to facilitate their entry into
treatment. Although treatment admission may
be the foremost goal of the worker and the
treatment program, prospective clients
frequently have other requests before agreeing
to participate. Much of the assistance offered by
outreach workers resembles case management
in that it is community-based, responds to an
immediate client need, and is pragmatic.
A pretreatment period is frequently the
result of waiting lists or client reluctance to
become fully engaged in primary treatment. In
a criminal justice setting, it may be a time to
prepare clients who are not ready for primary
treatment because they do not have support
systems in place and lack homes, transportation,
or necessary work and living skills. The
pretreatment period may be when clients lose
interest in treatment. When the appropriate
services are provided, however, it may actually
increase the commitment to treatment at a later
time. Numerous interventionsrole induction
techniques, pretreatment groups, and case
managementhave been instituted to improve
outcomes associated with the pretreatment
17
Chapter 2
period (Alterman et al., 1994; Gilbert, 1988; Stark
and Kane, 1985; Zweben, 1981).
Primary treatment
Primary treatment is a broad term used to define
the period in which substance abusers begin to
examine the impact of substance use on various
areas of their lives. The American Society of
Addiction Medicine (ASAM) delineates five
categories of primary treatment, characterized
by the level of treatment intensity: early
intervention, outpatient services, intensive
outpatient or partial hospitalization, residential
or inpatient services, and medically managed
intensive inpatient services (ASAM, 1997).
Whatever the setting, an extensive
biopsychosocial assessment is necessary. This
assessment provides both the client and the
treatment team the opportunity to determine
clinical severity, client preference, coexisting
diagnoses, prior treatment response, and other
factors relevant to matching the client with the
appropriate treatment modality and level of
care. If not already established during the case
finding/pretreatment phase, this assessment
should also consider the client’s needs for
various resources that case management can
help secure.
Aftercare
Aftercare, or continuing care, is the stage
following discharge, when the client no longer
requires services at the intensity required during
primary treatment. A client is able to function
using a self-directed plan, which includes
minimal interaction with a counselor.
Counselor interaction takes on a monitoring
function. Clients continue to reorient their
behavior to the ongoing reality of a pro-social,
sober lifestyle. Aftercare can occur in a variety
of settings, such as periodic outpatient aftercare,
relapse/recovery groups, 12-Step and self-help
groups, and halfway houses. Whether
individuals completed primary treatment in a
residential or outpatient program, they have at
least some of the skills to maintain sobriety and
begin work on remediating various areas of
their lives. Work is intrapersonal and
interpersonal as well as environmental. Areas
that relate to environmental issues, such as
vocational rehabilitation, finding employment,
and securing safe housing, fall within the
purview of case management.
If different individuals perform case
management and addictions counseling, they
must communicate constantly during aftercare
about the implementation and progress of all
service plans. Because case managers interact
with the client in the community, they are in a
unique position to see the results of work being
done in aftercare groups and provide
perspective about the client’s functioning in the
community. Recent findings suggest that the
case management relationship may be as
valuable to the client during this phase of
recovery as that with the addictions counselor
(Siegal et al., 1997; Godley et al., 1994).
Aftercare is important in completing treatment
both from a funding standpoint (many funders
refuse to pay for aftercare services), as well as
from the client’s perspective.
Case Management Functions and
the Treatment Continuum
In this section, case management functions are
presented against the backdrop of the substance
abuse continuum of care to highlight the
relationship between treatment and case
management. The primary difference between
the two is case management’s focus on assisting
the substance abuser in acquiring needed
resources. Treatment focuses on activities that
help substance abusers recognize the extent of
their substance abuse problem, acquire the
motivation and tools to stay sober, and use those
tools. Case management functions mirror the
stages of treatment and recovery. If properly
implemented, case management supports the
client as she moves through the continuum,
18
Case
Management and Treatment
encouraging participation, progress, retention,
and positive outcomes. The implementation of
the case management functions is shaped by
many factors, including the client’s place in the
continuum and level of motivation to change,
agency mission, staff training, configuration of
the treatment or case management team, needs
of the target population, and availability of
resources. The fact that not all clients move
through each phase of the treatment continuum
or through a particular phase at the same pace
adds to the variability inherent in case
management.
Engagement
Case finding and pretreatment
Engagement during the case
finding/pretreatment phase is particularly
proactive. The case manager frequently needs
to provide services in nontraditional ways,
reaching out to the client instead of waiting for
the client to seek help. Engagement is not just
meeting clients and telling them that a particular
resource exists. Engagement activities are
intended to identify and fulfill the client’s
immediate needs, often with something as
tangible as a pair of socks or a ride to the doctor.
This initial period is often difficult.
Motivation may be fleeting and access to
services limited. In many jurisdictions, there is a
significant wait to schedule an orientation,
assessment, or intake appointment. Third
parties responsible for authorizing behavioral
health benefits may be involved, and client
persistence may be a key factor in accessing
services.
Additional factors may come into play with
clients referred from the criminal justice system.
They may be angry about their treatment by the
criminal justice system and may resent efforts to
help them. Clients who begin treatment after
serving time in jail or prison have significant life
issues that must be addressed simultaneously
(such as safe housing, money, and other
subsistence issues) as well as resentment,
resistance, and anger. Others may have active
addictions or be engaged in criminal activity.
Requirements imposed by the criminal justice
system must also be met; these can present
conflicts with meeting other goals, including
participation in substance abuse treatment.
Potential clients may be unfamiliar with the
treatment process. Their expectations about
treatment may not be realistic, and they may
know very little about substance abuse and
addiction. It is not uncommon for people at this
stage to minimize the impact substance use or
abuse has on their lives. These factors often
manifest in client behaviors such as missing
appointments, continued use, excuses, apathy,
and an unwillingness to commit to change.
The goal of case management at this stage is
to reduce barriers, both internal and external,
that impede admission to treatment. Client
reluctance to enter into services can be reduced
by (1) motivational interviewing approaches; (2)
basic education about addiction and recovery;
(3) reminding clients of past and future
consequences of continued substance abuse; (4)
assistance in meeting the client’s basic survival
needs; and (5) commitment to developing the
case manager-client relationship. Prescreening
for program eligibility, coordinating referrals,
and working to reduce any administrative
barriers can facilitate access to services.
The process of motivating a client, beginning
the education process, identifying essential
needs, and forming a relationship can begin
during a prescreening or screening interview.
The motivational approaches suggested by
Miller and Rollnick encourage client
engagement through exploratory rather than
confrontational means (Miller and Rollnick,
1991). Recognizing that not every client enters
treatment with the same motivational levels,
they build on Prochaska and DiClemente’s
stages of motivation for treatment. The stages
move from the client’s non-recognition of a
19
Chapter 2
problem (precontemplation) to contemplation of
a need for treatment, to determination, to action,
and finally, to the maintenance of attained goals
(Prochaska and DiClemente, 1982). Case
management can use this framework to engage
the client with stage-appropriate services. This
means that clients who have not decided to
address their substance abuse can often be
“hooked” into more intensive treatment by
providing basic practical supports. Providing
these supports can have the additional effect of
reducing the perceived desirability of continued
substance use and the lifestyles associated with
it.
A structured interview provides the client
the opportunity to discuss her drug use and
history with the case manager and to explore the
losses that may have resulted from that use. For
some clients, this history may reveal a pattern of
increasing loss of control (and perhaps loss of
freedom). Review and discussion of losses can
serve to motivate clients to proceed to treatment.
Listening empathetically and showing genuine
concern about a client’s well-being can facilitate
the beginning of a meaningful, supportive
relationship between the client and the case
manager and can serve to motivate the client as
well. A good initial relationship between client
and case manager can also be invaluable when
the client experiences difficulties later on in
treatment (Miller and Rollnick, 1991).
In addition to information regarding
substance abuse and the treatment process,
clients must be informed about requirements
and obligations of the case manager or case
management program, and about requirements
they will be expected to meet once they are
admitted to treatment. This type of discussion
presents another opportunity to solidify the
client’s commitment to participate in treatment.
Even at the earliest stages, clients should be
reminded that permanent changes are necessary
for recovery. Finally, any questions the client
has should be addressed. This can be
particularly important for clients referred by the
criminal justice system, who may be somewhat
confused about that system’s requirements, the
consequences of noncompliance, and the
difficulties they encounter in meeting those
requirements.
While case management in the pretreatment
phase may be intended to route clients to a
particular program, engagement is not just a
“come-on” to treatment. Many prospective
clients will not formally enter treatment within
an agency-defined period, but, within flexible
limits, case management services should still be
made available to these individuals. The
transition from engagement to planning is a
gradual one and does not lend itself to agency-
created distinctions such as “pretreatment” and
“primary treatment.”
Primary treatment
For clients who elect to enter treatment,
engagement serves to orient the client to the
program. Orientation involves explaining
program rules and regulations in greater detail
than was possible or necessary during
pretreatment. The provider elicits the client’s
expectations of the program and describes what
the program expects of the client. The person
responsible for delivering case management to a
particular client is in a unique position to assist
in the match between individual and treatment.
During primary treatment, the case manager can
serve as one of the client's links with the outside
world, assisting the client to resolve immediate
concerns that may make it difficult to focus on
dealing with the goal of primary treatment—
coming to grips with a substance abuse
problem.
In addition to orienting clients to treatment
programs, case managers can orient treatment
programs to the clients they refer. Sharing
information gathered during the pretreatment
phase can provide support for the treatment
process that ensues upon program admission.
20
Case
Management and Treatment
Aftercare
While in treatment, most of a client’s time is
spent dealing with substance use. Although
discharge plans may have been considered, it is
not until discharge that the day-to-day realities
of living assume the most urgency. Because of
their relationship with their clients and their
community ties, case managers are well
positioned to help clients make this delicate
transition. Case management serves to
coordinate all aspects of the client’s treatment.
This coordination occurs within a given
treatment program, between the program and
other resources, and among these other
resources. The extent of the case manager’s
ability to work on the client’s behalf will be
guided both by the formal authority vested in
the individual by the service providers involved
and by the individual’s informal relationships.
The case manager’s extensive knowledge of
the client’s real-world needs can help the client
who is no longer using. Clients in aftercare have
an array of needs, including housing, a safe and
drug-free home environment, a source of
income, marketable skills, and a support system.
Many have postponed medical or dental care; in
recovery, they may seek it for the first time in
years. Once an individual is in recovery,
physician-prescribed medication for pain
management can become a major problem, an
issue that may require coordination and
advocacy.
Assessment
The primary difference between treatment and
case management assessments lies in case
management’s focus on the client’s need for
community resources. The findings from the
assessment, including specific skill deficits, basic
support needs, level of functioning, and risk
status, define the scope and focus of the service
plan.
Case finding and pretreatment
Depending on the structure and mission of the
program providing case management,
assessment may begin when engagement
begins. It is case management’s role to explore
client needs, wants, skills, strengths, and deficits
and relate those attributes to a service plan
designed to address those needs efficiently. If
the client is not eligible for a particular case
manager’s program, the case manager links the
client with appropriate external treatment
resources. This process includes assessing the
client’s eligibility and appropriateness for both
substance abuse and other services and for a
specific level of care within those services. If the
client is both eligible and appropriate for the
program, the case manager’s role is to engage
the client in treatment.
Primary treatment
For clients who enter primary treatment, the
case management assessment function, which is
primarily oriented to the acquisition of needed
resources, is merged with an assessment that
focuses on problems amenable to
therapysubstance use, psychological
problems, and family dysfunction. Ideally both
assessments are integrated into a
biopsychosocial assessment (Wallace, 1990).
This biopsychosocial assessment should, at a
minimum, examine the client’s situation in the
life domains of housing, finances, physical
health, mental health, vocational/educational,
social supports, family relationships, recreation,
transportation, and spiritual needs. Detailed
information should be gathered on drug use,
drug use history, health history, current medical
issues, mental health status, and family drug
and alcohol use. This assessment, used in
conjunction with the needs assessment, assists
the treatment team in developing a formal
treatment plan to be presented to, modified, and
approved by the client. Whether one person or
several conduct these two assessments is largely
21
Chapter 2
irrelevant. Where a team approach exists, all
members
of the team, including the case
manager or other professional identified in that
role, should bring their expertise to the
assessment. Discharge planning and long-range
needs identification, particularly with current
funding limitations, begins at treatment
admission. Because of this, intensive case
management for substance abuse clients,
regardless of the level of care, is imperative.
clients to learn how to obtain those services.
The client should therefore be assessed for
As the
individual responsible for
coordinating diverse services, the case manager
must take a broad view of client needs, look
beyond primary therapy to the impact of the
client’s addiction on broader domains, and
assess the impact of these domains on the
client’s recovery. He also must assess specific
areas of functional skill deficits, including
personal living skills, social or interpersonal
skills, service procurement skills, and vocational
skills. Individuals performing this function
need to have strong knowledge of and
experience in the field of substance abuse. The
greater the number of problems the case
manager can help the client identify and manage
during primary treatment, the fewer problems
the client must address during aftercare and
ongoing recoveryand the greater the chances
for treatment success.
A case management assessment should
include a review of the following functional
areas (Harvey et al., 1997; Bellack et al., 1997).
These items are not exhaustive, but demonstrate
some of the major skill and service need areas
that should be explored. The assessment of
these areas of functioning gives evidence of the
client’s degree of impairment and barriers to the
client’s recovery. The case manager may have to
perform many services on behalf of the client
until skills can be mastered.
Service procurement skills
While the focus of case management is to assist
clients in accessing social services, the goal is for
Ability to obtain and follow through on
medical services
Ability to apply for benefits
Ability to obtain and maintain safe housing
Skill in using social service agencies
Skill in accessing mental health and
substance abuse treatment services
Prevocational and vocation-related
skills
In order to reach the ultimate goal of
independence, clients must also have vocational
skills and should therefore be assessed for
Basic reading and writing skills
Skills in following instructions
Transportation skills
Manner of dealing with supervisors
Timeliness, punctuality
Telephone skills
The case management assessment should
include a scan for indications of harm to self or
others. The greater the deficits in social and
interpersonal skills, the greater the likelihood of
harm is to self and/or others, as well as
endangerment from others. The case manager
should also conduct an examination of criminal
records. If the client is under the supervision of
the criminal justice system, supervision officers
should be contacted to determine whether or not
there is a potential for violent behavior, and to
elicit support should a crisis erupt.
Aftercare
The client’s readiness to reintegrate into the
community is a focus of case management
assessment throughout the treatment
continuum. Because the case manager is often
out in the community with the client, she is in an
excellent position to evaluate this important
indicator. During aftercare, her assessment may
reveal new, recurring, or unresolved problems
the client must deal with before they interfere
with recovery. The potential for relapse is a
22
Case
Management and Treatment
particu
larly significant challenge, and the client
must be able to identify personal relapse triggers
and learn how to cope with them. Because case
managers are familiar with the community,
clients, and substance abuse treatment issues,
they can spot such triggers and intervene
appropriately. If, for example, a case manager
fears that a client’s decision to return to a
familiar neighborhood could result in contact
with drug-using friends that could jeopardize
sobriety, a new residence may be necessary.
Planning, goal-setting, and
implementation
Flowing directly and logically from the
assessment process, planning, goal-setting, and
implementation comprise the core of case
management. Based on the biopsychosocial or
case management assessment, the client and
case manager identify goals in all relevant life
domains, using the strengths, needs, and wants
articulated in the assessment process. Service
plan development and goal-setting are
discussed in detail in numerous works on
substance abuse and case management (Ballew
and Mink, 1996; Rothman, 1994; Sullivan, 1991).
These authors agree on several points: Each
goal in service plans should be broken down
into objectives and possibly into even smaller
steps or strategies that are behaviorally specific,
measurable, and tangible. Distinct, manageable
objectives help keep clients from feeling
overwhelmed and provide a benchmark against
which to measure progress. Goals, objectives,
and strategies should be developed in
partnership with the client. They should be
framed in a positive context—as something to be
achieved rather than something to be avoided.
Time frames for completing the objectives and
strategies should be identified. Abbreviated,
user-friendly treatment planning templates
make client participation in development of a
service plan more likely. The availability of staff
to assist in the planning, goal-setting, and
implementation of the case management aspects
of the treatment plan is crucial.
Successful completion of an objective should
provide the client the satisfaction of gaining a
needed resource and demonstrating success.
Failure to complete an objective should be
emphasized as an opportunity to reevaluate
one’s efforts. In the latter situation, the case
manager should be prepared to help the client
come up with alternative approaches or to begin
an advocacy process.
A deliberate, carefully considered approach
to identifying client goals offers benefits that go
beyond the actual acquisition of needed
resources. Clients benefit by
Learning a process for systematically setting
goals
Understanding how to achieve desired goals
through the accomplishment of smaller
objectives
Gaining mastery of themselves and their
environment through brainstorming ways
around possible barriers to a particular goal
or objective
Experiencing the process of accessing and
accepting assistance from others in goal-
setting and goal attainment
These and other individually centered
outcomes make the planning and goal-setting
process as important as the final outcome in
some cases. This is the action stage of case
management, when the client participates in
many new or foreign activities and may have
multiple requirements imposed by multiple
programs or systems. Many significant and
stressful transitions may be involved—from
substance use to abstinence, from
institutionalization or residential placement to
community reintegration, and from a drug- or
alcohol-using peer group to new, abstinent
friends. As clients struggle to stop using, many
will relapse, sometimes after a significant period
of abstinence. They may feel overwhelmed, and
23
Chapter 2
it is not uncommon for clients in recovery to
experience feelings of isolation and depression
as they develop new peer associations and
lifestyle patterns, and come to grips with their
losses. In addition, the very real pressures of
finances, employment, housing, and perhaps
reunifying with and caring for children can be
very stressful.
Case finding and pretreatment
During the pretreatment phase the planning
function of case management focuses on
supporting clients in achieving immediate needs
and facilitating their entry into treatment.
Ideally, the professional implementing case
management meets with the client to plan the
goals and objectives for the service plan. While
planning and goal setting are important in this
early stage of treatment, it may be difficult to
follow traditional approaches given the
immediacy of clients’ needs and the possibility
that they are still using alcohol or other drugs.
The case manager may decide to complete a
formal plan after an action is undertaken and
present it to the client as a summary of work
that was accomplished. If a client’s capacity is
diminished by substance abuse and the presence
of multiple, serious life problems, the case
manager may have to delay teaching and
modeling for the client, and instead trade on his
own contacts, resources, and abilities. As the
client progresses through the treatment
continuum, the case manager can turn more and
more of the responsibility for action over to the
client.
Clients who are using addictive substances
while receiving case management services
present a significant dilemma for the case
manager. On the one hand, the client may not
be willing or able to participate in treatment; on
the other, treatment providers normally expect
some commitment to sobriety before clients
begin the treatment process. As a result, the
case manager frequently needs to negotiate
common ground between client and program.
For example, a case manager might require the
client to identify and make progress toward
mutually understood goals pending entry into
treatment. Structured correctly, such an
approach fosters a win-win situation.
Attainment of these goals either eliminates the
client’s need for treatment or prepares him to
accept treatment more willingly. Even if the
client is unwilling or unable to achieve those
goals, the case manager and treatment program
have additional information to use in attempting
to motivate the client to seek treatment.
Primary treatment
During primary treatment, the case manager
and client develop a service plan that identifies
and proposes strategies to meet the client’s
short- and medium-term needs. The case
management plan should reflect the level and
intensity of the service along with the client’s
specific objectives. Virtually all clients have
multiple needs; consequently, the service plan
should be structured to enable clients to focus
on addressing their problems while they
participate in treatment. The idea that one can
put lack of housing, employment issues, or a
child’s illness aside to concentrate exclusively on
addiction treatment and recovery is unrealistic
and sets up both the treatment provider and the
client for failure. At the same time, it is often
necessary for the client and case manager to
prioritize problems.
During primary treatment, the case manager
must (1) continue to motivate the client to
remain engaged and to progress in treatment;
(2) organize the timing and application of
services to facilitate client success; (3) provide
support during transitions; (4) intervene to
avoid or respond to crises; (5) promote
independence; and (6) develop external support
structures to facilitate sustained community
integration. Case management techniques
should be designed to reduce the client’s
internal barriers, as well as external barriers that
may impede progress.
24
Providing ongoing motivation to clients is
critical throughout the treatment continuum.
Clients need encouragement to commit to
entering treatment, to remain in treatment, and
to continue to progress. The case manager must
continually seek client-specific incentives.
Clients are encouraged by different factors, and
the same client may respond differently
depending on the situation. For instance, many
clients referred by the criminal justice system
will be initially motivated to try treatment in
order to avoid a jail sentence; they may be
motivated to stay in treatment for very different
reasons (e.g., they start to feel better, they hope
to regain custody of children). The treatment
process is difficult, and many clients become
discouraged after their initial enthusiasm.
Recovery may require them to explore
uncomfortable issues. Physical discomfort, as
well as depression, can ensue. Case managers
can provide support during these periods by
supplying information on coping techniques
such as exercise, diet, and leisure activities. If
depression is significant, case managers can
work with substance abuse counselors to have a
mental health evaluation conducted, and, if
appropriate, enable the client to seek additional
therapeutic support for the depression.
Continued empathetic caring can also motivate
clients.
Disincentives may also be used. For
example, the case manager might remind clients
of the outcome of terminating treatment—for
some, this might mean a return to prison, for
others it might mean dealing with the health or
safety consequences of addictive behaviors. For
clients under the control of the criminal justice
system, sanctions, including possible jail stays,
may be necessary to regain commitment and
motivation.
In criminal justice settings, particularly drug
courts, regular “status hearings” before a judge
may motivate the client. In status hearings, the
judge is informed of the client’s progress (or lack
Case
Management and Treatment
thereof), and engages the client in a dialogue.
The judge can then apply rewards
(encouragement, or reduction of criminal
sanctions), adjust treatment requirements, or
apply sanctions. Sanctions vary, but may
include warnings, community service, short jail
stays, or ultimately, termination from the
program and incarceration.
Another fundamental role of case
management during the active treatment phase
is to coordinate the timing of various
interventions to ensure that the client can
achieve his goals. The case manager has to work
with the client to balance competing interests,
and to develop strategies so the client can meet
basic survival needs while in treatment. For
example, a case manager may have to negotiate
between probation and treatment to ensure that
the client can attend treatment sessions and
meet with his probation officer. Some activities
require staging to ensure that they are applied at
the right time and in the correct order. Clients
who are unemployed and lack employment
skills, for instance, should begin job readiness
and training activities after they are stabilized in
treatment; they will need additional support for
seeking and maintaining employment. It is not
uncommon for clients to feel they can take on
the world once they are stabilized in treatment.
If this is the case, the job of the case manager is
to encourage clients to go slowly and take on
responsibility one step at a time. This can be
particularly critical for women anxious to
reconnect with their children. The financial and
emotional responsibilities are great, and the case
manager should work with the woman and
child protective services to transition these
responsibilities in manageable ways.
Transition among programs—from
institutional programming to residential
treatment; from residential treatment to
outpatient; or to lower level services within an
outpatient setting — is always stressful, and
frequently triggers relapse. In order to avoid
25
Chapter 2
crises during transitions, case managers should
intensify their contact with clients. Case
managers should work to ensure that service is
not interrupted. When possible, release dates
should be coordinated to coincide with
admission to the next program.
If the client is under the control of the
criminal justice system, the case manager should
work to ensure that supervision activities
remain the same or increase when treatment
activity decreases. Too frequently, a client
completes a treatment program and is moved to
a lower level of supervision at the same time.
This pulls out support all at once. If possible,
supervision and treatment activities should be
coordinated to promote gradual movement to
independence in order to reduce the likelihood
of relapse.
In addition to activities designed to avoid a
crisis or relapse, the case manager should be
available to respond to relapses and crises when
they do occur. In many cases, the case manager
leads the response effort. Case managers should
be in frequent contact with the treatment
program to check on client attendance and
progress. Lapses in attendance and/or poor
progress can signal an impending crisis, and a
case conference should be held. The case
conference can resolve problems and prevent
the client’s termination from the program.
While violence toward staff or other patients is
obviously adequate grounds for immediate
program termination, other infractions do not
necessarily warrant expulsion. The case
management team and client should work
together to develop alternatives that will keep
the client engaged in treatment. If removal from
the program is absolutely necessary, it may be
possible to have the client readmitted after he
“adjusts his attitude” and re-commits to
treatment and to obeying the rules.
The Treatment Alternatives for Safe
Communities (TASC) Project has developed a
special form of case conference, known as
“jeopardy meetings” for treatment clients
involved in the criminal justice system. These
meetings are attended by the case manager,
treatment counselor, probation officer, client,
and anyone else involved in the case. The
purpose of the meeting is to confront the client
with the problem, and to discuss its resolution
as a team. The client must agree to the proposed
resolution in writing. The jeopardy meeting
provides a clear warning to the client (three
jeopardy meetings can result in client
termination); reduces the “triangulation” or
manipulation that can occur if all parties aren’t
working in a coordinated fashion; and brings
together the skills and resources of multiple
agencies and professionals. (For more on
jeopardy meetings, including structure and
format, see the TASC Implementation Guide
(Bureau of Justice Assistance, 1988).
Aftercare
One of the anticipatory roles for case
management during primary care is to plan for
aftercare, discharge, and community reentry.
During primary care and into aftercare, the case
manager helps the client master basic skills
needed to function independently in the
community, including budgeting, parenting,
and housekeeping. Short-term goals
increasingly become supplanted by long-term
goals of integrating the individual into a
recovery lifestyle. When appropriate, service
plans should reflect an ever-increasing emphasis
on clients’ accepting greater responsibility for
their actions. The case management
intervention may increase or decrease in
intensity, depending on client response to
independence and progress toward community
reintegration.
Linking, monitoring, and advocacy
Some findings suggest that while persons with
substance abuse problems are generally adept at
accessing resources on their own without case
management, they often have trouble using the
26
Case
Management and Treatment
service
s effectively (Ashery et al., 1995). This is
where the linking, ongoing monitoring, and, in
many cases, advocacy, of case management can
be valuable. An additional crucial function of
case management is coordinating all the various
providers and plans and integrating them into a
unified whole.
Linking goes beyond merely providing
clients with a referral list of available resources.
Case managers must work to develop a network
of formal and informal resources and contacts to
provide needed services for their clients.
Case finding and pretreatment
Case managers may be especially active in
providing linking and advocacy during the
pretreatment phase of the treatment continuum.
As with each of the case management functions,
the roots of linking begin much earlier, while
conducting an assessment with the client and in
creating goals in which the client is vested. The
authors of one primer on case management
identify five tasks related to linking that should
be undertaken with the client before actual
contact with a needed resource even occurs.
Case managers must (1) enhance the client’s
commitment to contacting the resource; (2) plan
implementation of the contact; (3) analyze
potential obstacles; (4) model and rehearse
implementation; and (5) summarize the first
four steps for the client (Ballew and Mink, 1996).
Primary treatment
After the linkage is made, the case manager
moves on to monitoring the fit and relationship
between client and resource. Monitoring client
progress, and adjusting services plans as
needed, is an essential function of case
management. Coupled with monitoring is the
need to share client information with relevant
parties. For instance, if a client who is involved
in the criminal justice system tests positive for
drugs, both the treatment counselor and the
probation officer may need to know. If the case
manager is aware that the client is having
problems at work, this information may need to
be shared with the treatment provider, within
the constraints of confidentiality regulations.
Case managers who are responsible for
offenders in treatment may oversee regular drug
testing. This is an effective way to obtain
objective information on a client’s drug use, as
well as to structure boundaries for the client to
help prevent relapse.
Monitoring may reveal that the case manager
needs to take additional steps on the client’s
behalf. Simply put, advocacy is speaking out on
behalf of clients. Advocacy can be precipitated
by any one of a number of events, such as
A client being refused resources because of
discrimination, whether discrimination is
based on some intrinsic aspect of the client,
such as gender or ethnicity, or on the nature
of the client’s problems, such as addiction
A client being refused services despite
meeting eligibility requirements
A client being discharged from services for
reasons outside the rules or guidelines of that
service
A client being refused services because they
were previously accessed but not utilized
The case manager’s belief that a service can
be broadened to include a client’s needs
without compromising the basic nature of
the service
Advocacy on behalf of a client should always
be direct and professional. Advocacy can take
many forms, from a straightforward discussion
with a landlord or an employer, to a letter to a
judge or probation officer, to reassuring the
community that the client’s recovery is stable
enough to permit reentry. Advocacy often
involves educating service providers to dispel
myths they may believe about substance
abusers, or ameliorating negative interactions
that may have taken place between the client
and the service provider. This is particularly
important for certain groups with whom some
27
Chapter 2
programs are reluctant to work, such as clients
with AIDS/HIV or clients involved in the
criminal justice system.
More complicated advocacy involves, for
example, appealing a particular decision by a
service staff member to progressively higher
levels of authority in an organization. The
highest, most involved levels of advocacy
include organizing a community response to a
particular situation or initiating a legal process.
Modrcin and colleagues provide an advocacy
strategy matrix that can help case managers
systematically plan advocacy efforts (Modrcin et
al., 1985). In this view of advocacy, the levels at
which advocacy can be effected (individual,
administrative, or policy) are weighed against
varying approaches (positive, negative, or
neutral). Three guidelines for advocating on
behalf of a client are getting at least three “No’s”
before escalating the advocacy effort,
understanding the point of view of the
organization that is withholding service, and
consulting with supervisory personnel regularly
before moving to the next level of advocacy
(Sullivan, 1991).
Client advocacy should always be geared
toward achieving the goals established in the
service plan. Advocacy does not mean that the
client always gets what she wants. Particularly
for clients whose continued drug use or
cessation of treatment will present considerable
negative consequences such as incarceration or
death, advocacy may involve doing whatever it
takes to keep them in treatment, even if that
means recommending jail to get them stabilized.
It is not uncommon, in fact, for clients to state
their preference for jail when treatment gets
difficult. Even when advocating for clients, the
case manger must respect system boundaries.
For example, a case manager might negotiate
hard to keep an offender client in community-
based treatment, but agree to inform the
probation office of positive drug tests or
suspected criminal behavior. While advocacy
for certain client populations is essential,
concern for the client should not override goals
of public safety. Effective, client-centered
advocacy may put the case manager in a
position of conflict with co-workers, program
administrators, or even supervisors. Case
managers who advocate for an extension of
benefits for their clients may put themselves and
their supervisors in jeopardy with funding
sources. A coordinated infrastructure with
existing policies and procedures for client
centered collaboration will help.
Disengagement
Disengagement in the case management setting,
as with clinical termination, is not an event but a
process. In some ways, the process begins
during engagement. For both client and case
manager, it entails physical as well as emotional
separation, set in motion once the client has
developed a sense of self-efficacy and is able to
function independently. To a significant degree,
this decision can be based on progress defined
by the service plan. If the plan has truly been
developed with the client’s active involvement,
there will be a great deal of objective
information that will help both the case manager
and client decide when disengagement is
appropriate. It is preferable that disengagement
be planned and deliberate rather than have the
relationship end in a flurry of missed
appointments, with no summary of what has
been learned by the client and professional.
Formal disengagement gives clients the
opportunity to explore what they learned about
interacting with service providers and about
setting and accomplishing goals. The case
manager has a chance to hear from clients what
they considered beneficial—or not beneficial—
about the relationship. Reviewing and
summarizing client progress can be an
important aspect of consolidating clients’ gains
and encouraging their future ability to access
resources on their own.
28
3 Case Management in the
Community Context: An
Interagency Perspective
T
he goal of interagency case management
is to connect agencies to one another to
provide additional services to clients.
All organizations have boundaries; case
managers or “boundary spanners” move across
them to facilitate interactions among agencies
(Steadman, 1992). While numerous researchers
have investigated the nature of these
connections (Tausig, 1987; Van de Ven and
Ferry, 1980; DiMaggio, 1986), a 1994 network
analysis of the “cracks in service delivery
system” provides especially useful insights into
the function and impact of various types of
community linkages (Gillespie and Murty, l994).
According to Gillespie and Murty, agencies can
be categorized by the connections they maintain
with other community-based agencies. Isolates,
the first category of agencies or programs,
operate self-sufficiently and establish no
connections to other organizations in the
community. Peripherals establish single or
limited linkages with other agencies and social
providers. A third category of agencies, which
the investigators leave unnamed, form effective
multiple connections with other organizations.
Applying Gillespie and Murty’s classification
scheme to substance abuse case management
yields three interorganizational models. The
three models are
The single agency
The informal partnership
The formal consortium
The single agency model is used by such
traditional community-based organizations as
grassroots domestic violence programs and
numerous medically oriented substance abuse
treatment agencies. In the single agency model,
the case manager personally establishes a series
of separate relationships on an as-needed basis
with professional colleagues or counterparts in
other agencies. The case manager retains full
and autonomous control over the case and is
accountable only to the parent agency.
In the informal partnership model, staff
members from several agencies work
collaboratively, but informally, as a temporary
team constituted to provide multiple services for
needy clients on a case-by-case basis. The
partnership can involve case managers from two
programs or agencies who consult with one
another on problematic cases and exchange
resource information. The partnership also can
consist of case managers and other types of
providers from two or more agencies who meet
on an informal basis to integrate and coordinate
services in response to clients’ needs.
Responsibility for a client’s well-being is shared,
29
Chapter 3
although accountability for the actual services
provided remains with the individual agencies.
The formal consortium model links case
managers and service providers through a
formal, written contract. Agencies work
together for multiple clients on an ongoing basis
and are accountable to the consortium. To
ensure coordination among consortium
members, a single agency typically takes the
lead in coordinating activities and maintains
final control over selected resources and
interagency processes (Cook, l977). A formal
consortium can enhance the systems of care for
substance abuse clients. For example,
Providence, Rhode Island’s Project Connect
sponsors a Coordinating Committee that meets
monthly on behalf of shared clients. Substance
abuse treatment programs, child welfare staff,
managed care providers, health care providers,
and representatives from the domestic violence
community come together to exchange
information and coordinate services. This
forum offers all participants an opportunity to
get to know each other, collaborate, and
advocate on behalf of substance abuse-affected
families.
Characteristics of the
Three Models
All three models describe arrangements for
interagency case management services and
methods for dispensing them. The most
appropriate model for a particular agency or
program hinges on its own history and mission,
the needs of its clients, and the environment in
which it operates. In developing a model, it is
important to remember that neither
organizations nor environments are static, and
interagency models may evolve in complexity
from the single agency to the informal
partnership to the formal consortium. Although
each model has advantages and disadvantages,
a model’s fit with its clients, the agency, and
environmental conditions determines its
effectiveness for a particular program (Rothman,
1992). Figure 3-1 summarizes the characteristics,
advantages, and disadvantages of each
organizational model.
Each model offers distinctive strengths
suitable for a particular organizational
environment. For example, in rural areas that
depend on “one-stop shopping” social service
programs, the relatively low-cost single agency
focus, with its capacity to respond quickly and
authoritatively, may be the optimal choice. On
the other hand, the informal partnership tends
to deliver more diverse services, so it is better
suited to culturally diverse communities. In
communities dominated by managed care, a
gatekeeper must make referrals for every
service, and a formal consortium may be the
best choice to supply the necessary
documentation.
Besides determining resource acquisition,
organizational environments impinge on
program decisions in other, less obvious ways.
In a volatile environment, a single focus agency
with its rapid startup and minimal up-front
investment may provide the only sensible
alternative. Where shared services can produce
savings through economies of scale, the
partnership arrangement may maximize scarce
resources. In an environment in which program
operations are routinely disrupted by political
upheaval, a formal consortium with its
mandated procedures may provide the stability
and continuity necessary to ensure that case
management services survive.
30
Interagency Case Management
Figure 3-1
Characteristics of the Three Interagency Models
Single Agency
Characteristics
Small grassroots agency or major provider of services for a single problem or to a single population
(may be “the only game in town“)
Tends to control a niche in the social service market by default (other agencies are not interested or
refuse to serve clients), history, design, or funding mandate
Often developed in response to an “acute” situation and implemented quickly
Less focused on organizational process than other case management models; more focused on client-
related tasks
Interagency case management services built on informal agreements
Case manager hired by and accountable solely to the single agency
Positive Features
Responds to crises quickly
Tends toward more cohesive or homogeneous values than other models
Tends to have single point of access to substance abuse treatment or other services for clients
Agency maintains sole control over implementation and coordination of case management program
Clients relate to a single individual concerning all problems
Often can respond more flexibly to individual client needs
Has the opportunity to exercise a broad range of skills
Is self-determining and self-accountable (monitors its own services)
Negative Features
Less control over social environment (e.g., policies and funding) and accessibility to services
Less influence over broad policies affecting case management services
Without a broad constituency and widespread community support, more vulnerable when funding
wanes or ends
More responsibility or burden on front-line case management staff to establish connections with
other community agencies
Case manager may feel especially burdened or taxed by having sole responsibility for client
Can require considerable training to equip case manager to deal autonomously with the diverse
needs of clients
Limited mix of services available to clients
Limited array of outcomes or solutions for client problems
31
Chapter 3
Figure 3-1 Continued
Informal Partnership
Characteristics
Establishes and maintains informal partnerships or networks to respond to the needs of multiple
populations with multiple problems
Initial motivation for forming partnerships may have been funding-driven as well as need-driven
Front-line case management staff from partnership agencies meet informally as a group (and without
a formal contractual obligation) to discuss client cases
Supervisors and other staff also may become involved and form relationships to share client-related
concerns
Staffing decisions are made internally by individual agencies
May evolve from a single agency model or be the model of choice from program inception
Less likely to have a lead agency than a formal consortium
Positive Features
Meets and functions only as needed
Avoids overlap of services
Has access to broader set of resources than single agency model
Coordinates care better among agencies at client level
Counters staff’s feelings of isolation by sharing burden of client responsibility
Shares information and possibly resources with partner agencies
Negative Features
Multiple problem orientations of partnership members may conflict with one another
More opportunity to compromise individual agency goals with respect to clients
Not as quick to respond to emerging problems as single agency model case management
Investment of staff and time resources greater than for single agency models (e.g., time to attend
meetings)
Possible breakdown of service coordination among multiple providers may result in service gaps
and fragmented care
Clients may find it difficult to relate to multiple providers
Formal Consortium
Characteristics
Two or more providers linked by a formal contractual arrangement
Represents multiple values and philosophies
Agencies cooperate and work together for a common purpose, which is formalized in the contractual
relationship
Agencies represent or cover multiple resources (e.g., housing and employment) in a particular social
service market
Typically identifies a lead agency (often the agency that funds or obtained the funds for case
management services) to coordinate the consortium’s case management services
The case manager may be supported through pooled resources from members of the consortium or
by the lead agency
32
Interagency Case Management
Figure 3-1 Continued
The lead agency generally hires the case manager, although multiple agencies within the consortium
may participate in the selection process
Accountability is shared across agencies
Case manager is accountable to the consortium
Entities primarily responsible for building and supporting the consortium (e.g., United Way; State,
county, or city government; National Institutes of Health; or Centers for Disease Prevention and
Control) may impose conditions or constraints on the case management process (e.g., mandated
community involvement)
Takes time and effort to develop; requires substantial up-front investment
Focuses more on organizational process than other interagency case management models
Tends to have a longer-term or more chronic orientation than other case management models
Positive Features
Access to more resources
Broader structure of constituent, political, and community support when resources are limited or the
economy is strained
More control in shaping the environment in which services are provided (e.g., more input into and
control over policies, funding, and the kind of case management interventions and services that are
offered)
More opportunities for coordination of care among agencies at both client and system level
Regularized contact between agencies increases occasions for strengthening service integration
Enhanced coordination across providers can decrease duplication of services
Consortium participants share information regarding changes in the organizational environment,
available and declining resources, and treatment information
Negative Features
Can be slow to respond due to problems of coordination
Must contend with multiple definitions of a problem or solution that may spark conflict among
consortium members
Time devoted to organizational process may reduce time given to client-related tasks
Clients may find it difficult to relate to multiple providers
Clients may need to travel to several locations for services
Multiple agency participation per case may involve higher costs and less intense personnel/agency
involvement, without added benefit to client
Potential systemic conflict over which agency takes lead and whose philosophy prevails when
differences occur
Forging the Linkages
Interagency case management arrangements are
designed to help providers connect with each
other to improve client services and enhance the
efficiency of their respective organizations. In
addition to trading useful information, agencies
also may exchange services, money, clients, and
client service slots. In the area of substance
abuse treatment, some case managers and
addiction specialists may be former users
themselves and may have known one another in
their former lives (Brown, l991). These ties often
strengthen or facilitate interagency exchanges
33
Chapter 3
and relations. Seasoned case managers tend
over time to form personal working
relationships with others in the field and often
trade on prior contact, previous service
reciprocities, and favors owed to get services for
clients (Levy et al., l992). Informal “quid pro
quo” arrangements are common, as are shared
resources to effect economies of scale.
While this system of informal exchange or
“social service bartering” is intrinsic to case
management, a more formalized connection
among agencies sometimes may be required.
Examples include memoranda of understanding
(MOUs) and interagency agreements and
contracts. Each of these methods for formalizing
expectations can be used in single agency
models, informal partnerships, and formal
consortia.
MOUs are a means to structure a relationship
among agencies. When agencies rely heavily on
each other’s services and function primarily as
brokers for their clients, MOUs are essential.
They specify such crucial information as the
number of service slots that agencies will make
available to one another’s clients and the
consequences for failure to implement or
comply with specified activities or procedures.
Program managers, rather than case managers,
typically draft MOUs and other formal
agreements and contracts with staff input. They
are particularly useful for
Ensuring continuity of services during staff
turnover
Clarifying lines of authority and control over
various aspects of the case management
process
Recording commitments for providing or
funding case management resources (e.g.,
staffing, operating funds, client referrals)
Providing a formal record of agencies’
agreements and responsibilities
Holding agencies accountable
MOUs and formal agreements have special
appeal when crediting or reporting the outcome
or delivery of case management services.
Among agencies and service providers that are
reimbursed for services on a per capita basis,
MOUs can be used to specify which agency or
personnel will receive credit. When services are
delivered as part of a research project, MOUs
can specify who has access to data and who may
claim authorship when research results are
published.
Some agencies also use Qualified Service
Organization Agreements (QSOAs) when an
agency or official outside the program provides
a service to the program itself. QSOAs might be
used, for example, when the program uses an
outside entity for laboratory analyses or data
processing. MOUs cannot be supplanted by
QSOAs.
MOUs and QSOAs are not the only type of
formalized agreements available to case
managers. Some programs use cooperative
service agreements to define what the parties
deliver to and receive from each other, and to
monitor the programs. A legal contract may be
needed when the lead agency in a formal
consortium subcontracts to other community-
based case management agencies to provide
specific services. Many case management
agencies also enter into agreements with
funding sources, including those providing
Federal entitlement benefits. Although some
experts question whether case managers should
function as payees (that is, accept and monitor
entitlement payments on their clients’ behalf), a
substantial number of case managers take on
that role. Until agencies become familiar with
such documents and procedures, obtaining
counsel prior to signing may be prudent.
34
Interagency Case Management
Identifying Potential
Partners
For any case management plan to be successful,
a provider must take a hard, objective look at
community resources. What form do they take?
What are the barriers to access? Who makes the
decisions about how they are used, how are
these decisions made, and how can they be
obtained? If housing is a major client concern,
for example, a community assessment should
ascertain if housing assistance is available and
how case management efforts might help clients
attain it. Similarly, a client’s legal status can
affect both the number and kinds of services
needed (e.g., client involvement in the criminal
justice system or with child protective services
agencies). Such legal pressures, in turn,
determine the range and type of agencies with
which a case management program must
interact and the conditions for these
relationships. Thus, depending on the legal
needs of its clients, a case management program
may need to identify and forge relationships
with such service providers as battered women’s
shelters, public assistance programs, legal aid,
churches, 12-Step groups, and other relevant
organizations.
Not all needed services are available, of
course, and at times the successful case manager
must create them. In other cases, needed
resources may exist but prove inaccessible or
unacceptable to clients. Ideally, case
management agencies or programs want to
provide or facilitate the full range of services
required by their clients. From a feasibility
standpoint, however, most providers must
confront painful realities during the assessment
process and be prepared to scale back
expectations.
Fortunately, most communities already have
tools to assist case management programs in
identifying resources, possible provider
linkages, and potential gaps in services. Public
Health Departments, United Way, and county
governments frequently produce directories of
social, welfare, health, housing, vocational, and
other services offered in the community. These
often include detailed information about hours,
location, eligibility, service mix, and costs; some
directories are computerized and regularly
updated. Although the costs associated with
purchasing these automated directories can be
steep (and should be considered when planning
the program budget), their timeliness and
convenience may justify the investment. In
many areas, the Yellow Pages serve as an
excellent resource for obtaining initial contact
information on a variety of health and social
services.
Another solid source of information is
geomapping, an automated package that assists in
resource identification. Philadelphia has
developed software that not only provides basic
program information but also indicates whether
a particular program has any openings.
Traditional paper maps or maps equipped with
overlays can fulfill the same function.
While directories and other service rosters
provide a useful starting point in identifying
potential resources and service providers,
additional work is required to determine which
listings will prove fruitful. There are often
delays in publishing and updating such
directories, so that they may be out of date even
before dissemination. It is critical that they be
updated on a consistent, timely basis.
Directories may not list all agencies or
programs, and more than one directory may be
necessary because an agency’s focus can shift.
Ouellet and colleagues report some
limitations in using directories, encountered
when they developed a case management
program for HIV-infected injection drug users
(Ouellet et al., 1995). Initially, during startup,
staff attempted to link clients to services solely
using a service directory, followed by contact
with organizations expressing willingness to
35
Chapter 3
provide support. Some resulting linkages were
found to be “largely useless” because
Some organizations misrepresent the number
or types of services they actually offer or
have available
Many services are poorly financed and
disappear quickly
Some organizations are incompetent or too
poorly managed or staffed to provide
adequate services
Some agencies are too far away for clients to
use (Ouellet et al., 1995)
In addition, Ouellet noted that some
organizations, such as hospitals, stigmatized
and treated injection drug users so badly that
clients didn’t want the services at all. Also,
many providers genuinely interested in service
collaboration underestimated the number of
people seeking help and the breadth of
expressed needs, and thus were unable to
handle the deluge of service requests. Other
organizations had the capability to work with
these clients but were unwilling to do so.
To counter such limitations, case
management programs often conduct “snowball
surveys” in their communities, using one
interagency contact to lead to another. This
technique can yield insider information about
other programs and agencies, their capabilities,
and experiences in service use. Identifying and
documenting resources and entitlements may be
best undertaken during the early phases of
program startup, when caseloads are low.
Experienced case management personnel
also recommend visiting the programs to which
clients will most likely be referred. Onsite visits
impart a wealth of information that may confirm
or refute the impression conveyed in written
materials. They also provide an opportunity to
establish valuable contacts with agency
personnel who can facilitate client services once
the case management collaboration is under
way.
Accurate, current information about
entitlements is essential for sound interagency
case management programs and often can be
obtained through local governments. New York
City, for example, posts menus of entitlements
on electronic kiosks. Many public libraries and
local government offices display updated
entitlement information regularly. Federal
Regional Offices of agencies such as the
Administration for Children and Families are
another resource for entitlement information.
As case managers compile and document
resources, they should also identify gaps in
services so that they and others understand
what is available in the community and where
advocacy efforts are needed. It is also important
to publicize case management programs
throughout the community. Brochures, fliers,
and simple one-page fact sheets can be used to
advertise or explain a program.
Announcements on the Internet, in community
newspapers, on bulletin boards, and in local
civic and professional club newsletters are
inexpensive methods for promoting new
services. Apprising local police of a new
program’s existence and the availability of
services may be particularly important as their
support can prove quite helpful with clients
involved in criminal justice matters.
The Agency Environment
Exploring the environment in which an agency
operates is essential in determining the
feasibility of mounting an interagency case
management effort. Several factors influence
the provider’s ability to conduct case
management within the community, including
Social service agencies’ number, type,
historic responsiveness to clients with
substance abuse problems, openness to case
management, and relationships with each
other. Communities with abundant social
service resources that address a wide range
36
of human necessities typically are better able
to meet the diverse needs of substance-
abusing clients than less endowed
communities. Similarly, social service
infrastructures in which providers are
willing to accept substance abusers as clients
and to accommodate innovative approaches
to addressing their problems are more likely
to welcome an agency’s case management
initiatives than more restrictive
organizational structures.
Community leaders’ support for or neglect
of substance abuse treatment and their
response to case management concepts.
Advocacy may be necessary because support
or pressure from community and political
leaders can facilitate a substance abuse
agency’s efforts to institute case
management. Conversely, implementation
can be stalled for months and sometimes
stopped entirely in communities when
leadership is opposed to substance abuse
treatment or case management services for
substance abuse clients. Identifying
proponents and adversaries is essential in
planning strategies that capitalize on support
or overcome/sidestep resistance to a case
management program. To form a strong
supportive voice within a community,
provider consortiums are often formed.
The economic situation in the community.
The more economically stable a community,
the more resources members of the civic,
governmental, and corporate power
structure have to bring to the table in
negotiations with other power brokers on
behalf of a case management program or
agency.
Social climate. Community acceptance of
substance abuse treatment and clients can
influence some agencies, particularly those
with a grassroots orientation, to accept and
cooperate with a case management program.
Bottom-up community acceptance can exert a
Interagenc
y Case Management
powerfu
l force in gaining agency leadership
cooperation, although this outcome may take
time.
Geographic considerations (distance,
terrain, isolation of the target population
from mainstream services). Availability of
case management services makes little
difference when clients cannot access
services because of transportation and other
barriers. In fact, accessibility may determine
the specific agencies with which programs
are able to connect on behalf of clients.
Legal and ethical issues affecting
implementation. Some communities have
zoning laws and other legal restrictions
specifying which, if any, social service
programs can be established within their
perimeters or near schools and other public
facilities. These statutes need to be clarified
before investing in program startup. In
addition, clients’ possible involvement in the
criminal justice system can raise issues of
confidentiality and other legal concerns
when creating cooperative arrangements
with other agencies. Special care needs to be
taken when an agency works with clients
who are involved with the criminal justice
system or who are in any way being coerced
or pressured into treatment. Issues that can
affect the transfer of confidential or sensitive
information need to be carefully worked out
before clients are actually admitted for
service. Policies and procedures should be
regularly reviewed in the face of experience
and adjusted accordingly.
Funding for program startup and program
continuation. Amount and type of available
funding (e.g., multiyear grant, limited
foundation support for project startup, and
matching or challenge grants) directly bear
on the nature and organizational complexity
of an agency’s case management program.
Multiyear funding permits substantial
advance planning prior to program
37
Chapter 3
implementation. It also enables agencies to
bring current and projected resources into
negotiations with other community
organizations. Continuing funds also allow
interagency linkages to develop and improve
over time. In contrast, restricted, one-year
funding may argue for front-loading
resources and selecting a case management
model that can be implemented quickly and
with immediate short-term payoff.
Incentives for entering into an interagency
agreement. Stakeholders who recognize the
benefits to their agencies will help facilitate
case management. Also, cooperative
relations tend to be more stable when
participating agencies have much to gain by
working together.
Volatility of the political, economic, or
social environment, such as the recent
introduction of Medicaid managed care.
Support for new initiatives can be difficult to
obtain in a climate in which reimbursement
criteria are being altered, State and Federal
funding is being redirected, or political
leadership is changing and the new players
are unknown. In an uncertain environment,
it is critical to justify the cost of a new service
with compelling evidence. When chaotic
conditions prevail, introducing a case
management program gradually protects
valuable resources while testing feasibility
before full implementation.
Agency administrators, whether they are
chief executive officers, executive directors, or
program directors, must develop working
relationships with the other social and human
services agencies with which the case managers
will be interacting. To be effective, case
management requires that connections be made
at the administrative/director levels of agencies.
Because case managers may be expected to
coordinate and implement a complex service
plan in an interagency environment, the case
manager needs sufficient power to implement
the plan. This comes from the explicit
endorsement of an agency’s top level
administration.
An honest appraisal of the community
environment equips an agency or program to
make key decisions about interagency case
management. Some potential cooperating
agencies cannot interact effectively with the
larger community or can only provide on-site
services. Other agencies may be willing to
cooperate, but their organizational missions
differ so radically from the case management
program’s that collaboration is impossible
(Ridgely and Willenbring, l992). Part of the
environmental assessment involves identifying
such providers to avoid creating linkages that
will ultimately prove unworkable.
Analysis of the community environment is
one in a series of ongoing assessments aimed at
understanding the changes that occur among
clients, within the program, and in the
community. As is true of other agency activities,
case management takes place within a dynamic
social service environment in which agencies are
in constant flux (Rothman, l992). Programs
considering interagency efforts must devise
coping strategies to respond to change while
providing necessary continuity for the client. In
addition, interagency networks are fragile and
frequently develop through personal trust
established between case managers. Staff
turnover disrupts such relationships and
threatens the case management system unless
guidelines or procedures exist to facilitate a
smooth transition (Levy et al., l995).
Because social environments for delivering
services do change over time, flexibility and
individuation are hallmarks of effective case
management. When programs become rigid in
their conceptualization, case management
services suffer. Regular reevaluation of
community resources helps ensure continued
relevance.
38
Finally, the philosophical orientation of a
program can affect the efficacy of any
interagency arrangements. Understanding a
program’s history and philosophy helps staff
members determine the type of interagency case
management services they offer their clients.
Compatibility in both program philosophy and
organizational structure in forging interagency
cooperation is essential, because services suffer
when the two clash.
Potential Conflicts
The potential for conflict exists whenever two
agencies or service providers work together.
Tension may be present from the very onset of
the collaboration. For example, existing social
service agencies may view a new project as
competition for scarce resources (Perl and
Jacobs, l992). Or, social pressures or the need to
maximize resources can force public agencies
into joint ventures even if they don’t mesh well
or have a history of competitiveness (Alter and
Hage, l993). Tensions also can develop in the
course of delivering services. Interagency
collaboration may result in a client having two
case managers, each of whom handles a
specialized problem, for example, a case
manager from a treatment program and a
probation officer. In such instances,
manipulative clients may pit one case manager
against another—a situation that can become
tense for all involved.
Recognizing potential triggers for
interagency conflict and antagonism is a
necessary first step to dealing with it. When
problems do erupt, case managers and other
agency personnel can use both informal and
formal communication mechanisms to clarify
issues, regain perspective, and refocus the
interagency case management process. The
following list highlights some of the common
sources of conflict that may arise as a result of
interagency case management.
Interagenc
y Case Management
Unrealistic expectations about the services
and outcomes that case management
linkages can produce
Unrealistic expectations of other agencies
Disagreements over resources
Conflicting loyalty between agency and
consortium or partnership
Final decisionmaking and other authority
over the management of a case
Disenchantment after the “honeymoon”
period ends
Differences in values, goals, and definitions
of the problem, solutions, or roles (e.g.,
conflict could arise when police officers
working with social service personnel
perceive that they are being asked to function
as “social workers“ and vice versa)
Dissatisfaction with case handling or other
agency’s case management performance
Clients who pit one case manager against
another
Inappropriate expectations of case managers
(improper demands, “asking too much”)
Resentment over time spent on
documentation, in meetings, or forging and
maintaining agency relationships rather than
on providing client services
Stratification, power, and reward
differentials among various agency case
managers
Differences in case manager credentials and
status among agencies
Unclear problem resolution protocols for
agency personnel
The solution to interagency conflict is open,
frank communication by personnel at all levels.
Frequent meetings and other activities that bring
people together foster such communication. In
the long run, the client’s welfare is a shared
objective, and the difficulties that are likely to
arise can be successfully resolved.
39
4 Evaluation and Quality
Assurance of Case Management
Services
S
ubstance abuse treatment programs,
including those that receive public
assistance, are increasingly operating in a
managed care environment. Policymaking and
clinical decisionmaking in a managed care
environment depend on outcome data that have
traditionally described the impact of case
management and substance abuse treatment
interventions in terms of services used and
money spent. (See Chapter 6 for more on
implementing case management in a managed
care setting.) An additional demand for data
comes from public and private payers who want
services linked to specific outcomes.
In the past, public sector substance abuse
programs were not paid to collect such data and
were discouraged from using funds designated
for service delivery to conduct evaluations.
Consequently, evaluation services often were
available only through demonstration grants or
through the efforts of university-based
evaluators. Today, however, many providers
plan, fund, and perform their own evaluations.
This reflects both the mandates of funding
organizations and agencies’ desire to refine or
improve their services. To prepare treatment
programs to get involved in these efforts, this
chapter first presents findings from previous
evaluation efforts and then proposes a
framework for facilitating quality improvement
and other evaluative efforts that consider
multiple stakeholders and focus on myriad
outcomes and data sources.
A Brief Overview of the
Research Literature
Researchers only recently have begun to assess
the effectiveness of case management. Studies
conducted thus far have suffered from
significant methodological problems that
include small sample sizes, poorly defined or
implemented case management interventions,
problems in evaluation design and
measurement, lack of distinction between case
management and comparison interventions,
poor timing, and unaccounted-for contextual
factors in communities where case management
was studied (Orwin et al., 1994). Problems in
research design are more than an academic
concernthey render results that may be
misleading, difficult to interpret, and unreliable
for use in developing case management
programs or policy.
Although problems in research design affect
other kinds of addiction treatment research, case
management is especially difficult to evaluate
because contextual factors play a critical role in
program operations. Case management
programs do not function in isolation. A key
41
Chapter 4
component of a successful case management
intervention is the establishment of linkages to
other agencies in a service network. Some
researchers have suggested that the effectiveness
of case management may have more to do with
the environment in which it functions than with
the functions of the program per se (Ridgely and
Willenbring, 1992; Morlock et al., 1988).
However, in spite of these difficulties, some
useful findings have emerged from work in the
mental health and substance abuse fields.
Much of the research on case management
has been conducted in the mental health field.
Reviews of its effectiveness are mixed (Bond et
al., 1995; Chamberlain and Rapp, 1991; Rubin,
1992; Soloman, 1995), revealing the need to
identify specific program models and
expectations about which type of case
management works for particular populations
and at what cost (Bond et al., 1995). The
Assertive Community Treatment (ACT) model
currently appears to have the strongest research
base for persons with initially high rates of
psychiatric hospitalization, both in terms of
increased retention in community based
treatment programs and in reduced psychiatric
in-patient days (Stein and Test, 1980). This
model includes a team of case managers who
work with clients in an intensive manner to
address problems of daily living and who have
a long-term commitment to providing services
to clients as long as their needs exist (McGrew
and Bond, 1995). While the model appears to be
effective in reducing psychiatric hospitalization,
there is little evidence that the approach results
in improved quality of life or level of
functioning for the client (Bond et al., 1995;
McGrew and Bond, 1995; Olfson, 1990; Soloman,
1992; Test, 1992).
Evaluation of so-called administrative
models in which case managers coordinate
services but provide little specific clinical care is
inconclusive. Some of these programs improved
clients’ quality of life but did not interrupt
patterns of rehospitalization. However, at least
one study revealed that administrative case
management both increased the use of services
and increased costs for clients without a
concomitant measure of improvement in clients’
lives (Willenbring et al., 1991).
Few studies have been undertaken on case
management in the substance abuse field, and it
is difficult to generalize the findings of those
studies that have. One study in Canada found
results similar to those in mental health studies:
There are positive, measurable effects of case
management, especially for clients with poor
prognostic indicators at admission (such as
heavy consumption of alcohol and other drugs,
previous treatment failures, and lack of social
support) (Lightfoot et al., 1982).
Other studies of case management in the
substance abuse field have reported few or no
differences for case managed clients compared
to those in treatment who do not receive case
management services (Inciardi et al., 1994; Falck
et al., 1994; Hasson et al., 1994). The authors of
those studies, however, speculate that
implementation and population issues may have
affected outcome. Other studies attribute some
of these negative findings not to poor case
management interventions, but rather to
methodological problems in the evaluations
(Orwin et al., 1994).
Even in light of the implementation and
methodological concerns about case
management research, all the studies together
with the findings of other addiction research
suggest that case management can be an
effective enhancement to intervention in and
treatment of substance abuse. This is especially
true for clients with other disorders, who may
not benefit from traditional substance abuse
treatments, who require multiple services over
extended periods of time, and who face
difficulty gaining access to those services.
In addition, research suggests two reasons
why case management may be effective as an
42
Evaluation and Quality Assurance
a
djunct to substance abuse treatment. First,
treatment may be more likely to succeed when
“drug use is treated as a complex of symptom
patterns involving various dimensions of the
individual’s life” (Inciardi et al., 1994, p. 146).
Case management focuses on the whole
individual and stresses comprehensive
assessment, service planning, and service
coordination to address multiple aspects of a
client’s life. Second, retention in treatment is
associated with better outcomes, and a principal
goal of case management is to keep clients
engaged in treatment and moving toward
recovery and independence (Institute of
Medicine, 1990). Studies looking at treatment
retention and case management posit a positive
relationship between the two (Siegal, 1997; Rapp
et al., in press).
Case management’s ambitious scope is one
of the reasons its effectiveness is difficult to
measure. Ashery and others have
recommended that practitioners in the field
maintain reasonable expectations for case
management, pay attention to the
implementation of programs, and understand
the enhancing or limiting factors of the
particular service context in which the case
management programs are implemented
(Ashery, 1994). The field should consider not
only how to best research case management but
what to expect from it.
Evaluating Case
Management Programs
In order for substance abuse programs to
ascertain if case management works, the
program and its various stakeholders (including
funding and regulatory agencies) must specify
and measure outcomes they regard as indicators
of success.
This section presents options for basic
evaluative methods, including documentation of
the case management program’s progress and
measurement of system and individual client
outcomes. It concludes by identifying the data
needs of various stakeholders. Whether an
evaluation is conducted internally by agency
personnel, or by experts hired from outside,
front-line case managers are the key source of
information.
In documenting a case management effort, it
is important to start with benchmarks
expectations that are made concrete as
measurable statements (e.g., “case managers
spend 60 percent of their time in face-to-face
contact with their clients”). Some of the sources
that programs can use to establish benchmarks
include
Policy and procedure manuals
Federal, State, and local case management
standards
Agency case management program
descriptions and mission statements
Literature on program models (if the
program under evaluation is a replication)
Consultants
If no written manuals or protocols are
available, or if it is clear that the program has
drifted from its original design, the program
managers and staff may use a consensus-
development process to arrive at benchmarks.
Measuring Practice
Once the process benchmarks are defined in
measurable terms, the next step is to develop
and implement a method for measuring
practiceto answer the question, “What are
case managers doing and how does their
practice conform to the benchmarks?” One
approach is to maintain a simple staff log that
measures case managers’ activities by contact.
The information should be comparable to the
benchmarks and brief enough to ensure
compliance and quality of data. Staff log
instruments such as the one used by John
Brekke and his colleagues (Brekke, 1987) have
43
Chapter 4
been widely adapted and used in the mental
health field. They usually record the client’s
name, location of the contact, duration of the
contact, activity, and whether other individuals
participated (e.g., staff of other agencies or
family members). The brevity and frequency of
case managers’ contacts with clients makes this
measure extremely burdensome, and as a result
many programs use time-limited or sampling
measures (for example, over a two-week period)
to get a “snapshot” of activities.
If time and resources permit, it may be
valuable to use several methods of
documentation to compare their usefulness and
sensitivity. Other methods and purposes
include
Reviews of case manager client records (to
evaluate how service planning and referrals
adhere to protocols and procedural
expectations)
Interviews or surveys of case managers or
clients and their family members (to collect
information on activities in which case
managers engage, to gauge how clients’ and
case managers’ views of those activities
differ)
Analysis of data from the agency’s
management information system (to examine
patterns on type, number, and duration of
case manager contacts with different target
populations)
In addition to using multiple methods of
documentation, it is important to review case
manager activities over time because programs
may drift from innovative to familiar patterns of
service delivery. In addition, the timing of data
collection is crucial. New programs need time
to stabilize, and new staff members need a
period of orientation before a true picture of
program activities can be established.
The key informant survey
Evaluators can use a key informant survey to
examine the operations of a program’s case
management activities. The survey is a fixed
series of questions about the functioning of both
the case management program and the system
of care and is administered to a variety of
stakeholders in the community. Different
stakeholders are identified by each agency,
depending on its particular case management
model and the system of care within which it
works. Appropriate stakeholders may include,
but are certainly not limited to
Agency staff
Staff from other substance abuse and human
service agencies, homeless shelters, and
hospital emergency rooms
Clients and their family members
Criminal justice and law enforcement
personnel
Survey participants might be asked about
their awareness of case management services,
their use of these services, types of ongoing
contact with the case management program, and
their perception of the impact of these services
on the community. To ensure a cross section of
informed opinion at various points in time, all
stakeholders are asked the same questions, and
the survey is repeated at several intervals. Such
surveys have been used to evaluate systems
change in the mental health field (Morrisey et
al., 1994) and could be adapted for use in case
management programs.
Client satisfaction
Knowing how clients perceive the services they
receive is essential to evaluative activities. One
can argue that satisfaction with service is related
to treatment retention. It is also important to
know whether the service provider—in this
instance the case manager—and client share a
common view of the services being offered and
their benefits. For example, did the client feel
that the case management services actually led
to needed resources? Other questions might
focus on client perceptions about those
providing the service: Did the case manager
44
Evaluation
and Quality Assurance
u
nderstand their needs and have the skills and
experience necessary to help them accomplish
their goals?
Such process data have direct utility for
program management and development. They
may help programs with defining staff training
needs and assuring that the needs of the
population they are working with are being
addressed. Such data are also quite useful for
those who have the responsibility for funding
programs.
Measuring System Outcomes
Many programs in the managed care
environment control access to services through
what is called “case management,” in which
gatekeeping procedures are used to limit clients’
use of expensive services such as hospitalization
and residential treatment. These programs may
be particularly interested in measuring system-
level outcomes to see whether case management
has a systemic effect on the delivery of
substance abuse and allied services (e.g., change
in patterns of service utilization or costs). Thus,
a net reduction in the number of inpatient
admissions for substance abuse treatment
would, by itself, be defined as a positive
outcome. This, of course, may not reflect the
needs of all clients.
If the goal is preventing clients from “falling
through the cracks” between discharge from
detoxification and entry into outpatient
substance abuse treatment, a system-level
outcome might be measured by continuity of
care. Greater continuity could be defined as
fewer clients with no outpatient treatment
episode after a detoxification discharge, patterns
showing shorter periods of time between
detoxification discharge and outpatient
treatment admission, and fewer people with
“revolving door” detoxification admissions.
Another case management program may aim for
increased access to care for certain target
populations (for example, cocaine-abusing
pregnant women). In this instance, it would be
useful to compare the number of admissions in
the target population to all admissions during a
specified time period.
In order to measure most system outcomes, it
is necessary to track clients within a
comprehensive service agency and, if a
program’s mandate includes managing care
across a network of agencies, to gather data on
encounters and costs and analyze them. Access
to a computerized management information
system (MIS) is essential for complete analyses.
Although these systems vary widely in their
level of sophistication, for this purpose, one
must be able to document more than units of
service information and should be able to link
encounter, claims, and cost data and produce
information quickly and easily. Over a period of
time, a comprehensive MIS tracks changes in
patterns of service utilization and changes in
costs, which gives the agency information
crucial to management and planning. For
example, an MIS that combines utilization and
cost data could help identify high utilizers for a
program that focuses on clients who use
numerous or expensive services. A later section
in this chapter describes how a program can
evaluate and enhance its MIS system.
Measuring Client Outcomes
While most would agree that “evaluation” is
generally worthwhile, there is considerably less
agreement about the measurement and
documentation of specific outcomes for
individual clients. When trying to evaluate case
management in an ongoing service agency
setting, additional challenges—conceptual,
methodological, and ethical—are posed. The
field has seen a long-standing and often strident
debate about what kinds of outcomes should be
measured. Some claim a single measure such as
sobriety or complete abstinence from any drug
use is the only meaningful measure of treatment
success. Others assert that treatment success is
45
Chapter 4
most appropriately measured by a constellation
of factors, including diminished alcohol and/or
other drug use, improved family functioning,
improved occupational functioning, less deviant
and/or criminal activity, fewer contacts with the
criminal justice system, and improvement on a
range of psychological variables. The debate
will continue. In the meantime, programs
should carefully consider treatment objectives to
articulate and then operationalize those outcome
variables they want to measure.
Another significant complication arises when
trying to evaluate case management activities
and client outcomes. A program must be able to
articulate the role of case management and how
it meshes with other program activities.
However, when “standard” client outcomes—
such as reduced substance use or fewer contacts
with the criminal justice system—are measured,
it is very difficult to separate the effects of
substance abuse treatment activities from the
effects of case management activities.
Finally, conducting research in community-
based treatment/service organizations presents
significant challenges. Experimentation, that is,
comparison and control, is at the heart of any
scientific research study. One group—typically
defined as the “experimental group”—receives
one kind of treatment and the control group
does not. The two groups are then compared,
and conclusions can be reached about the
efficacy of the treatment. However, in the
context of community-based treatment, a
potentially beneficial service like case
management cannot be withheld from some
clients. This makes it extremely difficult to
definitively attribute specific client outcomes to
case management or some other service.
Anticipating Quality Assurance
Data Needs
The types of data required for an evaluation of
case management, how the data are collected,
and the manner in which data are put to use
vary among different stakeholders. It is
important to understand the types of data that
various stakeholders need to evaluate the
program. Structured feedback loops should be
established to ensure that the data gathered are
returned to various stakeholders in some
meaningful way so that they have an impact on
shaping future program development (and
future data needs). One of the benefits of the
case management approach is that it can be
adapted to meet the sometimes contradictory
needs of the various stakeholders.
Data needs of case managers
Although the data needs of case managers may
vary from agency to agency, rapid access to data
in three particular areas is critical:
Information about clients currently on the
caseload (roster management), including
outcome data so case managers have
feedback on their performance
Data that allow case managers to track clients
through various services
Data that produce “flags” for follow-up
letters, aftercare, and other time-sensitive
functions
In addition to these elements, case managers
with gatekeeping or budgeting responsibility
need overall service utilization and cost figures
by client in order to manage services within a
budget. To evaluate process, case managers
need access (preferably computerized) to
referral networks, bed allocation systems,
progress notes, and data related to the daily
conduct of their jobs. In terms of outcome data,
case managers may want rapid access to client
status, especially if it would prompt additional
efforts.
Data needs of program managers
Program managers must ensure that the data
collected reflect the program mission and
facilitate the program’s management. While the
case manager focuses on individual clients, the
46
Evaluation
and Quality Assurance
program
ma
nager analyzes data elements to see
patterns and to flag and investigate “outliers”—
those who deviate drastically from the statistical
norms of the population.
The initial data needs of program managers
reflect concerns with concrete aspects of
program operation. To program managers, case
management essentially begins when the phone
rings, and therefore, their data needs are filled
by asking the following basic questions:
How many inquiries are we getting about
services?
Are we getting clients?
From what area are our clients?
Are clients entering care once they make
contact?
Are we responsive to clients’ needs from first
contact forward?
Is the type of client changing?
In addition to collecting these initial data,
program manager
s must be able to track clients
through their services so they can decide how to
alter service provision. Important questions
include
Who is in what level of care at what time?
How does the service fit with their treatment
plans?
Is the program meeting clients’ different
cultural needs?
Who is dropping out, and why?
What service not currently provided is
requested most frequently?
How much money is being spent on a
particular service?
Other questions relate to the program
manager’s administrative functions, including
What are the case managers doing? What are
their caseloads?
What are the results of internal monitoring?
Are we reaching the target populations?
Are clients retained at the appropriate level
of care?
Data needs of community
policymakers
Community policymakers may be local
government officials, members of community
coalitions, representatives of local law
enforcement agencies, school board members, or
other interested community-based stakeholders.
Since they are not often directly associated with
treatment programs, they may not have a very
sophisticated understanding of program goals
and may think of outcomes in terms of questions
like “Is the client sober or not?” or “Is there less
crime?” They tend to be less interested in
improved scores on standardized measures of
client functioning than in easily defined and
observable outcomes that affect the community,
principally
TaxesReducing costs
to taxpayers in the
areas of incarceration, unemployment, and
welfare enrollment and reducing costs of
case management and substance abuse
treatment by substituting a costly treatment
with a less expensive one
SafetyReducing neighborhood crime and
the number of homeless persons loitering in
business districts
Social costsIncreasing the number of
substance abusers who are working and
improving care for children of substance
abusers
Data needs of directors of State
alcohol and drug abuse agencies
Directors of State substance abuse agencies
value data elements that describe the overall
accessibility, quality, and cost of the substance
abuse treatment system. In addition, these
directors require data to track and contain the
growth of Medicaid and public sector behavioral
health care expenditures, to put managed care
systems in place, and to evaluate the effect of
managed care (including the provision of case
management) on the delivery of behavioral
health care services.
47
Chapter 4
Key data elements that State directors often
want to see in evaluation efforts include
Patterns of service utilization and costs,
including the use of public hospital and
residential treatment centers
Numbers of clients working and
withdrawing from welfare and Medicaid
Numbers of clients avoiding prison, reducing
child welfare cases and costs, and reducing
food stamp usage
Numbers of appeals and grievances by
clients
Number and characteristics of substance
abuse patients accessing other publicly
funded social services
Increasingly, State directors of substance
abuse agencies are becoming less isolated and
are beginning to look for opportunities to
exchange data among previously independent
departments (e.g., mental health departments,
Medicaid offices, and criminal justice offices).
Some State agencies share access to statewide
data sets. In addition, the movement toward
managed behavioral health care has prompted
more integration of data between State Medicaid
offices and State substance abuse and mental
health authorities.
Data needs of third party payers
Third party payers such as insurance companies
need data that justify case management as a cost
above and beyond the direct costs of treatment
services (see Chapter 6). In addition, when case
management is used to coordinate care, third
party payers want to know whether clients are
receiving the right services, at the right level of
care, and in the right sequence, and to ensure
that clients who are no longer in need are no
longer receiving services. To that end,
important data elements include
The severity of the client’s illness
Assignment to levels of care
Patterns of service utilization
Use of free self-help or volunteer
organization services
Urinalysis results, use of other drugs, and
scores on standardized outcome indicators
Discharge determinations
Data needs of clients and family
members
Clients and family members may serve on
advisory or governing boards of local programs
or may be involved in family or peer support
groups within the community. They may use
outcome data, especially results of client
satisfaction surveys, to change programs and
policies or to choose services and providers.
They may be less interested in patterns of
service utilization or standardized scores on
outcome evaluations than in how the system
functions from the user’s perspective. In fact,
clients might consider a program successful if it
is supportive, reliable, and easily accessible, as
opposed to “efficient.”
Data elements important to clients and
family members include
The availability and accessibility of services
The freedom of choice (of services and
providers) that the system allows
The use and effectiveness of the appeals and
grievance process
The influence of input from consumers and
family members
Effectiveness of treatment
Acceptability of treatment among the
targeted populations
Specifically, clients seek answers to the
questions
Am I getting the right services, in the right
setting?
Are there systems I can access myself?
How appropriate is my care?
48
Evaluation and Quality Assurance
Management Information Systems
The management information system contains
all this information and allows stakeholders to
use it. Managed care has provided the
behavioral health care field with an example of
how to manage far-flung data on clients.
One evaluation task for local programs is
determining how to use data already routinely
collected by a statewide MIS or managed care
company-based MIS, saving the program from
duplicating primary data collection. Another
important task is to develop or enhance
program-level MIS that track data the program
needs locally, integrate with other computer-
based or paper-based systems, and supply data
required by third party payer and governmental
bodies. All staff members of a specific program
should be stakeholders in the MIS, which
increases both system accuracy and the
likelihood that a broad array of staff members
will use it. If an agency does not have the
resources to develop a sophisticated system, it
should be able to automate at least a minimum
amount of client information through
commercially available software.
Local programs that are part of a managed
care network undoubtedly will be included in a
larger MIS sponsored by the umbrella provider.
Providers who are not part of these networks
may need to assess their readiness to take on
managed care activities by evaluating their
current MIS capabilities. Today, it is critical that
an MIS be designed with the data requirements
of managed care organizations in mind. The
following guidelines, adapted from a Federal
technical assistance publication, may help a
program determine whether its existing MIS is
sophisticated enough to support managed care
operations. A program’s MIS will suffice if it
does each of the following:
Retrieves patient information online or in
less than an hour
Cross-matches client records, use of services,
and financial and insurance information
Permits individual inquiries from managed
care organizations
Produces information that is used by
clinicians, supervisors, and managers
Integrates information from other programs
and sites
Allows client and service information to be
reported to all major payers
Generates patient invoices (CSAT, 1995d)
An existing MIS that can perform all of the
above functions will likely support managed
care and program demands; if it cannot, the
program needs to strengthen deficient areas.
Changes and advancements in data collection
and access to patient information must be
accompanied by appropriate protections for
client confidentiality.
Future Research
Research focused on case management in the
substance abuse field is limited and offers many
opportunities for local substance abuse
programs to make significant contributions to
the field. Suggested directions for future
research include the following:
Key ingredients of successful programs,
especially for hard-to-reach populations
Relative cost-effectiveness of particular case
management models, including cost outcome
results within systems incorporating full
parity of substance abuse with other health
care, outcome results when a full continuum
of care is available to patients, and outcome
results associated with use of standardized
guidelines for placement, continued stay,
and discharge for substance abuse patients
Improved methodology to investigate
research questions in “real world” settings
Development of brief versions of valid and
reliable research outcome instrumentation
The effect of particular forms of case
management on societal costs of substance
abuse and its treatment
49
Chapter 4
Cost shifting among health, behavioral
health, criminal justice, and other systems
that ca
n be accessed by the target population
Creative ways to use secondary data sets
(such
as Medicaid and Medicare) to
determine trends and patterns of care
Research questions from broader sociological
or multi-disciplinary perspectives
50
5 Case Management for Clients
With Special Needs
C
ase management is an appropriate
intervention for substance abusers
because they generally have trouble
with other aspects of their lives. This is
especially true for those clients whose problems
or issues can be overwhelming even for non-
addicted people. Among these special treatment
needs are HIV infection or AIDS, mental illness,
chronic and acute health problems, poverty,
homelessness, responsibility for parenting
young children, social and developmental
problems associated with adolescence and
advanced age, involvement with illegal
activities, physical disabilities, and sexual
orientation.
In an ideal world, case managers would be
knowledgeable about all those problems and
needs. However, understanding the
ramifications of even one can be a staggering
task. For example, a case manager dealing with
a client who has AIDS would need to be
conversant in epidemiology, transmission
routes, the disease’s clinical progression,
advances in treatment regimens, financial and
legal ramifications, available social services, as
well as psychotherapeutic approaches to AIDS
patients’ grief and fear. Given the many other
special needs the case manager confronts, it is
apparent that no one individual can be an expert
in every area. In the absence of such
comprehensive knowledge, several general
attitudes and skills provide a basic foundation
for the professional delivering case management
services to “special needs clients.” The case
manager serving special needs clients should
Make every effort to be competent in
addressing the special circumstances that
affect clients typically referred to a particular
substance abuse treatment program
Understand the range of clients’ reactions to
the challenges associated with particular
special circumstances
Remain aware of the limits of one’s own
knowledge and expertise
Evaluate personal beliefs and biases about
clients who have special problems
Maintain an open attitude toward seeking
and accepting assistance on behalf of a client
Know where additional information on
special problems can be accessed
While it is impossible to discuss all the
special needs that case managers confront,
several occur repeatedly. This information is
not intended to be a comprehensive treatment of
any of these areas, but rather an introduction to
the issues that most directly relate to the
implementation of case management.
Minority Clients
Demographic realities in the United States
dictate that case managers will be called on to
work with individuals of different gender, color,
51
Chapter 5
ethnicity, and sexual orientation. Some will be
persons of color; some will be poor, not
conversant in English, disadvantaged, and over
represented in many areas of the social services
system. Case managers must “respond
proactively and reactively to racism,
ethnocentrism, anti-Semitism, classism, and
sexism . . . ageism and ‘ableism’” (Rogers,
1995, p. 61).
There are five elements are associated with
becoming culturally competent: (1) valuing
diversity, (2) making a cultural self-assessment,
(3) understanding the dynamics when cultures
interact, (4) incorporating cultural knowledge,
and (5) adapting practices to the address of
diversity (Cross et al., 1989). According to
Rogers, culturally competent case managers
have the
Ability to be self-aware
Ability to identify differences as an issue
Ability to accept others
Ability to see clients as individuals and not
just as members of a group
Willingness to advocate
Ability to understand culturally specific
responses to problems (Rogers, 1995)
Case managers should either speak any
foreign languages common in their locale or
refer non-English speakers to someone who
does. It is also crucial for the case manager to be
aware of what may inhibit minorities’
participation in the substance abuse treatment
continuum. For example, while “accepting
one’s powerlessness” is a central tenet of 12-Step
self-help programs, members of oppressed
groups may not accept it, given their own
societal powerlessness. The case manager must
always be sensitive to such cultural differences
and identify recovery resources that are relevant
to the individual’s values. Some minority group
members may be inclined to seek help for a
substance abuse problem from sources outside
the treatment continuum, such as clergy, group
elders, or members of their own social support
networks. Others may prefer to be treated in a
program that uses principles and treatment
approaches specific to their own cultures. Case
managers must advocate for culturally
appropriate services for their clients.
Clients With HIV
Infection and AIDS
The usual functions and activities associated
with case management in substance abuse
treatment—engagement, helping orient the
client to treatment, goal planning, and especially
resource acquisition—are made more difficult in
dealing with clients who have HIV or AIDS by
Providers’ and other clients’ fear of
contracting HIV
The dual stigma of being a person with both
a drug abuse problem and HIV
The progressive and debilitating nature of
the disease
The complex array of medical, especially
pharmacological, interventions used to treat
HIV
The onerous financial consequences of the
disease and of treatment
The hopelessness—and lack of motivation for
treatment—among the terminally ill
Case managers who provide services to this
population must be prepared to work with “a
base of diverse resources, enhancement or
adaptation of the capabilities of existing
resources, or the development of new service
programs specifically designed to address [the
HIV-infected individual’s] needs” (Sonsel et al.,
1988, p. 390). The Linkage Program in
Worcester, Massachusetts, is typical of this
arrangement. It engaged 19 diverse agencies—
including drug treatment programs, area
churches, AIDS advocacy and support agencies,
the city’s department of public health and a
regional medical center—in a consortium of care
52
Clients With Special Needs
for
substance abusers who also had HIV
infection (McCarthy et al., 1992). The Worcester
consortium and other linkage programs
demonstrated a positive relationship between
the amount of case management services
provided and the receipt of drug abuse, health
care, and other services (Schlenger et al., 1992).
While one person should assume primary
case management responsibility for clients with
HIV or AIDS, a team approach is particularly
useful in combating the feelings of frustration,
abandonment, grief, over-identification with the
client, and anger that frequently confront
professionals in this setting (Shernoff and
Springer, 1992). To avoid staff burnout,
providers should avoid designating the same
individual as case manager for all clients with
AIDS and HIV infection.
The overwhelming nature of life for a person
with two life-threatening conditions—AIDS and
addiction—cannot be overstated. The
magnitude of even daily tasks holds significant
stress for both the client and the case manager.
Addicted people with AIDS or HIV need help
with physical functioning, interpersonal
relationships, adjustment to the treatment
program, housing, and practical and
psychological adjustment to the two conditions.
Part of the case manager’s linking function in
working with an HIV-positive client is to
educate the network of service providers,
including substance abuse treatment staff, to
recognize the competing demands of staying
sober and dealing with the social and physical
sequelae of HIV disease.
Clients With Mental
Illness
Almost 40 percent of people with an alcohol
disorder meet criteria for a psychiatric disorder,
and more than half of those with other drug
disorders report symptoms of a psychiatric
disorder (Regier et al., 1990). Not unexpectedly,
the prevalence of coexisting disorders is
significantly higher in treatment populations
than in the general population, approaching 80
percent in some studies of substance abuse
patients (Khantzian and Treece, 1985; Ross et al.,
1988; Kosten and Kleber, 1988). Given those
high comorbidity rates, substance abuse
treatment staff must be prepared to address the
problems of dual-diagnosis clients.
Treatment services for clients with a dual
diagnosis are organized in sequential, parallel,
or integrated models (CSAT, 1994b). In the
integrated model, both disorders are dealt with
at the same time and in the same program. Case
management’s primary role includes facilitating
clients’ transition from residential programs to
the community, helping them identify and
access needed resources, and providing long
term support for their functioning in the
community.
In the case of sequential treatment, the case
manager helps the client move from either
substance abuse to mental health treatment or
from mental health to substance abuse
treatment. In parallel treatment, the case
manager must facilitate communication and
service coordination between two agencies
whose treatment approaches may be based on
different assumptions. Examples of the possible
issues the case manager may have to address on
behalf of a client in mental health treatment
programs include the following:
Bias against substance abusers affects the
provision of mental health services
Many inpatient facilities establish an
arbitrary minimum number of days of
sobriety for their clients
Some service providers will not accept clients
who are on medication, including methadone
Conversely, issues in substance abuse
treatment programs that might be
counterproductive to mental health treatment
include
53
Chapter 5
Treatment approaches may rely on insight
and introspection that some mental health
clients are intrinsically incapable of achieving
The approach used in substance abuse
treatment may be too confrontational
The treatment program and other clients may
reject clients taking psychotropic medication
Many of the special case management issues
for clients with mental illness center on the
client’s use of prescription drugs to stabilize
mood and reduce the negative effects of the
mental disorder. Some substance abuse
treatment providers oppose the use of any
psychotropic drugs, fearing that they will
interfere with the recovery process and become
a new source of chemical dependency or that the
prescribing physician is not adequately aware of
the client’s problems with addiction. Some
treatment programs unwittingly precipitate a
client’s relapse by requiring the client to stop
taking all medications as a condition of
acceptance to a treatment program. Participants
in 12-Step meetings may pressure clients to be
free of the “crutch” of prescription drug use.
As substance abuse treatment providers
become familiar with prescribed neuroleptic
drugs, they are more likely to accept the medical
management of the client’s illness and
communicate more with the professionals
providing the client’s medical care. To manage
client symptoms and behaviors, anticipate
problems, and reinforce the medical
management of the client, all staff who work
with dual-diagnosis clients need some
knowledge of the benefits of commonly
prescribed drugs, their potential side effects,
actual abuse potential, and their interactions
with other drugs.
Aftercare tends to be long-term for clients
with mental illness because of the continuing
possibility that the client will stop taking
medications when he begins to feel more stable
and then take illicit drugs to cope with the re-
emergent symptoms of mental illness. 12-Step
programs such as Double Jeopardy, Double
Trouble, and Dual Recovery Anonymous
designed specifically for people with mental
health and substance abuse problems can be
valuable sources of support.
While case managers may not be experts in
the treatment of any one of these disorders, it is
vital that they know enough to work with the
client in identifying her needs and be able to
translate and coordinate those needs with the
two types of treatment.
Homeless Clients
Alcoholism rates among the nation’s homeless
are estimated to be as much as two to four times
the levels for individuals of the same gender in
the general population. Besides alcohol, the
substances most frequently used by homeless
people are marijuana, cocaine, and crack cocaine
(National Institute on Alcohol Abuse and
Alcoholism, 1989). Crack use in particular has
increased in the last 10 years, primarily among
younger homeless people (Crystal, 1982).
Numerous efforts at engaging homeless
individuals in substance abuse treatment have
been undertaken, many involving case
management as a central component (Braucht et
al., 1995; Conrad et al., 1993; Sosin et al., 1995;
Stahler et al., 1995).
The need for case management with this
population is obvious. Clients need suitable
short- and long-term housing; many have
mental disorders. Homeless individuals
frequently suffer from significant health
problems secondary to their lifestyle, including
tuberculosis, HIV, and AIDS. Unemployment is
high. This constellation of tangible needs can
best be addressed by one individual at the
interface between the streets and social service
agencies.
A case manager always begins by working
on issues the client feels are most pressing, and
the need for stable shelter may not be at the top
54
of the client’s list. Many homeless people feel
safer and more comfortable on the streets than
in a shelter because the streets are familiar to
them and because they have established
routines and a network of people to watch out
for them. While this setting is hardly ideal, it
may be one in which the client can function well
enough to benefit from treatment. However,
some programs may claim they cannot help
homeless individuals until their other life
problems are solved, requiring the case manager
to advocate on the client’s behalf (Sosin et al.,
1994).
The case manager’s rapport-building skills
are critical to break through the many defensive
behaviors and protective attitudes that clients
develop to survive in shelters and on the streets.
These behaviorslooking tough, acting with
bravado, wariness of social services,
maintaining a hard exterior, and letting go of
social gracesmake homeless clients difficult to
engage and interfere with their ability to
succeed in treatment or maintain stable housing.
One solution to this difficulty in engaging
homeless clients is through the use of peer case
managers: homeless individuals who are in
recovery themselves and are based in shelter
care facilities. In one such setting, peer case
managers proved to be as successful as degreed
professionals or an intensive residential
treatment program in assisting homeless
individuals in the areas of substance use,
housing stability, employment, and
psychological functioning (Stahler et al., 1995).
In addition, clients were more satisfied with the
services provided by the peer case managers
than by the degreed professional case managers.
This finding may be explained by clients’ beliefs
that case managers who have experienced
homelessness first-hand are more likely to
provide needed services.
To meet their linking and advocacy
responsibilities, case managers must recognize
that some services generally available to
Clients
With Special Needs
substance abusers are not available to homeless
people and that new services may need to be
created to fill those gaps. For example,
Louisville’s Project Connect used case
management to help homeless alcoholic and
drug abusing men move from a sobering-up
shelter (the pretreatment phase of the treatment
continuum) through a vocational program at the
exit point of treatment (Bonham et al., 1990).
Another substance abuse program at the
Coatesville Veterans’ Affairs (VA) Medical
Center picks up homeless veterans at local
shelters, takes them in vans to the VA for day
treatment, feeds them, and takes them back to
the shelter. This has helped to keep veterans
engaged in treatment as they await placement in
a VA domicile or other housing arrangement.
The Department of Veterans' Affairs conducts
stand-downs in its homeless program, during
which veterans temporarily housed in tents
receive medical services and are assessed for
treatment needs. They are brought into
residential care for treatment as needed.
The delivery of social services is complicated
by the fact that homeless clients usually are
turned out of shelters from 9:00 a.m. until 4:00
p.m. The client’s social network during these
hours consists of other people, often not sober,
who are also out of the shelter. Providers may
find it useful to provide a day room with snacks
and a television where clients can stay during
the day or some sort of day work where clients
can earn a few dollars. Case finding can be
accomplished by mobile case management
teams who seek out homeless substance abusers
in shelters and other areas where they sleep and
congregate (Rife et al., 1991).
Women With Substance
Abuse Problems
Case-finding is an especially important case
management activity with female substance
abusers, who seem to follow a different path to
55
Chapter 5
treatment than males. Because women are often
referred by other service providers (Beckman
and Amaro, 1986), case managers affiliated with
substance abuse treatment programs must help
their counterparts in other social service
agencies identify women in need of treatment.
Women with children are likely to be involved
in numerous child-related services; women who
have been victims of domestic violence present
for services at battered women shelters; other
women may appear at mental health centers and
women’s health centers. A significant number
of women clients have suffered physical, verbal,
psychological, or sexual mistreatment (Miller
and Rollnick, 1991; Mondanaro et al., 1982), and
many who present for treatment live in an
unsafe environment.
Once identified, women with substance
abuse problems may be difficult to engage in
treatment. Society judges substance-abusing
women more harshly than male substance
abusers. A woman’s substance abuse problem is
likely to have progressed significantly before
being identified, and treatment may be
complicated by factors like psychological
functioning, situational realities, and systemic
barriers (Wildwind, 1984). Other issues such as
sexual abuse, victimization, and emotional
dependency are frequently associated with
women who have substance abuse problems
(Markoff and Cawley, 1996). Transportation is a
common barrier, especially in primary
outpatient and aftercare treatment.
Women substance abusers who have
children confront these problems and more
when considering treatment. A mother’s
decision to enter treatment means the case
manager must either identify a program that
will take both the woman and her children or
assist the woman in finding appropriate child
care. These mothers may avoid treatment out of
guilt and shame for the activities in which they
have engaged to acquire drugs and the
situations in which they have placed their
children. Compounding a mother’s shame is the
fear that authorities will take her children away
from her. As a result, an assessment of such a
mother’s needs is complicated by the fact that
she is likely to lie to the case manager about her
addiction and the way her family lives.
The basic functions and tenets of case
management are well suited to improving
retention and outcomes for women in treatment.
There is evidence that women in particular do
not adequately focus on their substance use and
recovery until their needs for such resources as
housing, food, medical care, and personal safety
are adequately addressed (Hepburn, 1990).
Case managers should assist female clients in
developing a safety plan setting out well-
defined steps to take should she fear, or be
subjected to, violence. It is imperative to
determine if women are living in a safe
environment. Women who have children are
even more extensively involved, or need to be,
with community resources, including the school
system, pediatric physicians, and children’s
protective services if their substance use has
resulted in neglect or abuse. Case managers are
responsible for facilitating the acquisition of
these resources as their clients more through the
treatment continuum.
A woman’s involvement with community
resources frequently places the case manager in
a position to advocate for her needs. Advocacy
means securing resources not only outside the
treatment program, but also within the program,
especially if the program primarily treats male
clients (Brindis and Theidon, 1997). Advocacy
not only improves the woman’s acquisition of
needed resources, but also empowers her to
become more assertive on her own behalf and
builds a closer relationship with the case
manager. Advocacy cannot, however, stop the
case manager from fulfilling her legal obligation
to report child abuse or neglect.
Two excellent sources of information on the
role that case management plays in the
56
Clients With Special Needs
treatment
of women substance abusers are
Pregnant, Substance-Using Women (CSAT, 1993)
and Case Management in Substance Abuse
Treatment: Improving Client Outcomes (Sullivan et
al., 1992).
Adolescent Substance
Abusers
Substance use and dependence are significant
problems among adolescents in the United
States. Some substance use is due to a
developmental tendency to experiment, results
in few consequences, and abates with maturity.
However, a number of adolescents progress to
the point of substance abuse or dependence.
Because of the problems associated with abuse
and dependence these adolescents are
frequently involved with multiple systems,
including child welfare, juvenile justice, mental
health, and special education (CSAT, 1993).
A case manager is in a unique position to
help adolescents and their families interact with
those systems. The case manager of a teenager
must have a thorough understanding of the
developmental issues pertinent to adolescence,
an ability to establish rapport with young
people, a knowledge of family dynamics, and
the ability to provide support and skills training.
The case manager working with adolescents
will almost inevitably provide extensive case
management services to the entire family as
well. Problems such as poverty, child neglect, or
parental substance abuse cannot be ignored.
Acquiring an entire family as clients has
numerous implications for caseload size,
available resources, confidentiality, and whether
the client is the adolescent, the family, or both.
Challenges can arise in numerous contexts, for
instance when an adolescent tells the case
manager she plans to have an abortion. When
State or Federal laws do not provide explicit
guidance, the case manager must carefully
consider who is actually the client and what are
the best interests of the adolescent.
One case management model describes a
three-phase approach, providing services during
pre-treatment/screening, residential treatment,
and continuing care (Godley et al., 1994). The
goal of case management services during pre
treatment/intake is to improve access to
services, provide initial orientation to the
treatment process, and begin skills training.
Case management for clients in residential
programs links the client to needed services
outside the residential facility and ensures a
coordinated response by multiple agencies
involved in an adolescent’s life. During
aftercare, the professional implementing case
management continues the linkage and
monitoring process and provides booster
relapse prevention skills training with the goal
of decreasing the likelihood of relapse or
interrupting a relapse episode.
Family engagement in transition and
aftercare activities is paramount for the
adolescent juvenile justice client. The transition
work with the family needs to begin before the
end of the primary treatment episode, and
preferably occurs throughout the treatment
episode.
Clients in Criminal
Justice Settings
The number of substance abusers in the criminal
justice system is staggering. The Drug Use
Forecasting Project, which tested arrestees in 26
major U.S. cities for illicit drug use, found
positive results ranging from 48 percent to 80
percent. In one jurisdiction, 80 percent of all
women arrested tested positive for at least one
illicit drug. The Bureau of Justice Statistics (U.S.
Department of Justice, 1991) reported that 54
percent of State prisoners reported drug use at
the time of the offense, and 52 percent reported
use during the previous month.
57
Chapter 5
Case management for substance abuse
clients in the criminal justice system evolved in a
unique fashion, bringing together two complex
systems with different goals and philosophies.
While the criminal justice system is interested in
the rehabilitation of offenders, its main focus is
on public safety, which is maintained with
punishment and legal sanctions. Likewise,
while the substance abuse treatment system
supports public safety goals, its primary mission
is to change individual behaviors. These goals
are not mutually exclusive; in fact, experience
has demonstrated that integrating the
techniques of these two systems can have a
powerful effect on reducing the drug use and
criminal activity of drug-involved offenders.
Because participation in substance abuse
treatment and other social services is often
mandated, case managers have the opportunity
to engage clients over a longer period of time
and may be more likely to effect successful
change.
Integrating the two systems requires some
effort, however. The need to establish and
maintain a therapeutic relationship with clients
while integrating the sanction and control
obligations of the criminal justice system poses
particular challenges. Ambiguities about the
case manager’s role in client supervision and
confidentiality considerations surface
frequently.
The criminal justice system is fragmented
into numerous components through which
offenders may be assigned. In most
jurisdictions, supervision can be provided for
certain pretrial offenders who have not yet gone
to trial. In other jurisdictions, such offenders
may be given the option of diversion, in which
successful completion of certain activities will
avoid a conviction. Convicted offenders may be
sentenced to county jails, state prisons, or
probation; probation can include halfway house
supervision, intensive probation, or electronic
monitoring. Released offenders may be on
parole or some other sort of post-incarceration
supervision; in some jurisdictions probation
sentences may follow sentences of incarceration.
Linkages between prison and probation, or
between county jails and community-based
supervision, may be weak; databases are often
not connected; and entities often report to
different management structures. For example,
probation offices are part of the court system in
some jurisdictions, the corrections department
in others. Case management efforts are critical
to ensuring continuity when offenders move
from one supervision level to the next, or
between one status or location and another.
Managing offenders who are changing status
within this system while they are participating
in substance abuse treatment services (both
inside institutions and in the community) is
exponentially more complicated.
Case management with offender populations
may be implemented at any point in the
criminal justice continuum. Case management
can assist offenders in securing resources that
are not only vital to their recovery and overall
well-being, but also required by their deferred
sentencing or probation. Establishing
appropriate housing that will facilitate sobriety
and helping the offender develop job-seeking
skills are but two of the specific activities that
may form the basis of the case management
relationship. Offenders incarcerated in State
and local correctional facilities frequently need
assistance in managing their lives as they reenter
the larger community. Institutional life is highly
regimented, presenting special problems when
offenders are released. In working with paroled
individuals, the case manager must recognize
that prison life encourages behaviors that are
not appropriate on the outside. Parolees who
have been imprisoned longer than a year may
require more time in a semi-structured setting
(for example, a halfway house) in order to make
the transition from institution to community.
58
Clients Wi
th Special Needs
The case manager should address the needs
of clients released from institutions in order of
importance. The first priority is immediate
stability, which can be facilitated by safe
housing, access to either primary substance
abuse treatment or aftercare, and social
networks that facilitate positive behavior.
Second, the case manager should either provide
or make referral to sources of skills training,
since individuals who have served lengthy
sentences will likely need either habilitation or
rehabilitation training in the areas of job
searches, interactions with non-offender social
groups, and problem-solving strategies. Third,
the case manager should train or find training in
setting and accomplishing short- and long-term
goals. Incarceration often leads offenders to
believe that the locus for control of their lives
lies totally with other persons or institutions.
While goal-setting is important to any client
group, it is particularly important to clients who
have had most basic needs provided for them.
Ideally, the case manager will begin providing
these services several weeks or months before a
scheduled release, then follow the offender into
the community. Lastly, the case manager can
advocate for the offender both in the treatment
environment and the criminal justice system.
In order to maximize effectiveness, several
configurations of case management functions
have been attempted, including:
Case management provided by the justice
system. Justice system case managers are
assigned caseloads at specific stages of the
system, such as probation or parole. An
advantage of this model is that justice system
officials are invested in the process because their
staff members are implementing it and
reporting back to them. Major disadvantages
are the expense and the fact that there may be
conflicts between the philosophies and goals of
the substance abuse and criminal justice
systems. Another issue in this model is whether
the case manager has actual training in
substance abuse treatment approaches and
community referral techniques, as opposed to
primarily correctional interventions.
Case management provided by a treatment
agency. The advantage of a community-based
treatment model is that the case manager has a
thorough understanding of the substance abuse
treatment process. The disadvantages include,
again, the expense and the possibilities that the
case manager may not be familiar with the
criminal justice system or that the treatment
agencies may not have the resources for
effective case management.
Case management provided by an agency
separate from the treatment and justice
systems. To reduce costs, a case management
coordinator may be employed, with or without a
caseload, to conduct intake interviews and
supervise paraprofessional staff. The
disadvantages of this approach include the
addition of another agency to the collaboration.
Case management provided by a
coordinator from the justice system who
provides consulting services and technical
assistance to support existing criminal justice
case management. One advantage of this model
is system ownership. A coordinator, with or
without a caseload, oversees the work of a
paraprofessional staff. The coordinator can
move the criminal justice system toward a
greater awareness of treatment issues by
providing technical assistance that demonstrates
service coordination.
Case management provided by
multidisciplinary groups in the criminal
justice system for offender management. This
type of group may meet regularly and during
crises. This model is the most inexpensive;
however, it is the most difficult to successfully
operate because no one is assigned overall
responsibility for the offender (CSAT, 1995b).
One of the earliest models for case
management services in the criminal justice
system was created in 1972, when the White
59
Chapter 5
House launched a demonstration program
known as Treatment Alternatives to Street
Crime (TASC) to divert offenders from the
criminal justice system into substance abuse
treatment. (The program name has since been
changed to Treatment Alternatives for Safe
Communities.) TASC was initially designed to
identify appropriate offenders from the criminal
justice system, assess their needs for drug and
alcohol treatment, refer them to treatment
services, monitor their progress in treatment
(including conducting regular and random
urinalysis testing), and report that progress back
to the criminal justice system. In order to meet
its goals of ensuring continuous treatment for
offender clients, increasing treatment retention,
improving treatment outcomes, and reducing
criminal recidivism, TASC developed a set of
core functions or critical elements, including
Organizational Elements
♦ A broad base of support within the justice
system with a protocol for continued and
effective communication
♦ A broad base of support within the
treatment system with a protocol for
continued and effective communication
♦ An independent TASC unit with a
designated administrator
♦ Policies and procedures for required staff
training
♦ A data collection system for program
management and evaluation
Operational Elements
♦ Agreed-upon offender eligibility criteria
♦ Procedures for the identification of
eligible offenders that stress early justice
and treatment intervention
♦ Documented procedures for assessment
and referral
♦ Documented policies and procedures for
random urinalysis and other physical
tests
♦ Procedures for monitoring offenders,
including criteria for success/failure,
required frequency of contact, schedule of
reporting and notification of termination
to the justice system
One helpful development is that recent
research has convincingly documented the
success of compulsory and coerced treatment for
drug involved offenders (Leukenfeld and Tims,
1988; Hubbard et al., 1989; Platt et al., 1988;
DeLeon, 1988). TASC clients tend to remain in
treatment longer than other criminal justice-
referred clients and than voluntary clients;
retention in treatment is linked to better
treatment outcomes (Toborg et al., 1976).
TASC programs have been successful in
identifying a large number of offenders in need
of substance abuse services (Cook, 1992). The
TASC evaluation conducted in 1976 stated that
various programs had achieved success in
identifying a large number of offenders
qualified for TASC services and that self reports,
urinalysis, and referrals from lawyers and
judges seemed to increase client flow (Toborg,
1976).
This type of structured case management
between the criminal justice and treatment
systems has facilitated the traditional goals of
each system. Case management benefits the
criminal justice system by
Increasing supervision through drug testing
Reducing drug use and criminal behavior
Broadening the range of sanctions available
to the criminal justice system
Providing systems of graduated
interventions
Offering treatment in lieu of or in
combination with punishment
Providing information to the criminal justice
system
Providing a basis for judicial decisionmaking
Extending the power of the court to influence
drug-using behavior
60
Case management has benefited the
treatment system by
Increasing treatment outreach
Providing assessments and making
appropriate referrals
Utilizing resources more effectively
Orienting clients to treatment
Retaining clients in treatment by utilizing
criminal justice leverage
Supporting treatment compliance
Facilitating access to additional services
Providing a framework and structure for
managing criminal justice clients (Cook,
1997)
Over the years, the TASC model has been
expanded to include offenders throughout the
criminal justice system, including mixed
offender populations and specific populations
such as women or adolescents. Depending on a
TASC program’s administrative and
programmatic structure, the approach to
delivery of services may vary. The various
models include operation as a separate
administrative entity within a court system or
functioning as a separate nonprofit organization.
Acknowledging the diversity of program
design, Cook noted:
“There are clear variations in the
management of TASC clients. Some TASC
programs are more ‘system centered’ as an
extension of criminal justice system control.
Other TASC programs are more ‘client
centered,’ focusing on the rehabilitation needs of
the offender. A mix of both seems to produce a
healthy symbiosis of criminal justice system
leverage, access to treatment, and therapeutic
tension” (Cook, 1997).
The TASC model has also been adapted and
incorporated in recent innovations such as drug
courts, which began managing drug-involved
offenders in the late 1980s, and have now been
implemented in more than 300 jurisdictions.
Judges, prosecutors and defense attorneys,
Clients
With Special Needs
treatment professionals, case managers, and
pretrial or probation departments together
apply continuous oversight of participants as
they undergo substance abuse treatment as part
of or in lieu of a criminal sentence. Key
components include
Integration of alcohol and other drug
treatment services with justice system case
processing
Prosecution’s and defense counsel’s
promotion of public safety while protecting
participants’ due process rights, using a
nonadversarial approach
Eligible participants identified early and
promptly placed in the program
Access to a continuum of alcohol, drug, and
other related treatment and rehabilitation
services
Frequent alcohol and other drug testing
Coordinated strategy governing responses to
participants’ compliance
Ongoing judicial interaction with each
participant
Measurement through monitoring and
evaluation the achievement of program goals
and gauge effectiveness; continuing
interdisciplinary education promotes
effective planning, implementation and
operations
Forging partnerships among drug courts,
public agencies, and community-based
organizations generates local support and
enhances drug court effectiveness
See TIP 23, Treatment Drug Courts: Integrating
Substance Abuse Treatment With Legal Case
Processing (CSAT,1996a) for more on drug
courts.
While TASC programs have been designed
with the interaction of treatment and criminal
justice systems in mind, case managers in non-
TASC settings must be careful not to encourage
or support goals or objectives that place the
offender in conflict with expectations of the
61
Chapter 5
criminal justice system. The roles of the criminal
justice official (usually a probation officer) and
the case manager should be defined in advance
in agreements forged at the highest levels of
both the court and the agency providing
services. Typically, the case manager negotiates
with the parole or probation officer for sanctions
that make clinical sense. Such a relationship
affords the case manager the opportunity to
educate a representative of the justice system
about the value of treatment and case
management. An upcoming TIP, Transition from
Incarceration to Community-Based Treatment,
addresses treatment for recently released
offenders. It will be available in 1998.
Clients With Physical
Disabilities
Chemical dependency is a coexisting problem
for many people with physical disabilities
(Moore and Polsgrove, 1991). Some 15 to 30
percent of all people with disabilities have a
substance abuse problem, more than twice the
rate in the general population. Among
disabilities, rates of substance abuse are highest
among people with traumatic brain injury,
spinal cord injury, mental illness, and learning
disabilities (Rehabilitation Research and
Training Center on Drugs and Disability, 1997).
The case manager delivering services to this
population must know and understand those
conditions as well as blindness, deafness, and
chronic disease. Other suggested areas of
knowledge are
The etiology and course of various physical
disabilities
Effective treatment options, both group and
individual
The difference between appropriate
disability accommodations and enabling
“handicapped” behavior
How disability acceptance and anger affect
substance abuse treatment
Because many social service professionals
still assume that people with disabilities are too
helpless or too removed from the world to gain
access to drugs, the case manager’s role may lie
chiefly in education—both about physical
disabilities and about substance abuse
treatment. Clients with disabilities may not
recognize their need for substance abuse
treatment or may expect to be denied treatment.
Once in treatment, they may be misunderstood,
or singled out for mobility or communication
problems (Rehabilitation Research and Training
Center on Drugs and Disability, 1996). The
Americans with Disabilities Act (ADA) provides
support for treatment programs oriented to this
population by mandating that facilities be
physically accessible to people with disabilities
and that treatment professionals have an
understanding of disability issues.
Assessment includes many issues unique to
physically disabled persons. The case manager
should explore the relationship between the
client’s disability, substance abuse, and recovery
potential. For example, clients who had a
significant substance abuse problem before
becoming disabled need different treatment
approaches than those who started using to cope
with a new disability. An individual with a
disability that predates his substance abuse may
be obsessively focused on his “disability” and
not be aware of the functional limitations
imposed by the chemical dependency. Others
may have acquired a disability as a direct result
of substance abuse, but without “sober” time for
understanding the disability they may not be
aware of their functional limitations and how
their current functioning levels make it difficult
to learn or perform certain tasks. Mentors who
have disabilities or physical rehabilitation
professionals can assist newly disabled
individuals in understanding their disability.
Treatment programs may need to be
expanded to accommodate clients’ disabilities.
The case manager may also need to educate
62
Clients With Special Needs
other
service providers about the needs of
people with disabilities. To reach those with
physical disabilities, 12-Step groups must be
willing to use hearing enhancement equipment
(e.g., hearing loops) in meetings and to hold
meetings in accessible places. The case manager
should become familiar with special equipment
in order to help organizations purchase or
borrow appropriate resources as required under
the ADA.
The person in a wheelchair who must take
medication for chronic pain from an injury may
prompt resistance from recovery-oriented self-
help groups. Similarly, some vocational
programs within a treatment setting require
clients to be sober for some time before they can
be placed in a training setting. As a result,
vocational rehabilitation services, while
appropriate, are not available to individuals
receiving pharmacotherapy for opiate addiction
within those programs that do not consider such
people drug-free. A case manager from either
the disability field or the substance abuse field
should educate members of other disciplines on
how to structure treatment appropriately. The
Center for Substance Abuse Treatment is
producing a TIP on persons with disabilities
who have substance abuse problems, which will
be available in late 1998.
Gay, Lesbian,
Transgendered, and
Bisexual Clients
Gay, lesbian, transgendered, and bisexual
cultures are often associated with substance use
in general and alcohol use in particular.
Findings suggest that both gay men and lesbians
are more likely to be involved in the use of
alcohol, marijuana, and cocaine than
heterosexual members of all age cohorts
(McKirnan and Peterson, 1989; Skinner, 1994),
with the differences particularly pronounced
among younger people. Gay and lesbian clients
may also find their sexual partners in areas
prevalent with drugs, increasing the risk of
contracting the AIDS virus. The prevalence of
use, coupled with homophobia, makes the
recognition and treatment of substance abuse
problems more difficult.
Given the emotionally charged atmosphere
that often surrounds sexuality, case managers
must be especially aware of their own feelings
and beliefs. The link between personal beliefs
and interviewing skills is especially important in
the assessment of these clients, who may be
reluctant to discuss health problems or issues
related to sexual practices. The case manager
must know the context of the client’s life and
ideally, the specialized language used to
describe sexual practices in the client’s
community. The interviewer should gather
precise information regarding the nature of the
individual’s sexual practices and number of
sexual partners, unless a client is particularly
vulnerable, in crisis, or might otherwise see the
inquiry as intrusive or inappropriate.
To help gay or lesbian clients gain access to
services, the case manager must know more
than just an agency’s formal stance toward
them. Some agencies that are officially
accepting are in fact hostile to homosexual
clients, or simply are not familiar enough with
their special needs to serve them effectively. A
case manager should know which 12-Step
meetings, clinics, and other resources are
available, knowledgeable, and accommodating
to the gay and lesbian communities. As with
any client, treatment planning includes helping
the gay client identify and develop social
opportunities that do not involve drugs and
alcohol. Advocacy for gay clients includes
helping clients seek treatment for injuries and
infections sustained through sexual activity and
seeing that clients’ needs are taken seriously.
63
Chapter 5
Case Management in
Rural Areas
The delivery of case management services in
rural areas presents unique challenges. Social
services may be lacking or so geographically
dispersed that effective access and coordination
is difficult. In addition, case managers working
in rural areas must frequently deal with a
culture in which “everyone knows everyone
else,” from both the client’s and the service
provider’s standpoint.
Given the scarcity of resources, agencies, and
specialty services, the professional in this setting
is more likely to be a generalist. Case
management is more likely to provide both
service and service coordination. The substance
abuse case manager must be a tireless source of
information and education about substance
abuse problems, not just for the client, but for
the community as well. Perhaps the most
difficult function of the case manager in a rural
setting is advocacy. In a close-knit environment,
advocating for a client may mean challenging
the decisions of other service providers. On the
other hand, the professional’s close relationships
with those providers may benefit the client.
Case management in a rural setting can take
one of several forms. Telecommunication and
video-conferencing practice models have been
used to allow clients relatively easy access to
providers and to facilitate providers’
communication and recordkeeping (Alemi et
al., 1992). Where the client lives far away from
the program, services may be provided in an
intensive manner, for example, daylong sessions
with a particular client. A lack of formal
services can be mitigated by the use of informal
helping networks such as Alcoholics
Anonymous. However, in using informal
networks, the case manager will have to deal
with the unique challenges to confidentiality
occasioned by the rural environment.
64
6 Funding Case Management in a
Managed Care Environment
M
anaged care is “an organized system
of care which attempts to balance
access, quality, and cost effectively
by using utilization management, intensive case
management, provider selection, and cost-
containment methods” (CSAT, 1995d). Despite
the antipathy that many public sector health
care providers feel toward managed care, those
providers are actually striving toward the same
ends using similar means as managed care
organizations (MCOs). Many substance abuse
treatment providers have been working within a
managed care framework for decades, that is,
looking at utilization data and developing a
continuum of care. Substance abuse treatment
providers, particularly those who use case
management, have historically recognized the
importance of connecting disparate services to
meet the needs of clients.
Whatever treatment providers’ attitudes
toward managed care, they will have to learn to
operate within its bounds. More than half the
States are currently in the process of adopting
some form of managed care to provide
behavioral health care services, and more than
one-third have received Federal waivers to
implement Medicaid managed behavioral health
programs, with other waivers planned or
pending. Some experts predict that many
substance abuse programs, already accustomed
to scarcity of resources, will make a smooth
transition to a managed care environment.
However, many programs, particularly those
that operate the least like businesses, may find
this an extremely challenging time. The need to
be accountable for outcomes, particularly in the
face of a tax-conscious public, will undoubtedly
increase in the managed care era.
To adapt to the world of managed care,
treatment programs must assess how their
services are currently delivered and identify
which elements should be preserved and which
should be modified. They also must have a firm
grasp on how changes in Federal and State
reforms will affect their current and future
funding mechanisms.
Funding Case
Management in a
Managed Care World
Despite the promise of case management as an
important adjunct to substance abuse services, it
will not survive without empirical data that
support its efficacy. Key decisionmakers must
believe that case management is an integral
component of treatment service before they will
incorporate it into the funding structure. This is
especially true of States choosing to offer
services through managed Medicaid HMOs. It
is also true for people who receive services
through Medicare HMOs. (See Chapter 4 for a
discussion of program evaluation and
measuring outcomes.)
65
Chapter 6
Controlling costs while providing care offers
program administrators and case managers an
opportunity to demonstrate case management’s
utility to a newly engaged managed care
company. For example, clients with long-term
or chronic conditions may be required to move
from residential facilities to the community
before some treatment providers believe they
are ready. In this scenario, case management
can prove its value by providing the clients with
wraparound or supportive services to aid in a
successful transition. As another example,
outreach case management can help in the area
of relapse prevention and aftercare and thus
avert the need for high-cost services like
inpatient treatment.
Managed care tools—clinical pathways,
standardized assessments, and treatment
protocols—can work well in a case management
context. The challenge then lies in tailoring
services to the unique needs of each consumer
and avoiding “cookie cutter” services. Use of
these tools can increase case management’s
attractiveness to program administrators who
operate in capitated or other forms of shared-
risk environments.
The true test is to develop a comprehensive
case management system within a managed care
framework with the inherent flexibility and
resources necessary to eventually show tangible
savings. Only then will an MCO be able to
clearly justify case management as a
reimbursable service.
Who Decides?
The decision to include case management in the
array of treatment services usually rests with a
primary funding source or at the program level.
As many traditional public sector providers
overhaul their delivery systems to participate in
managed care, they must recognize the
importance of case management as a key
element of effective treatment and communicate
that to the funding source. If the primary source
of funding (usually a State agency) expects or
requires specific outcomes that go beyond
sobriety or cost containment, then a program
administrator must develop ways to measure
those outcomes.
To undertake scientifically valid outcomes
studies is beyond the reach of most treatment
programs. Providers can, however, increase the
chances of having case management activities
reimbursed if they measure everything that
helps the client, such as consumer-run support
groups, drop-in centers, or “Compeer”
programs, in which volunteers help clients
maintain sobriety and manage other aspects of
their lives. Keeping good records will allow
managed care companies to determine exactly
what’s being provided—and what constitutes
case management.
Funding Models
The multiple players involved in funding public
substance abuse treatment have posed complex
and ongoing problems for program
administrators. Each funding stream has its
own eligibility rules, service conditions, and
reporting requirements, which frequently differ
from those of other agencies supporting a
program’s operations. Case management
services are no exception and have traditionally
been funded through a variety of sources as
well. These include
Block grants from Federal agencies
Medicaid, which included options that allow
for non-medical services (e.g., the Medicaid
Rehabilitation Option)
Medicare and Supplemental Security Income
(SSI) for disabled clients
Migrant health funds
Private foundations and funds, such as
United Way
State and/or local tax dollars
Private insurance
66
Fun
ding in a Managed Care Environment
Far too often, the disparate mandates of these
funders have exacerbated system and service
fragmentation. Integration of funding streams
has emerged as a strategy to meld services and
provide continuity of care. Some States, in fact,
have used Medicaid managed care initiatives as
the catalyst for blending funding streams,
particularly in full capitation models.
As States gain more freedom to allocate
Medicaid dollars as they see fit, the prospect of
increased flexibility in services offered at the
program level improves. Programs that can
account for funds received in terms of positive
client outcomes will be better able to structure
their service mix in response to clients’ specific
needs rather than to the dictates of funding
agencies removed from the service delivery
level.
Managed care is frequently used as a vehicle
for integrating funding streams and for fostering
collaboration among health care providers. For
example, many managed care organizations
establish (or will only contract with) integrated
provider networks that
Offer a full range of services
Extend coverage over a wider geographical
or population area (thus increasing the
number of potential enrollees and sharing
the financial risk among more providers)
Maximize efficiencies in areas like
management information systems
When providers are organized in such a
manner, administrative service organizations
are engaged to handle a wide range of business
duties for the network.
Blended funding approaches, especially
those that give providers the necessary freedom
to make clinical decisions while still holding
them fiscally accountable, can preserve and
support the case management function as an
integral facet of modern substance abuse
treatment. Capitation or enrollment rates based
on genuine costs associated with providing
treatment and “stop-loss” clauses that cover
such contingencies as reimbursement for longer
or more intensive treatment than anticipated
may help satisfy the providers’ desire for
flexibility and the payer’s demand for fiscal
responsibility.
Substance abuse treatment services are
treated in different ways depending on which
overarching health care delivery model is
implemented by the State or by the managed
care organization(s) contracted to provide
behavioral healthcare. The two models
currently prevailing are the carve-in model and
the carve-out model.
Carve-in models
The carve-in model integrates physical (e.g.,
traditional medical services) and behavioral
(e.g., mental health and substance abuse
services) health care and is often the model
chosen to manage a State’s Medicaid population.
Although the purchaser of services may elect a
carve-in approach, frequently the MCO may
elect to carve out behavioral health care by
contracts with managed care organizations.
This is because behavioral health care tends to
be the most expensive cost center of treatment
within an integrated, managed care model of
treatment. The carve-in model generally
appeals to providers because many individuals
with mental illness and substance abuse
problems also have serious physical health
problems. Integrating the two also underscores
the notion that since body and brain are part of
the same system, mental illness and substance
abuse are bona fide health problems.
However, in such a model, case management
is often administrative in nature and involves
clinical oversight and activities such as
utilization review and prior authorization
procedures. The primary care physician
functions as the case manager or gatekeeper
who assesses the range of services the client
needs and, ideally, refers him to network
providers who offer specialty services. This
67
Chapter 6
happens when the physician is ill-equipped to
provide the often labor-intensive, client-specific
case management functions needed to
successfully manage the client/member.
This model for behavioral health care has
two major drawbacks. First, primary care
physicians may underdiagnose substance abuse
problems, especially in populations such as
women (in whom depression is often diagnosed
but seldom tied to substance abuse) and the
elderly. Lack of knowledge or the desire to hold
down costs also may lead to underutilization of
services, with consumers denied access to
needed care.
Second, since the course and overall
treatment costs of behavioral health problems
are less predictable than many physical health
problems, the ability to establish firm
enrollment or capitated rates is difficult. If rates
are too low, the problem of inadequately
treating or excluding those most in need of
costly or long-term care (e.g., clients needing
residential treatment) becomes a legitimate
concern. When services are subcontracted,
skimming may become a problem. In this
situation, the opportunity exists to cost-shift
“difficult” clients to subcontractors who receive
only a percentage of the capitated rate. Not only
are funds insufficient to provide proper
treatment when this happens, but the
subcontracting provider’s resources are strained
to the maximum.
Carve-out models
In carve-out arrangements, behavioral health care
is considered distinct from other physical
problems and is handled either as a separate
contract or is intentionally excluded from a
managed care plan. If behavioral health care is
carved out and handled as a separate managed
care account, it is possible to develop capitation
or enrollment fees specifically tailored to this
population. Carve-outs also provide States with
a mechanism to monitor and control the use of
substance abuse or mental health funds and
some assurance that those problems are being
addressed. Ideally, carve-out managed care
organizations will have expertise in substance
abuse services or will work jointly with
providers who possess that expertise. In all
cases, State officials must develop specific
contract language to carefully define their
responsibilities (CSAT’s Technical Assistance
Publication Purchasing Managed Care Services for
Alcohol and Other Drug Treatment offers
suggestions for assessing managed care
approaches and structuring effective contracts
for managed care services.)
Case management in a carve-out model is
likely to remain a service function, particularly if
the responsibility for behavioral health care is
delegated to the public sector. Given the trends
in behavioral health care, the public sector might
be advised to learn from the example of the
proprietary, more precise matching of clients
and service packages through management
information capabilities, some aspects of
utilization review procedures, and the
development of clinical pathways. These efforts
also help providers use their resources wisely
and ensure that appropriate and cost-effective
services are available to individual consumers.
Unfortunately, this method lacks integration
with the physical medicine side of treatment,
which can lead to ineffective case management
and duplication of services by the behavioral
health provider and the primary care physician.
Preparing a Program for
Managed Care
To adjust their current operations to meet new
demands, programs need to assess their
systems, appraise their readiness to operate in a
managed care environment, and position
themselves and their case management services
in a competitive market by identifying market
niches and preparing for increased staff
licensing and accreditation.
68
Fun
ding in a Managed Care Environment
Systems Assessment
As discussed in Chapter 1, case management
assumes different forms depending on its setting
and organizational context. Before integrating
with managed care, program directors and
administrators need to understand how case
management is practiced in their program.
Administrators must identify potential buyers of
case management services and must stay abreast
of plans to integrate Medicaid with public funds
and efforts to secure private vendors to manage
public behavioral health care services.
Administrators also need to ascertain exactly
who their program is serving, the nature and the
range of clients’ problems, and the gaps between
what the program offers and what clients need.
They must be able to articulate how these gaps
are hindering the successful execution of their
programs’ mission.
With the blending of systems via managed
Medicaid and Medicare, providers are now
forced to compete directly with each other.
Eventually, all services now delivered by
traditional community providers will be
delivered within a managed care framework.
Currently, many public sector providers of
services to people under Medicaid managed
care guidelines (for managed care companies)
are providing administrative and clinical case
management services for a “fixed,” “blended,”
or “bundled” rate. That rate is a small piece of
the pie that comprises the total per-member
capitation payment the provider receives and
usually is not assigned a specific dollar value.
What is the program doing?
As a first step in organizational assessment,
administrators must clearly define the case
management model(s) being used in the
program. At the agency level, community needs
and available resources must be reviewed.
Often case management services are subsumed
under the general category of “the costs of doing
business.” Under managed care, it is important
to know precisely what services are being
offered, what they cost, and what outcomes can
reasonably be expected. Case management
must be scrutinized both as a stand-alone
activity and as part of a total package of services
potentially available to consumers. The
importance of auditing the costs and revenues
associated with various services cannot be over
emphasized, particularly if a system is moving
toward a capitated or shared-risk paradigm.
Case management, whether a direct service or
administrative function, must add value and
provide cost benefit to justify its inclusion in the
total array of services.
Clinical case management must demonstrate
direct or indirect benefits above those that
consumers can expect from traditional services.
The gatekeeping function in administrative-level
case management limits the discretion and
treatment planning authority of a substance
abuse professional. Offsetting this
disadvantage, ideally, are two systemwide
advantages: reduced costs by denying
unnecessary services and by providing support
for people in the community so that they do not
need more expensive residential or inpatient
care, and better clinical decisionmaking. The
gatekeepers’ decisions are based on established
clinical pathways and protocols—the goals of
this standardization being improved care as well
as lowered costs.
Who is paying for case management?
Reimbursement for the case management
aspects of treatment may come from one or all of
the following sources:
Private managed-care organizations (MCOs)
Fee-for-service clients
Private payers such as corporate employee
assistance programs, foundations, and grant
funding
Volunteer and local sources
Courts and criminal justice funding
Social service providers (e.g., child welfare)
69
Chapter 6
User taxes and State and federally
appropriated funds
Providers should understand exactly how
these funding streams are integrated or
separated, as well as the inherent flexibility in
their use. Such knowledge will help design a
case management program and will also help in
advocacy efforts to shape State policy on
funding streams.
How does the program model fit
within the system?
It is equally important for providers to
understand how case management is defined in
their State’s managed care contract, if at all.
What specific activities are considered case
management and are they reimbursable? If they
are reimbursable, are there limits on the number
of billable units per consumer? Is there a finite
pool of funds available on a fee-for-service
basis? Given the melding of clinical and fiscal
functions at the provider level, it is also critical
to consider who benefits from case management
and who does not. What is a reasonable length
of time to offer services to a consumer? It is
imperative that program staff grapple with these
questions to best allocate available resources.
Readiness Review
In some cases, conversion to managed care must
be accomplished in as little as six months after
the enactment of legislation or by corporate
decree, so providers must assess their readiness
to make this transition rapidly and effectively.
Tools and surveys can help administrators
do a readiness review by providing a clear
picture of what models they are using and how
they fit in the changing environment. One such
tool is the Managed Healthcare Organizational
Readiness Guide and Checklist reproduced in
Appendix C. This and similar tools can help
agencies evaluate their current operations
within each of the following areas
Program services and structure
MIS capacities
Fiscal/financial structures
Utilization review capabilities
Program evaluation and quality management
Staff development and training needs
Board and management structure
Marketing
Licensure and accreditation (CSAT, 1995d)
Identifying Market Niches
In the managed care environment, programs
will have to function as businesses and therefore
must position themselves and their case
management services in a competitive market
(Brokowski and Eaddy, 1994). By focusing on
the establishment of a market niche like the
treatment of special populations (e.g., drug
users, criminal justice clients, older adults,
clients with HIV and AIDS), an agency can be a
player in the transition to managed care. In
addition, issues such as staffing, pricing, and
salaries can be revisited within the market
framework.
Despite its inefficiencies, the public system of
behavioral health has more experience and
expertise than private programs do in caring for
the most seriously disabled populations and in
providing services that focus on their everyday
life problems, such as employment and housing.
Since this chronically needy clientele is least
likely to be covered by private employer health
plans, it offers a natural market niche for public-
sector service providers.
Providers who serve Medicaid and Medicare
recipients will see an increase in commercial
business as a result of managed care contracts
but will primarily be paid indirectly. MCOs will
become the main source of revenue for the
providers, as opposed to the local or state
government. Medicaid and Medicare revenues
will flow from the government to the managed
care company to the service provider. High-
volume providers, who are successful at
delivering high-quality, cost-effective services
70
Funding in a Managed Care Environment
may
even find themselves acquired by the
managed care company.
State and Federal governments, in
anticipation of the changing public sector
system, have been disseminating resources to
help publicly funded treatment providers
survive and compete in a marketplace
dominated by managed care organizations. The
Federal Government is also currently designing
programs and projects via the Center for
Substance Abuse Treatment (CSAT) and the
Center for Substance Abuse Prevention (CSAP).
The National Leadership Institute Coordinating
Center (NLICC) will provide resources,
technical assistance, and materials to assist
public sector providers in making the internal
changes necessary to compete.
Licensing and Accreditation
One of the most controversial aspects of case
management is the issue of licensing. Many
believe that case managers should have earned
at least a master’s degree. Others argue that
some of the best addictions counselors have
received their education through overcoming
their own substance abuse.
While both viewpoints—and the many in
between—are valid, managed care will
increasingly require higher levels of education
as case management becomes a common
ingredient in its mix of services. Case
management functions were performed by
paraprofessionals in the 1980s and early 1990s.
Today, however, credentialing standards of
managed care organizations and other providers
require that case management be performed by
people with master’s degrees in social work or
education. All case managers may need to earn
advanced degrees to perform reimbursable case
management in the near future.
Provider profiling and performance reviews
of individual practitioners are commonplace in
managed care systems. Because data drive so
many managed care decisions, any outlier,
whether the cost of one consumer’s care or the
performance level of an organization or
professional, is likely to prompt a closer look. It
seems likely that, as managed care organizations
gain greater influence in the substance abuse
world, there will be an increased demand for
more professionally trained treatment personnel
and for provider organizations to gain
accreditation from national organizations such
as the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), the
Rehabilitation Accreditation Commission
(CARF), Community Mental Health Services
(CMHS), SAMHSA, or the National Committee
for Quality Assurance (NCQA).
Future Directions
The profound changes in reimbursement
patterns have sent shock waves through the
substance abuse treatment field. And change
clearly will persist. Payers and those who
allocate resources will continue to demand that
the efficacy of services be demonstrated. On the
programmatic level this will necessitate
evaluating each service component and
determining how it contributes to overall
objectives. Programs must articulate their
service expectations and decide what kinds of
training and experience a practitioner must have
to successfully deliver them.
What is needed now is more research on case
management. Several promising lines of
research, presented in Chapter 4, suggest that
certain forms of case management activities
improved client outcomes, resulting in fewer
employment problems, increased income, longer
treatment retention, and diminished drug use.
Other studies focusing on a criminal justice
population suggest far-ranging benefits.
However, the applicability of those studies to
the population outside prison and jail has yet to
be established.
71
Chapter 6
This research should be undertaken in a
variety of settings and should address issues
that demonstrate the efficacy of case
management activities. What approaches work
best for what populations in which kind of
setting? While such questions are typically
investigated by university researchers through
demonstration projects, the research community
must work with community-based programs in
this case. It will require hands-on experience to
fully understand how case management
functions, what benefits it achieves for program
clients, and how much it costs to provide this
service. Case managers must be able to follow
their clients from pretreatment to aftercare to
determine if treatment and services have
succeeded. Quantifying its benefits is the most
compelling argument for case management.
72
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Wholey, J.; Hatry, H.; and Newcomer, K.M., eds.
Handbook of Practical Program Evaluation. San
Francisco: Jossey-Bass, 1994.
Wildwind, L. When women resist treatment:
Approaches for counselors. Journal of
Substance Abuse Treatment 1:47-54, 1984.
Willenbring, M.; Ridgely, M.S.; Stinchfield, R.;
and Rose, M. Application of Case Management
in Alcohol and Drug Dependence: Matching
Techniques and Populations. Rockville, MD:
National Institute on Alcohol Abuse and
Alcoholism, 1991.
Willenbring, M.L.; Whelan, J.A.; Dahlquist, J.S.;
and O’Neal, M.E. Community treatment of
the chronic public inebriate. I:
Implementation. Alcoholism Treatment
Quarterly 7(2):79−97, 1990.
Zweben, A. The efficacy of role induction in
preventing early dropout from outpatient
treatment of drug dependency. American
Journal of Drug and Alcohol Abuse
8(2):171−183, 1981.
85
Appendix B
Practice Dimensions
Referral and service coordination are the two practice dimensions of addiction counseling that involve
case management, according to the Addiction Technology Transfer Centers (ATTC). The following list of
attributes that help a case manager perform these functions is excerpted from the ATTCs’ publication
Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice (CSAT, 1998).
This material also appears as an upcoming Technical Assistance Publication (TAP), Number 21, available
through the SAMHSA's Publications Ordering Web page at http://store.samhsa.gov or by calling
1-877-SAMHSA-7 (1-877-726-4727) (English and Español).
Referral
The process of facilitating the client's utilization of available support systems and community resources
to meet needs identified in clinical evaluation and/or treatment planning.
1. Establish and maintain relations with civic
groups, agencies, other professionals,
governmental entities, and the community
at-large to ensure appropriate referrals,
identify service gaps, expand community
resources, and help to address unmet needs
Knowledge
a. The mission, function, resources, and quality
of services offered by such entities as the
following
♦ civic groups, community groups,
neighborhood organizations; and
religious organizations
♦ governmental entities
♦ health and allied health care systems
(managed care)
♦ criminal justice systems
♦ housing administrations
♦ employment and vocational rehabilitation
services
♦ child care facilities
♦ crisis intervention programs
♦ abused persons programs
♦ mutual and self-help groups
♦ cultural enhancement organizations
♦ advocacy groups
♦ other agencies
b. Community demographics
c. The community's political and cultural
systems
d. Criteria for receiving community services,
including fee and funding structures
e. How to access community agencies and
service providers
f. State and Federal legislative mandates and
regulations
87
Confidentiality regulations
Appendix B
g. b. Willingness t
o advocate on behalf of the
h. Service gaps and appropriate ways of client
advocating for new resources
3. Differentiate between situations in which it
is most appropriate for the client to self-
refer to a resource and instances requiring
counselor referral
i. Effective communication styles
Skills
a. Networking and communication
b. Using existing community resource
directories including computer databases
c. Advocating for clients
d. Working with others as part of a team
Attitudes
a. Respect for interdisciplinary service delivery
b. Respect for both client needs and agency
services
c. Respect for collaboration and cooperation
d. Patience and perseverance
2. Continuously assess and evaluate referral
resources to determine their
appropriateness
Knowledge
a. The needs of the client population served
b. How to access current information on the
function, mission, and resources of
community service providers
c. How to access current information on
referral criteria and accreditation status of
community service providers
d. How to access client satisfaction data
regarding community service providers
Skills
a. Establishing and nurturing collaborative
relationships with key contacts in
community service organizations
b. Interpreting and using evaluation and client
feedback data
c. Giving feedback to community resources
regarding their service delivery
Attitudes
a. Respect for confidentiality regulations
Knowledge
a. Client motivation and ability to initiate and
follow through with referrals
b. Factors in determining the optimal time to
engage client in referral process
c. Clinical assessment methods
d. Empowerment techniques
e. Crisis intervention methods
Skills
a. Interpreting assessment and treatment
planning materials to determine
appropriateness of client or counselor
referral
b. Assessing the client's readiness to participate
in the referral process
c. Educating the client regarding appropriate
referral processes
d. Motivating clients to take responsibility for
referral and follow-up
e. Applying crisis intervention techniques
Attitudes
a. Respect for the client's ability to initiate and
follow-up with referral
b. Willingness to share decision-making power
with the client
c. Respect for the goal of positive self-
determination
d. Recognition of the counselor's responsibility
to carry out client advocacy when needed
4. Arrange referrals to other professionals,
agencies, community programs, or other
appropriate resources to meet client needs
Knowledge
a. Comprehensive treatment planning
88
Practice
Dimensions
b. Methods
of assessing client's progress
toward treatment goals
c. How to tailor resources to client treatment
needs
d. How to access key resource persons in
community service provider network
e. Mission, function, and resources of
appropriate community service providers
f. Referral protocols of selected service
providers
g. Logistics necessary for client access and
follow through with the referral
h. Applicable confidentiality regulations and
protocols
i. Factors to consider when determining the
appropriate time to engage client in referral
process
Skills
a. Using written and verbal communication for
successful referrals
b. Using appropriate technology to access,
collect, and forward necessary
documentation
c. Conforming to all applicable confidentiality
regulations and protocols
d. Documenting the referral process accurately
e. Maintaining and nurturing relationships
with key contacts in community
f. Maintaining follow-up activity with client
Attitudes
a. Respect for the client and the client's needs
b. Respect for collaboration and cooperation
c. Respect for interdisciplinary, comprehensive
approaches to meet client needs
5. Explain in clear and specific language the
necessity for and process of referral to
increase the likelihood of client
understanding and follow through
Knowledge
a. How treatment planning and referral relate
to the goals of recovery
b. How client defenses, abilities, personal
preferences, cultural influences, presentation,
and appearance effect referral and follow
through
c. Comprehensive referral information and
protocols
d. Terminology and structure used in referral
settings
Skills
a. Using language and terms the client will
easily understand
b. Interpreting the treatment plan and how
referral relates to progress
c. Engaging in effective communication related
to the referral process
♦ negotiating
♦ educating
♦ personalizing risks and benefits
♦ contracting
Attitudes
a. Awareness of personal biases toward referral
resources
6. Exchange relevant information with the
agency or professional to whom the referral
is being made in a manner consistent with
confidentiality regulations and generally
accepted professional standards of care
Knowledge
a. Mission, function, and resources of the
referral agency or professional
b. Protocols and documentation necessary to
make referral
c. Pertinent local, State, and Federal
confidentiality regulations, applicable client
rights and responsibilities, client consent
procedures, and other guiding principles for
exchange of relevant information
d. Ethical standards of practice related to this
exchange of information
89
Appendix B
Skills
a. Using written and verbal communication for
successful referrals
b. Using appropriate technology to access,
collect, and forward relevant information
needed by the agency or professional
c. Obtaining informed client consent and
documentation needed for the exchange of
relevant information
d. Reporting relevant information accurately
and objectively
Attitudes
a. Commitment to professionalism
b. Respect for the importance of confidentiality
regulations and professional standards
c. Appreciation for the need to exchange
relevant information with other professionals
7. Evaluate the outcome of the referral
Service Coordination
Knowledge
a. Methods of assessing client's progress
toward treatment goals
b. Appropriate sources and techniques for
evaluating referral outcomes
Skills
a. Using appropriate measurement processes
and instruments
b. Collecting objective and subjective data on
the referral process
Attitudes
a. Appreciation of the value of the evaluation
process
b. Appreciation of the value of inter-agency
collaboration
c. Appreciation of the value of interdisciplinary
referral
The administrative, clinical, and evaluative activities that bring the client, treatment services, community
agencies, and other resources together to focus on issues and needs identified in the treatment plan.
Service coordination, which includes case management and client advocacy, establishes a framework
of action for the client to achieve specified goals. It involves collaboration with the client and significant
others, coordination of treatment and referral services, liaison activities with community resources and
managed care systems, client advocacy, and ongoing evaluation of treatment progress and client needs.
Implementing the Treatment Plan
1. Initiate collaboration with referral source
Knowledge
a. How to access and transmit information
necessary for referral
b. Missions, functions, and resources of
community service network
c. Managed care and other systems affecting
the client
d. Eligibility criteria for referral to community
service providers
e. Appropriate confidentiality regulations
f. Terminologies appropriate to the referral
source
Skills
a. Using appropriate technology to access,
collect, summarize, and transmit referral data
on client
b. Communicating respect and empathy for
cultural and lifestyle differences
c. Demonstrating appropriate written and
verbal communication
d. Establishing trust and rapport with
colleagues in the community
e. Assessing level and intensity of client care
needed
90
Practice
Dimensions
Attitudes 3. Confirm the client’s eligibility for
admission and continued readiness for
treatment and change
a. Respect for contributions and needs of
multiple disciplines to treatment process
b. Confidence in using diverse systems and
treatment approaches
c. Open-mindedness to a variety of treatment
approaches
d. Willingness to modify or adapt plans
2. Obtain, review, and interpret all relevant
screening, assessment, and initial
treatment-planning information
Knowledge
a. Methods for obtaining relevant screening,
assessment, and initial treatment-planning
information
b. How to interpret information for the purpose
of service coordination
c. Theory, concepts, and philosophies of
screening and assessment tools
d. How to define long- and short-term goals of
treatment
e. Biopsychosocial assessment methods
Skills
a. Using accurate, clear, and concise written
and verbal communication
b. Interpreting, prioritizing, and using client
information
c. Soliciting comprehensive and accurate
information from numerous sources
including the client
d. Using appropriate technology to document
appropriate information
Attitudes
a. Appreciation for all sources and types of data
and their possible treatment implications
b. Awareness of personal biases that may
impact work with client
c. Respect for client self-assessment and
reporting
Knowledge
a. Philosophies, policies, procedures, and
admission protocols for community agencies
b. Eligibility criteria for referral to community
service providers
c. Principles for tailoring treatment to client
needs
d. Methods of assessing and documenting client
change over time
e. Federal and State confidentiality regulations
Skills
a. Working with client to select the most
appropriate treatment
b. Accessing available funding resources
c. Using effective communication styles
d. Recognizing, documenting, and
communicating client change
e. Involving family and significant others in
treatment planning
Attitudes
a. Recognition of the importance of continued
support, encouragement, and optimism
b. Willingness to accept the limitations of
treatment for some clients
c. Appreciation for the goal of self-
determination
d. Recognition of the importance of family and
significant others to treatment planning
e. Appreciation of the need for continuing
assessment and modifications to the
treatment plan
4. Complete necessary administrative
procedures for admission to treatment
Knowledge
a. Admission criteria and protocols
b. Documentation requirements and
confidentiality regulations
91
Appendix B
c. Appropriate Federal, State, and local
regulations related to admission
d. Funding mechanisms, reimbursement
protocols, and required documentation
e. Protocols required by managed care
organizations
Skills
a. Demonstrating accurate, clear, and concise
written and verbal communication
b. Using language the client will easily
understand
c. Negotiating with diverse treatment systems
d. Advocating for client services
Attitudes
a. Acceptance of the necessity to deal with
bureaucratic systems
b. Recognition of the importance of cooperation
c. Patience and perseverance
5. Establish accurate treatment and recovery
expectations with the client and involved
significant others including, but not limited
to
♦ nature of services
♦ program goals
♦ program procedures
♦ rules regarding client conduct
♦ schedule of treatment activities
♦ costs of treatment
♦ factors affecting duration of care
♦ client rights and responsibilities
Knowledge
a. Functions and resources provided by
treatment services and managed care
systems
b. Available community services
c. Effective communication styles
d. Client rights and responsibilities
e. Treatment schedule, time frames, discharge
criteria, and costs
f. Rules and regulations of the treatment
program
g. Role and limitations of significant others in
treatment
h. How to apply confidentiality regulations
Skills
a. Demonstrating clear and concise written and
verbal communication
b. Establishing appropriate boundaries with
client and significant others
Attitudes
a. Respect for the contribution of clients and
significant others
6. Coordinate all treatment activities with
services provided to the client by other
resources
Knowledge
a. Methods for determining the client’s
treatment status
b. Documenting and reporting methods used
by community agencies
c. Service reimbursement issues and their
impact on the treatment plan
d. Case presentation techniques and protocols
e. Applicable confidentiality regulations
f. Terminology and methods used by
community agencies
Skills
a. Delivering case presentations
b. Using appropriate technology to collect and
interpret client treatment information from
diverse sources
c. Demonstrating accurate, clear, and concise
verbal and written communication
d. Participating in interdisciplinary team
building
e. Participating in negotiation, advocacy,
conflict-resolution, problem solving, and
mediation
Attitudes
a. Willingness to collaborate
92
Practice
Dimensions
Consulting
1. Summarize client’s personal and cultural
background, treatment plan, recovery
progress, and problems inhibiting progress
for purpose of assuring quality of care,
gaining feedback, and planning changes in
the course of treatment
Knowledge
a. Methods for assessing client’s past and
present biopsychosocial status
b. Methods for assessing social systems that
may affect the client’s progress
c. Methods for continuous assessment and
modification of the treatment plan
Skills
a. Demonstrating clear and concise written and
verbal communication
b. Synthesizing information and developing
modified treatment goals and objectives
c. Soliciting and interpreting feedback related
to the treatment plan
d. Prioritizing and documenting relevant client
data
e. Observing and identifying problems that
might impede progress
f. Soliciting client satisfaction feedback
Attitudes
a. Respect for the personal nature of the
information shared by the client and
significant others
b. Respect for interdisciplinary work
c. Appreciation for incremental changes
d. Recognition of relapse as an opportunity for
positive change
2. Understand terminology, procedures, and
roles of other disciplines related to the
treatment of substance use disorders
Knowledge
a. Functions and unique terminology of related
disciplines
Skills
a. Demonstrating accurate, clear, and concise
verbal and written communication
b. Participating in interdisciplinary
collaboration
c. Interpreting written and verbal data from
various sources
Attitudes
a. Comfort in asking questions and providing
information across disciplines
3. Contribute as part of a multidisciplinary
treatment team
Knowledge
a. Roles, responsibilities, and areas of expertise
of other team members and disciplines
b. Confidentiality regulations
c. Team dynamics and group process
Skills
a. Demonstrating clear and concise verbal and
written communication
b. Participating in problem solving, decision
making, mediation, and advocacy
c. Communicating about confidentiality issues
d. Coordinating the client’s treatment with
representatives of multiple disciplines
e. Participating in team building and group
process
Attitudes
a. Interest in cooperation and collaboration
with diverse service providers
b. Respect and appreciation for other team
members and their disciplines
4. Apply confidentiality regulations
appropriately
Knowledge
a. Federal, State, and local confidentiality
regulations
93
Appendix B
b. How to app
ly confidentiality regulations to
documentation and sharing of client
information
c. Ethical standards related to confidentiality
d. Client rights and responsibilities
Skills
a. Explaining and applying confidentiality
regulations
b. Obtaining informed consent
c. Communicating with the client, family and
significant others, and with other service
providers within the boundaries of existing
confidentiality regulations
Attitudes
a. Recognition of the importance of
confidentiality regulations
b. Respect for a client’s right to privacy
5. Demonstrate respect and non-judgmental
attitudes toward clients in all contacts with
community professionals and agencies
Knowledge
a. Behaviors appropriate to professional
collaboration
b. Client rights and responsibilities
Skills
a. Establishing and maintaining non
judgmental, respectful relationships with
clients and other service providers
b. Demonstrating clear, concise, accurate
communication with other professionals or
agencies
c. Applying the confidentiality regulations
when communicating with agencies
d. Transferring client information to other
service providers in a professional manner
Attitudes
a. Willingness to advocate on behalf of the
c. Commitment to professionalism
Continuing Assessment And
Treatment Planning
1. Maintain ongoing contact with client and
involved significant others to ensure
adherence to the treatment plan
Knowledge
a. Social, cultural, and family systems
b. Techniques to engage the client in treatment
process
c. Outreach, follow-up, and aftercare
techniques
d. Methods for determining the client’s goals,
treatment plan, and motivational level
e. Assessment mechanisms to measure client’s
progress toward treatment objectives
Skills
a. Engaging client, family, and significant
others in the ongoing treatment process
b. Assessing client progress toward treatment
goals
c. Helping the client maintain motivation to
change
d. Assessing the comprehension level of the
client, family, and significant others
e. Documenting the client’s adherence to the
treatment plan
f. Recognizing and addressing ambivalence
and resistance
g. Implementing follow-up and aftercare
protocols
Attitudes
a. Professional concern for the client, the
family, and significant others
b. Therapeutic optimism
c. Recognition of relapse as an opportunity for
positive change
d. Patience and perseverance
client
2. Understand and recognize stages of change
and other signs of treatment progress
b. Professional concern for the client
94
Practice
Dimensions
Knowledge
a. How to recognize incremental progress
toward treatment goals
b. Client’s cultural norms, biases, unique
characteristics, and preferences for treatment
c. Generally accepted treatment outcome
measures
d. Methods for evaluating treatment progress
e. Methods for assessing client’s motivation
and adherence to treatment plans
f. Theories and principles of the stages of
change and recovery
Skills
a. Identifying and documenting change
b. Assessing adherence to treatment plans
c. Applying treatment outcome measures
d. Communicating with people of other
cultures
e. Reinforcing positive change
Attitudes
a. Appreciation for cultural issues that impact
treatment progress
b. Respect for individual differences
c. Therapeutic optimism
3. Assess treatment and recovery progress
and, in consultation with the client and
significant others, make appropriate
changes to the treatment plan to ensure
progress toward treatment goals
Knowledge
a. Continuum of care
b. Interviewing techniques
c. Stages in the treatment and recovery process
d. Individual differences in the recovery
process
e. Methods for evaluating treatment progress
f. Methods for re-involving the client in the
treatment planning process
Skills
a. Participating in conflict resolution, problem
solving, and mediation
b. Observing, recognizing, assessing, and
documenting client progress
c. Eliciting client perspectives on progress
d. Demonstrating clear and concise written and
verbal communication
e. Interviewing individuals, groups, and
families
f. Acquiring and prioritizing relevant
treatment information
g. Assisting the client in maintaining
motivation
h. Maintaining contact with client, referral
sources, and significant others
Attitudes
a. Willingness to be flexible
b. Respect for the client’s right to self-
determination
c. Appreciation of the role significant others
play in the recovery process
d. Appreciation of individual differences in the
recovery process
4. Describe and document treatment process,
progress, and outcome
Knowledge
a. Treatment modalities
b. Documentation of process, progress, and
outcome
c. Factors affecting client’s success in treatment
d. Treatment planning
Skills
a. Demonstrating clear and concise oral and
written communication
b. Observing and assessing client progress
c. Engaging client in the treatment process
d. Applying progress and outcome measures
95
Appendix B
Attitudes
a. Appreciation of the importance of accurate
documentation
b. Recognition of the importance of
multidisciplinary treatment planning
5. Use accepted treatment outcome measures
Knowledge
a. Treatment outcome measures
b. Understand concepts of validity and
reliability of outcome measures
Skills
a. Using outcome measures in the treatment
planning process
Attitudes
a. Appreciation of the need to measure
outcomes
6. Conduct continuing care, relapse
prevention, and discharge planning with
the client and involved significant others
Knowledge
a. Treatment planning process
b. Continuum of care
c. Available social and family systems for
continuing care
d. Available community resources for
continuing care
e. Signs and symptoms of relapse
f. Relapse prevention strategies
g. Family and social systems theories
h. Discharge planning process
Skills
a. Accessing information from referral sources
b. Demonstrating clear and concise oral and
written communication
c. Assessing and documenting treatment
progress
d. Participating in confrontation, conflict
resolution, and problem solving
e. Collaborating with referral sources
f. Engaging client and significant others in
treatment process and continuing care
g. Assisting client to develop a relapse
prevention plan
Attitudes
a. Therapeutic optimism
b. Patience and perseverance
7. Document service coordination activities
throughout the continuum of care
Knowledge
a. Documentation requirements including, but
not limited to
♦ addiction counseling
♦ other disciplines
♦ funding sources
♦ agencies and service providers
b. Service coordination role in the treatment
process
Skills
a. Demonstrating clear and concise written
communication
b. Using appropriate technology to report
information in an accurate and timely
manner within the bounds of confidentiality
regulations
Attitudes
a. Acceptance of documentation as an integral
part of the treatment process
b. Willingness to use appropriate technology
8. Apply placement, continued stay, and
discharge criteria for each modality on the
continuum of care
Knowledge
a. Treatment planning along the continuum of
care
b. Initial and ongoing placement criteria
c. Methods to assess current and ongoing client
status
96
Practice
Dimensions
d. Stages of progress associated with treatment
modalities
e. Appropriate discharge indicators
Skills
a. Observing and assessing client progress
b. Demonstrating clear and concise written and
verbal communication
c. Participating in conflict resolution, problem
solving, mediation, and negotiation
,
d. Tailoring treatment to meet client needs
e. Applying placement, continued stay, and
discharge criteria
Attitudes
a. Confidence in client’s ability to progress
within a continuum of care
b. Appreciation for the fair and objective use of
placement, continued stay, and discharge
criteria
97
Appendix C
Managed Healthcare
Organizational Readiness Guide
and Checklist: Special Report
By James B. Bixler, M.S.
This material first appeared in the Center for Substance Abuse Treatment's Technical Assistance
Publication (TAP) 16, Purchasing Managed Care Services for Alcohol and Other Drug Treatment: Essential
Elements and Policy Issues.
M
anaged care has become a primary
method of organizing and financing
healthcare services in the United
States, and the delivery of substance abuse
treatment services is being significantly affected.
Introduction
A majority of the Fortune 500 companies and
more than half of the health maintenance
organizations (HMOs) now use managed care
arrangements for purchasing substance abuse
treatment. Thirty-six State Medicaid programs
were using managed care approaches as of early
1993, and another 13 States planned to
implement managed care programs by 1994
(U.S. General Accounting Office 1993). Several
States have "carved out" substance abuse as well
as mental health services for Medicaid
recipients.
Publicly funded substance abuse treatment
providers must adapt to meet the challenge of
managed care, which will expand as the
healthcare system changes in response to market
forces and as healthcare reform discussions
continue in Washington.
Purpose
The guide and checklist have been prepared to
assist publicly funded treatment providers
become more competitive in a managed care
environment. The document is intended
especially for use by treatment providers
receiving financial support from State funds,
Medicaid, and the Federal Substance Abuse
Prevention and Treatment Block Grant.
99
Appendix C
Goals and Objectives
The goal of the checklist is to assist State
substance abuse agencies and publicly
supported treatment providers to design and
implement strategies that will result in these
providers being able to participate successfully
in managed care programs.
Background
The readiness checklist was developed for the
technical assistance program of the Center for
Substance Abuse Treatment's Division of State
Programs. It built upon the Managed Care
Readiness Inventory developed in 1993 by the
Oregon community mental health providers and
the National Community Mental Healthcare
Council.
The checklist was first used at a workshop on
managed care issues for project directors, part of
the Fall Training Institute of the Pennsylvania
Office of Drug and Alcohol Problems. Attendees
completed the checklist, and the presenter
conducted an interactive discussion about the
importance of the issues identified.
After this pilot effort, the checklist was
refined during its use in workshops conducted
in Oregon, Arkansas, and Tennessee. The guide
was added to provide additional information
and to help treatment providers use the
checklist as a freestanding self-assessment
instrument.
Ways To Use the Guide
and Checklist
The checklist can be very effective as part of a
workshop for treatment providers. Such a
workshop would include substantial discussion
of strategies for meeting the challenges of
healthcare reform, changes in the organization
and financing of health care, and the expanded
use of managed care.
The guide and checklist can also be used:
In meetings of regional or local networks of
providers
By providers or networks and their
consultants
By providers as a self-assessment tool
The checklist can be an important part of the
development of an organization's strategic plan,
as a treatment provider or service network
decides how to improve service delivery and
position itself for a more successful future.
Why Prepare for Managed Care?
The healthcare system is undergoing very rapid
change in response to several fundamental
economic forces.
1. Healthcare expenditures consumed 13.2
percent of the Gross Domestic Product (GDP)
of the United States in 1991 (Letsch 1993) and
rose to more than 14 percent in 1993, which
means that almost $1 of every $7 is spent for
healthcare services.
2. The growth rate of healthcare expenditures
in 1991 was four times the growth rate of the
national economy (Letsch 1993).
3. Some experts estimate that national
healthcare expenditures will reach 18 to 19
percent of the GDP by 1998.
4. Medicaid expenditures, an important source
of payment for substance abuse services,
doubled between 1988 and 1992. By 1992, the
$199 billion cost of Medicaid equaled the
total cost of the Medicare program (Holahan
et al. 1993).
5. State Medicaid expenditures have grown
until they are second only to the combined
State costs of elementary and secondary
education (Holahan et al. 1993).
High inflation in healthcare expenditures has
led employers and States to seek ways to limit
the growth of their insurance premiums, benefit
costs, and Medicaid programs.
Substance abuse treatment services and costs
increased during the 1980s for many reasons:
100
Managed Care Checklist
Increased public acceptance of the need for
care
Increased benefit coverages in many health
plans
State activities to include substance abuse
services in State Medicaid programs
A rapid growth in inpatient hospital-based
substance abuse and psychiatric units,
supported by benefit plans that paid for
inpatient treatment and a surplus of hospital
beds
Increases in State and Federal funding of
community services, such as the Substance
Abuse Prevention and Treatment Block
Grant program
Some employers perceived that mental
health and substance abuse treatment costs were
"out of control" and that service delivery was
fragmented. Claire Wilson, in a 1993 article on
substance abuse and managed care, wrote: "The
skyrocketing utilization and costs of substance
abuse treatment during the last 10 years have
alarmed corporate benefit managers" (Wilson
1993).
England and Vacarro (1991) identified 21
percent increases in 1990 healthcare
expenditures to employers/purchasers as the
impetus behind managed care, despite cost
containment efforts spanning more than a
decade. They said: "Mental health and chemical
dependency services, with reported cost
increases of up to 60 percent per year, are a
prime target for managed care."
These perceptions also were shared by some
insurance carriers and HMOs, forcing payers to
seek ways to coordinate care and control costs.
The result is greater use of HMOs, preferred
provider arrangements, increased competition,
and—for substance abuse and mental health
services—the development of behavioral health
managed care organizations (MCOs).
These firms have expanded rapidly in the
last 10 years, with the three largest MCOs each
reporting more than 10 million persons enrolled,
a total of almost 40 million persons for these
three firms alone (Oss 1994).
A survey conducted in January 1994
determined that more than 102 million
Americans, 45.9 percent of those with health
insurance, are enrolled in some type of managed
behavioral healthcare program (Oss 1994). The
survey did not separate managed care for
substance abuse from mental health services;
however, almost all behavioral MCOs use an
integrated approach. There were:
20.0 million in employee assistance programs
(EAPs)
6.6 million in integrated managed behavioral
health/EAPs
20.5 million in risk-based behavioral health
network programs
15.0 million in nonrisk-based network
programs
37.0 million in stand-alone behavioral health
utilization review programs (Oss 1994)
What Is Managed Care and How Is
It Changing?
Managed care approaches, such as utilization
review and second opinions, have been in place
for more than a decade for medical-surgical
insured health benefits. Their general purpose is
to assure payers that consumers receive the
appropriate level of care and that excessive,
inappropriate, or unnecessary care is not
delivered or reimbursed. These practices arose
to regulate the functioning of the fee-for-service
system, where financial incentives tend to
encourage the delivery of more health services
and more expensive procedures.
Another way to define managed care is by
the organizational structures used to deliver
treatment. Health maintenance organizations
are "managed care," because clinical
management and financial incentives exist
within staff HMOs and independent-practice
model HMOs to encourage preventive care and
to reduce cost increases.
101
Appendix C
Feldman and Goldman (1993) indicated that
the behavioral health managed care industry
"arose as a response to the economic imperatives
of spiraling unmanaged mental health and
substance abuse costs. In light of escalating
costs, payers were essentially faced with two
alternatives–cut benefits (which many have
done) or manage them so as to control costs and
ensure quality."
In addition to concerns about costs,
purchasers identified several quality-related
problems:
Overuse of hospitalization
Purchase of services without any indication
of clinical effectiveness–making it difficult to
identify good care and good providers
Incentives in traditional benefit plans to use
hospitalization rather than outpatient
alternatives
Fragmented service delivery and the lack of
coverage for case management services in
traditional indemnity plans (England and
Vacarro 1991).
Without a doubt, the industry has grown
rapidly. In general, it has gone through three
major phases since the mid-1980s.
1. The first generation of MCOs managed
access to health care, with a primary focus on
utilization review (UR). Access was
controlled by limiting benefits and requiring
significant co-payments to contain costs.
MCOs also introduced such administrative
barriers as preadmission certification.
2. The second generation of managed care
focused on managing benefits. MCOs added
fee-for-service provider networks, selective
contracting, and treatment planning to the
UR function.
3. The current generation of MCOs focuses on
managing care, performing utilization
management instead of utilization review–
with a greater emphasis on treatment
planning, delivery of the most appropriate
care in the most appropriate setting, and
moving patients through a continuum of
services.
Managed care organizations expect
development of a fourth-generation product in
which they manage outcomes as part of an
integrated services system, moving both public
and private patients through a full continuum of
treatment services (Waxman 1994).
The impact on treatment providers over the
last 10 years has been dramatic. Hospitals that
deliver substance abuse care have reduced staff
and closed units or have integrated their
inpatient care for substance abuse within
psychiatric units. Many hospitals have
expanded ambulatory substance abuse services.
Community agencies have scrambled to learn
about managed care and to become members of
MCO provider panels.
These changes are likely to continue as the
managed care industry increases its focus on
Medicaid recipients, State and local
governments, and services to other public
clients.
How Do Managed Care
Organizations Select Treatment
Providers?
Behavioral health managed care organizations
(MCOs) work for self-insured businesses,
HMOs, insurance carriers, unions, State
Medicaid agencies, and others. Prior to deciding
which providers to select, they first listen to
their customers.
Some payers will dictate the qualifications of
substance abuse treatment providers. These
payers may require hospitals for residential care
and require licensed professionals for outpatient
treatment. Increasingly, MCOs are
recommending that less expensive yet well-
qualified community providers be included on
the "provider panel." This enables MCOs to
lower costs and to offer a more complete range
of services.
102
Mana
ged Care Checklist
The selection criteria of MCOs cover several
areas:
Access to care and a provider's response
time; i.e., the availability of inpatient and
residential beds as needed, and access to
outpatient services based on:
♦ Emergencies: immediate access
♦ Urgent services: 1-2 days
♦ Routine services: 4-6 days
Minimal delays for patients transferring from
one service to another, particularly within a
single provider
Administrative and clinical responsiveness
Use of brief, problem-centered clinical
approaches rather than long-term
rehabilitative approaches
Positive practice profiles; i.e., providers who
are pragmatic, innovative, team-oriented,
consumer-oriented, case management-
oriented, and outcomes-oriented
Cultural competence
Willingness to arrange for related social
services as needed, e.g., housing or job
placements
What Strategies Should a Treatment
Provider Consider?
The specific strategies that a substance abuse
provider adopts will depend on the level of
readiness of the provider and the State and local
managed care environment.
The provider should develop an
individualized plan that is specific to the
circumstances and locality. The first step can be
to complete the readiness checklist and consider
potential change strategies within the
organization. Providers may find it necessary to
make changes in their clinical and management
services in order to become more attractive to
MCOs and other payers.
Short-range strategies
Short-range strategies could include:
Strengthening relationships with businesses
through relationships with EAPs
Maximizing Medicaid reimbursements and
positioning the provider organization to
expand its participation in Medicaid as
managed care arrangements are
implemented
Becoming a preferred provider for several
managed care organizations
Longer range strategies
Longer range strategies to be considered might
include:
Determining the extent to which the provider
organization will address a broad client
group by delivering a range of services or by
focusing on one or more niche markets, i.e.,
specialty services for a limited population
Joining or forming a regionally integrated
substance abuse and/or behavioral health
service network, which can seek preferred
provider and other contracts
Marketing to primary care medical group
practices and multipractice physician groups,
which have an increasingly critical
"gatekeeper/service manager" role in
healthcare reform
Marketing directly to payers, such as HMOs,
insurance carriers, and self-insured
businesses
Integrating fully into the healthcare system
by becoming part of a physician-hospital
organization or an arm of a large physician
group practice.
Use the following checklist to assist you in
developing your agency's individualized plan
for future challenges.
103
No, None, Never
1
Very Limited, Not
Often
2
Partially,
Frequently
3
Mostly, R egularly
4
Yes, Fully, Always
5
Appendix C
Figure C-1
Sample Selection Criteria
First Mental Health, an MCO that operates the Medicaid substance abuse and mental health
managed care program in Massachusetts as MHMA, Inc., looks for organizations and programs
that:
Are consumer-oriented, e.g., have satisfaction surveys and use the information
Have no long waiting lists
Deliver focused treatment, e.g., an average of six outpatient sessions
Are part of a system that promotes clinical continuity, e.g., a consumer can move from service
to service without interruption
Direct their attention to outcomes, e.g., functional levels and employment
Have an interest in innovation, with the ability to move rapidly and to be responsive
Managed Healthcare
Organizational Readiness
Checklist
Following is a managed care readiness checklist
for publicly funded substance abuse treatment
service providers, a vital segment of the health
services system. The checklist is intended:
1. To identify a program's strengths and
weaknesses in specific areas, and
2. To enhance a strategic planning process that
will assist your organization to prepare for
success in a managed care environment.
Use of the checklist will help treatment
providers anticipate the skills that will be
needed to prosper in a changing healthcare
system.
Use of the checklist cannot substitute for an
onsite assessment. However, it is likely to
generate productive thought and discussion.
It is not necessary to have a perfect score to
secure a contract with a managed care firm for
private or public patients. In general, the better
prepared your organization, the more likely it is
that you will be selected to provide services.
Twelve areas are assessed:
Adult services
Adolescent services
Service characteristics
Quality assurance and utilization
management
Managed care and employee assistance
program experience
Management information system
Staff and staff training
Organizational relationships
Board and management
Marketing
Fiscal analysis
Business office
There are survey questions for each area. In
addition, there is a summary at the end of the
checklist.
Please answer each question using a whole
number, i.e. 1, 2, 3, 4, or 5. One is the lowest
score, while 5 is the highest score. Use the
following scale for your response.
104
For adults, do you deliver:
Please circle the answer...
1. Centralized screening, assessment, intake, and crisis intervention services? 1 2 3 4 5
2. Comprehensive outpatient services? 1 2
3 4 5
3. Intensive
outpatient services, or do you h ave strong network relationships
with providers of such services?
1 2 3 4 5
4. Partial hospitalization/day treatment services, or do you have strong network
relationships with providers of such services?
1 2 3 4 5
5. Short-term residential treatment, or do you have strong network relationships
with providers of such services?
1 2 3 4 5
6. Inpatient treatment, or do you have strong network relationships with
providers of such services?
1 2 3 4 5
For children and adolescents, do you deliver:
7. Centralized screening, assessment, intake, and crisis intervention services?
1 2 3 4 5
8. Outpatient services? 1 2 3 4 5
9. Intensive outpatient services, or do you have strong network relationships
with providers of such services?
1 2 3 4 5
10. Partial hospitalization/day treatment services, or do you have strong network
relationships with providers of such services?
1 2 3 4 5
11. Short-term residential treatment, or do you have strong network relationships
with providers of such services?
1 2 3 4 5
12. Inpa
tient treatment, or do you have strong network relationship
s with
providers of such services?
1 2 3 4 5
No, None, Never
1
Very Limited, Not
Often
2
Partially
, Frequently
3
Mostly, Regularly
4
Yes, Fully, Always
5
Service Comprehensiveness
Managed Care Checklist
105
No, None, Never
1
Very Limited, Not
Often
2
Partially,
Frequently
3
Mostly, R egularly
4
Yes, Fully, Always
5
Service Characteristics
Please circle the answer...
13. Do you have skilled clinical staff assigned to all aspects of the screening and
assessment process, including initial telephone contacts?
1 2 3 4 5
14. Do your services ensure rapid access (1-2 days) to assessment services and
initial placement?
1 2 3 4 5
15. Do your services have a brief intervention focus, e.g., six to eight sessions for
outpatient care, for most patients?
1 2 3 4 5
16. Do you have internal case management services for focusing on repeating
patients and others who have high utilization patterns?
1 2 3 4 5
17. Do you have ensured linkages with primary healthcare providers for needed
healthcare?
1 2 3 4 5
18. Do you adapt standard services to meet the needs of special populations, such
as mentally ill substance abusers, injecting drug users, and pregnant addicts?
1 2 3 4 5
19. Are service needs constantly reevaluated, and service plans modified, based on
patient progress?
1 2 3 4 5
20. Are admission, treatment, and discharge criteria in place and used consistently
by staff?
1 2 3 4 5
21. Do your admission, treatment, and discharge criter ia take into consideration
the practice standards of managed care firms with which you have (or hope to
have) contracts?
1 2 3 4 5
22. Do your serv
ices ensure rapid l
inkage to succeeding levels of care? 1 2 3 4 5
23. Do your
services emphasize family involvement and use of natural support
systems, including self-help groups?
1 2 3 4 5
24. Do your services focus on patient outcomes and satisfaction? 1 2 3 4 5
Appendix C
106
Quality Assurance (QA) and Utilization Management (UM)
Please circle the answer...
No, None, Never
1
Very Limited, Not
Often
2
Partia
lly, Frequently
3
Mostly, Regularly
4
Yes, Fully, Always
5
25. Do you hav
e QA and UM procedures that
have been shared with clinical staff? 1 2 3 4 5
26. Does the
staff you have designated to perform the QA/UM function review
clinical activities for consistent use of established admission, treatment, and
discharge criteria?
1 2 3 4 5
27. Is the information from the QA/UM function received rapidly enough to assist
clinicians during an episode of care?
1 2 3 4 5
28. Does the QA/UM function include maintaining records of managed care
appeals, and suggest strategies for improving relationships and/or modifying
service delivery to reduce denials?
1 2 3 4 5
29. Do you hav
e sufficient staff ass
igned to the QA/UM function? 1 2 3 4 5
30. To wha
t extent is the QA/UM function designed to "stay ahead" of staff from
managed care firms by anticipating their concerns?
1 2 3 4 5
31. Do clinicians, clin
ical superv
isors, and management all receive and act on
regular QA and UM reports?
1 2 3 4 5
32. Is the QA/UM function ti
ed closely to your management information system? 1 2 3 4 5
33. To wha
t extent is the QA/UM function focused on patient outcomes? 1 2 3 4 5
34. Are patient satisfaction surveys a regular function of QA/UM? 1 2 3 4 5
Managed Care and Employee Assistance Program (EAP)
Experience
Please circle the answer...
35. Do you have contract(s) with managed care firms or EAPs as a preferred
provider?
1 2 3 4 5
36. If yes to #35, are any of your contracts paid on a fee-per-case or a capitation
basis?
1 2 3 4 5
37. Do you offer an employee assistance program wh
ich includes crisis
intervention, assessment and linkage to service, followup to assure receipt of
appropriate services, and coordination of benefits?
1 2 3 4 5
38. Does
your EAP provide consultation to management on policies and
procedures, training to managers and supervisors, assistance with specific
cases, employee education and orientation programs, critical incident
debriefing, and reporting on utilization and effectiveness?
1 2 3 4 5
39. Has your EAP business increased over the last 2 years? 1 2 3 4 5
Managed Care Checklist
107
No, None, Never
1
Very Limited, Not
Often
2
Partially, Frequently
3
Mostly, Regularly
4
Yes, Fully, Always
5
Appendix C
Management Information Systems (MIS)
Please circle the answer...
40. Do you have an MIS which can retrieve patient information either online or in
less than 1 hour?
1 2 3 4 5
41. Does your MIS have integrated functions for client information; service
utilization; financial information, including payer type by client; and client
1 2 3 4 5
records?
42. To what extent does your MIS permit single-source response inquiries from
1 2 3 4 5
managed care organizations?
43. To what extent does your MIS produce information that is used by clinicians,
1 2 3 4 5
supervisors, and management?
44. To what extent does your MIS integrate information from various programs
1 2 3 4 5
and sites?
45. Is your MIS designed so that client and service information can be reported to
1 2 3 4 5
all major payers?
1 2 3 4 5
46. Does your MIS generate patient invoices?
Staff and Staff Training
47. Do clinical staff accept shared responsibility with case managers from
1 2 3 4 5
managed care organizations for clinical decisions?
48. Are staff informed concerning the funding and managed care environment,
1 2 3 4 5
including managed care criteria for admission and discharge?
49. Have clinical and supervisory staff resolved concerns about cost, service
1 2 3 4 5
quality, access, and managed care?
50. Do you have an ongoing staff training program that includes brief service
intervention skills, patient assessment and reassessment, and instructions on
1 2 3 4 5
how to respond to managed care organizations?
108
No, None, Never
1
Very Limited, Not
Often
2
Partially, Frequently
3
Mostly, Regularly
4
Yes, Fully, Always
5
Organizational Relationships
Please circle the answer...
51. To what extent have you implemented referral and business arrangements
with other behavioral healthcare organizations, e.g., mental health and
substance abuse programs?
1 2 3 4 5
52. To what extent have you implemented referral and business arrangements
with primary or specialty healthcare organizations, e.g., hospital emergency
rooms and physician group practices?
1 2 3 4 5
53. To what extent have you been involved in economic arrangements with other
healthcare?
1 2 3 4 5
Board and Management
54. Do you have significant experience at contract negotiation and management? 1 2 3 4 5
55. To what extent is the board oriented to service effectiveness and business
success?
1 2 3 4 5
56. Are you experienced at strategic planning, modifying plans, and developing
contingency plans to meet emerging opportunities and challenges?
1 2 3 4 5
57. How well informed are board members and top management concerning
healthcare reform, managed care, financing options, and interorganizational
arrangements?
1 2 3 4 5
58. Are mechanisms in place which would allow for prompt shifts in response to
business opportunities?
1 2 3 4 5
59. To what extent
will the board and management be proactive and
entrepreneurial in pursuit of managed care initiatives?
1 2 3 4 5
Managed Care Checklist
109
No, None, Never
1
Very Limited, Not
Often
2
Partia
lly, Frequently
3
Mostly, Regularly
4
Yes, Fully, Always
5
Marketing
Please circle the answer...
60. Do you have marketing plans that target payers, referral sources, and the
general public?
1 2 3 4 5
61. Do you
have sufficient staff re
sources assigned to the marketing function?
1 2 3 4 5
62. To what extent does your service line emphasize acute and primary services
(rather than long-term, rehabilitative, and wraparound care)?
1 2 3 4 5
63. Have you prepared a managed care capability statement?
1 2 3 4 5
64. To what extent have you made marketing presentations to the large employers
in
your service area?
1 2 3 4 5
65. Do
your costs per episode and lengths of stay compare favorably with the
competition?
1 2 3 4 5
Fiscal Analysis
66. To what extent is your revenue diversified?
1 2 3 4 5
67. Do you have adequate liquid reserves for at least 2-3 months operating
expenses?
1 2 3 4 5
68. Have you accumulated (or can you access) venture capital sufficient to respond
to a major business opportunity?
1 2 3 4 5
69. Have you maximized Medicaid revenue?
1 2 3 4 5
70. Does your fiscal system, in combination with the MIS, allow analysis of cost-
per-unit of service, cost-per-episode of care, and cost by disability type and
level of functioning?
1 2 3 4 5
71. Can the fiscal staff assist with pric
ing issues during contract negotiations,
especially when capitated contracts are considered?
1 2 3 4 5
72. C
an the fiscal staff readily compare actual to anticipated revenue and expense
by contract?
1 2 3 4 5
Business Office
73. Is the business office experienced at fee-for-service invoicing for Medicaid,
preferred provider organization (PPO) contracts, insurance, patient fees, etc.?
1 2 3 4 5
74. Does the business office conduct internal service audits to ensure that
documentation of services in patient records can withstand an external audit?
1 2 3 4 5
75. To what extent is the business office's invoicing function integrated into your
MIS?
1 2 3 4 5
Appendix C
110
Adult Service
s Comprehensiveness 6 1 2 3 4 5
Total
Divide
by Composite
We
akest
Positio
n
Strongest
Position
Adolescent Se
rvices Comprehensivenes
s 6 1 2 3 4 5
Service C
haracteristics 12 1 2 3 4 5
QA and UM
area
10
1 2 3 4 5
Managed Care an EAP area
5
1 2 3 4 5
MIS area
7
1 2 3 4 5
Staff and Training
4
1 2 3 4 5
Organizational
Relations
3
1 2 3 4 5
Board
and
Management
6
1 2 3 4 5
Marketing
6
1 2 3 4 5
Fiscal
Analysis
7
1 2 3 4 5
Business
Office
3
1 2 3 4 5
All
scores
75
1 2 3 4 5
Summary of Answers
This section allows you to generate a score for each area. Add together the individual response scores for
the questions in each of the 12 sections. Then divide the total by the number of questions in that section to
generate a composite score for the section. Enter the composite score on the 1 to 5 scale at right.
This approach will
show you the areas in which your
organization is well prepared for managed care
participation, the areas in
which additional work may be needed,
and the areas
of relative weakness
where immediate remedial
activities can be targeted.
It may also be helpful to inspect the variations in the scores among the various persons in your
organization who complete the checklist. You may find a range of
answers and perceptions on a specific
question or within one or two sections. It might be illuminating to note the differences, for instance,
between management, board members, and clinical
staff.
Managed Care Checklist
111
Appendix C
Common Questions and
Answers
There were several common questions asked by
treatment providers who attended workshops in
which the checklist was used. This part of the
guide gives answers to a few of those questions.
QUESTION: Do I have to pay attention to these
managed care issues? I have contracts with the State
and revenue from fees, so won't my organization
survive intact?
ANSWER: Economic forces are leading to
the use of managed care approaches by almost
all payers. If you have secured a "niche market,"
where it is unlikely that other organizations will
compete with you, then you may be in a unique
situation where the payers will continue to buy
your service. However, organizations that
deliver basic outpatient and residential
substance abuse care cannot ignore managed
care.
QUESTION: My organization delivers
residential treatment. Should I add outpatient
services or otherwise diversify?
ANSWER: Managed care organizations
frequently shift services from hospital inpatient
to community residential facilities. A second
strategy of MCOs is to then shift the location of
care from brief residential services to intensive
outpatient or outpatient care as quickly as
possible. The best strategy would be to offer all
needed services and plan to shift the balance
between services as referral patterns and MCO
practices change.
QUESTION: What staff qualifications do
managed care firms require for outpatient services,
and are graduate degrees a necessity?
ANSWER: There is considerable variation.
Staff qualifications are frequently determined by
the payer rather than the MCO. Some MCOs
require State-licensed practitioners, while others
accept all staff working within a licensed or
State-approved program.
QUESTION: How cost competitive is managed
care? Will I be asked to accept reimbursement rates
below my cost?
ANSWER: Most MCOs attempt to secure
discounted rates. It is important to know your
costs and establish a level below which you will
not negotiate. It is also important to be aware of
the costs and rates of your competitors, in order
to be able to judge the marketplace.
QUESTION: Will managed care require my
organization to change our clinical practices?
ANSWER: As you market your services,
carefully consider the types of services that
managed care organizations want. Most will
favor brief and focused counseling models, with
rapid step-down to less intensive levels of care.
You may have to modify your service
practices in order to secure and maintain
business.
QUESTION: My staff are concerned about
losing clinical control of our services to a gatekeeper
or case manager. Is it necessary to give up clinical
control if I get a contract?
ANSWER: It's best to think of working with
an MCO as a partnership where you exchange
information about clients and determine a plan
of treatment together. Most MCOs watch the
length of treatment episode very carefully,
either through a case manager or by reviewing
your organization's practice patterns (based on
the analysis of your organization's paid claims).
QUESTION: We don't do outcome studies. How
can I begin to focus on the impact of treatment?
ANSWER: Implementing a consumer
satisfaction survey is a good place to begin. It
can provide feedback on access, staff, the most
(and least) valuable components of services, and
the value of care to clients and family members.
QUESTION: Will it be necessary to create new
alliances, join networks, establish joint ventures, or
merge with another organization to be successful?
ANSWER: It depends on your local situation
and your organization's goals. There are many
new relationships currently being established to
112
improve the likelihood of doing well as the
healthcare system changes. You may find
arrangements that strengthen your organization
clinically and managerially. No organization
should rule out considering these options.
How Can We Design an
Action Program for
Change?
The information you gained from completing
the readiness checklist is a good start. There are
several steps in classic organizational planning.
The action planning steps are to:
1. Assess Your Current Position
Assess your organization's strengths: What
do you have going for you, and what should
you be sure to maintain and/or expand?
Assess your organization's limitations: What
areas need improvement, and what is your
realistic capability to address these areas
internally?
Assess the opportunities emerging in the
marketplace: What are the commercial and
public managed care developments in your
State and locality?
Assess the competition and other challenges:
What threatens your plans, how quickly will
you need to implement changes, and what
are your competitors planning which will
impact on your future?
2. Develop an Achievable Plan
Establish clear long-range goals: What
changes are needed in the organization's
mission and long-range targets, if any?
Chart 1-2 year objectives: What are the
priority actions that will make the greatest
difference as you penetrate the managed care
market?
Develop targets: What are the numerical
targets and the schedule to be used for each
priority action?
Mana
ged Care Checklist
Involve the staff and board: What steps must
be approved and accomplished by the
various actors, and what are the resource
requirements?
Consider strategic partnerships: What new
organizational relationships will strengthen
your ability to reach your objectives, and
what scarce skills or resources are essential to
success?
3. Implement the Plan
Assign the tasks: What are the expectations
for all of the key persons and organizational
units?
Coordinate the work: Manage the process
and make the needed adjustments in day-to
day activities.
4. Check Progress and Adjust the
Targets
Review achievements against the objectives:
What was accomplished and what were the
deviations from the plan?
Reassess the environment: What has
occurred in the business environment, with
Medicaid managed care, in healthcare
reform, or in your local service system that
will impact on your success?
Change the strategic plan: What better
strategies have been identified and how
should the plan, targets, or timetable be
modified based on your experiences?
Summary and Conclusion
This guide and checklist were developed for the
Center for Substance Abuse Treatment (CSAT)
to assist States and publicly funded substance
abuse treatment providers to succeed in a
managed care environment. The objectives are
to increase managed care participation by
expanding knowledge, assessing readiness
through use of the checklist, and encouraging
effective action planning.
113
Appendix C
Remember, the checklist will be helpful but
should not be the only tool your organization
uses to prepare for managed care participation.
Providers should attend workshops, read, share
ideas with colleagues, and participate in State
association activities.
Treatment providers seeking additional
assistance should contact their State authority or
CSAT's Quality Assurance and Evaluation
Branch within the Division of State Programs.
References
England, M.J., and Vacarro, V.A. New systems
to manage mental health care. Health Affairs
10(4): 129-137, 1991.
Feldman, S., and Goldman, W., eds. Editors'
Notes. New Directions for Mental Health
Services: Managed Mental Health Care. San
Francisco: Jossey-Bass, 1993.
Holahan, J.; Rowland, D.; Feder, J.; and Heslan,
D. Explaining the recent growth in Medicaid
spending. Health Affairs 12(3):177-193, 1993.
Letsch, S.W. National health care spending in
1991. Health Affairs 12(1):94-110, 1993.
Oss, M.E. Industry statistics: Managed
behavioral health programs widespread
among insured Americans. Open Minds: The
Behavioral Health Industry Analyst 8(3), n.p.,
1994.
U.S. General Accounting Office. Medicaid: States
Turn to Managed Care to Improve Access and
Control Costs. Washington, DC: GAO
(GAO/HRD-93-46), 1993.
Waxman, A.S. "Managed mental health care:
How to survive in the next decade."
Presentation at the 2nd Annual Managed
Care Conference, Psychotherapy Finances,
Palm Beach, Florida, 1994.
Wilson, C.V. Substance abuse and managed
care. In: Feldman, S. and Goldman, W., eds.
New Directions for Mental Health Services:
Managed Mental Health Care. San Francisco:
Jossey-Bass, 1993.
Additional Readings
Ansoff, H.; DeClerk, R.; and Hayes, R., eds. From
Strategic Planning to Strategic Management.
New York: John Wiley and Sons, 1976.
Bryson, John M. Strategic Planning for Public and
Nonprofit Organizations. San Francisco:
Jossey-Bass, 1988.
Center for Substance Abuse Treatment, Division
of State Programs. Managed Care and
Substance Abuse Treatment: A Need for
Dialogue. Rockville, MD: CSAT, 1992.
Center for Substance Abuse Treatment, Division
of State Programs. Reports on the Meetings of
the Center for Substance Abuse Treatment
(Executive Summary); September 9-10, 1993
Kansas City, Missouri; January 12-13, 1994
Cincinnati, Ohio; and February 24-25, 1994
Phoenix, Arizona. Rockville, MD: CSAT, 1994.
Harwood, H.J.; Thomsom, M.; Nesmith, T.
Healthcare Reform and Substance Abuse
Treatment: The Cost of Financing Under
Alternative Approaches–A Final Report. Lewin-
VHI, Inc., February 1994.
Join Together: A National Resource for
Communities Fighting Substance Abuse.
Health Reform for Communities: Financing
Substance Abuse Services. Boston: Join
Together, 1993.
Koteen, J. Strategic management explained.
Strategic Management in Public and Non-profit
Organizations. New York: Praeger Publishers,
1989.
114
115
Appendix D
Resource Panel
Note: The information given indicates each participant's affiliation during the time the panel was convened
and may no longer reflect the individual's
current affiliation.
Robert E. Anderson Director
Quality Assurance Programs
National Association of State Alcohol and
Drug Abuse Directors, Inc.
Washington, D.C.
Lynn A
ronson
Housing Resource Manager
Homeless Programs Branch Center
for Mental Health Services
Division of State and Community Systems
Development
Rockville, Maryland
James B
rennan
Senior Staff Associate
National Association of Social Workers
Washington, D.C.
Peter J. Cohen, M.D., J.D.
Special Expert
Medications Development Division National
Institute on Drug Abuse Rockville, Maryland
Linda S. Foley, M.A. Member
TIPS Editorial Advisory Board
Director
Treatment Improvement Exchange Health
Systems Research, Inc.
Washington, D.C.
Helen H
owerton, M.A.
Director
Child and Family Development
Office of Planning, Research, and Evaluation
Administration for Children and Families Washington,
D.C.
Mar
y Nakashian
Vice President and Director of Program Demonstration
National Center on Addiction and Substance Abuse
Columbia University New
York, NY
Elizabeth R
ahdert, Ph.D. Research
Psychologist Treatment
Research Branch
Division of Clinical and Services Research
National Institute on Drug Abuse Rockville,
Maryland
Larry Rickards, Ph.D. Director
Intergovernmental Initiatives
Homeless Programs Branch Center
for Mental Health Services
Rockville, Maryland
Appendix D
Barbara Roberts, Ph.D.
Senior
Policy Analyst
Executive Office
White House Office of National Drug
Control Policy
Washington, D.C.
Santo Ruiz
Project Officer
Community Support Program
Division of State and Community Systems
Development
Center for Mental Health Services
Rockville, Maryland
Richard T. Suchinsky, M.D.
Associate Chief
Addictive Disorders
Mental Health and Behavioral Sciences
Services
Department of Veterans Affairs
Washington, D.C.
11
6
117
Appendix E
Field Reviewers
Note: The information given indicates each participant's affiliation during the time the review was conducted and may no
longer reflect the individual's current affiliation.
Darlene A
llen, M.S. Director
Child Welfare Services Children's
Friend and Services Providence,
Rhode Island
And
rea G. Barthwell, M.D.
President
Encounter Medical Group, P.C.
Oak Park, Illinois
Janice S. B
ennett, M.S., C.S.A.C. Project
Director
Addiction Technology Transfer Center of
Hawaii
Honolulu, Hawaii
Saroja A. Boaz Executive
Director
Intake Assessment and Referral Center Flint,
Michigan
Kim Bowman Director
Government Services Center
Chester County Department of Drug and and
Alcohol Services
West Chester, Pennsylvania
Patricia B
radford, L.I.S.W., L.M.F.T., C.T.S.
P.A. Bradford and Associates
Columbia, South Carolina
Mar
y Candace Burger, Ph.D. Assistant
Professor
Division of Geriatric Psychiatry
Department of Psychiatry
Vanderbilt Medical School
Nashville, Tennessee
Donna L
. Caldwell, Ph.D. Senior
Research Associate
National Perinatal Information Center Providence,
Rhode Island
Donna H. Caum, M.S.S.W. Treatment
Program Consultant
Bureau of Alcohol and Drug Abuse Services
Tennessee Department of Health
Nashville, Tennessee
Patrick R. Connelly
Substance Abuse Program Consultant Division of
Mental Health, Development
Disabilities and Substance Abuse Services North
Carolina Department of Health and
Human Services Raleigh,
North Carolina
Appendix E
Gary Cox, Ph.D.
Research Associate Professor
ADAI
University of Washington
Seattle, Washington
Martin C. Doot, M.D.
Chief
Division of Addiction Medicine
Addiction Medicine/ Family Practice
Lutheran General Hospital Advocate
Park Ridge, Illinois
Larry W. Dupree, Ph.D.
Professor
Department of Aging and Mental Health
Florida Mental Health Institute
University of South Florida
Tampa, Florida
Mary E. Evans, R.N, Ph.D.
Director of Research
College of Nursing (MDC 22)
University of South Florida
Tampa, Florida
Gary L. Fisher, Ph.D.
Addiction Technology Transfer Center
College of Education
University of Nevada at Reno
Reno, Nevada
Steven L. Gallon, Ph.D.
Program Director
Office of Alcohol and Drug Abuse Programs
Northwest Frontier Addiction Technology
Transfer Center
Salem, Oregon
Theodore M. Godlaski, M.Div., I.C.D.C.
Director of Community Treatment Project
Center for Alcohol and Drug Research
University of Kentucky
Lexington, Kentucky
Susan H. Godley, Ph.D.
Senior Research Consultant
Lighthouse Institute
Chestnut Health Systems
Bloomington, Illinois
Darryl M. Grafton, M.Div., C.C.D.C.
Clinical Supervisor
Southeast Baltimore Center for Treatment
Bayview Medical Center
Johns Hopkins University
Baltimore, MD
Marge L. Hazen
Systems and Funding Development
Specialist
Bureau of Substance Abuse Services
Department of Health and Social Services
State of Wisconsin
Madison, Wisconsin
Maya Hennessey, C.R.A.D.C.
Women's Specialist
Office of Special Programs
Illinois Department of Alcoholism and
Substance Abuse
Chicago, Illinois
Robert Holden, M.A.
Program Director
Partners in Drug Abuse Rehabilitation
Counseling
Washington, D.C.
Deborah Horan
Manager
Special Issues
American College of Obstetrics and
Gynecology
Washington, D.C.
Mary Beth Johnson, M.S.W.
University of Missouri at Kansas City
Kansas City, Missouri
118
Field Reviewers
Pat
ti Juliana
Director of Clinical Services
Division of Substance Abuse
Albert Einstein College of Medicine
Bronx, New York
Linda Kaplan
Executive Director
National Association of Alcoholism and
Drug Abuse Counselors
Arlington, Virginia
Karen Kelly-Woodall, M.S., M.A.C., N.C.A.C.II
Cork Institute
Morehouse School of Medicine
Atlanta, Georgia
Michael W. Kirby, Jr., Ph.D.
Chief Executive Officer
Arapahoe House, Inc.
Thornton, Colorado
Mark L. Kraus, M.D.
Westside Medical Group
Waterbury, Connecticut
Jeffrey N. Kushner
Drug Court Administrator
22nd Judicial District
Municipal Court of Saint Louis
Saint Louis, Missouri
Carl G. Leukefeld, D.S.W.
Director
Center on Drug and Alcohol Research
University of Kentucky
Lexington, Kentucky
Sheera Lipshitz
Director
Assertive Treatment Team
Brandywine Counseling, Inc.
Wilmington, Delaware
Bruce Lorenz, N.C.A.C. II
Director
Thresholds, Inc.
Dover, Delaware
Greg J. Madden, Ph.D.
Research Associate
Human Behavioral Pharmacology
Laboratory
University of Vermont
Burlington, Vermont
Jennifer Mankey, B.S.W., M.P.A.
Project Director
Denver Juvenile Justice Treatment Network
Denver, Colorado
Patrice Muchowski, Sc.D.
Vice President
Clinical Services
Adcare Hospital of Worcester
Worcester, Massachusetts
Marlene O'Connell, R.N.
Manager
Behavioral Health Services
Benefits Healthcare
Great Falls, Montana
Gennaro Ottomanelli, Ph.D.
Director
Division of Drug Dependence
Kings County Addictive Disease Hospital
Brooklyn, New York
Elizabeth A. Peyton
Executive Director
National TASC
Silver Spring, Maryland
Ronald Pike, M.D.
AdCare Hospital of Worcester
Worcester, Massachusetts
119
Appendix E
Deborah Powers
IDU/AIDS Treatment Specialist
State Methadone Authority
State Department of Health and Family
Services
Madison, Wisconsin
Lynda A. Price, Ph.D., I.C.A.D.C.
Treatment Coordinator
National Drug Commission
Global House
Hamilton, Bermuda
Anthony Quintiliani, Ph.D.
Clinical Director, Chief Psychologist
Drug and Alcohol Division
Howard Center for Human Services
South Burlington, Vermont
Patricia Reihl
Coordinator
Spring House
Paramus, New Jersey
Margaret M. Salinger, M.S.N., R.N., C.A.R.N.
National Nurses Society on Addiction
c/o Department of Veterans Affairs Medical
Center
Coatesville, Pennsylvania
Anna M. Scheyett, M.S.W.
Program Coordinator
Behavioral Health Care Resource Program
School of Social Work
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
Stephen Schoen, Ph.D.
Director
Alcohol and Drug Awareness Program
Department of State
Medical Services
Washington, D.C.
Rene W. Seidel
Director
HIV Services
Tarzana Treatment Center
Tarzana, California
Michael R. Sosin, M.S.W., Ph.D.
Professor
School of Social Service Administration
University of Chicago
Chicago, Illinois
Flo A. Stein, M.P.A.
Acting Section Chief
Division of Mental Health, Developmental
Disabilities and Substance Abuse Services
Alcohol and Drug Services
Raleigh, North Carolina
Richard T. Suchinsky, M.D.
Associate Chief
Addictive Disorders
Mental Health and Behavioral Sciences
Services
Department of Veterans Affairs
Washington, D.C.
Suzan Swanton
Clinical Supervisor
Glenwood Life Counseling Center
Baltimore, Maryland
Donald L. Tomlin
Specialist
Nashville Area Indian Health Service
Substance Abuse
Indian Health Service
Cherokee, North Carolina
Robert Walker, M.S.W., L.C.S.W., B.C.D.
Director
Bluegrass East Comprehensive Care Center
Lexington, Kentucky
120
Deborah Watson, Ph.D.
Program Operations Manager
Cleveland CARES Target Cities
Alcohol and Drug Addiction Services Board
Cleveland, Ohio
Robert Whitney, M.D.
Medical Consultant
Office of Alcoholism and Substance Abuse
Research Institute on Addiction
Buffalo, New York
Field Reviewers
Annette
H. Wieser
Regional Director
Program Administration
Texas Commission on Alcohol and Drug
Abuse
Austin, Texas
Janet S. Woodburn
President
Bridgeway Counseling Services, Inc.
Saint Charles, Missouri
121
The TIPs Series
TIP 5 Improving Treatment for Drug‐Exposed Infants
TIP 14 Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment
TIP 16 Alcohol and Other Drug Screening of Hospitalized Trauma Patients
TIP 21 Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System
TIP 23 Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing
TIP 24 A Guide to Substance Abuse Services for Primary Care Clinicians
TIP 25 Substance Abuse Treatment and Domestic Violence
TIP 26 Substance Abuse Among Older Adults
TIP 27 Comprehensive Case Management for Substance Abuse Treatment
TIP 29 Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities
TIP 30 Continuity of Offender Treatment for Substance Use Disorders From Institution to Community
TIP 31 Screening and Assessing Adolescents for Substance Use Disorders
TIP 32 Treatment of Adolescents With Substance Use Disorders
TIP 33 Treatment for Stimulant Use Disorders
TIP 34 Brief Interventions and Brief Therapies for Substance Abuse
TIP 35 Enhancing Motivation for Change in Substance Abuse Treatment
TIP 36 Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues
TIP 37 Substance Abuse Treatment for Persons With HIV/AIDS
TIP 38 Integrating Substance Abuse Treatment and Vocational Services
TIP 39 Substance Abuse Treatment and Family Therapy
TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction
TIP 41 Substance Abuse Treatment: Group Therapy
TIP 42 Substance Abuse Treatment for Persons With Co‐Occurring Disorders
TIP 43 Medication‐Assisted Treatment for Opioid Addiction in Opioid Treatment Programs
TIP 44 Substance Abuse Treatment for Adults in the Criminal Justice System
TIP 45 Detoxification and Substance Abuse Treatment
TIP 46 Substance Abuse: Administrative Issues in Outpatient Treatment
TIP 47 Substance Abuse: Clinical Issues in Outpatient Treatment
TIP 48 Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery
TIP 49 Incorporating Alcohol Pharmacotherapies Into Medical Practice
TIP 50 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment
TIP 51 Substance Abuse Treatment: Addressing the Specific Needs of Women
TIP 52 Supervision and the Professional Development of the Substance Abuse Counselor
TIP 53 Addressing Viral Hepatitis in People With Substance Use Disorders
TIP 54 Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders
TIP 55 Behavioral Health Services for People Who Are Homeless
TIP 56 Addressing the Specific Behavioral Health Needs of Men
TIP 57 Trauma‐Informed Care in Behavioral Health Services
TIP 58 Addressing Fetal Alcohol Spectrum Disorders (FASD)
TIP 59 Improving Cultural Competence
Other TIPs may be ordered by calling
1‐877‐SAMHSA‐7 (1‐877‐726‐4727) (English and Español)
or visiting http://store.samhsa.gov.
HHS Publication No. (SMA) 15‐4215
Substance Abuse and Mental Health Services Administration
Printed 2000
Revised 2002, 2003, 2006, 2008, 2010, 2012, and 2015
