Professional Documents
Culture Documents
Comprehensive
Case Management
for Substance Abuse
Treatment
27
Comprehensive
Case Management
for Substance
Abuse Treatment
Treatment Improvement Protocol (TIP) Series
27
ii
Contents
What Is a TIP?............................................................................................................................................................ v
Foreword.................................................................................................................................................................... xi
Appendix A—Bibliography...................................................................................................................................73
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
iv
What Is a TIP?
T
reatment Improvement Protocols (TIPs) are Although each consensus-based TIP strives to
developed by the Substance Abuse and include an evidence base for the practices it
Mental Health Services Administration recommends, SAMHSA recognizes that behavioral
(SAMHSA) within the U.S. Department of Health health is continually evolving, and research
and Human Services (HHS). Each TIP involves the frequently lags behind the innovations pioneered in
development of topic-specific best-practice the field. A major goal of each TIP is to convey
guidelines for the prevention and treatment of "front-line" information quickly but responsibly. If
substance use and mental disorders. TIPs draw on the research supports a particular approach, citations are
experience and knowledge of clinical, research, and provided. When no citation is provided, the
administrative experts of various forms of treatment information is based on the collective clinical
and prevention. TIPs are distributed to facilities and knowledge and experience of the consensus panel.
individuals across the country. Published TIPs can be
accessed via the Internet at http://store.samhsa.gov.
v
Editorial Advisory Board
Note: The information 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. Wayde A. Glover, MIS, NCAC II Director
President Commonwealth Addictions Consultants and Trainers
National Nurses Society on Addictions Richmond, Virginia
Associate Professor
Department of Psychiatry, Community Health, Pedro J. Greer, M.D.
and Adult Primary Care Assistant Dean for Homeless Education
University of Maryland, Baltimore University of Miami School of Medicine
Baltimore, Maryland Miami, Florida
vii
Editorial Advisory Board
viii
Consensus 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.
ix
Consensus Panel
x
Foreword
T
he Substance Abuse and Mental Health Federal clinical researchers, clinicians, program
Services Administration (SAMHSA) is the administrators, and patient advocates debates and
agency within the U.S. Department of Health discusses their particular area of expertise until they
and Human Services that leads public health efforts to reach a consensus on best practices. Field reviewers
advance the behavioral health of the nation. then review and critique this panel’s work.
SAMHSA’s mission is to reduce the impact of The talent, dedication, and hard work that TIPs
substance abuse and mental illness on America’s panelists and reviewers bring to this highly
communities. participatory process have helped bridge the gap
The Treatment Improvement Protocol (TIP) series between the promise of research and the needs of
fulfills SAMHSA’s mission to reduce the impact of practicing clinicians and administrators to serve, in the
substance abuse and mental illness on America's most scientifically sound and effective ways, people in
communities by providing evidence-based and best need of behavioral health services. We are grateful to
practices guidance to clinicians, program all who have joined with us to contribute to advances in
administrators, and payers. TIPs are the result of the behavioral health field.
careful consideration of all relevant clinical and health
services research findings, demonstration experience,
and implementation requirements. A panel of non-
Daryl W. Kade
Acting Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
xi
Executive Summary
C
ase management has been variously and service coordination to address multiple
classified as a skill group, a core aspects of a client’s life. Comprehensive
function, service coordination, or a substance abuse treatment often requires that
network of “friendly neighbors.” Although it clients move to different levels of care or
defies precise definition, case management systems; case management facilitates such
generally can be described as a coordinated movement.
approach to the delivery of health, substance Any definition of case management will be
abuse, mental health, and social services, linking contextual, depending on who is implementing
clients with appropriate services to address the program. Perhaps a more helpful way to
specific needs and achieve stated goals. The understand it is to examine the functions that
Consensus Panel that developed this TIP generally comprise case management: (1)
believes that case management lends itself to the assessment, (2) planning, (3) linkage, (4)
treatment of substance abuse, particularly for monitoring, and (5) advocacy.
clients with other disorders and conditions who
require multiple services over extended periods Case Management and
of time and who face difficulty in gaining access
to those services. This document details the
Substance Abuse
factors that programs should consider as they Treatment
decide to implement case management or When implemented to its fullest, case
modify their current case management activities. management will enhance the scope of
This summary is excerpted from the main text, addictions treatment and the recovery
in which references to the research appear. continuum. A treatment professional utilizing
Research suggests two reasons why case case management will
management is effective as an adjunct to
substance abuse treatment. First, retention in Provide the client a single point of contact for
treatment is associated with better outcomes, multiple health and social services systems
and a principal goal of case management is to Advocate for the client
keep clients engaged in treatment and moving Be flexible, community-based, and client-
problems are addressed concurrently with thought to be outside the realm of substance
substance abuse. Case management focuses on abuse treatment
the whole individual and stresses
comprehensive assessment, service planning,
xiii
Executive Summary
To provide optimal services for clients, a are distinct goals and treatment activities at each
treatment professional should possess particular point on the continuum, rarely do clients’ needs
knowledge, skills, and attitudes including fit neatly into any one area at a given time; case
management serves to span client needs and
Understanding various models and theories
program structure. Substance abuse treatment
of addiction and other problems related to
and case management functions differ in that
substance abuse
treatment involves activities that help substance
Ability to describe the philosophies,
abusers recognize their problems, acquire the
practices, policies, and outcomes of the most
motivation and tools to stay abstinent, and use
generally accepted and scientifically
the acquired tools; case management focuses on
supported models of treatment, recovery,
helping the substance abuser acquire needed
relapse prevention, and continuing care for
resources. Case management supports a client
addiction and other substance-related
as he moves through the recovery continuum
problems
and reinforces treatment goals.
Ability to recognize the importance of family,
social networks, community systems, and
self-help groups in the treatment and Interagency Case
recovery process Management
Understanding the variety of insurance and
The goal of interagency case management is to
health maintenance options available and the
expand the network of services available to
importance of helping clients access those
clients. All organizations have boundaries to
benefits
what they can do, and case managers or
Understanding diverse cultures and
“boundary spanners” transcend them to
incorporating the relevant needs of culturally
facilitate interactions among agencies. In the
diverse groups, as well as people with
field of substance abuse, three interagency
disabilities, into clinical practice
models have been identified. In the single agency
Understanding the value of an
model, the case manager personally establishes
interdisciplinary approach to addiction
a series of distinct relationships on an as-needed
treatment
basis with counterparts in other agencies. In the
In addition to the above competencies, informal partnership model, staff members from
treatment professionals must have skills relating several agencies work as a collaborative team,
to interagency functioning, negotiating, and often constituted case by case; the formal
advocacy. CSAT’s Addiction Technology consortium binds case managers and service
Transfer Centers classify referral and service providers through formal written agreements.
coordination—basic case management Clearly defined roles are essential to all three
functions—as core competencies for substance models to ensure that services are coordinated
abuse treatment providers. and relevant gaps addressed.
Although informal exchange or “social
The Substance Abuse Treatment
service bartering” among different agencies is
Continuum and Functions of Case
intrinsic to case management, a more formalized
Management
connection among agencies sometimes may be
The continuum of substance abuse treatment required. Examples include memoranda of
ranges from case finding and pretreatment to understanding and interagency agreements and
primary treatment to aftercare. Although there contracts; each of these methods for formalizing
xiv
Executive Summary
expectations can be used in single agency Sometimes social pressures or the need to
models, informal partnerships, and formal maximize resources can force public agencies
consortia. into joint ventures even if they do not mesh well
To be successful, a case management plan or have a history of being service competitors.
must thoroughly and critically examine Tensions can also develop in the course of
community resources to determine what forms delivering services; for example, interagency
of assistance are available and how case collaboration may result in a client having two
management efforts can help clients attain case managers. Recognizing potential triggers
necessary assistance. Many communities have for conflict is a necessary first step in developing
published directories of social, health, welfare, a system to handle them. When problems do
housing, vocational, and other service arise, case managers and other agency personnel
organizations to help case management can use both informal and formal
programs identify resources, possible provider communication to clarify issues, regain
linkages, and potential gaps in services for their perspective, and refocus the interagency case
clients. Although such directories are a good management process.
starting point, it is important to follow up on the
listings to ensure they are still accurate and will Evaluation and Quality
be of use to the client.
Assurance of Case
The Environmental Assessment Management Services
Exploring the environment in which an agency
Substance abuse treatment programs, including
operates is crucial to determining the feasibility
those that receive public funding, are
of an interagency effort. Analysis of the
increasingly operating in a managed care
community environment will enhance
environment. In such an environment, policy
understanding of the changes that occur among
and clinical decisionmaking rely on outcome
clients, within the program, and in the
data that traditionally describe the impact of
community. Case management takes place
case management and substance abuse
within a dynamic social service environment in
treatment interventions in the context of services
which agencies are in constant flux. Programs
used and money spent. An additional demand
considering interagency efforts must devise
for data comes from public and private payers
strategies to respond to change while providing
who want services linked to specific outcomes.
continuity for the client. Regular reevaluation
To gauge the effectiveness of case
helps ensure continued relevance; community
management, indicators of “success” must be
service provider networks or consortia are
defined by the substance abuse program and its
particularly effective in sharing information
stakeholders (including funding and regulatory
about changes and developments.
agencies). In documenting a case management
Potential Conflicts effort, it is necessary to establish benchmarks to
measure the case management process, for
Whenever agencies or service providers work
example, recording how often a client shows up
together, the potential for conflict exists. Areas
at treatment. Once the benchmarks are defined
of tension may be present from the very onset of
in measurable terms, the next step is to develop
the collaboration. For example, a new project
and implement a method for measuring
may be viewed by established social service
practice; that is, to answer the questions, “What
agencies as competition for scarce resources.
are case managers doing, and how does their
xv
Executive Summary
practice conform to the benchmarks?” Methods success should be gauged against a range of
of such documentation include factors, including reduced substance use,
improved family functioning, and fewer
Maintenance of a simple staff log procedure
encounters with the criminal justice system.
that measures case managers’ activities by
Until the debate is resolved, programs should
contact
identify treatment objectives and extrapolate
Reviews of case manager client records to
from them the outcome variables they want to
evaluate how service planning and referrals
measure.
adhere to benchmarks
Interviews or surveys of case managers or Anticipating Quality Assurance
clients and their family members to collect Data Needs
information on activities in which case
The types of data required for an evaluation of
managers engage, to identify how clients’
case management, how the data are collected,
and case managers’ views of case
and the manner in which data are put to use
management activities differ
vary among different stakeholders. It is
Analysis of data from the agency’s
important to understand the types of data that
management information system (to examine
various stakeholders need to evaluate the
patterns on type, number, and duration of
program. Structured feedback loops should be
case manager contacts with different target
established to ensure that the gathered data are
populations).
returned to various stakeholders in some
Measuring System Outcomes meaningful way so that they have an impact on
shaping future program development (and
System outcomes are particularly important in a
future data needs). One of the benefits of the
managed care environment, where overall use
case management approach is that it can be
of expensive services such as hospitalization and
adapted to meet the sometimes contradictory
residential treatment is strictly monitored.
needs of the various stakeholders.
System outcomes can measure cost savings and
quality of care: For example, continuity of care is Management Information Systems
an appropriate measure for a client at risk for
A management information system contains all
relapse after detoxification and before entry into
of the case management services information
outpatient treatment. Tracking clients within a
and allows stakeholders to access it. In
comprehensive service agency or analyzing data
evaluating a MIS, local programs should
on costs and encounters within a network of
agencies are two methods for measuring system Determine how to use data already routinely
outcomes. For such analyses, a computerized collected by a statewide MIS or a managed
management information system (MIS) is care company-based MIS, saving the
essential. program from duplicating primary data
collection
Measuring Client Outcomes Develop or enhance a program-level MIS
Although “evaluation” is generally considered that tracks data the program needs locally
worthwhile, there is little agreement about the Integrate with other computer-based or
measurement and documentation of specific paper-based systems
outcomes for individual clients. Some view a Supply data required by third party payer
single measure such as sobriety to be the only and governmental bodies
meaningful indicator of success; others believe
xvi
Executive Summary
All staff members of a specific program Research questions from broader sociological
should be stakeholders in the MIS, which or multidisciplinary perspectives
increases both system accuracy and the
likelihood that a broad array of staff members Case Management for
will use it. If an agency does not have the
resources to develop a sophisticated system, it
Clients With Special
should be able to automate at least a minimum Needs
amount of client information through Case management is especially appropriate for
commercially available software. When substance abusers with special treatment needs,
designing today’s MIS, the data requirements of related to such issues as HIV infection or AIDS,
managed care organizations must be addressed. mental illness, chronic and acute health
problems, poverty, homelessness, responsibility
Future Research
for parenting young children, social and
Research centered on case management and the
developmental problems associated with
substance abuse field is limited, thus offering
adolescence and advanced age, involvement
local substance abuse programs the opportunity
with illegal activities, physical disabilities, and
to make significant contributions to the field.
sexual orientation. Ideally, a case manager will
Suggested directions for future research include
possess all the expertise and skills needed to
the following:
treat the many special needs she confronts, but
Key ingredients of successful programs, this is unlikely—understanding the
especially for hard-to-reach populations ramifications of even one special need can be a
Relative cost-effectiveness of particular case staggering task. In the absence of such
management models, including cost outcome comprehensive knowledge, a case manager
results within systems incorporating full should have a basic foundation of attitudes and
parity of substance abuse with other health skills for delivering services to “special needs
care; outcome results when a full continuum clients.” The case manager should
of care is available to patients; and outcome
Make every effort to be competent in the
results associated with use of standardized
special circumstances that affect clients
guidelines for placement, continued stay,
typically referred to a particular substance
and discharge for substance abuse patients
abuse treatment program
Improved methodology to investigate
Understand the range of clients’ reactions to
research questions in “real world” settings
the challenges associated with particular
Development of brief versions of valid and
special circumstances
reliable research outcome instrumentation
Remain aware of the limits of his own
The effect of particular forms of case
knowledge and expertise
management on societal costs of substance
Evaluate personal beliefs and biases about
abuse and its treatment
clients who have special problems or needs
Cost shifting among health, behavioral
Maintain an open attitude toward seeking
health, criminal justice, and other systems
and accepting assistance on behalf of a client
that can be accessed by the target population
Know where additional information on
Creative ways to use secondary data sets
special problems can be accessed
(such as Medicaid and Medicare) to
determine trends and patterns of care
xvii
Executive Summary
xviii
1 Substance Abuse and Case
Management: An Introduction
T
he term case management has appeared in hepatitis—are transmitted by substance abuse,
social services literature more than 600 either directly or indirectly.
times in the last 30 years, referring to Substance abusers also have a higher
everything from the routing of court dockets incidence of mental health disorders than the
through the judicial system to the medical general population. Up to 70 percent of
management of a hospitalized patient’s care. individuals treated for substance abuse have a
This TIP uses the term to refer to interventions lifetime history of depression (Mirin et al., 1988).
designed to help substance abusers access Between 23 and 56 percent of individuals with
needed social services. diagnosable Axis I mental disorders also have a
Support for the use of case management in substance abuse or dependence disorder (Regier
this setting developed from both clinical practice et al., 1990).
and empirical observation suggesting that Substance abuse clients often arrive in
substance abusers who seek treatment have treatment programs with numerous social
significant problems in addition to using problems as well. Many are unemployed or
psychoactive substances. Alcohol or other drug under-employed, lacking job skills or work
use often damages many aspects of an experience. Many in publicly funded treatment
individual’s life, including housing, programs do not have a high school diploma.
employment, and relationships (Oppenheimer et Some are homeless, and those who have been
al., 1988; Westermeyer, 1989). Clients in incarcerated may face significant barriers in
substance abuse treatment programs, accessing safe and affordable housing. Many
particularly publicly funded treatment substance abuse clients have alienated their
programs, present a variety of associated families and friends or have peer affiliations
problems. Many use multiple substances and only with other substance abusers. Women in
may be poly-addicted. Many suffer from related treatment have often been victims of domestic
health disorders, either caused by their violence, including sexual abuse; some women
substance abuse—such as liver disease and in treatment may be living with an abuser.
organic brain disorders—or exacerbated by Achieving and maintaining abstinence and
neglect of health and lack of preventive health recovery nearly always requires forming new,
care. In addition, some diseases—including healthy peer associations.
HIV/AIDS, tuberculosis, and some strains of
1
Chapter 1
A significant number of clients in treatment relapse. Case management can help accomplish
are also under some form of control by the all of the above.
criminal justice system. Criminal justice Case management is needed because, in most
substance abuse clients represent more than half jurisdictions, services are fragmented and
of all clients in treatment in many state and local inadequate to meet the needs of the substance-
jurisdictions. Although those afflicted by abusing population. This lack of coordinated
chemical addiction are found among all services results from a variety of factors,
socioeconomic groups, persons already plagued including
by poverty, disease, and unemployment are
Different funding streams. Substance abuse
over-represented (CSAT, 1994). Particularly in
treatment is funded from a variety of
publicly funded treatment programs, substance
sources—block grants, competitive grants,
abuse clients have limited resources and may
state and local funding, criminal justice
lack health insurance. Many are eligible for
funding, and others. The different
publicly supported health and social benefits,
requirements or goals of these sources can
including Medicare, food stamps, or welfare.
result in a piecemeal approach to
Data suggest that substance abusers who
programming
receive professional attention for these
A focus on program funding rather than
additional problems will see improvements in
system funding
occupational and family functioning and a
Funding focused on single modalities rather
lessening of psychiatric symptoms (McLellan et
than a continuum of care
al., 1993; McLellan et al., 1982; Moos et al., 1990;
Inadequate funding created by missing
Siegal et al., 1995). Clinicians who develop a
pieces in the continuum
"helping alliance" with substance abusers have
Waiting lists caused by inadequate funding
been shown to produce better treatment
Barriers between systems (e.g., mental health
outcomes than those who do not (Luborsky et
vs. substance abuse, criminal justice vs.
al., 1985).
mental health and substance abuse)
Lack of incentives geared to client outcome;
Why Case Management programs rewarded for process measures,
Because addiction affects so many facets of the not outcome measures
addicted person’s life, a comprehensive Eligibility/admission criteria that exclude
continuum of services promotes recovery and certain clients
enables the substance abuse client to fully Lack of agreement on priority for
integrate into society as a healthy, substance-free admission/treatment
individual. The continuum must be designed to Lack of incentives for programs to work
provide engagement and motivation, primary together
treatment services at the appropriate intensity Due to the fragmentation of services, the
and level, and support services that will enable accompanying inefficiency, and a growing
the individual to maintain long-term sobriety scarcity of resources, some form of case
while managing life in the community. management is used with virtually every
Treatment must be structured to ensure smooth population that routinely seeks social services.
transitions to the next level of care, avoid gaps The variability in social services system
in service, and respond rapidly to the threat of configurations has led to many different
implementations of case management, resulting
2
Introduction
management, clients and professionals 1982; Stein and Test, 1980; Test, 1981; Turner and
practicing case management now negotiate a TenHoor, 1978).
drastically constricted menu of services. Each of Substance abusers historically were never
these contemporary conditions makes institutionalized as often as were persons with
implementation and evaluation an increasingly chronic mental illness and so were not directly
difficult task. impacted by deinstitutionalization legislation.
Substance abusers were not generally targeted
Case Management – A for the development of categorical systems of
Brief History service delivery and were not generally
recipients of case management services.
More than 70 years ago when Mary Richmond However, case management-like services were
envisioned a cadre of “friendly neighbors” provided to substance abusers under other titles,
helping others in their struggles with real world such as “mission work,” and frequently
needs (Richmond, 1922), she created not only delivered by the clergy or others in skid row
the field of social work, but case management as missions, detoxification centers, and ad hoc
well. While she applied the term social casework halfway houses. Jails and county work farms
to the activities that affected the adjustment were generally the institutions of choice in
between an individual and the social dealing with this population. Only after
environment, she could well have been substance abuse began to be decriminalized and
describing the key functions that now comprise defined as a disease were substance abusers
case management. referred to various social services.
One of the first legislative embodiments of Policymakers in Canada were among the first
case management occurred in the 1963 Federal to translate many generic case management
Community Mental Health Center Act functions into the field of substance abuse
(Intagliata, 1982) in anticipation of treatment, outlining the essential elements of a
deinstitutionalization, in which persons in long union of case management and substance abuse
term psychiatric care were moved into treatment (Graham and Birchmore-Timney,
community settings. The expectation that these 1990; Ogborne and Rush, 1983; Rush and
individuals would need services previously Ekdahl, 1990). Case management for substance
provided in the institution led to the rapid abusers initially gained attention in the United
expansion of community-based social services. States through the Treatment Alternatives for
Unfortunately, these services were often created Safe Communities (TASC) program (formerly
independently of one another and, coupled with known as Treatment Alternatives to Street
the categorical nature of the eligibility for Crime), which began linking the criminal justice
services, led to difficulties for persons used to system with the drug abuse treatment system in
having these services provided in institutions. 1972 and has grown to over 185 programs
The Community Support System developed by (Cook, 1992) today.
the National Institutes of Mental Health in 1977 A 1987 National Institute of Mental Health
envisioned case management as a mechanism initiative funded 13 demonstration projects
for helping clients navigate this fragmented targeted at young adults with coexisting mental
social service system. Accessing these resources health and substance use problems. Of these 13
would thus enable them to live and function projects, 10 identified some form of case
adequately in their communities (Intagliata, management as a primary service and provided
a general description of the case management
4
Introduction
intervention (Teague et al., 1990). Initiatives they are social workers, nurses, or case
undertaken by both the National Institute on management specialists. Nonetheless, there is
Drug Abuse (NIDA) and National Institute on relatively widespread agreement on the basic
Alcohol Abuse and Alcoholism (NIAAA) definition, as illustrated in Figure1-1.
resulted in numerous projects that used case While definitions are useful in guiding
management to enhance treatment (Bonham et general discussions, functions are a more helpful
al., 1990; Conrad et al., 1993; Cox et al., 1993; way to approach case management as it is
Inciardi et al., 1993; Fletcher et al., 1994; Mejta et actually practiced. As with definitions, there is a
al., 1994). Case management in these projects high degree of consensus about a core group of
was designed to increase retention in the functions. One widely accepted set of functions
treatment continuum and to improve treatment comprises (1) assessment, (2) planning, (3)
outcomes. linkage, (4) monitoring, and (5) advocacy (Joint
Commission on Accreditation of Healthcare
Definitions and Functions Organizations, 1979). The National Association
Any definition of case management today is of Social Workers’ standards for social work
inevitably contextual, based on the needs of a case management include assessing, arranging,
particular organizational structure, coordinating, monitoring, evaluating, and
environmental reality, and prior training of the advocacy (National Association of Social
individuals who are implementing it, whether 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 Addiction Counseling Competencies describes
management functions in the specific context of the knowledge, skills, and attitudes required for
substance abuse treatment. Case management is all eight practice dimensions. Those supporting
one of eight counseling skills identified by the referral and service coordination are reproduced
National Association of Alcoholism and Drug in full in Appendix B.
Abuse Counselors (National Association of
Alcoholism and Drug Abuse Counselors, 1986) Models of Case
and one of five performance domains developed
Management With
in the Role Delineation Study (International
Certification and Reciprocity Consortium, 1993). Substance Abusers
Another framework is supplied by the Case management models, like the definitions of
Addiction Technology Transfer Centers case management, vary with the context. Some
(ATTCs), established by CSAT to transmit models focus on delivering social services,
current information on treatment to providers in others on coordinating the delivery of services
the field. The essential elements of case by other providers. Some provide both. The
management are laid out in their publication models result as much from the needs of specific
Addiction Counseling Competencies: The Knowledge, client populations and service settings as they
Skills, and Attitudes of Professional Practice (CSAT, do from distinct theoretical differences about
1998). That document has been endorsed by what case management should be. Four models
many leading addiction organizations. from the mental illness field have been adapted
Referral and service coordination are two of for the field of substance abuse treatment. Each
eight practice dimensions the ATTCs deem of these models—broker/generalist, strengths-
essential to the effective practice of addiction based, assertive community treatment, and
counseling. Activities considered part of those clinical/rehabilitation—has proved valuable in
two dimensions include engagement; treating substance abusers in a particular
assessment; planning, goal-setting, and setting.
implementation; linking, monitoring, and For example, the strengths-based approach
advocacy; and disengagement. The document was adapted to work with crack cocaine users.
defines service coordination as: This approach was chosen not only for its focus
“The administrative, clinical, and evaluative on resource acquisition but also because it helps
activities that bring the client, treatment clients see their own assets as a valuable part of
services, community agencies, and other recovery (Siegal and Rapp, 1996). Assertive
resources together to focus on issues and needs community treatment was implemented to
identified in the treatment plan. Service provide parolees a wide range of integrated
coordination, which includes case management services, including drug treatment, skills
and client advocacy, establishes a framework of building, and resource acquisition.
action for the client to achieve specified goals. It Figure 1-2 compares the four models across
involves collaboration with the client and 11 activities of case management and specifies
significant others, coordination of treatment and which models are appropriate for particular
referral services, liaison activities with substance abuse populations. Implementation of
community resources and managed care these models may vary with other populations
systems, client advocacy, and ongoing and from setting to setting.
evaluation of treatment progress and client
needs” (CSAT, 1998, p. 53).
6
Introduction
Figure 1-2
Models of Case Management
Primary Case Broker/Generalist Strengths Assertive Clinical/
Management Perspective Community Rehabilitation
Activities Treatment
Conducts outreach Not usually Depends on Depends on Depends on
and case finding agency mission & agency mission & agency mission &
structure structure structure
Provides assessment Specific to Strengths-based, Broad-based, part Broad-based, part
and ongoing immediate applicable to any of a of a
reassessment resource of client life areas comprehensive comprehensive
acquisition needs (biopsychosocial) (biopsychosocial)
assessment assessment
Assists in goal Generally brief, Client-driven, Comprehensive, Comprehensive,
planning related to teaches specific goals may include goals may include
acquiring process on how to any of client life any of client life
resources, possibly set goals and areas areas
informal objectives, goals
may include any
of client life areas
Makes referral to Case manager may As negotiated with As needed, many As negotiated with
needed resources initiate contact or client, may contact resources client, may contact
have client make resource, integrated into resource,
contact on own accompany client, broad package of accompany client,
or client may case management or client may
contact on own services contact on own
Monitors referrals Follow-up checks Close involvement Close involvement Close involvement
made in ongoing in ongoing in ongoing
relationship relationship relationship
between client and between client and between client and
resource resource resource
7
Chapter 1
Engages advocacy in Not usually Usually in context Either advocates Usually in context
support of resource of specific client for needed of specific client
development needs resources or may needs
create resources as
part of case
management
services
8
Introduction
10
Introduction
integrated with the disease model of treatment Many substance abuse treatment programs
and that its presence leads to improved use a clinical model in which the same treatment
outcomes for clients. The improved outcomes professional provides, or at least coordinates,
include employability, retention in treatment, both therapy and case management activities.
and (through retention in treatment) reduced Such an approach is frequently driven by
drug use (Rapp et al., in press; Siegal et al., 1996; staffing considerations: It is more economical to
Siegal et al., 1997). have one treatment professional provide all
services than to have separate clinical and case
Clinical/Rehabilitation managers deliver them.
Clinical/rehabilitation approaches to case One example of combining clinical and case
management are those in which clinical management activities is found in a program for
(therapy) and resource acquisition (case women who have substance abuse problems
management) activities are joined together and (Markoff and Cawley, 1996). In Project Second
addressed by the case manager. It has been Beginning, an emphasis on relationships and
suggested that the separation of these two empowerment is used both to secure needed
activities is not feasible over an extended period resources and to guide implementation of
of time and that the case manager must be therapy activities. This approach is based on the
trained to respond to client-focused, as opposed belief that women have special needs in the
to solely environmental issues (Kanter, 1996). treatment setting—needs that can most
Client-focused services could include providing appropriately be addressed through a
psychotherapy to clients, teaching specific skills, therapeutic relationship with a single caregiver.
and family therapy. Beyond the usual repertoire The clinical/rehabilitation approach has been
of case management functions (e.g., monitoring), widely used in the treatment of persons with
the case manager should be aware of numerous diagnoses of both substance abuse and
issues including transference, psychiatric problems (Anthony and Farkas,
countertransference, how clients internalize 1982; Drake et al., 1993; Drake and Noordsey,
what they observe, and theories of ego 1994; Lehman et al., 1993; Shilony et al., 1993).
functioning (Harris and Bergman, 1987; Kanter,
1996).
11
2 Applying Case Management to
Substance Abuse Treatment
C
ase management is almost infinitely professionals. The case manager must mobilize
adaptable, but several broad principles needed resources, which requires the ability to
are true of almost every application. negotiate formal systems, to barter informally
This chapter will discuss those principles, the among service providers, and to consistently
competencies necessary to implement case pursue informal networks. These include self-
management functions, and the relationship help groups and their members, halfway and
between those functions and the substance three-quarter-way houses, neighbors, and
abuse treatment continuum. For the purposes of numerous other resources that are sometimes
discussion, case management and substance not identified in formal service directories.
abuse treatment are presented as separate and Case management is client-driven and
distinct aspects of the treatment continuum, driven by client need. Throughout models of
although in reality they are complementary and case management, in the substance abuse field
at times thoroughly blended. and elsewhere, there is an overriding belief that
clients must take the lead in identifying needed
Case Management resources. The case manager uses her expertise
to identify options for the client, but the client’s
Principles right of self-determination is emphasized. Once
Case management offers the client a single the client chooses from the options identified,
point of contact with the health and social the case manager’s expertise comes into play
services systems. The strongest rationale for again in helping the client access the chosen
case management may be that it consolidates to services. Case management is grounded in an
a single point responsibility for clients who understanding of clients’ experiences and the
receive services from multiple agencies. Case world they inhabit⎯the nature of addiction and
management replaces a haphazard process of the problems it causes, and other problems with
referrals with a single, well-structured service. which clients struggle (such as HIV infection,
In doing so, it offers the client continuity. As the mental illness, or incarceration). This
single point of contact, case managers have understanding forms the context for the case
obligations not only to their clients but also to manager’s work, which focuses on identifying
the members of the systems with whom they psychosocial issues and anticipating and
interact. Case managers must familiarize helping the client obtain resources. The aim of
themselves with protocols and operating case management is to provide the least
procedures observed by these other
13
Chapter 2
restrictive level of care necessary so that the case manager. Because it often transcends
client’s life is disrupted as little as possible. facility boundaries, and because the case
Case management involves advocacy. The manager is more involved in the community
paramount goal when dealing with substance and the client’s life, case management may be
abuse clients and diverse services with more successful in re-engaging the client in
frequently contradictory requirements is the treatment and the community than agency-
need to promote the client’s best interests. Case based efforts. For clients who are
managers need to advocate with many systems, institutionalized, case management involves
including agencies, families, legal systems, and preparing the client for community-based
legislative bodies. The case manager can treatment and living in the community. Case
advocate by educating non-treatment service management can ensure that transitions are
providers about substance abuse problems in smooth and that obstacles to timely admissions
general and about the specific needs of a given into community-based programs are removed.
client. At times the case manager must Case management can also coordinate release
negotiate an agency’s rules in order to gain dates to ensure that there are no gaps in service.
access or continued involvement on behalf of a The type of relationship described here is likely
client. Advocacy can be vigorous, such as when at times to stretch the more narrow boundaries
a case manager must force an agency to serve its of the traditional therapist-client relationship.
clients as required by law or contract. For Case management is pragmatic. Case
criminal justice clients, advocacy may entail the management begins “where the client is,” by
recommendation of sanctions to encourage responding to such tangible needs as food,
client compliance and motivation. shelter, clothing, transportation, or child care.
Case management is community-based. All Entering treatment may not be a client priority;
case management approaches can be considered finding shelter, however, may be. Meeting these
community-based because they help the client goals helps the case manager develop a
negotiate with community agencies and seek to relationship with and effectively engage the
integrate formalized services with informal care client. This client-centered perspective is
resources such as family, friends, self-help maintained as the client moves through
groups, and church. However, the degree of treatment. At the same time, however, the case
direct community involvement by the case manager must keep in mind the difficulty in
manager varies with the agency. Some agencies achieving a balance between help that is positive
mount aggressive community outreach efforts. and help that may impede treatment
In such programs, case managers accompany engagement. For example, the loss of housing
clients as they take buses or wait in lines to may provide the impetus for residential
register for entitlements. This personal treatment. Teaching clients the day-to-day skills
involvement validates clients’ experiences in a necessary to live successfully and substance free
way that other approaches cannot. It suits the in the community is an important part of case
subculture of addiction because it enables the management. These pragmatic skills may be
case manager to understand the client’s world taught explicitly, or simply modeled during
better, to learn what streets are safe and where interactions between case manager and client.
drug dealing takes place. This familiarity helps Case management is anticipatory. Case
the professional appreciate the realities that management requires an ability to understand
clients face and set more appropriate treatment the natural course of addiction and recovery, to
goals—and helps the client trust and respect the foresee a problem, to understand the options
14
Case Management and Treatment
available to manage it, and to take appropriate quickly, an awareness of how to maintain
action. In some instances, the case manager may appropriate boundaries in the fluid case
intervene directly; in others, the case manager management relationship, the willingness to be
will take action to ensure that another person on nonjudgmental toward clients, and certain
the care team intervenes as needed. The case “transdisciplinary foundations” created by the
manager, working with the treatment team, lays Addiction Technology Transfer Centers (ATTCs)
the foundation for the next phase of treatment. (see page 6). These foundations—
Case management must be flexible. Case understanding addiction, treatment knowledge,
management with substance abusers must be application to practice, and professional
adaptable to variations occasioned by a wide readiness—are articulated in 23 competencies
range of factors, including co-occurring and 82 specific points of knowledge and
problems such as AIDS or mental health issues, attitude. Examples of competencies include
agency structure, availability or lack of
Understanding a variety of models and
particular resources, degree of autonomy and
theories of addiction and other problems
power granted to the case manager, and many
related to substance use
others. The need for flexibility is largely
Ability to describe the philosophies,
responsible for the numerous models of case
practices, policies, and outcomes of the most
management and difficulties in evaluating
generally accepted and scientifically
interventions.
supported models of treatment, recovery,
Case management is culturally sensitive.
relapse prevention, and continuing care for
Accommodation for diversity, race, gender,
addiction and other substance-related
ethnicity, disability, sexual orientation, and life
problems
stage (for example, adolescence or old age),
Recognizing the importance of family, social
should be built into the case management
networks, and community systems in the
process. Five elements are associated with
treatment and recovery process
becoming culturally competent: (1) valuing
Understanding the variety of insurance and
diversity, (2) making a cultural self-assessment,
health maintenance options available and the
(3) understanding the dynamics of cultural
importance of helping clients access those
interaction, (4) incorporating cultural
benefits
knowledge, and (5) adapting practices to the
Understanding diverse cultures and
diversity present in a given setting (Cross et al.,
incorporating the relevant needs of culturally
1989).
diverse groups, as well as people with
disabilities, into clinical practice
Case Management Understanding the value of an
Practice—Knowledge, interdisciplinary approach to addiction
must not only have many of the same abilities as Obtain, review, and interpret all relevant
other professionals who work with substance screening, assessment, and initial treatment-
abusers (such as counselors), they must also planning information
possess special abilities relating to such areas as Confirm the client’s eligibility for admission
interagency functioning, negotiating, and and continued readiness for treatment and
advocacy. In recognition of the specific change
competencies applicable to conducting case Complete necessary administrative
management functions, two of the eight core procedures for admission to treatment
dimensions—referral and service coordination— Establish realistic treatment and recovery
provide critical knowledge, skills, and attitudes expectations with the client and involved
pertinent to case management. Below are the significant others including, but not limited
activities covered under those dimensions. to
♦ Nature of services
Referral ♦ Program goals
Establish and maintain relations with civic ♦ Program procedures
groups, agencies, other professionals, ♦ Rules regarding client conduct
governmental entities, and the community at ♦ Schedule of treatment activities
large to ensure appropriate referrals, identify ♦ Costs of treatment
service gaps, expand community resources, ♦ Factors affecting duration of care
and help to address unmet needs ♦ Client rights and responsibilities
Continuously assess and evaluate referral Coordinate all treatment activities with
resources to determine their appropriateness services provided to the client by other
Differentiate between situations in which it is resources
more appropriate for the client to self-refer to
a resource and those in which counselor Consulting
referral is required
Summarize the client’s personal and cultural
Arrange referrals to other professionals,
background, treatment plan, recovery
agencies, community programs, or other
progress, and problems inhibiting progress
appropriate resources to meet client needs
for purpose of ensuring quality of care,
Explain in clear and specific language the
gaining feedback, and planning changes in
necessity for and process of referral to
the course of treatment
increase the likelihood of client
Understand terminology, procedures, and
understanding and follow-through
roles of other disciplines related to the
Exchange relevant information with the
treatment of substance use disorders
agency or professional to whom the referral
Contribute as part of a multidisciplinary
is being made in a manner consistent with
treatment team
confidentiality regulations and professional
Apply confidentiality regulations
standards of care
appropriately
Evaluate the outcome of the referral
Demonstrate respect and nonjudgmental
attitudes toward clients in all contacts with
Service Coordination community professionals and agencies
Implement the treatment plan (CSAT, 1998)
Almost 200 specific knowledge items, skills, and services available under managed care plans
attitudes are associated with these dimensions: have been severely curtailed. Many individuals
They can be found in Appendix B. identified as viable treatment candidates cannot
get through the gate, and pretreatment may in
The Substance Abuse fact constitute brief intervention therapy.
Treatment programs may undertake case-
Treatment Continuum finding activities through formal liaisons with
and Functions of Case potential referral sources such as employers, law
period (Alterman et al., 1994; Gilbert, 1988; Stark least some of the skills to maintain sobriety and
and Kane, 1985; Zweben, 1981). begin work on remediating various areas of
their lives. Work is intrapersonal and
Primary treatment
interpersonal as well as environmental. Areas
Primary treatment is a broad term used to define
that relate to environmental issues, such as
the period in which substance abusers begin to
vocational rehabilitation, finding employment,
examine the impact of substance use on various
and securing safe housing, fall within the
areas of their lives. The American Society of
purview of case management.
Addiction Medicine (ASAM) delineates five
If different individuals perform case
categories of primary treatment, characterized
management and addictions counseling, they
by the level of treatment intensity: early
must communicate constantly during aftercare
intervention, outpatient services, intensive
about the implementation and progress of all
outpatient or partial hospitalization, residential
service plans. Because case managers interact
or inpatient services, and medically managed
with the client in the community, they are in a
intensive inpatient services (ASAM, 1997).
unique position to see the results of work being
Whatever the setting, an extensive
done in aftercare groups and provide
biopsychosocial assessment is necessary. This
perspective about the client’s functioning in the
assessment provides both the client and the
community. Recent findings suggest that the
treatment team the opportunity to determine
case management relationship may be as
clinical severity, client preference, coexisting
valuable to the client during this phase of
diagnoses, prior treatment response, and other
recovery as that with the addictions counselor
factors relevant to matching the client with the
(Siegal et al., 1997; Godley et al., 1994).
appropriate treatment modality and level of
Aftercare is important in completing treatment
care. If not already established during the case
both from a funding standpoint (many funders
finding/pretreatment phase, this assessment
refuse to pay for aftercare services), as well as
should also consider the client’s needs for
from the client’s perspective.
various resources that case management can
help secure. Case Management Functions and
Aftercare the Treatment Continuum
Aftercare, or continuing care, is the stage In this section, case management functions are
following discharge, when the client no longer presented against the backdrop of the substance
requires services at the intensity required during abuse continuum of care to highlight the
primary treatment. A client is able to function relationship between treatment and case
using a self-directed plan, which includes management. The primary difference between
minimal interaction with a counselor. the two is case management’s focus on assisting
Counselor interaction takes on a monitoring the substance abuser in acquiring needed
function. Clients continue to reorient their resources. Treatment focuses on activities that
behavior to the ongoing reality of a pro-social, help substance abusers recognize the extent of
sober lifestyle. Aftercare can occur in a variety their substance abuse problem, acquire the
of settings, such as periodic outpatient aftercare, motivation and tools to stay sober, and use those
relapse/recovery groups, 12-Step and self-help tools. Case management functions mirror the
groups, and halfway houses. Whether stages of treatment and recovery. If properly
individuals completed primary treatment in a implemented, case management supports the
residential or outpatient program, they have at client as she moves through the continuum,
18
Case Management and Treatment
19
Chapter 2
20
Case Management and Treatment
21
Chapter 2
irrelevant. Where a team approach exists, all clients to learn how to obtain those services.
members of the team, including the case The client should therefore be assessed for
manager or other professional identified in that
Ability to obtain and follow through on
role, should bring their expertise to the
medical services
assessment. Discharge planning and long-range
Ability to apply for benefits
needs identification, particularly with current
Ability to obtain and maintain safe housing
funding limitations, begins at treatment
Skill in using social service agencies
admission. Because of this, intensive case
Skill in accessing mental health and
management for substance abuse clients,
substance abuse treatment services
regardless of the level of care, is imperative.
Prevocational and vocation-related
As the individual responsible for skills
coordinating diverse services, the case manager In order to reach the ultimate goal of
must take a broad view of client needs, look independence, clients must also have vocational
beyond primary therapy to the impact of the skills and should therefore be assessed for
client’s addiction on broader domains, and
Basic reading and writing skills
assess the impact of these domains on the
Skills in following instructions
client’s recovery. He also must assess specific
Transportation skills
areas of functional skill deficits, including
Manner of dealing with supervisors
personal living skills, social or interpersonal
Timeliness, punctuality
skills, service procurement skills, and vocational
Telephone skills
skills. Individuals performing this function
need to have strong knowledge of and The case management assessment should
experience in the field of substance abuse. The include a scan for indications of harm to self or
greater the number of problems the case others. The greater the deficits in social and
manager can help the client identify and manage interpersonal skills, the greater the likelihood of
during primary treatment, the fewer problems harm is to self and/or others, as well as
the client must address during aftercare and endangerment from others. The case manager
ongoing recovery⎯and the greater the chances should also conduct an examination of criminal
for treatment success. records. If the client is under the supervision of
A case management assessment should the criminal justice system, supervision officers
include a review of the following functional should be contacted to determine whether or not
areas (Harvey et al., 1997; Bellack et al., 1997). there is a potential for violent behavior, and to
These items are not exhaustive, but demonstrate elicit support should a crisis erupt.
some of the major skill and service need areas
that should be explored. The assessment of
Aftercare
The client’s readiness to reintegrate into the
these areas of functioning gives evidence of the
community is a focus of case management
client’s degree of impairment and barriers to the
assessment throughout the treatment
client’s recovery. The case manager may have to
continuum. Because the case manager is often
perform many services on behalf of the client
out in the community with the client, she is in an
until skills can be mastered.
excellent position to evaluate this important
Service procurement skills
indicator. During aftercare, her assessment may
While the focus of case management is to assist
reveal new, recurring, or unresolved problems
clients in accessing social services, the goal is for
the client must deal with before they interfere
with recovery. The potential for relapse is a
22
Case Management and Treatment
particularly significant challenge, and the client implementation of the case management aspects
must be able to identify personal relapse triggers of the treatment plan is crucial.
and learn how to cope with them. Because case Successful completion of an objective should
managers are familiar with the community, provide the client the satisfaction of gaining a
clients, and substance abuse treatment issues, needed resource and demonstrating success.
they can spot such triggers and intervene Failure to complete an objective should be
appropriately. If, for example, a case manager emphasized as an opportunity to reevaluate
fears that a client’s decision to return to a one’s efforts. In the latter situation, the case
familiar neighborhood could result in contact manager should be prepared to help the client
with drug-using friends that could jeopardize come up with alternative approaches or to begin
sobriety, a new residence may be necessary. an advocacy process.
A deliberate, carefully considered approach
Planning, goal-setting, and
to identifying client goals offers benefits that go
implementation
beyond the actual acquisition of needed
Flowing directly and logically from the
resources. Clients benefit by
assessment process, planning, goal-setting, and
implementation comprise the core of case Learning a process for systematically setting
management. Based on the biopsychosocial or goals
case management assessment, the client and Understanding how to achieve desired goals
case manager identify goals in all relevant life through the accomplishment of smaller
domains, using the strengths, needs, and wants objectives
articulated in the assessment process. Service Gaining mastery of themselves and their
plan development and goal-setting are environment through brainstorming ways
discussed in detail in numerous works on around possible barriers to a particular goal
substance abuse and case management (Ballew or objective
and Mink, 1996; Rothman, 1994; Sullivan, 1991). Experiencing the process of accessing and
These authors agree on several points: Each accepting assistance from others in goal-
goal in service plans should be broken down setting and goal attainment
into objectives and possibly into even smaller These and other individually centered
steps or strategies that are behaviorally specific, outcomes make the planning and goal-setting
measurable, and tangible. Distinct, manageable process as important as the final outcome in
objectives help keep clients from feeling some cases. This is the action stage of case
overwhelmed and provide a benchmark against management, when the client participates in
which to measure progress. Goals, objectives, many new or foreign activities and may have
and strategies should be developed in multiple requirements imposed by multiple
partnership with the client. They should be programs or systems. Many significant and
framed in a positive context—as something to be stressful transitions may be involved—from
achieved rather than something to be avoided. substance use to abstinence, from
Time frames for completing the objectives and institutionalization or residential placement to
strategies should be identified. Abbreviated, community reintegration, and from a drug- or
user-friendly treatment planning templates alcohol-using peer group to new, abstinent
make client participation in development of a friends. As clients struggle to stop using, many
service plan more likely. The availability of staff will relapse, sometimes after a significant period
to assist in the planning, goal-setting, and of abstinence. They may feel overwhelmed, and
23
Chapter 2
it is not uncommon for clients in recovery to For example, a case manager might require the
experience feelings of isolation and depression client to identify and make progress toward
as they develop new peer associations and mutually understood goals pending entry into
lifestyle patterns, and come to grips with their treatment. Structured correctly, such an
losses. In addition, the very real pressures of approach fosters a win-win situation.
finances, employment, housing, and perhaps Attainment of these goals either eliminates the
reunifying with and caring for children can be client’s need for treatment or prepares him to
very stressful. accept treatment more willingly. Even if the
client is unwilling or unable to achieve those
Case finding and pretreatment
goals, the case manager and treatment program
During the pretreatment phase the planning
have additional information to use in attempting
function of case management focuses on
to motivate the client to seek treatment.
supporting clients in achieving immediate needs
and facilitating their entry into treatment. Primary treatment
Ideally, the professional implementing case During primary treatment, the case manager
management meets with the client to plan the and client develop a service plan that identifies
goals and objectives for the service plan. While and proposes strategies to meet the client’s
planning and goal setting are important in this short- and medium-term needs. The case
early stage of treatment, it may be difficult to management plan should reflect the level and
follow traditional approaches given the intensity of the service along with the client’s
immediacy of clients’ needs and the possibility specific objectives. Virtually all clients have
that they are still using alcohol or other drugs. multiple needs; consequently, the service plan
The case manager may decide to complete a should be structured to enable clients to focus
formal plan after an action is undertaken and on addressing their problems while they
present it to the client as a summary of work participate in treatment. The idea that one can
that was accomplished. If a client’s capacity is put lack of housing, employment issues, or a
diminished by substance abuse and the presence child’s illness aside to concentrate exclusively on
of multiple, serious life problems, the case addiction treatment and recovery is unrealistic
manager may have to delay teaching and and sets up both the treatment provider and the
modeling for the client, and instead trade on his client for failure. At the same time, it is often
own contacts, resources, and abilities. As the necessary for the client and case manager to
client progresses through the treatment prioritize problems.
continuum, the case manager can turn more and During primary treatment, the case manager
more of the responsibility for action over to the must (1) continue to motivate the client to
client. remain engaged and to progress in treatment;
Clients who are using addictive substances (2) organize the timing and application of
while receiving case management services services to facilitate client success; (3) provide
present a significant dilemma for the case support during transitions; (4) intervene to
manager. On the one hand, the client may not avoid or respond to crises; (5) promote
be willing or able to participate in treatment; on independence; and (6) develop external support
the other, treatment providers normally expect structures to facilitate sustained community
some commitment to sobriety before clients integration. Case management techniques
begin the treatment process. As a result, the should be designed to reduce the client’s
case manager frequently needs to negotiate internal barriers, as well as external barriers that
common ground between client and program. may impede progress.
24
Case Management and Treatment
Providing ongoing motivation to clients is thereof), and engages the client in a dialogue.
critical throughout the treatment continuum. The judge can then apply rewards
Clients need encouragement to commit to (encouragement, or reduction of criminal
entering treatment, to remain in treatment, and sanctions), adjust treatment requirements, or
to continue to progress. The case manager must apply sanctions. Sanctions vary, but may
continually seek client-specific incentives. include warnings, community service, short jail
Clients are encouraged by different factors, and stays, or ultimately, termination from the
the same client may respond differently program and incarceration.
depending on the situation. For instance, many Another fundamental role of case
clients referred by the criminal justice system management during the active treatment phase
will be initially motivated to try treatment in is to coordinate the timing of various
order to avoid a jail sentence; they may be interventions to ensure that the client can
motivated to stay in treatment for very different achieve his goals. The case manager has to work
reasons (e.g., they start to feel better, they hope with the client to balance competing interests,
to regain custody of children). The treatment and to develop strategies so the client can meet
process is difficult, and many clients become basic survival needs while in treatment. For
discouraged after their initial enthusiasm. example, a case manager may have to negotiate
Recovery may require them to explore between probation and treatment to ensure that
uncomfortable issues. Physical discomfort, as the client can attend treatment sessions and
well as depression, can ensue. Case managers meet with his probation officer. Some activities
can provide support during these periods by require staging to ensure that they are applied at
supplying information on coping techniques the right time and in the correct order. Clients
such as exercise, diet, and leisure activities. If who are unemployed and lack employment
depression is significant, case managers can skills, for instance, should begin job readiness
work with substance abuse counselors to have a and training activities after they are stabilized in
mental health evaluation conducted, and, if treatment; they will need additional support for
appropriate, enable the client to seek additional seeking and maintaining employment. It is not
therapeutic support for the depression. uncommon for clients to feel they can take on
Continued empathetic caring can also motivate the world once they are stabilized in treatment.
clients. If this is the case, the job of the case manager is
Disincentives may also be used. For to encourage clients to go slowly and take on
example, the case manager might remind clients responsibility one step at a time. This can be
of the outcome of terminating treatment—for particularly critical for women anxious to
some, this might mean a return to prison, for reconnect with their children. The financial and
others it might mean dealing with the health or emotional responsibilities are great, and the case
safety consequences of addictive behaviors. For manager should work with the woman and
clients under the control of the criminal justice child protective services to transition these
system, sanctions, including possible jail stays, responsibilities in manageable ways.
may be necessary to regain commitment and Transition among programs—from
motivation. institutional programming to residential
In criminal justice settings, particularly drug treatment; from residential treatment to
courts, regular “status hearings” before a judge outpatient; or to lower level services within an
may motivate the client. In status hearings, the outpatient setting — is always stressful, and
judge is informed of the client’s progress (or lack frequently triggers relapse. In order to avoid
25
Chapter 2
crises during transitions, case managers should “jeopardy meetings” for treatment clients
intensify their contact with clients. Case involved in the criminal justice system. These
managers should work to ensure that service is meetings are attended by the case manager,
not interrupted. When possible, release dates treatment counselor, probation officer, client,
should be coordinated to coincide with and anyone else involved in the case. The
admission to the next program. purpose of the meeting is to confront the client
If the client is under the control of the with the problem, and to discuss its resolution
criminal justice system, the case manager should as a team. The client must agree to the proposed
work to ensure that supervision activities resolution in writing. The jeopardy meeting
remain the same or increase when treatment provides a clear warning to the client (three
activity decreases. Too frequently, a client jeopardy meetings can result in client
completes a treatment program and is moved to termination); reduces the “triangulation” or
a lower level of supervision at the same time. manipulation that can occur if all parties aren’t
This pulls out support all at once. If possible, working in a coordinated fashion; and brings
supervision and treatment activities should be together the skills and resources of multiple
coordinated to promote gradual movement to agencies and professionals. (For more on
independence in order to reduce the likelihood jeopardy meetings, including structure and
of relapse. format, see the TASC Implementation Guide
In addition to activities designed to avoid a (Bureau of Justice Assistance, 1988).
crisis or relapse, the case manager should be
Aftercare
available to respond to relapses and crises when
One of the anticipatory roles for case
they do occur. In many cases, the case manager
management during primary care is to plan for
leads the response effort. Case managers should
aftercare, discharge, and community reentry.
be in frequent contact with the treatment
During primary care and into aftercare, the case
program to check on client attendance and
manager helps the client master basic skills
progress. Lapses in attendance and/or poor
needed to function independently in the
progress can signal an impending crisis, and a
community, including budgeting, parenting,
case conference should be held. The case
and housekeeping. Short-term goals
conference can resolve problems and prevent
increasingly become supplanted by long-term
the client’s termination from the program.
goals of integrating the individual into a
While violence toward staff or other patients is
recovery lifestyle. When appropriate, service
obviously adequate grounds for immediate
plans should reflect an ever-increasing emphasis
program termination, other infractions do not
on clients’ accepting greater responsibility for
necessarily warrant expulsion. The case
their actions. The case management
management team and client should work
intervention may increase or decrease in
together to develop alternatives that will keep
intensity, depending on client response to
the client engaged in treatment. If removal from
independence and progress toward community
the program is absolutely necessary, it may be
reintegration.
possible to have the client readmitted after he
“adjusts his attitude” and re-commits to Linking, monitoring, and advocacy
treatment and to obeying the rules. Some findings suggest that while persons with
The Treatment Alternatives for Safe substance abuse problems are generally adept at
Communities (TASC) Project has developed a accessing resources on their own without case
special form of case conference, known as management, they often have trouble using the
26
Case Management and Treatment
services effectively (Ashery et al., 1995). This is problems at work, this information may need to
where the linking, ongoing monitoring, and, in be shared with the treatment provider, within
many cases, advocacy, of case management can the constraints of confidentiality regulations.
be valuable. An additional crucial function of Case managers who are responsible for
case management is coordinating all the various offenders in treatment may oversee regular drug
providers and plans and integrating them into a testing. This is an effective way to obtain
unified whole. objective information on a client’s drug use, as
Linking goes beyond merely providing well as to structure boundaries for the client to
clients with a referral list of available resources. help prevent relapse.
Case managers must work to develop a network Monitoring may reveal that the case manager
of formal and informal resources and contacts to needs to take additional steps on the client’s
provide needed services for their clients. behalf. Simply put, advocacy is speaking out on
behalf of clients. Advocacy can be precipitated
Case finding and pretreatment
by any one of a number of events, such as
Case managers may be especially active in
providing linking and advocacy during the A client being refused resources because of
pretreatment phase of the treatment continuum. discrimination, whether discrimination is
As with each of the case management functions, based on some intrinsic aspect of the client,
the roots of linking begin much earlier, while such as gender or ethnicity, or on the nature
conducting an assessment with the client and in of the client’s problems, such as addiction
creating goals in which the client is vested. The A client being refused services despite
authors of one primer on case management meeting eligibility requirements
identify five tasks related to linking that should A client being discharged from services for
be undertaken with the client before actual reasons outside the rules or guidelines of that
contact with a needed resource even occurs. service
Case managers must (1) enhance the client’s A client being refused services because they
commitment to contacting the resource; (2) plan were previously accessed but not utilized
implementation of the contact; (3) analyze The case manager’s belief that a service can
potential obstacles; (4) model and rehearse be broadened to include a client’s needs
implementation; and (5) summarize the first without compromising the basic nature of
four steps for the client (Ballew and Mink, 1996). the service
27
Chapter 2
programs are reluctant to work, such as clients for certain client populations is essential,
with AIDS/HIV or clients involved in the concern for the client should not override goals
criminal justice system. of public safety. Effective, client-centered
More complicated advocacy involves, for advocacy may put the case manager in a
example, appealing a particular decision by a position of conflict with co-workers, program
service staff member to progressively higher administrators, or even supervisors. Case
levels of authority in an organization. The managers who advocate for an extension of
highest, most involved levels of advocacy benefits for their clients may put themselves and
include organizing a community response to a their supervisors in jeopardy with funding
particular situation or initiating a legal process. sources. A coordinated infrastructure with
Modrcin and colleagues provide an advocacy existing policies and procedures for client
strategy matrix that can help case managers centered collaboration will help.
systematically plan advocacy efforts (Modrcin et
Disengagement
al., 1985). In this view of advocacy, the levels at
Disengagement in the case management setting,
which advocacy can be effected (individual,
as with clinical termination, is not an event but a
administrative, or policy) are weighed against
process. In some ways, the process begins
varying approaches (positive, negative, or
during engagement. For both client and case
neutral). Three guidelines for advocating on
manager, it entails physical as well as emotional
behalf of a client are getting at least three “No’s”
separation, set in motion once the client has
before escalating the advocacy effort,
developed a sense of self-efficacy and is able to
understanding the point of view of the
function independently. To a significant degree,
organization that is withholding service, and
this decision can be based on progress defined
consulting with supervisory personnel regularly
by the service plan. If the plan has truly been
before moving to the next level of advocacy
developed with the client’s active involvement,
(Sullivan, 1991).
there will be a great deal of objective
Client advocacy should always be geared
information that will help both the case manager
toward achieving the goals established in the
and client decide when disengagement is
service plan. Advocacy does not mean that the
appropriate. It is preferable that disengagement
client always gets what she wants. Particularly
be planned and deliberate rather than have the
for clients whose continued drug use or
relationship end in a flurry of missed
cessation of treatment will present considerable
appointments, with no summary of what has
negative consequences such as incarceration or
been learned by the client and professional.
death, advocacy may involve doing whatever it
Formal disengagement gives clients the
takes to keep them in treatment, even if that
opportunity to explore what they learned about
means recommending jail to get them stabilized.
interacting with service providers and about
It is not uncommon, in fact, for clients to state
setting and accomplishing goals. The case
their preference for jail when treatment gets
manager has a chance to hear from clients what
difficult. Even when advocating for clients, the
they considered beneficial—or not beneficial—
case manger must respect system boundaries.
about the relationship. Reviewing and
For example, a case manager might negotiate
summarizing client progress can be an
hard to keep an offender client in community-
important aspect of consolidating clients’ gains
based treatment, but agree to inform the
and encouraging their future ability to access
probation office of positive drug tests or
resources on their own.
suspected criminal behavior. While advocacy
28
3 Case Management in the
Community Context: An
Interagency Perspective
T
he goal of interagency case management
The single agency
is to connect agencies to one another to
The informal partnership
provide additional services to clients.
The formal consortium
All organizations have boundaries; case
managers or “boundary spanners” move across The single agency model is used by such
them to facilitate interactions among agencies traditional community-based organizations as
(Steadman, 1992). While numerous researchers grassroots domestic violence programs and
have investigated the nature of these numerous medically oriented substance abuse
connections (Tausig, 1987; Van de Ven and treatment agencies. In the single agency model,
Ferry, 1980; DiMaggio, 1986), a 1994 network the case manager personally establishes a series
analysis of the “cracks in service delivery of separate relationships on an as-needed basis
system” provides especially useful insights into with professional colleagues or counterparts in
the function and impact of various types of other agencies. The case manager retains full
community linkages (Gillespie and Murty, l994). and autonomous control over the case and is
According to Gillespie and Murty, agencies can accountable only to the parent agency.
be categorized by the connections they maintain In the informal partnership model, staff
with other community-based agencies. Isolates, members from several agencies work
the first category of agencies or programs, collaboratively, but informally, as a temporary
operate self-sufficiently and establish no team constituted to provide multiple services for
connections to other organizations in the needy clients on a case-by-case basis. The
community. Peripherals establish single or partnership can involve case managers from two
limited linkages with other agencies and social programs or agencies who consult with one
providers. A third category of agencies, which another on problematic cases and exchange
the investigators leave unnamed, form effective resource information. The partnership also can
multiple connections with other organizations. consist of case managers and other types of
Applying Gillespie and Murty’s classification providers from two or more agencies who meet
scheme to substance abuse case management on an informal basis to integrate and coordinate
yields three interorganizational models. The services in response to clients’ needs.
three models are Responsibility for a client’s well-being is shared,
29
Chapter 3
although accountability for the actual services from the single agency to the informal
provided remains with the individual agencies. partnership to the formal consortium. Although
The formal consortium model links case each model has advantages and disadvantages,
managers and service providers through a a model’s fit with its clients, the agency, and
formal, written contract. Agencies work environmental conditions determines its
together for multiple clients on an ongoing basis effectiveness for a particular program (Rothman,
and are accountable to the consortium. To 1992). Figure 3-1 summarizes the characteristics,
ensure coordination among consortium advantages, and disadvantages of each
members, a single agency typically takes the organizational model.
lead in coordinating activities and maintains Each model offers distinctive strengths
final control over selected resources and suitable for a particular organizational
interagency processes (Cook, l977). A formal environment. For example, in rural areas that
consortium can enhance the systems of care for depend on “one-stop shopping” social service
substance abuse clients. For example, programs, the relatively low-cost single agency
Providence, Rhode Island’s Project Connect focus, with its capacity to respond quickly and
sponsors a Coordinating Committee that meets authoritatively, may be the optimal choice. On
monthly on behalf of shared clients. Substance the other hand, the informal partnership tends
abuse treatment programs, child welfare staff, to deliver more diverse services, so it is better
managed care providers, health care providers, suited to culturally diverse communities. In
and representatives from the domestic violence communities dominated by managed care, a
community come together to exchange gatekeeper must make referrals for every
information and coordinate services. This service, and a formal consortium may be the
forum offers all participants an opportunity to best choice to supply the necessary
get to know each other, collaborate, and documentation.
advocate on behalf of substance abuse-affected Besides determining resource acquisition,
families. organizational environments impinge on
program decisions in other, less obvious ways.
Characteristics of the In a volatile environment, a single focus agency
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
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
Forging the Linkages also may exchange services, money, clients, and
client service slots. In the area of substance
Interagency case management arrangements are abuse treatment, some case managers and
designed to help providers connect with each addiction specialists may be former users
other to improve client services and enhance the themselves and may have known one another in
efficiency of their respective organizations. In their former lives (Brown, l991). These ties often
addition to trading useful information, agencies strengthen or facilitate interagency exchanges
33
Chapter 3
and relations. Seasoned case managers tend MOUs and formal agreements have special
over time to form personal working appeal when crediting or reporting the outcome
relationships with others in the field and often or delivery of case management services.
trade on prior contact, previous service Among agencies and service providers that are
reciprocities, and favors owed to get services for reimbursed for services on a per capita basis,
clients (Levy et al., l992). Informal “quid pro MOUs can be used to specify which agency or
quo” arrangements are common, as are shared personnel will receive credit. When services are
resources to effect economies of scale. delivered as part of a research project, MOUs
While this system of informal exchange or can specify who has access to data and who may
“social service bartering” is intrinsic to case claim authorship when research results are
management, a more formalized connection published.
among agencies sometimes may be required. Some agencies also use Qualified Service
Examples include memoranda of understanding Organization Agreements (QSOAs) when an
(MOUs) and interagency agreements and agency or official outside the program provides
contracts. Each of these methods for formalizing a service to the program itself. QSOAs might be
expectations can be used in single agency used, for example, when the program uses an
models, informal partnerships, and formal outside entity for laboratory analyses or data
consortia. processing. MOUs cannot be supplanted by
MOUs are a means to structure a relationship QSOAs.
among agencies. When agencies rely heavily on MOUs and QSOAs are not the only type of
each other’s services and function primarily as formalized agreements available to case
brokers for their clients, MOUs are essential. managers. Some programs use cooperative
They specify such crucial information as the service agreements to define what the parties
number of service slots that agencies will make deliver to and receive from each other, and to
available to one another’s clients and the monitor the programs. A legal contract may be
consequences for failure to implement or needed when the lead agency in a formal
comply with specified activities or procedures. consortium subcontracts to other community-
Program managers, rather than case managers, based case management agencies to provide
typically draft MOUs and other formal specific services. Many case management
agreements and contracts with staff input. They agencies also enter into agreements with
are particularly useful for funding sources, including those providing
Federal entitlement benefits. Although some
Ensuring continuity of services during staff
experts question whether case managers should
turnover
function as payees (that is, accept and monitor
Clarifying lines of authority and control over
entitlement payments on their clients’ behalf), a
various aspects of the case management
substantial number of case managers take on
process
that role. Until agencies become familiar with
Recording commitments for providing or
such documents and procedures, obtaining
funding case management resources (e.g.,
counsel prior to signing may be prudent.
staffing, operating funds, client referrals)
Providing a formal record of agencies’
agreements and responsibilities
Holding agencies accountable
34
Interagency Case Management
35
Chapter 3
provide support. Some resulting linkages were Accurate, current information about
found to be “largely useless” because entitlements is essential for sound interagency
case management programs and often can be
Some organizations misrepresent the number
obtained through local governments. New York
or types of services they actually offer or
City, for example, posts menus of entitlements
have available
on electronic kiosks. Many public libraries and
Many services are poorly financed and
local government offices display updated
disappear quickly
entitlement information regularly. Federal
Some organizations are incompetent or too
Regional Offices of agencies such as the
poorly managed or staffed to provide
Administration for Children and Families are
adequate services
another resource for entitlement information.
Some agencies are too far away for clients to
As case managers compile and document
use (Ouellet et al., 1995)
resources, they should also identify gaps in
In addition, Ouellet noted that some services so that they and others understand
organizations, such as hospitals, stigmatized what is available in the community and where
and treated injection drug users so badly that advocacy efforts are needed. It is also important
clients didn’t want the services at all. Also, to publicize case management programs
many providers genuinely interested in service throughout the community. Brochures, fliers,
collaboration underestimated the number of and simple one-page fact sheets can be used to
people seeking help and the breadth of advertise or explain a program.
expressed needs, and thus were unable to Announcements on the Internet, in community
handle the deluge of service requests. Other newspapers, on bulletin boards, and in local
organizations had the capability to work with civic and professional club newsletters are
these clients but were unwilling to do so. inexpensive methods for promoting new
To counter such limitations, case services. Apprising local police of a new
management programs often conduct “snowball program’s existence and the availability of
surveys” in their communities, using one services may be particularly important as their
interagency contact to lead to another. This support can prove quite helpful with clients
technique can yield insider information about involved in criminal justice matters.
other programs and agencies, their capabilities,
and experiences in service use. Identifying and The Agency Environment
documenting resources and entitlements may be
best undertaken during the early phases of Exploring the environment in which an agency
program startup, when caseloads are low. operates is essential in determining the
Experienced case management personnel feasibility of mounting an interagency case
also recommend visiting the programs to which management effort. Several factors influence
clients will most likely be referred. Onsite visits the provider’s ability to conduct case
impart a wealth of information that may confirm management within the community, including
or refute the impression conveyed in written Social service agencies’ number, type,
materials. They also provide an opportunity to historic responsiveness to clients with
establish valuable contacts with agency substance abuse problems, openness to case
personnel who can facilitate client services once management, and relationships with each
the case management collaboration is under other. Communities with abundant social
way. service resources that address a wide range
36
Interagency Case Management
of human necessities typically are better able powerful force in gaining agency leadership
to meet the diverse needs of substance- cooperation, although this outcome may take
abusing clients than less endowed time.
communities. Similarly, social service Geographic considerations (distance,
infrastructures in which providers are terrain, isolation of the target population
willing to accept substance abusers as clients from mainstream services). Availability of
and to accommodate innovative approaches case management services makes little
to addressing their problems are more likely difference when clients cannot access
to welcome an agency’s case management services because of transportation and other
initiatives than more restrictive barriers. In fact, accessibility may determine
organizational structures. the specific agencies with which programs
Community leaders’ support for or neglect are able to connect on behalf of clients.
of substance abuse treatment and their Legal and ethical issues affecting
response to case management concepts. implementation. Some communities have
Advocacy may be necessary because support zoning laws and other legal restrictions
or pressure from community and political specifying which, if any, social service
leaders can facilitate a substance abuse programs can be established within their
agency’s efforts to institute case perimeters or near schools and other public
management. Conversely, implementation facilities. These statutes need to be clarified
can be stalled for months and sometimes before investing in program startup. In
stopped entirely in communities when addition, clients’ possible involvement in the
leadership is opposed to substance abuse criminal justice system can raise issues of
treatment or case management services for confidentiality and other legal concerns
substance abuse clients. Identifying when creating cooperative arrangements
proponents and adversaries is essential in with other agencies. Special care needs to be
planning strategies that capitalize on support taken when an agency works with clients
or overcome/sidestep resistance to a case who are involved with the criminal justice
management program. To form a strong system or who are in any way being coerced
supportive voice within a community, or pressured into treatment. Issues that can
provider consortiums are often formed. affect the transfer of confidential or sensitive
The economic situation in the community. information need to be carefully worked out
The more economically stable a community, before clients are actually admitted for
the more resources members of the civic, service. Policies and procedures should be
governmental, and corporate power regularly reviewed in the face of experience
structure have to bring to the table in and adjusted accordingly.
negotiations with other power brokers on Funding for program startup and program
behalf of a case management program or continuation. Amount and type of available
agency. funding (e.g., multiyear grant, limited
Social climate. Community acceptance of foundation support for project startup, and
substance abuse treatment and clients can matching or challenge grants) directly bear
influence some agencies, particularly those on the nature and organizational complexity
with a grassroots orientation, to accept and of an agency’s case management program.
cooperate with a case management program. Multiyear funding permits substantial
Bottom-up community acceptance can exert a advance planning prior to program
37
Chapter 3
implementation. It also enables agencies to the plan. This comes from the explicit
bring current and projected resources into endorsement of an agency’s top level
negotiations with other community administration.
organizations. Continuing funds also allow An honest appraisal of the community
interagency linkages to develop and improve environment equips an agency or program to
over time. In contrast, restricted, one-year make key decisions about interagency case
funding may argue for front-loading management. Some potential cooperating
resources and selecting a case management agencies cannot interact effectively with the
model that can be implemented quickly and larger community or can only provide on-site
with immediate short-term payoff. services. Other agencies may be willing to
Incentives for entering into an interagency cooperate, but their organizational missions
agreement. Stakeholders who recognize the differ so radically from the case management
benefits to their agencies will help facilitate program’s that collaboration is impossible
case management. Also, cooperative (Ridgely and Willenbring, l992). Part of the
relations tend to be more stable when environmental assessment involves identifying
participating agencies have much to gain by such providers to avoid creating linkages that
working together. will ultimately prove unworkable.
Volatility of the political, economic, or Analysis of the community environment is
social environment, such as the recent one in a series of ongoing assessments aimed at
introduction of Medicaid managed care. understanding the changes that occur among
Support for new initiatives can be difficult to clients, within the program, and in the
obtain in a climate in which reimbursement community. As is true of other agency activities,
criteria are being altered, State and Federal case management takes place within a dynamic
funding is being redirected, or political social service environment in which agencies are
leadership is changing and the new players in constant flux (Rothman, l992). Programs
are unknown. In an uncertain environment, considering interagency efforts must devise
it is critical to justify the cost of a new service coping strategies to respond to change while
with compelling evidence. When chaotic providing necessary continuity for the client. In
conditions prevail, introducing a case addition, interagency networks are fragile and
management program gradually protects frequently develop through personal trust
valuable resources while testing feasibility established between case managers. Staff
before full implementation. turnover disrupts such relationships and
threatens the case management system unless
Agency administrators, whether they are
guidelines or procedures exist to facilitate a
chief executive officers, executive directors, or
smooth transition (Levy et al., l995).
program directors, must develop working
Because social environments for delivering
relationships with the other social and human
services do change over time, flexibility and
services agencies with which the case managers
individuation are hallmarks of effective case
will be interacting. To be effective, case
management. When programs become rigid in
management requires that connections be made
their conceptualization, case management
at the administrative/director levels of agencies.
services suffer. Regular reevaluation of
Because case managers may be expected to
community resources helps ensure continued
coordinate and implement a complex service
relevance.
plan in an interagency environment, the case
manager needs sufficient power to implement
38
Interagency Case Management
39
4 Evaluation and Quality
Assurance of Case Management
Services
S
ubstance abuse treatment programs, and other evaluative efforts that consider
including those that receive public multiple stakeholders and focus on myriad
assistance, are increasingly operating in a outcomes and data sources.
managed care environment. Policymaking and
clinical decisionmaking in a managed care A Brief Overview of the
environment depend on outcome data that have
traditionally described the impact of case
Research Literature
management and substance abuse treatment Researchers only recently have begun to assess
interventions in terms of services used and the effectiveness of case management. Studies
money spent. (See Chapter 6 for more on conducted thus far have suffered from
implementing case management in a managed significant methodological problems that
care setting.) An additional demand for data include small sample sizes, poorly defined or
comes from public and private payers who want implemented case management interventions,
services linked to specific outcomes. problems in evaluation design and
In the past, public sector substance abuse measurement, lack of distinction between case
programs were not paid to collect such data and management and comparison interventions,
were discouraged from using funds designated poor timing, and unaccounted-for contextual
for service delivery to conduct evaluations. factors in communities where case management
Consequently, evaluation services often were was studied (Orwin et al., 1994). Problems in
available only through demonstration grants or research design are more than an academic
through the efforts of university-based concern⎯they render results that may be
evaluators. Today, however, many providers misleading, difficult to interpret, and unreliable
plan, fund, and perform their own evaluations. for use in developing case management
This reflects both the mandates of funding programs or policy.
organizations and agencies’ desire to refine or Although problems in research design affect
improve their services. To prepare treatment other kinds of addiction treatment research, case
programs to get involved in these efforts, this management is especially difficult to evaluate
chapter first presents findings from previous because contextual factors play a critical role in
evaluation efforts and then proposes a program operations. Case management
framework for facilitating quality improvement programs do not function in isolation. A key
41
Chapter 4
42
Evaluation and Quality Assurance
adjunct to substance abuse treatment. First, measurement of system and individual client
treatment may be more likely to succeed when outcomes. It concludes by identifying the data
“drug use is treated as a complex of symptom needs of various stakeholders. Whether an
patterns involving various dimensions of the evaluation is conducted internally by agency
individual’s life” (Inciardi et al., 1994, p. 146). personnel, or by experts hired from outside,
Case management focuses on the whole front-line case managers are the key source of
individual and stresses comprehensive information.
assessment, service planning, and service In documenting a case management effort, it
coordination to address multiple aspects of a is important to start with benchmarks⎯
client’s life. Second, retention in treatment is expectations that are made concrete as
associated with better outcomes, and a principal measurable statements (e.g., “case managers
goal of case management is to keep clients spend 60 percent of their time in face-to-face
engaged in treatment and moving toward contact with their clients”). Some of the sources
recovery and independence (Institute of that programs can use to establish benchmarks
Medicine, 1990). Studies looking at treatment include
retention and case management posit a positive
Policy and procedure manuals
relationship between the two (Siegal, 1997; Rapp
Federal, State, and local case management
et al., in press).
standards
Case management’s ambitious scope is one
Agency case management program
of the reasons its effectiveness is difficult to
descriptions and mission statements
measure. Ashery and others have
Literature on program models (if the
recommended that practitioners in the field
program under evaluation is a replication)
maintain reasonable expectations for case
Consultants
management, pay attention to the
implementation of programs, and understand If no written manuals or protocols are
the enhancing or limiting factors of the available, or if it is clear that the program has
particular service context in which the case drifted from its original design, the program
management programs are implemented managers and staff may use a consensus-
(Ashery, 1994). The field should consider not development process to arrive at benchmarks.
only how to best research case management but
Measuring Practice
what to expect from it.
Once the process benchmarks are defined in
43
Chapter 4
been widely adapted and used in the mental management activities. The survey is a fixed
health field. They usually record the client’s series of questions about the functioning of both
name, location of the contact, duration of the the case management program and the system
contact, activity, and whether other individuals of care and is administered to a variety of
participated (e.g., staff of other agencies or stakeholders in the community. Different
family members). The brevity and frequency of stakeholders are identified by each agency,
case managers’ contacts with clients makes this depending on its particular case management
measure extremely burdensome, and as a result model and the system of care within which it
many programs use time-limited or sampling works. Appropriate stakeholders may include,
measures (for example, over a two-week period) but are certainly not limited to
to get a “snapshot” of activities.
Agency staff
If time and resources permit, it may be
Staff from other substance abuse and human
valuable to use several methods of
service agencies, homeless shelters, and
documentation to compare their usefulness and
hospital emergency rooms
sensitivity. Other methods and purposes
Clients and their family members
include
Criminal justice and law enforcement
Reviews of case manager client records (to personnel
evaluate how service planning and referrals
Survey participants might be asked about
adhere to protocols and procedural
their awareness of case management services,
expectations)
their use of these services, types of ongoing
Interviews or surveys of case managers or
contact with the case management program, and
clients and their family members (to collect
their perception of the impact of these services
information on activities in which case
on the community. To ensure a cross section of
managers engage, to gauge how clients’ and
informed opinion at various points in time, all
case managers’ views of those activities
stakeholders are asked the same questions, and
differ)
the survey is repeated at several intervals. Such
Analysis of data from the agency’s
surveys have been used to evaluate systems
management information system (to examine
change in the mental health field (Morrisey et
patterns on type, number, and duration of
al., 1994) and could be adapted for use in case
case manager contacts with different target
management programs.
populations)
Client satisfaction
In addition to using multiple methods of
Knowing how clients perceive the services they
documentation, it is important to review case
receive is essential to evaluative activities. One
manager activities over time because programs
can argue that satisfaction with service is related
may drift from innovative to familiar patterns of
to treatment retention. It is also important to
service delivery. In addition, the timing of data
know whether the service provider—in this
collection is crucial. New programs need time
instance the case manager—and client share a
to stabilize, and new staff members need a
common view of the services being offered and
period of orientation before a true picture of
their benefits. For example, did the client feel
program activities can be established.
that the case management services actually led
The key informant survey to needed resources? Other questions might
Evaluators can use a key informant survey to focus on client perceptions about those
examine the operations of a program’s case providing the service: Did the case manager
44
Evaluation and Quality Assurance
understand their needs and have the skills and pregnant women). In this instance, it would be
experience necessary to help them accomplish useful to compare the number of admissions in
their goals? the target population to all admissions during a
Such process data have direct utility for specified time period.
program management and development. They In order to measure most system outcomes, it
may help programs with defining staff training is necessary to track clients within a
needs and assuring that the needs of the comprehensive service agency and, if a
population they are working with are being program’s mandate includes managing care
addressed. Such data are also quite useful for across a network of agencies, to gather data on
those who have the responsibility for funding encounters and costs and analyze them. Access
programs. to a computerized management information
system (MIS) is essential for complete analyses.
Measuring System Outcomes Although these systems vary widely in their
Many programs in the managed care level of sophistication, for this purpose, one
environment control access to services through must be able to document more than units of
what is called “case management,” in which service information and should be able to link
gatekeeping procedures are used to limit clients’ encounter, claims, and cost data and produce
use of expensive services such as hospitalization information quickly and easily. Over a period of
and residential treatment. These programs may time, a comprehensive MIS tracks changes in
be particularly interested in measuring system- patterns of service utilization and changes in
level outcomes to see whether case management costs, which gives the agency information
has a systemic effect on the delivery of crucial to management and planning. For
substance abuse and allied services (e.g., change example, an MIS that combines utilization and
in patterns of service utilization or costs). Thus, cost data could help identify high utilizers for a
a net reduction in the number of inpatient program that focuses on clients who use
admissions for substance abuse treatment numerous or expensive services. A later section
would, by itself, be defined as a positive in this chapter describes how a program can
outcome. This, of course, may not reflect the evaluate and enhance its MIS system.
needs of all clients.
If the goal is preventing clients from “falling Measuring Client Outcomes
through the cracks” between discharge from While most would agree that “evaluation” is
detoxification and entry into outpatient generally worthwhile, there is considerably less
substance abuse treatment, a system-level agreement about the measurement and
outcome might be measured by continuity of documentation of specific outcomes for
care. Greater continuity could be defined as individual clients. When trying to evaluate case
fewer clients with no outpatient treatment management in an ongoing service agency
episode after a detoxification discharge, patterns setting, additional challenges—conceptual,
showing shorter periods of time between methodological, and ethical—are posed. The
detoxification discharge and outpatient field has seen a long-standing and often strident
treatment admission, and fewer people with debate about what kinds of outcomes should be
“revolving door” detoxification admissions. measured. Some claim a single measure such as
Another case management program may aim for sobriety or complete abstinence from any drug
increased access to care for certain target use is the only meaningful measure of treatment
populations (for example, cocaine-abusing success. Others assert that treatment success is
45
Chapter 4
46
Evaluation and Quality Assurance
47
Chapter 4
Key data elements that State directors often Use of free self-help or volunteer
want to see in evaluation efforts include organization services
Urinalysis results, use of other drugs, and
Patterns of service utilization and costs,
scores on standardized outcome indicators
including the use of public hospital and
Discharge determinations
residential treatment centers
Numbers of clients working and
Data needs of clients and family
withdrawing from welfare and Medicaid
members
Numbers of clients avoiding prison, reducing
Clients and family members may serve on
child welfare cases and costs, and reducing
advisory or governing boards of local programs
food stamp usage
or may be involved in family or peer support
Numbers of appeals and grievances by
groups within the community. They may use
clients
outcome data, especially results of client
Number and characteristics of substance
satisfaction surveys, to change programs and
abuse patients accessing other publicly
policies or to choose services and providers.
funded social services
They may be less interested in patterns of
Increasingly, State directors of substance service utilization or standardized scores on
abuse agencies are becoming less isolated and outcome evaluations than in how the system
are beginning to look for opportunities to functions from the user’s perspective. In fact,
exchange data among previously independent clients might consider a program successful if it
departments (e.g., mental health departments, is supportive, reliable, and easily accessible, as
Medicaid offices, and criminal justice offices). opposed to “efficient.”
Some State agencies share access to statewide Data elements important to clients and
data sets. In addition, the movement toward family members include
managed behavioral health care has prompted
The availability and accessibility of services
more integration of data between State Medicaid
The freedom of choice (of services and
offices and State substance abuse and mental
providers) that the system allows
health authorities.
The use and effectiveness of the appeals and
Data needs of third party payers grievance process
Third party payers such as insurance companies The influence of input from consumers and
need data that justify case management as a cost family members
above and beyond the direct costs of treatment Effectiveness of treatment
services (see Chapter 6). In addition, when case Acceptability of treatment among the
management is used to coordinate care, third targeted populations
party payers want to know whether clients are
Specifically, clients seek answers to the
receiving the right services, at the right level of
questions
care, and in the right sequence, and to ensure
that clients who are no longer in need are no Am I getting the right services, in the right
longer receiving services. To that end, setting?
important data elements include Are there systems I can access myself?
How appropriate is my care?
The severity of the client’s illness
Assignment to levels of care
Patterns of service utilization
48
Evaluation and Quality Assurance
Cost shifting among health, behavioral Creative ways to use secondary data sets
health, criminal justice, and other systems (such as Medicaid and Medicare) to
that can be accessed by the target population 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 for the professional delivering case management
intervention for substance abusers services to “special needs clients.” The case
because they generally have trouble manager serving special needs clients should
with other aspects of their lives. This is
Make every effort to be competent in
especially true for those clients whose problems
addressing the special circumstances that
or issues can be overwhelming even for non-
affect clients typically referred to a particular
addicted people. Among these special treatment
substance abuse treatment program
needs are HIV infection or AIDS, mental illness,
Understand the range of clients’ reactions to
chronic and acute health problems, poverty,
the challenges associated with particular
homelessness, responsibility for parenting
special circumstances
young children, social and developmental
Remain aware of the limits of one’s own
problems associated with adolescence and
knowledge and expertise
advanced age, involvement with illegal
Evaluate personal beliefs and biases about
activities, physical disabilities, and sexual
clients who have special problems
orientation.
Maintain an open attitude toward seeking
In an ideal world, case managers would be
and accepting assistance on behalf of a client
knowledgeable about all those problems and
Know where additional information on
needs. However, understanding the
special problems can be accessed
ramifications of even one can be a staggering
task. For example, a case manager dealing with While it is impossible to discuss all the
a client who has AIDS would need to be special needs that case managers confront,
conversant in epidemiology, transmission several occur repeatedly. This information is
routes, the disease’s clinical progression, not intended to be a comprehensive treatment of
advances in treatment regimens, financial and any of these areas, but rather an introduction to
legal ramifications, available social services, as the issues that most directly relate to the
well as psychotherapeutic approaches to AIDS implementation of case management.
patients’ grief and fear. Given the many other
special needs the case manager confronts, it is Minority Clients
apparent that no one individual can be an expert
Demographic realities in the United States
in every area. In the absence of such
dictate that case managers will be called on to
comprehensive knowledge, several general
work with individuals of different gender, color,
attitudes and skills provide a basic foundation
51
Chapter 5
ethnicity, and sexual orientation. Some will be elders, or members of their own social support
persons of color; some will be poor, not networks. Others may prefer to be treated in a
conversant in English, disadvantaged, and over program that uses principles and treatment
represented in many areas of the social services approaches specific to their own cultures. Case
system. Case managers must “respond managers must advocate for culturally
proactively and reactively to racism, appropriate services for their clients.
ethnocentrism, anti-Semitism, classism, and
sexism . . . ageism and ‘ableism’” (Rogers, Clients With HIV
1995, p. 61).
There are five elements are associated with
Infection and AIDS
becoming culturally competent: (1) valuing The usual functions and activities associated
diversity, (2) making a cultural self-assessment, with case management in substance abuse
(3) understanding the dynamics when cultures treatment—engagement, helping orient the
interact, (4) incorporating cultural knowledge, client to treatment, goal planning, and especially
and (5) adapting practices to the address of resource acquisition—are made more difficult in
diversity (Cross et al., 1989). According to dealing with clients who have HIV or AIDS by
Rogers, culturally competent case managers
Providers’ and other clients’ fear of
have the
contracting HIV
Ability to be self-aware The dual stigma of being a person with both
Ability to identify differences as an issue a drug abuse problem and HIV
Ability to accept others The progressive and debilitating nature of
Ability to see clients as individuals and not the disease
just as members of a group The complex array of medical, especially
Willingness to advocate pharmacological, interventions used to treat
Ability to understand culturally specific HIV
responses to problems (Rogers, 1995) The onerous financial consequences of the
disease and of treatment
Case managers should either speak any
The hopelessness—and lack of motivation for
foreign languages common in their locale or
treatment—among the terminally ill
refer non-English speakers to someone who
does. It is also crucial for the case manager to be Case managers who provide services to this
aware of what may inhibit minorities’ population must be prepared to work with “a
participation in the substance abuse treatment base of diverse resources, enhancement or
continuum. For example, while “accepting adaptation of the capabilities of existing
one’s powerlessness” is a central tenet of 12-Step resources, or the development of new service
self-help programs, members of oppressed programs specifically designed to address [the
groups may not accept it, given their own HIV-infected individual’s] needs” (Sonsel et al.,
societal powerlessness. The case manager must 1988, p. 390). The Linkage Program in
always be sensitive to such cultural differences Worcester, Massachusetts, is typical of this
and identify recovery resources that are relevant arrangement. It engaged 19 diverse agencies—
to the individual’s values. Some minority group including drug treatment programs, area
members may be inclined to seek help for a churches, AIDS advocacy and support agencies,
substance abuse problem from sources outside the city’s department of public health and a
the treatment continuum, such as clergy, group regional medical center—in a consortium of care
52
Clients With Special Needs
for substance abusers who also had HIV the prevalence of coexisting disorders is
infection (McCarthy et al., 1992). The Worcester significantly higher in treatment populations
consortium and other linkage programs than in the general population, approaching 80
demonstrated a positive relationship between percent in some studies of substance abuse
the amount of case management services patients (Khantzian and Treece, 1985; Ross et al.,
provided and the receipt of drug abuse, health 1988; Kosten and Kleber, 1988). Given those
care, and other services (Schlenger et al., 1992). high comorbidity rates, substance abuse
While one person should assume primary treatment staff must be prepared to address the
case management responsibility for clients with problems of dual-diagnosis clients.
HIV or AIDS, a team approach is particularly Treatment services for clients with a dual
useful in combating the feelings of frustration, diagnosis are organized in sequential, parallel,
abandonment, grief, over-identification with the or integrated models (CSAT, 1994b). In the
client, and anger that frequently confront integrated model, both disorders are dealt with
professionals in this setting (Shernoff and at the same time and in the same program. Case
Springer, 1992). To avoid staff burnout, management’s primary role includes facilitating
providers should avoid designating the same clients’ transition from residential programs to
individual as case manager for all clients with the community, helping them identify and
AIDS and HIV infection. access needed resources, and providing long
The overwhelming nature of life for a person term support for their functioning in the
with two life-threatening conditions—AIDS and community.
addiction—cannot be overstated. The In the case of sequential treatment, the case
magnitude of even daily tasks holds significant manager helps the client move from either
stress for both the client and the case manager. substance abuse to mental health treatment or
Addicted people with AIDS or HIV need help from mental health to substance abuse
with physical functioning, interpersonal treatment. In parallel treatment, the case
relationships, adjustment to the treatment manager must facilitate communication and
program, housing, and practical and service coordination between two agencies
psychological adjustment to the two conditions. whose treatment approaches may be based on
Part of the case manager’s linking function in different assumptions. Examples of the possible
working with an HIV-positive client is to issues the case manager may have to address on
educate the network of service providers, behalf of a client in mental health treatment
including substance abuse treatment staff, to programs include the following:
recognize the competing demands of staying
Bias against substance abusers affects the
sober and dealing with the social and physical
provision of mental health services
sequelae of HIV disease.
Many inpatient facilities establish an
arbitrary minimum number of days of
Clients With Mental sobriety for their clients
Illness Some service providers will not accept clients
who are on medication, including methadone
Almost 40 percent of people with an alcohol
disorder meet criteria for a psychiatric disorder, Conversely, issues in substance abuse
and more than half of those with other drug treatment programs that might be
disorders report symptoms of a psychiatric counterproductive to mental health treatment
disorder (Regier et al., 1990). Not unexpectedly, include
53
Chapter 5
Treatment approaches may rely on insight programs such as Double Jeopardy, Double
and introspection that some mental health Trouble, and Dual Recovery Anonymous
clients are intrinsically incapable of achieving designed specifically for people with mental
The approach used in substance abuse health and substance abuse problems can be
treatment may be too confrontational valuable sources of support.
The treatment program and other clients may While case managers may not be experts in
reject clients taking psychotropic medication the treatment of any one of these disorders, it is
vital that they know enough to work with the
Many of the special case management issues
client in identifying her needs and be able to
for clients with mental illness center on the
translate and coordinate those needs with the
client’s use of prescription drugs to stabilize
two types of treatment.
mood and reduce the negative effects of the
mental disorder. Some substance abuse
treatment providers oppose the use of any Homeless Clients
psychotropic drugs, fearing that they will Alcoholism rates among the nation’s homeless
interfere with the recovery process and become are estimated to be as much as two to four times
a new source of chemical dependency or that the the levels for individuals of the same gender in
prescribing physician is not adequately aware of the general population. Besides alcohol, the
the client’s problems with addiction. Some substances most frequently used by homeless
treatment programs unwittingly precipitate a people are marijuana, cocaine, and crack cocaine
client’s relapse by requiring the client to stop (National Institute on Alcohol Abuse and
taking all medications as a condition of Alcoholism, 1989). Crack use in particular has
acceptance to a treatment program. Participants increased in the last 10 years, primarily among
in 12-Step meetings may pressure clients to be younger homeless people (Crystal, 1982).
free of the “crutch” of prescription drug use. Numerous efforts at engaging homeless
As substance abuse treatment providers individuals in substance abuse treatment have
become familiar with prescribed neuroleptic been undertaken, many involving case
drugs, they are more likely to accept the medical management as a central component (Braucht et
management of the client’s illness and al., 1995; Conrad et al., 1993; Sosin et al., 1995;
communicate more with the professionals Stahler et al., 1995).
providing the client’s medical care. To manage The need for case management with this
client symptoms and behaviors, anticipate population is obvious. Clients need suitable
problems, and reinforce the medical short- and long-term housing; many have
management of the client, all staff who work mental disorders. Homeless individuals
with dual-diagnosis clients need some frequently suffer from significant health
knowledge of the benefits of commonly problems secondary to their lifestyle, including
prescribed drugs, their potential side effects, tuberculosis, HIV, and AIDS. Unemployment is
actual abuse potential, and their interactions high. This constellation of tangible needs can
with other drugs. best be addressed by one individual at the
Aftercare tends to be long-term for clients interface between the streets and social service
with mental illness because of the continuing agencies.
possibility that the client will stop taking A case manager always begins by working
medications when he begins to feel more stable on issues the client feels are most pressing, and
and then take illicit drugs to cope with the re- the need for stable shelter may not be at the top
emergent symptoms of mental illness. 12-Step
54
Clients With Special Needs
of the client’s list. Many homeless people feel substance abusers are not available to homeless
safer and more comfortable on the streets than people and that new services may need to be
in a shelter because the streets are familiar to created to fill those gaps. For example,
them and because they have established Louisville’s Project Connect used case
routines and a network of people to watch out management to help homeless alcoholic and
for them. While this setting is hardly ideal, it drug abusing men move from a sobering-up
may be one in which the client can function well shelter (the pretreatment phase of the treatment
enough to benefit from treatment. However, continuum) through a vocational program at the
some programs may claim they cannot help exit point of treatment (Bonham et al., 1990).
homeless individuals until their other life Another substance abuse program at the
problems are solved, requiring the case manager Coatesville Veterans’ Affairs (VA) Medical
to advocate on the client’s behalf (Sosin et al., Center picks up homeless veterans at local
1994). shelters, takes them in vans to the VA for day
The case manager’s rapport-building skills treatment, feeds them, and takes them back to
are critical to break through the many defensive the shelter. This has helped to keep veterans
behaviors and protective attitudes that clients engaged in treatment as they await placement in
develop to survive in shelters and on the streets. a VA domicile or other housing arrangement.
These behaviors⎯looking tough, acting with The Department of Veterans' Affairs conducts
bravado, wariness of social services, stand-downs in its homeless program, during
maintaining a hard exterior, and letting go of which veterans temporarily housed in tents
social graces⎯make homeless clients difficult to receive medical services and are assessed for
engage and interfere with their ability to treatment needs. They are brought into
succeed in treatment or maintain stable housing. residential care for treatment as needed.
One solution to this difficulty in engaging The delivery of social services is complicated
homeless clients is through the use of peer case by the fact that homeless clients usually are
managers: homeless individuals who are in turned out of shelters from 9:00 a.m. until 4:00
recovery themselves and are based in shelter p.m. The client’s social network during these
care facilities. In one such setting, peer case hours consists of other people, often not sober,
managers proved to be as successful as degreed who are also out of the shelter. Providers may
professionals or an intensive residential find it useful to provide a day room with snacks
treatment program in assisting homeless and a television where clients can stay during
individuals in the areas of substance use, the day or some sort of day work where clients
housing stability, employment, and can earn a few dollars. Case finding can be
psychological functioning (Stahler et al., 1995). accomplished by mobile case management
In addition, clients were more satisfied with the teams who seek out homeless substance abusers
services provided by the peer case managers in shelters and other areas where they sleep and
than by the degreed professional case managers. congregate (Rife et al., 1991).
This finding may be explained by clients’ beliefs
that case managers who have experienced Women With Substance
homelessness first-hand are more likely to
provide needed services.
Abuse Problems
To meet their linking and advocacy Case-finding is an especially important case
responsibilities, case managers must recognize management activity with female substance
that some services generally available to abusers, who seem to follow a different path to
55
Chapter 5
treatment than males. Because women are often children. Compounding a mother’s shame is the
referred by other service providers (Beckman fear that authorities will take her children away
and Amaro, 1986), case managers affiliated with from her. As a result, an assessment of such a
substance abuse treatment programs must help mother’s needs is complicated by the fact that
their counterparts in other social service she is likely to lie to the case manager about her
agencies identify women in need of treatment. addiction and the way her family lives.
Women with children are likely to be involved The basic functions and tenets of case
in numerous child-related services; women who management are well suited to improving
have been victims of domestic violence present retention and outcomes for women in treatment.
for services at battered women shelters; other There is evidence that women in particular do
women may appear at mental health centers and not adequately focus on their substance use and
women’s health centers. A significant number recovery until their needs for such resources as
of women clients have suffered physical, verbal, housing, food, medical care, and personal safety
psychological, or sexual mistreatment (Miller are adequately addressed (Hepburn, 1990).
and Rollnick, 1991; Mondanaro et al., 1982), and Case managers should assist female clients in
many who present for treatment live in an developing a safety plan setting out well-
unsafe environment. defined steps to take should she fear, or be
Once identified, women with substance subjected to, violence. It is imperative to
abuse problems may be difficult to engage in determine if women are living in a safe
treatment. Society judges substance-abusing environment. Women who have children are
women more harshly than male substance even more extensively involved, or need to be,
abusers. A woman’s substance abuse problem is with community resources, including the school
likely to have progressed significantly before system, pediatric physicians, and children’s
being identified, and treatment may be protective services if their substance use has
complicated by factors like psychological resulted in neglect or abuse. Case managers are
functioning, situational realities, and systemic responsible for facilitating the acquisition of
barriers (Wildwind, 1984). Other issues such as these resources as their clients more through the
sexual abuse, victimization, and emotional treatment continuum.
dependency are frequently associated with A woman’s involvement with community
women who have substance abuse problems resources frequently places the case manager in
(Markoff and Cawley, 1996). Transportation is a a position to advocate for her needs. Advocacy
common barrier, especially in primary means securing resources not only outside the
outpatient and aftercare treatment. treatment program, but also within the program,
Women substance abusers who have especially if the program primarily treats male
children confront these problems and more clients (Brindis and Theidon, 1997). Advocacy
when considering treatment. A mother’s not only improves the woman’s acquisition of
decision to enter treatment means the case needed resources, but also empowers her to
manager must either identify a program that become more assertive on her own behalf and
will take both the woman and her children or builds a closer relationship with the case
assist the woman in finding appropriate child manager. Advocacy cannot, however, stop the
care. These mothers may avoid treatment out of case manager from fulfilling her legal obligation
guilt and shame for the activities in which they to report child abuse or neglect.
have engaged to acquire drugs and the Two excellent sources of information on the
situations in which they have placed their role that case management plays in the
56
Clients With Special Needs
treatment of women substance abusers are consider who is actually the client and what are
Pregnant, Substance-Using Women (CSAT, 1993) the best interests of the adolescent.
and Case Management in Substance Abuse One case management model describes a
Treatment: Improving Client Outcomes (Sullivan et three-phase approach, providing services during
al., 1992). pre-treatment/screening, residential treatment,
and continuing care (Godley et al., 1994). The
Adolescent Substance goal of case management services during pre
57
Chapter 5
Case management for substance abuse parole or some other sort of post-incarceration
clients in the criminal justice system evolved in a supervision; in some jurisdictions probation
unique fashion, bringing together two complex sentences may follow sentences of incarceration.
systems with different goals and philosophies. Linkages between prison and probation, or
While the criminal justice system is interested in between county jails and community-based
the rehabilitation of offenders, its main focus is supervision, may be weak; databases are often
on public safety, which is maintained with not connected; and entities often report to
punishment and legal sanctions. Likewise, different management structures. For example,
while the substance abuse treatment system probation offices are part of the court system in
supports public safety goals, its primary mission some jurisdictions, the corrections department
is to change individual behaviors. These goals in others. Case management efforts are critical
are not mutually exclusive; in fact, experience to ensuring continuity when offenders move
has demonstrated that integrating the from one supervision level to the next, or
techniques of these two systems can have a between one status or location and another.
powerful effect on reducing the drug use and Managing offenders who are changing status
criminal activity of drug-involved offenders. within this system while they are participating
Because participation in substance abuse in substance abuse treatment services (both
treatment and other social services is often inside institutions and in the community) is
mandated, case managers have the opportunity exponentially more complicated.
to engage clients over a longer period of time Case management with offender populations
and may be more likely to effect successful may be implemented at any point in the
change. criminal justice continuum. Case management
Integrating the two systems requires some can assist offenders in securing resources that
effort, however. The need to establish and are not only vital to their recovery and overall
maintain a therapeutic relationship with clients well-being, but also required by their deferred
while integrating the sanction and control sentencing or probation. Establishing
obligations of the criminal justice system poses appropriate housing that will facilitate sobriety
particular challenges. Ambiguities about the and helping the offender develop job-seeking
case manager’s role in client supervision and skills are but two of the specific activities that
confidentiality considerations surface may form the basis of the case management
frequently. relationship. Offenders incarcerated in State
The criminal justice system is fragmented and local correctional facilities frequently need
into numerous components through which assistance in managing their lives as they reenter
offenders may be assigned. In most the larger community. Institutional life is highly
jurisdictions, supervision can be provided for regimented, presenting special problems when
certain pretrial offenders who have not yet gone offenders are released. In working with paroled
to trial. In other jurisdictions, such offenders individuals, the case manager must recognize
may be given the option of diversion, in which that prison life encourages behaviors that are
successful completion of certain activities will not appropriate on the outside. Parolees who
avoid a conviction. Convicted offenders may be have been imprisoned longer than a year may
sentenced to county jails, state prisons, or require more time in a semi-structured setting
probation; probation can include halfway house (for example, a halfway house) in order to make
supervision, intensive probation, or electronic the transition from institution to community.
monitoring. Released offenders may be on
58
Clients With Special Needs
The case manager should address the needs substance abuse treatment approaches and
of clients released from institutions in order of community referral techniques, as opposed to
importance. The first priority is immediate primarily correctional interventions.
stability, which can be facilitated by safe Case management provided by a treatment
housing, access to either primary substance agency. The advantage of a community-based
abuse treatment or aftercare, and social treatment model is that the case manager has a
networks that facilitate positive behavior. thorough understanding of the substance abuse
Second, the case manager should either provide treatment process. The disadvantages include,
or make referral to sources of skills training, again, the expense and the possibilities that the
since individuals who have served lengthy case manager may not be familiar with the
sentences will likely need either habilitation or criminal justice system or that the treatment
rehabilitation training in the areas of job agencies may not have the resources for
searches, interactions with non-offender social effective case management.
groups, and problem-solving strategies. Third, Case management provided by an agency
the case manager should train or find training in separate from the treatment and justice
setting and accomplishing short- and long-term systems. To reduce costs, a case management
goals. Incarceration often leads offenders to coordinator may be employed, with or without a
believe that the locus for control of their lives caseload, to conduct intake interviews and
lies totally with other persons or institutions. supervise paraprofessional staff. The
While goal-setting is important to any client disadvantages of this approach include the
group, it is particularly important to clients who addition of another agency to the collaboration.
have had most basic needs provided for them. Case management provided by a
Ideally, the case manager will begin providing coordinator from the justice system who
these services several weeks or months before a provides consulting services and technical
scheduled release, then follow the offender into assistance to support existing criminal justice
the community. Lastly, the case manager can case management. One advantage of this model
advocate for the offender both in the treatment is system ownership. A coordinator, with or
environment and the criminal justice system. without a caseload, oversees the work of a
In order to maximize effectiveness, several paraprofessional staff. The coordinator can
configurations of case management functions move the criminal justice system toward a
have been attempted, including: greater awareness of treatment issues by
Case management provided by the justice providing technical assistance that demonstrates
system. Justice system case managers are service coordination.
assigned caseloads at specific stages of the Case management provided by
system, such as probation or parole. An multidisciplinary groups in the criminal
advantage of this model is that justice system justice system for offender management. This
officials are invested in the process because their type of group may meet regularly and during
staff members are implementing it and crises. This model is the most inexpensive;
reporting back to them. Major disadvantages however, it is the most difficult to successfully
are the expense and the fact that there may be operate because no one is assigned overall
conflicts between the philosophies and goals of responsibility for the offender (CSAT, 1995b).
the substance abuse and criminal justice One of the earliest models for case
systems. Another issue in this model is whether management services in the criminal justice
the case manager has actual training in system was created in 1972, when the White
59
Chapter 5
60
Clients With Special Needs
Case management has benefited the treatment professionals, case managers, and
treatment system by pretrial or probation departments together
apply continuous oversight of participants as
Increasing treatment outreach
they undergo substance abuse treatment as part
Providing assessments and making
of or in lieu of a criminal sentence. Key
appropriate referrals
components include
Utilizing resources more effectively
Orienting clients to treatment Integration of alcohol and other drug
Retaining clients in treatment by utilizing treatment services with justice system case
criminal justice leverage processing
Supporting treatment compliance Prosecution’s and defense counsel’s
Facilitating access to additional services promotion of public safety while protecting
Providing a framework and structure for participants’ due process rights, using a
managing criminal justice clients (Cook, nonadversarial approach
1997) Eligible participants identified early and
promptly placed in the program
Over the years, the TASC model has been
Access to a continuum of alcohol, drug, and
expanded to include offenders throughout the
other related treatment and rehabilitation
criminal justice system, including mixed
services
offender populations and specific populations
Frequent alcohol and other drug testing
such as women or adolescents. Depending on a
Coordinated strategy governing responses to
TASC program’s administrative and
participants’ compliance
programmatic structure, the approach to
Ongoing judicial interaction with each
delivery of services may vary. The various
participant
models include operation as a separate
Measurement through monitoring and
administrative entity within a court system or
evaluation the achievement of program goals
functioning as a separate nonprofit organization.
and gauge effectiveness; continuing
Acknowledging the diversity of program
interdisciplinary education promotes
design, Cook noted:
effective planning, implementation and
“There are clear variations in the
operations
management of TASC clients. Some TASC
Forging partnerships among drug courts,
programs are more ‘system centered’ as an
public agencies, and community-based
extension of criminal justice system control.
organizations generates local support and
Other TASC programs are more ‘client
enhances drug court effectiveness
centered,’ focusing on the rehabilitation needs of
the offender. A mix of both seems to produce a See TIP 23, Treatment Drug Courts: Integrating
healthy symbiosis of criminal justice system Substance Abuse Treatment With Legal Case
leverage, access to treatment, and therapeutic Processing (CSAT,1996a) for more on drug
tension” (Cook, 1997). courts.
The TASC model has also been adapted and While TASC programs have been designed
incorporated in recent innovations such as drug with the interaction of treatment and criminal
courts, which began managing drug-involved justice systems in mind, case managers in non-
offenders in the late 1980s, and have now been TASC settings must be careful not to encourage
implemented in more than 300 jurisdictions. or support goals or objectives that place the
Judges, prosecutors and defense attorneys, offender in conflict with expectations of the
61
Chapter 5
criminal justice system. The roles of the criminal Because many social service professionals
justice official (usually a probation officer) and still assume that people with disabilities are too
the case manager should be defined in advance helpless or too removed from the world to gain
in agreements forged at the highest levels of access to drugs, the case manager’s role may lie
both the court and the agency providing chiefly in education—both about physical
services. Typically, the case manager negotiates disabilities and about substance abuse
with the parole or probation officer for sanctions treatment. Clients with disabilities may not
that make clinical sense. Such a relationship recognize their need for substance abuse
affords the case manager the opportunity to treatment or may expect to be denied treatment.
educate a representative of the justice system Once in treatment, they may be misunderstood,
about the value of treatment and case or singled out for mobility or communication
management. An upcoming TIP, Transition from problems (Rehabilitation Research and Training
Incarceration to Community-Based Treatment, Center on Drugs and Disability, 1996). The
addresses treatment for recently released Americans with Disabilities Act (ADA) provides
offenders. It will be available in 1998. support for treatment programs oriented to this
population by mandating that facilities be
Clients With Physical physically accessible to people with disabilities
other service providers about the needs of among younger people. Gay and lesbian clients
people with disabilities. To reach those with may also find their sexual partners in areas
physical disabilities, 12-Step groups must be prevalent with drugs, increasing the risk of
willing to use hearing enhancement equipment contracting the AIDS virus. The prevalence of
(e.g., hearing loops) in meetings and to hold use, coupled with homophobia, makes the
meetings in accessible places. The case manager recognition and treatment of substance abuse
should become familiar with special equipment problems more difficult.
in order to help organizations purchase or Given the emotionally charged atmosphere
borrow appropriate resources as required under that often surrounds sexuality, case managers
the ADA. must be especially aware of their own feelings
The person in a wheelchair who must take and beliefs. The link between personal beliefs
medication for chronic pain from an injury may and interviewing skills is especially important in
prompt resistance from recovery-oriented self- the assessment of these clients, who may be
help groups. Similarly, some vocational reluctant to discuss health problems or issues
programs within a treatment setting require related to sexual practices. The case manager
clients to be sober for some time before they can must know the context of the client’s life and
be placed in a training setting. As a result, ideally, the specialized language used to
vocational rehabilitation services, while describe sexual practices in the client’s
appropriate, are not available to individuals community. The interviewer should gather
receiving pharmacotherapy for opiate addiction precise information regarding the nature of the
within those programs that do not consider such individual’s sexual practices and number of
people drug-free. A case manager from either sexual partners, unless a client is particularly
the disability field or the substance abuse field vulnerable, in crisis, or might otherwise see the
should educate members of other disciplines on inquiry as intrusive or inappropriate.
how to structure treatment appropriately. The To help gay or lesbian clients gain access to
Center for Substance Abuse Treatment is services, the case manager must know more
producing a TIP on persons with disabilities than just an agency’s formal stance toward
who have substance abuse problems, which will them. Some agencies that are officially
be available in late 1998. accepting are in fact hostile to homosexual
clients, or simply are not familiar enough with
Gay, Lesbian, their special needs to serve them effectively. A
63
Chapter 5
64
6 Funding Case Management in a
Managed Care Environment
M
anaged care is “an organized system However, many programs, particularly those
of care which attempts to balance that operate the least like businesses, may find
access, quality, and cost effectively this an extremely challenging time. The need to
by using utilization management, intensive case be accountable for outcomes, particularly in the
management, provider selection, and cost- face of a tax-conscious public, will undoubtedly
containment methods” (CSAT, 1995d). Despite increase in the managed care era.
the antipathy that many public sector health To adapt to the world of managed care,
care providers feel toward managed care, those treatment programs must assess how their
providers are actually striving toward the same services are currently delivered and identify
ends using similar means as managed care which elements should be preserved and which
organizations (MCOs). Many substance abuse should be modified. They also must have a firm
treatment providers have been working within a grasp on how changes in Federal and State
managed care framework for decades, that is, reforms will affect their current and future
looking at utilization data and developing a funding mechanisms.
continuum of care. Substance abuse treatment
providers, particularly those who use case Funding Case
management, have historically recognized the
importance of connecting disparate services to
Management in a
meet the needs of clients. Managed Care World
Whatever treatment providers’ attitudes Despite the promise of case management as an
toward managed care, they will have to learn to important adjunct to substance abuse services, it
operate within its bounds. More than half the will not survive without empirical data that
States are currently in the process of adopting support its efficacy. Key decisionmakers must
some form of managed care to provide believe that case management is an integral
behavioral health care services, and more than component of treatment service before they will
one-third have received Federal waivers to incorporate it into the funding structure. This is
implement Medicaid managed behavioral health especially true of States choosing to offer
programs, with other waivers planned or services through managed Medicaid HMOs. It
pending. Some experts predict that many is also true for people who receive services
substance abuse programs, already accustomed through Medicare HMOs. (See Chapter 4 for a
to scarcity of resources, will make a smooth discussion of program evaluation and
transition to a managed care environment. measuring outcomes.)
65
Chapter 6
Controlling costs while providing care offers of funding (usually a State agency) expects or
program administrators and case managers an requires specific outcomes that go beyond
opportunity to demonstrate case management’s sobriety or cost containment, then a program
utility to a newly engaged managed care administrator must develop ways to measure
company. For example, clients with long-term those outcomes.
or chronic conditions may be required to move To undertake scientifically valid outcomes
from residential facilities to the community studies is beyond the reach of most treatment
before some treatment providers believe they programs. Providers can, however, increase the
are ready. In this scenario, case management chances of having case management activities
can prove its value by providing the clients with reimbursed if they measure everything that
wraparound or supportive services to aid in a helps the client, such as consumer-run support
successful transition. As another example, groups, drop-in centers, or “Compeer”
outreach case management can help in the area programs, in which volunteers help clients
of relapse prevention and aftercare and thus maintain sobriety and manage other aspects of
avert the need for high-cost services like their lives. Keeping good records will allow
inpatient treatment. managed care companies to determine exactly
Managed care tools—clinical pathways, what’s being provided—and what constitutes
standardized assessments, and treatment case management.
protocols—can work well in a case management
context. The challenge then lies in tailoring
Funding Models
services to the unique needs of each consumer The multiple players involved in funding public
and avoiding “cookie cutter” services. Use of substance abuse treatment have posed complex
these tools can increase case management’s and ongoing problems for program
attractiveness to program administrators who administrators. Each funding stream has its
operate in capitated or other forms of shared- own eligibility rules, service conditions, and
risk environments. reporting requirements, which frequently differ
The true test is to develop a comprehensive from those of other agencies supporting a
case management system within a managed care program’s operations. Case management
framework with the inherent flexibility and services are no exception and have traditionally
resources necessary to eventually show tangible been funded through a variety of sources as
savings. Only then will an MCO be able to well. These include
clearly justify case management as a Block grants from Federal agencies
reimbursable service. Medicaid, which included options that allow
for non-medical services (e.g., the Medicaid
Who Decides?
Rehabilitation Option)
The decision to include case management in the
Medicare and Supplemental Security Income
array of treatment services usually rests with a
(SSI) for disabled clients
primary funding source or at the program level.
Migrant health funds
As many traditional public sector providers
Private foundations and funds, such as
overhaul their delivery systems to participate in
United Way
managed care, they must recognize the
State and/or local tax dollars
importance of case management as a key
Private insurance
element of effective treatment and communicate
that to the funding source. If the primary source
66
Funding in a Managed Care Environment
Far too often, the disparate mandates of these treatment and “stop-loss” clauses that cover
funders have exacerbated system and service such contingencies as reimbursement for longer
fragmentation. Integration of funding streams or more intensive treatment than anticipated
has emerged as a strategy to meld services and may help satisfy the providers’ desire for
provide continuity of care. Some States, in fact, flexibility and the payer’s demand for fiscal
have used Medicaid managed care initiatives as responsibility.
the catalyst for blending funding streams, Substance abuse treatment services are
particularly in full capitation models. treated in different ways depending on which
As States gain more freedom to allocate overarching health care delivery model is
Medicaid dollars as they see fit, the prospect of implemented by the State or by the managed
increased flexibility in services offered at the care organization(s) contracted to provide
program level improves. Programs that can behavioral healthcare. The two models
account for funds received in terms of positive currently prevailing are the carve-in model and
client outcomes will be better able to structure the carve-out model.
their service mix in response to clients’ specific
Carve-in models
needs rather than to the dictates of funding
The carve-in model integrates physical (e.g.,
agencies removed from the service delivery
traditional medical services) and behavioral
level.
(e.g., mental health and substance abuse
Managed care is frequently used as a vehicle
services) health care and is often the model
for integrating funding streams and for fostering
chosen to manage a State’s Medicaid population.
collaboration among health care providers. For
Although the purchaser of services may elect a
example, many managed care organizations
carve-in approach, frequently the MCO may
establish (or will only contract with) integrated
elect to carve out behavioral health care by
provider networks that
contracts with managed care organizations.
Offer a full range of services This is because behavioral health care tends to
Extend coverage over a wider geographical be the most expensive cost center of treatment
or population area (thus increasing the within an integrated, managed care model of
number of potential enrollees and sharing treatment. The carve-in model generally
the financial risk among more providers) appeals to providers because many individuals
Maximize efficiencies in areas like with mental illness and substance abuse
management information systems problems also have serious physical health
When providers are organized in such a problems. Integrating the two also underscores
manner, administrative service organizations the notion that since body and brain are part of
are engaged to handle a wide range of business the same system, mental illness and substance
duties for the network. abuse are bona fide health problems.
Blended funding approaches, especially However, in such a model, case management
those that give providers the necessary freedom is often administrative in nature and involves
to make clinical decisions while still holding clinical oversight and activities such as
them fiscally accountable, can preserve and utilization review and prior authorization
support the case management function as an procedures. The primary care physician
integral facet of modern substance abuse functions as the case manager or gatekeeper
treatment. Capitation or enrollment rates based who assesses the range of services the client
on genuine costs associated with providing needs and, ideally, refers him to network
providers who offer specialty services. This
67
Chapter 6
happens when the physician is ill-equipped to some assurance that those problems are being
provide the often labor-intensive, client-specific addressed. Ideally, carve-out managed care
case management functions needed to organizations will have expertise in substance
successfully manage the client/member. abuse services or will work jointly with
This model for behavioral health care has providers who possess that expertise. In all
two major drawbacks. First, primary care cases, State officials must develop specific
physicians may underdiagnose substance abuse contract language to carefully define their
problems, especially in populations such as responsibilities (CSAT’s Technical Assistance
women (in whom depression is often diagnosed Publication Purchasing Managed Care Services for
but seldom tied to substance abuse) and the Alcohol and Other Drug Treatment offers
elderly. Lack of knowledge or the desire to hold suggestions for assessing managed care
down costs also may lead to underutilization of approaches and structuring effective contracts
services, with consumers denied access to for managed care services.)
needed care. Case management in a carve-out model is
Second, since the course and overall likely to remain a service function, particularly if
treatment costs of behavioral health problems the responsibility for behavioral health care is
are less predictable than many physical health delegated to the public sector. Given the trends
problems, the ability to establish firm in behavioral health care, the public sector might
enrollment or capitated rates is difficult. If rates be advised to learn from the example of the
are too low, the problem of inadequately proprietary, more precise matching of clients
treating or excluding those most in need of and service packages through management
costly or long-term care (e.g., clients needing information capabilities, some aspects of
residential treatment) becomes a legitimate utilization review procedures, and the
concern. When services are subcontracted, development of clinical pathways. These efforts
skimming may become a problem. In this also help providers use their resources wisely
situation, the opportunity exists to cost-shift and ensure that appropriate and cost-effective
“difficult” clients to subcontractors who receive services are available to individual consumers.
only a percentage of the capitated rate. Not only Unfortunately, this method lacks integration
are funds insufficient to provide proper with the physical medicine side of treatment,
treatment when this happens, but the which can lead to ineffective case management
subcontracting provider’s resources are strained and duplication of services by the behavioral
to the maximum. health provider and the primary care physician.
Carve-out models
In carve-out arrangements, behavioral health care
Preparing a Program for
is considered distinct from other physical Managed Care
problems and is handled either as a separate
To adjust their current operations to meet new
contract or is intentionally excluded from a
demands, programs need to assess their
managed care plan. If behavioral health care is
systems, appraise their readiness to operate in a
carved out and handled as a separate managed
managed care environment, and position
care account, it is possible to develop capitation
themselves and their case management services
or enrollment fees specifically tailored to this
in a competitive market by identifying market
population. Carve-outs also provide States with
niches and preparing for increased staff
a mechanism to monitor and control the use of
licensing and accreditation.
substance abuse or mental health funds and
68
Funding in a Managed Care Environment
69
Chapter 6
may even find themselves acquired by the whether the cost of one consumer’s care or the
managed care company. performance level of an organization or
State and Federal governments, in professional, is likely to prompt a closer look. It
anticipation of the changing public sector seems likely that, as managed care organizations
system, have been disseminating resources to gain greater influence in the substance abuse
help publicly funded treatment providers world, there will be an increased demand for
survive and compete in a marketplace more professionally trained treatment personnel
dominated by managed care organizations. The and for provider organizations to gain
Federal Government is also currently designing accreditation from national organizations such
programs and projects via the Center for as the Joint Commission on Accreditation of
Substance Abuse Treatment (CSAT) and the Healthcare Organizations (JCAHO), the
Center for Substance Abuse Prevention (CSAP). Rehabilitation Accreditation Commission
The National Leadership Institute Coordinating (CARF), Community Mental Health Services
Center (NLICC) will provide resources, (CMHS), SAMHSA, or the National Committee
technical assistance, and materials to assist for Quality Assurance (NCQA).
public sector providers in making the internal
changes necessary to compete. Future Directions
Licensing and Accreditation The profound changes in reimbursement
One of the most controversial aspects of case patterns have sent shock waves through the
management is the issue of licensing. Many substance abuse treatment field. And change
believe that case managers should have earned clearly will persist. Payers and those who
at least a master’s degree. Others argue that allocate resources will continue to demand that
some of the best addictions counselors have the efficacy of services be demonstrated. On the
received their education through overcoming programmatic level this will necessitate
their own substance abuse. evaluating each service component and
While both viewpoints—and the many in determining how it contributes to overall
between—are valid, managed care will objectives. Programs must articulate their
increasingly require higher levels of education service expectations and decide what kinds of
as case management becomes a common training and experience a practitioner must have
ingredient in its mix of services. Case to successfully deliver them.
management functions were performed by What is needed now is more research on case
paraprofessionals in the 1980s and early 1990s. management. Several promising lines of
Today, however, credentialing standards of research, presented in Chapter 4, suggest that
managed care organizations and other providers certain forms of case management activities
require that case management be performed by improved client outcomes, resulting in fewer
people with master’s degrees in social work or employment problems, increased income, longer
education. All case managers may need to earn treatment retention, and diminished drug use.
advanced degrees to perform reimbursable case Other studies focusing on a criminal justice
management in the near future. population suggest far-ranging benefits.
Provider profiling and performance reviews However, the applicability of those studies to
of individual practitioners are commonplace in the population outside prison and jail has yet to
managed care systems. Because data drive so be established.
many managed care decisions, any outlier,
71
Chapter 6
This research should be undertaken in a this case. It will require hands-on experience to
variety of settings and should address issues fully understand how case management
that demonstrate the efficacy of case functions, what benefits it achieves for program
management activities. What approaches work clients, and how much it costs to provide this
best for what populations in which kind of service. Case managers must be able to follow
setting? While such questions are typically their clients from pretreatment to aftercare to
investigated by university researchers through determine if treatment and services have
demonstration projects, the research community succeeded. Quantifying its benefits is the most
must work with community-based programs in compelling argument for case management.
72
Appendix A
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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 ♦ employment and vocational rehabilitation
groups, agencies, other professionals, services
governmental entities, and the community ♦ child care facilities
at-large to ensure appropriate referrals, ♦ crisis intervention programs
identify service gaps, expand community ♦ abused persons programs
resources, and help to address unmet needs ♦ mutual and self-help groups
♦ cultural enhancement organizations
Knowledge ♦ advocacy groups
a. The mission, function, resources, and quality ♦ other agencies
of services offered by such entities as the b. Community demographics
following c. The community's political and cultural
♦ civic groups, community groups, systems
neighborhood organizations; and d. Criteria for receiving community services,
religious organizations including fee and funding structures
♦ governmental entities e. How to access community agencies and
♦ health and allied health care systems service providers
(managed care) f. State and Federal legislative mandates and
♦ criminal justice systems regulations
♦ housing administrations
87
Appendix B
89
Appendix B
Skills Knowledge
a. Using written and verbal communication for a. Methods of assessing client's progress
successful referrals toward treatment goals
b. Using appropriate technology to access, b. Appropriate sources and techniques for
collect, and forward relevant information evaluating referral outcomes
needed by the agency or professional
Skills
c. Obtaining informed client consent and
documentation needed for the exchange of a. Using appropriate measurement processes
relevant information and instruments
d. Reporting relevant information accurately b. Collecting objective and subjective data on
and objectively the referral process
Attitudes Attitudes
a. Commitment to professionalism a. Appreciation of the value of the evaluation
b. Respect for the importance of confidentiality process
regulations and professional standards b. Appreciation of the value of inter-agency
c. Appreciation for the need to exchange collaboration
relevant information with other professionals c. Appreciation of the value of interdisciplinary
referral
7. Evaluate the outcome of the referral
Service Coordination
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.
Skills Attitudes
a. Using accurate, clear, and concise written a. Recognition of the importance of continued
and verbal communication support, encouragement, and optimism
b. Interpreting, prioritizing, and using client b. Willingness to accept the limitations of
information treatment for some clients
c. Soliciting comprehensive and accurate c. Appreciation for the goal of self-
information from numerous sources determination
including the client d. Recognition of the importance of family and
d. Using appropriate technology to document significant others to treatment planning
appropriate information e. Appreciation of the need for continuing
assessment and modifications to the
Attitudes
treatment plan
a. Appreciation for all sources and types of data
and their possible treatment implications
4. Complete necessary administrative
b. Awareness of personal biases that may
procedures for admission to treatment
impact work with client Knowledge
c. Respect for client self-assessment and
a. Admission criteria and protocols
reporting
b. Documentation requirements and
confidentiality regulations
91
Appendix B
c. Appropriate Federal, State, and local g. Role and limitations of significant others in
regulations related to admission treatment
d. Funding mechanisms, reimbursement h. How to apply confidentiality regulations
protocols, and required documentation
Skills
e. Protocols required by managed care
organizations a. Demonstrating clear and concise written and
verbal communication
Skills b. Establishing appropriate boundaries with
a. Demonstrating accurate, clear, and concise client and significant others
written and verbal communication
Attitudes
b. Using language the client will easily
understand a. Respect for the contribution of clients and
c. Negotiating with diverse treatment systems significant others
d. Advocating for client services
6. Coordinate all treatment activities with
Attitudes services provided to the client by other
resources
a. Acceptance of the necessity to deal with
bureaucratic systems Knowledge
b. Recognition of the importance of cooperation a. Methods for determining the client’s
c. Patience and perseverance treatment status
5. Establish accurate treatment and recovery b. Documenting and reporting methods used
expectations with the client and involved by community agencies
significant others including, but not limited c. Service reimbursement issues and their
to impact on the treatment plan
♦ nature of services d. Case presentation techniques and protocols
♦ program goals e. Applicable confidentiality regulations
♦ program procedures f. Terminology and methods used by
♦ rules regarding client conduct community agencies
♦ schedule of treatment activities
Skills
♦ costs of treatment
♦ factors affecting duration of care a. Delivering case presentations
♦ client rights and responsibilities b. Using appropriate technology to collect and
interpret client treatment information from
Knowledge diverse sources
a. Functions and resources provided by c. Demonstrating accurate, clear, and concise
treatment services and managed care verbal and written communication
systems d. Participating in interdisciplinary team
b. Available community services building
c. Effective communication styles e. Participating in negotiation, advocacy,
d. Client rights and responsibilities conflict-resolution, problem solving, and
e. Treatment schedule, time frames, discharge mediation
criteria, and costs
Attitudes
f. Rules and regulations of the treatment
program a. Willingness to collaborate
92
Practice Dimensions
Consulting Skills
1. Summarize client’s personal and cultural a. Demonstrating accurate, clear, and concise
background, treatment plan, recovery verbal and written communication
progress, and problems inhibiting progress b. Participating in interdisciplinary
for purpose of assuring quality of care, collaboration
gaining feedback, and planning changes in c. Interpreting written and verbal data from
the course of treatment various sources
Knowledge Attitudes
a. Methods for assessing client’s past and a. Comfort in asking questions and providing
present biopsychosocial status information across disciplines
b. Methods for assessing social systems that
3. Contribute as part of a multidisciplinary
may affect the client’s progress
treatment team
c. Methods for continuous assessment and
modification of the treatment plan Knowledge
Skills a. Roles, responsibilities, and areas of expertise
of other team members and disciplines
a. Demonstrating clear and concise written and
b. Confidentiality regulations
verbal communication
c. Team dynamics and group process
b. Synthesizing information and developing
modified treatment goals and objectives Skills
c. Soliciting and interpreting feedback related a. Demonstrating clear and concise verbal and
to the treatment plan written communication
d. Prioritizing and documenting relevant client b. Participating in problem solving, decision
data making, mediation, and advocacy
e. Observing and identifying problems that c. Communicating about confidentiality issues
might impede progress d. Coordinating the client’s treatment with
f. Soliciting client satisfaction feedback representatives of multiple disciplines
Attitudes e. Participating in team building and group
process
a. Respect for the personal nature of the
information shared by the client and Attitudes
significant others a. Interest in cooperation and collaboration
b. Respect for interdisciplinary work with diverse service providers
c. Appreciation for incremental changes b. Respect and appreciation for other team
d. Recognition of relapse as an opportunity for members and their disciplines
positive change
4. Apply confidentiality regulations
2. Understand terminology, procedures, and appropriately
roles of other disciplines related to the
treatment of substance use disorders Knowledge
Knowledge a. Federal, State, and local confidentiality
regulations
a. Functions and unique terminology of related
disciplines
93
Appendix B
Knowledge Skills
a. How to recognize incremental progress a. Participating in conflict resolution, problem
toward treatment goals solving, and mediation
b. Client’s cultural norms, biases, unique b. Observing, recognizing, assessing, and
characteristics, and preferences for treatment documenting client progress
c. Generally accepted treatment outcome c. Eliciting client perspectives on progress
measures d. Demonstrating clear and concise written and
d. Methods for evaluating treatment progress verbal communication
e. Methods for assessing client’s motivation e. Interviewing individuals, groups, and
and adherence to treatment plans families
f. Theories and principles of the stages of f. Acquiring and prioritizing relevant
change and recovery treatment information
g. Assisting the client in maintaining
Skills
motivation
a. Identifying and documenting change h. Maintaining contact with client, referral
b. Assessing adherence to treatment plans sources, and significant others
c. Applying treatment outcome measures
d. Communicating with people of other
Attitudes
cultures a. Willingness to be flexible
e. Reinforcing positive change b. Respect for the client’s right to self-
determination
Attitudes
c. Appreciation of the role significant others
a. Appreciation for cultural issues that impact play in the recovery process
treatment progress d. Appreciation of individual differences in the
b. Respect for individual differences recovery process
c. Therapeutic optimism
4. Describe and document treatment process,
3. Assess treatment and recovery progress progress, and outcome
and, in consultation with the client and
significant others, make appropriate
Knowledge
changes to the treatment plan to ensure a. Treatment modalities
progress toward treatment goals b. Documentation of process, progress, and
outcome
Knowledge
c. Factors affecting client’s success in treatment
a. Continuum of care d. Treatment planning
b. Interviewing techniques
c. Stages in the treatment and recovery process
Skills
d. Individual differences in the recovery a. Demonstrating clear and concise oral and
process written communication
e. Methods for evaluating treatment progress b. Observing and assessing client progress
f. Methods for re-involving the client in the c. Engaging client in the treatment process
treatment planning process d. Applying progress and outcome measures
95
Appendix B
d. Stages of progress associated with treatment d. Tailoring treatment to meet client needs
modalities e. Applying placement, continued stay, and
e. Appropriate discharge indicators discharge criteria
Skills Attitudes
a. Observing and assessing client progress a. Confidence in client’s ability to progress
b. Demonstrating clear and concise written and within a continuum of care
verbal communication b. Appreciation for the fair and objective use of
c. Participating in conflict resolution, problem placement, continued stay, and discharge
solving, mediation, and negotiation criteria
,
97
Appendix C
Managed Healthcare
Organizational Readiness Guide
and Checklist: Special Report
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 as mental health services for Medicaid
method of organizing and financing recipients.
healthcare services in the United Publicly funded substance abuse treatment
States, and the delivery of substance abuse providers must adapt to meet the challenge of
treatment services is being significantly affected. managed care, which will expand as the
healthcare system changes in response to market
99
Appendix C
Increased public acceptance of the need for a total of almost 40 million persons for these
care three firms alone (Oss 1994).
Increased benefit coverages in many health A survey conducted in January 1994
plans determined that more than 102 million
State activities to include substance abuse Americans, 45.9 percent of those with health
services in State Medicaid programs insurance, are enrolled in some type of managed
A rapid growth in inpatient hospital-based behavioral healthcare program (Oss 1994). The
substance abuse and psychiatric units, survey did not separate managed care for
supported by benefit plans that paid for substance abuse from mental health services;
inpatient treatment and a surplus of hospital however, almost all behavioral MCOs use an
beds integrated approach. There were:
Increases in State and Federal funding of
20.0 million in employee assistance programs
community services, such as the Substance
(EAPs)
Abuse Prevention and Treatment Block
6.6 million in integrated managed behavioral
Grant program
health/EAPs
Some employers perceived that mental 20.5 million in risk-based behavioral health
health and substance abuse treatment costs were network programs
"out of control" and that service delivery was 15.0 million in nonrisk-based network
fragmented. Claire Wilson, in a 1993 article on programs
substance abuse and managed care, wrote: "The 37.0 million in stand-alone behavioral health
skyrocketing utilization and costs of substance utilization review programs (Oss 1994)
abuse treatment during the last 10 years have
alarmed corporate benefit managers" (Wilson
What Is Managed Care and How Is
1993). It Changing?
England and Vacarro (1991) identified 21 Managed care approaches, such as utilization
percent increases in 1990 healthcare review and second opinions, have been in place
expenditures to employers/purchasers as the for more than a decade for medical-surgical
impetus behind managed care, despite cost insured health benefits. Their general purpose is
containment efforts spanning more than a to assure payers that consumers receive the
decade. They said: "Mental health and chemical appropriate level of care and that excessive,
dependency services, with reported cost inappropriate, or unnecessary care is not
increases of up to 60 percent per year, are a delivered or reimbursed. These practices arose
prime target for managed care." to regulate the functioning of the fee-for-service
These perceptions also were shared by some system, where financial incentives tend to
insurance carriers and HMOs, forcing payers to encourage the delivery of more health services
seek ways to coordinate care and control costs. and more expensive procedures.
The result is greater use of HMOs, preferred Another way to define managed care is by
provider arrangements, increased competition, the organizational structures used to deliver
and—for substance abuse and mental health treatment. Health maintenance organizations
services—the development of behavioral health are "managed care," because clinical
managed care organizations (MCOs). management and financial incentives exist
These firms have expanded rapidly in the within staff HMOs and independent-practice
last 10 years, with the three largest MCOs each model HMOs to encourage preventive care and
reporting more than 10 million persons enrolled, to reduce cost increases.
101
Appendix C
Feldman and Goldman (1993) indicated that care in the most appropriate setting, and
the behavioral health managed care industry moving patients through a continuum of
"arose as a response to the economic imperatives services.
of spiraling unmanaged mental health and
Managed care organizations expect
substance abuse costs. In light of escalating
development of a fourth-generation product in
costs, payers were essentially faced with two
which they manage outcomes as part of an
alternatives–cut benefits (which many have
integrated services system, moving both public
done) or manage them so as to control costs and
and private patients through a full continuum of
ensure quality."
treatment services (Waxman 1994).
In addition to concerns about costs,
The impact on treatment providers over the
purchasers identified several quality-related
last 10 years has been dramatic. Hospitals that
problems:
deliver substance abuse care have reduced staff
Overuse of hospitalization and closed units or have integrated their
Purchase of services without any indication inpatient care for substance abuse within
of clinical effectiveness–making it difficult to psychiatric units. Many hospitals have
identify good care and good providers expanded ambulatory substance abuse services.
Incentives in traditional benefit plans to use Community agencies have scrambled to learn
hospitalization rather than outpatient about managed care and to become members of
alternatives MCO provider panels.
Fragmented service delivery and the lack of These changes are likely to continue as the
coverage for case management services in managed care industry increases its focus on
traditional indemnity plans (England and Medicaid recipients, State and local
Vacarro 1991). governments, and services to other public
clients.
Without a doubt, the industry has grown
rapidly. In general, it has gone through three How Do Managed Care
major phases since the mid-1980s. Organizations Select Treatment
1. The first generation of MCOs managed Providers?
access to health care, with a primary focus on Behavioral health managed care organizations
utilization review (UR). Access was (MCOs) work for self-insured businesses,
controlled by limiting benefits and requiring HMOs, insurance carriers, unions, State
significant co-payments to contain costs. Medicaid agencies, and others. Prior to deciding
MCOs also introduced such administrative which providers to select, they first listen to
barriers as preadmission certification. their customers.
2. The second generation of managed care Some payers will dictate the qualifications of
focused on managing benefits. MCOs added substance abuse treatment providers. These
fee-for-service provider networks, selective payers may require hospitals for residential care
contracting, and treatment planning to the and require licensed professionals for outpatient
UR function. treatment. Increasingly, MCOs are
3. The current generation of MCOs focuses on recommending that less expensive yet well-
managing care, performing utilization qualified community providers be included on
management instead of utilization review– the "provider panel." This enables MCOs to
with a greater emphasis on treatment lower costs and to offer a more complete range
planning, delivery of the most appropriate of services.
102
Managed Care Checklist
103
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
No, None, Never Very Limited, Not Partially, Mostly, Regularly Yes, Fully, Always
Often Frequently
1 2 3 4 5
104
Managed Care Checklist
No, None, Never Very Limited, Not Partially, Frequently Mostly, Regularly Yes, Fully, Always
Often
1 2 3 4 5
Service Comprehensiveness
8. Outpatient services? 1 2 3 4 5
105
Appendix C
No, None, Never Very Limited, Not Partially, Mostly, Regularly Yes, Fully, Always
Often Frequently
1 2 3 4 5
14. Do your services ensure rapid access (1-2 days) to assessment services and
1 2 3 4 5
initial placement?
15. Do your services have a brief intervention focus, e.g., six to eight sessions for
1 2 3 4 5
outpatient care, for most patients?
16. Do you have internal case management services for focusing on repeating
1 2 3 4 5
patients and others who have high utilization patterns?
17. Do you have ensured linkages with primary healthcare providers for needed
1 2 3 4 5
healthcare?
18. Do you adapt standard services to meet the needs of special populations, such
1 2 3 4 5
as mentally ill substance abusers, injecting drug users, and pregnant addicts?
19. Are service needs constantly reevaluated, and service plans modified, based on
1 2 3 4 5
patient progress?
20. Are admission, treatment, and discharge criteria in place and used consistently
1 2 3 4 5
by staff?
21. Do your admission, treatment, and discharge criteria take into consideration
the practice standards of managed care firms with which you have (or hope to 1 2 3 4 5
have) contracts?
23. Do your services emphasize family involvement and use of natural support
1 2 3 4 5
systems, including self-help groups?
106
Managed Care Checklist
No, None, Never Very Limited, Not Partially, Frequently Mostly, Regularly Yes, Fully, Always
Often
1 2 3 4 5
Quality Assurance (QA) and Utilization Management (UM) Please circle the answer...
25. Do you have 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 1 2 3 4 5
discharge criteria?
27. Is the information from the QA/UM function received rapidly enough to assist
1 2 3 4 5
clinicians during an episode of care?
28. Does the QA/UM function include maintaining records of managed care
appeals, and suggest strategies for improving relationships and/or modifying 1 2 3 4 5
service delivery to reduce denials?
30. To what extent is the QA/UM function designed to "stay ahead" of staff from
1 2 3 4 5
managed care firms by anticipating their concerns?
31. Do clinicians, clinical supervisors, and management all receive and act on
1 2 3 4 5
regular QA and UM reports?
32. Is the QA/UM function tied closely to your management information system? 1 2 3 4 5
Managed Care and Employee Assistance Program (EAP) Please circle the answer...
Experience
35. Do you have contract(s) with managed care firms or EAPs as a preferred
1 2 3 4 5
provider?
36. If yes to #35, are any of your contracts paid on a fee-per-case or a capitation
1 2 3 4 5
basis?
39. Has your EAP business increased over the last 2 years? 1 2 3 4 5
107
Appendix C
No, None, Never Very Limited, Not Partially, Frequently Mostly, Regularly Yes, Fully, Always
Often
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
records? 1 2 3 4 5
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?
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
how to respond to managed care organizations? 1 2 3 4 5
108
Managed Care Checklist
No, None, Never Very Limited, Not Partially, Frequently Mostly, Regularly Yes, Fully, Always
Often
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
1 2 3 4 5
healthcare?
55. To what extent is the board oriented to service effectiveness and business
1 2 3 4 5
success?
56. Are you experienced at strategic planning, modifying plans, and developing
1 2 3 4 5
contingency plans to meet emerging opportunities and challenges?
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
1 2 3 4 5
business opportunities?
59. To what extent will the board and management be proactive and
1 2 3 4 5
entrepreneurial in pursuit of managed care initiatives?
109
Appendix C
No, None, Never Very Limited, Not Partially, Frequently Mostly, Regularly Yes, Fully, Always
Often
1 2 3 4 5
61. Do you have sufficient staff resources 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
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
71. Can the fiscal staff assist with pricing issues during contract negotiations,
especially when capitated contracts are considered? 1 2 3 4 5
72. Can 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
1 2 3 4 5
MIS?
110
Managed Care Checklist
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.
Service Characteristics 12 1 2 3 4 5
QA and UM area 10 1 2 3 4 5
MIS area 7 1 2 3 4 5
Organizational Relations 3 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
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.
111
Appendix C
112
Managed Care Checklist
improve the likelihood of doing well as the Involve the staff and board: What steps must
healthcare system changes. You may find be approved and accomplished by the
arrangements that strengthen your organization various actors, and what are the resource
clinically and managerially. No organization requirements?
should rule out considering these options. Consider strategic partnerships: What new
organizational relationships will strengthen
How Can We Design an your ability to reach your objectives, and
113
Appendix C
Remember, the checklist will be helpful but Wilson, C.V. Substance abuse and managed
should not be the only tool your organization care. In: Feldman, S. and Goldman, W., eds.
uses to prepare for managed care participation. New Directions for Mental Health Services:
Providers should attend workshops, read, share Managed Mental Health Care. San Francisco:
ideas with colleagues, and participate in State Jossey-Bass, 1993.
association activities.
Treatment providers seeking additional Additional Readings
assistance should contact their State authority or
CSAT's Quality Assurance and Evaluation Ansoff, H.; DeClerk, R.; and Hayes, R., eds. From
Branch within the Division of State Programs. Strategic Planning to Strategic Management.
New York: John Wiley and Sons, 1976.
114
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.
115
Appendix D
116
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.
117
Appendix E
118
Field Reviewers
119
Appendix E
120
Field Reviewers
121
The TIPs Series
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HHS Publication No. (SMA) 15‐4215
Substance Abuse and Mental Health Services Administration
Printed 2000
Revised 2002, 2003, 2006, 2008, 2010, 2012, and 2015