Case management has been variously classified as a skill group, a core function, service coordination, or a network of "friendly neighbors." Although it defies precise definition, case management generally can be described as a coordinated approach to the delivery of health, substance abuse, mental health, and social services, linking clients with appropriate services to address specific needs and achieve stated goals. The Consensus Panel that developed this TIP believes that case management lends itself to the treatment of substance abuse, particularly for clients with other disorders and conditions who require multiple services over extended periods of time and who face difficulty in gaining access to those services. This document details the factors that programs should consider as they decide to implement case management or modify their current case management activities. This summary is excerpted from the main text, in which references to the research appear.
Research suggests two reasons why case management is effective as an adjunct to substance abuse treatment. First, retention in treatment is associated with better outcomes, and a principal goal of case management is to keep clients engaged in treatment and moving toward recovery. Second, treatment may be more likely to succeed when a client's other problems are addressed concurrently with substance abuse. Case management focuses on the whole individual and stresses comprehensive assessment, service planning, and service coordination to address multiple aspects of a client's life. Comprehensive substance abuse treatment often requires that clients move to different levels of care or systems; case management facilitates such movement.
Any definition of case management will be contextual, depending on who is implementing the program. Perhaps a more helpful way to understand it is to examine the functions that generally comprise case management: (1) assessment, (2) planning, (3) linkage, (4) monitoring, and (5) advocacy.
When implemented to its fullest, case management will enhance the scope of addictions treatment and the recovery continuum. A treatment professional utilizing case management will
Provide the client a single point of contact for multiple health and social services systems
Advocate for the client
Be flexible, community-based, and client-oriented
Assist the client with needs generally thought to be outside the realm of substance abuse treatment
To provide optimal services for clients, a treatment professional should possess particular knowledge, skills, and attitudes including
Understanding various models and theories of addiction and other problems related to substance abuse
Ability to describe the philosophies, practices, policies, and outcomes of the most generally accepted and scientifically supported models of treatment, recovery, relapse prevention, and continuing care for addiction and other substance-related problems
Ability to recognize the importance of family, social networks, community systems, and self-help groups in the treatment and recovery process
Understanding the variety of insurance and health maintenance options available and the importance of helping clients access those benefits
Understanding diverse cultures and incorporating the relevant needs of culturally diverse groups, as well as people with disabilities, into clinical practice
Understanding the value of an interdisciplinary approach to addiction treatment
In addition to the above competencies, treatment professionals must have skills relating to interagency functioning, negotiating, and advocacy. CSAT's Addiction Technology Transfer Centers classify referral and service coordination - basic case management functions - as core competencies for substance abuse treatment providers.
The continuum of substance abuse treatment ranges from case finding and pretreatment to primary treatment to aftercare. Although there are distinct goals and treatment activities at each point on the continuum, rarely do clients' needs fit neatly into any one area at a given time; case management serves to span client needs and program structure. Substance abuse treatment and case management functions differ in that treatment involves activities that help substance abusers recognize their problems, acquire the motivation and tools to stay abstinent, and use the acquired tools; case management focuses on helping the substance abuser acquire needed resources. Case management supports a client as he moves through the recovery continuum and reinforces treatment goals.
The goal of interagency case management is to expand the network of services available to clients. All organizations have boundaries to what they can do, and case managers or "boundary spanners" transcend them to facilitate interactions among agencies. In the field of substance abuse, three interagency models have been identified. In the single agency model, the case manager personally establishes a series of distinct relationships on an as-needed basis with counterparts in other agencies. In the informal partnership model, staff members from several agencies work as a collaborative team, often constituted case by case; the formal consortium binds case managers and service providers through formal written agreements. Clearly defined roles are essential to all three models to ensure that services are coordinated and relevant gaps addressed.
Although informal exchange or "social service bartering" among different agencies is intrinsic to case management, a more formalized connection among agencies sometimes may be required. Examples include memoranda of understanding and interagency agreements and contracts; each of these methods for formalizing expectations can be used in single agency models, informal partnerships, and formal consortia.
To be successful, a case management plan must thoroughly and critically examine community resources to determine what forms of assistance are available and how case management efforts can help clients attain necessary assistance. Many communities have published directories of social, health, welfare, housing, vocational, and other service organizations to help case management programs identify resources, possible provider linkages, and potential gaps in services for their clients. Although such directories are a good starting point, it is important to follow up on the listings to ensure they are still accurate and will be of use to the client.
Exploring the environment in which an agency operates is crucial to determining the feasibility of an interagency effort. Analysis of the community environment will enhance understanding of the changes that occur among clients, within the program, and in the community. Case management takes place within a dynamic social service environment in which agencies are in constant flux. Programs considering interagency efforts must devise strategies to respond to change while providing continuity for the client. Regular reevaluation helps ensure continued relevance; community service provider networks or consortia are particularly effective in sharing information about changes and developments.
Whenever agencies or service providers work together, the potential for conflict exists. Areas of tension may be present from the very onset of the collaboration. For example, a new project may be viewed by established social service agencies as competition for scarce resources. Sometimes social pressures or the need to maximize resources can force public agencies into joint ventures even if they do not mesh well or have a history of being service competitors. Tensions can also develop in the course of delivering services; for example, interagency collaboration may result in a client having two case managers. Recognizing potential triggers for conflict is a necessary first step in developing a system to handle them. When problems do arise, case managers and other agency personnel can use both informal and formal communication to clarify issues, regain perspective, and refocus the interagency case management process.
Substance abuse treatment programs, including those that receive public funding, are increasingly operating in a managed care environment. In such an environment, policy and clinical decisionmaking rely on outcome data that traditionally describe the impact of case management and substance abuse treatment interventions in the context of services used and money spent. An additional demand for data comes from public and private payers who want services linked to specific outcomes.
To gauge the effectiveness of case management, indicators of "success" must be defined by the substance abuse program and its stakeholders (including funding and regulatory agencies). In documenting a case management effort, it is necessary to establish benchmarks to measure the case management process, for example, recording how often a client shows up at treatment. Once the benchmarks are defined in measurable terms, the next step is to develop and implement a method for measuring practice; that is, to answer the questions, "What are case managers doing, and how does their practice conform to the benchmarks?" Methods of such documentation include
Maintenance of a simple staff log procedure that measures case managers' activities by contact
Reviews of case manager client records to evaluate how service planning and referrals adhere to benchmarks
Interviews or surveys of case managers or clients and their family members to collect information on activities in which case managers engage, to identify how clients' and case managers' views of case management activities differ
Analysis of data from the agency's management information system (to examine patterns on type, number, and duration of case manager contacts with different target populations).
System outcomes are particularly important in a managed care environment, where overall use of expensive services such as hospitalization and residential treatment is strictly monitored. System outcomes can measure cost savings and quality of care: For example, continuity of care is an appropriate measure for a client at risk for relapse after detoxification and before entry into outpatient treatment. Tracking clients within a comprehensive service agency or analyzing data on costs and encounters within a network of agencies are two methods for measuring system outcomes. For such analyses, a computerized management information system (MIS) is essential.
Although "evaluation" is generally considered worthwhile, there is little agreement about the measurement and documentation of specific outcomes for individual clients. Some view a single measure such as sobriety to be the only meaningful indicator of success; others believe success should be gauged against a range of factors, including reduced substance use, improved family functioning, and fewer encounters with the criminal justice system. Until the debate is resolved, programs should identify treatment objectives and extrapolate from them the outcome variables they want to measure.
The types of data required for an evaluation of case management, how the data are collected, and the manner in which data are put to use vary among different stakeholders. It is important to understand the types of data that various stakeholders need to evaluate the program. Structured feedback loops should be established to ensure that the gathered data are returned to various stakeholders in some meaningful way so that they have an impact on shaping future program development (and future data needs). One of the benefits of the case management approach is that it can be adapted to meet the sometimes contradictory needs of the various stakeholders.
A management information system contains all of the case management services information and allows stakeholders to access it. In evaluating a MIS, local programs should
Determine how to use data already routinely collected by a statewide MIS or a managed care company-based MIS, saving the program from duplicating primary data collection
Develop or enhance a program-level MIS that tracks data the program needs locally
Integrate with other computer-based or paper-based systems
Supply data required by third party payer and governmental bodies
All staff members of a specific program should be stakeholders in the MIS, which increases both system accuracy and the likelihood that a broad array of staff members will use it. If an agency does not have the resources to develop a sophisticated system, it should be able to automate at least a minimum amount of client information through commercially available software. When designing today's MIS, the data requirements of managed care organizations must be addressed.
Research centered on case management and the substance abuse field is limited, thus offering local substance abuse programs the opportunity to make significant contributions to the field. Suggested directions for future research include the following:
Key ingredients of successful programs, especially for hard-to-reach populations
Relative cost-effectiveness of particular case management models, including cost outcome results within systems incorporating full parity of substance abuse with other health care; outcome results when a full continuum of care is available to patients; and outcome results associated with use of standardized guidelines for placement, continued stay, and discharge for substance abuse patients
Improved methodology to investigate research questions in "real world" settings
Development of brief versions of valid and reliable research outcome instrumentation
The effect of particular forms of case management on societal costs of substance abuse and its treatment
Cost shifting among health, behavioral health, criminal justice, and other systems that can be accessed by the target population
Creative ways to use secondary data sets (such as Medicaid and Medicare) to determine trends and patterns of care
Research questions from broader sociological or multidisciplinary perspectives
Case management is especially appropriate for substance abusers with special treatment needs, related to such issues as HIV infection or AIDS, mental illness, chronic and acute health problems, poverty, homelessness, responsibility for parenting young children, social and developmental problems associated with adolescence and advanced age, involvement with illegal activities, physical disabilities, and sexual orientation. Ideally, a case manager will possess all the expertise and skills needed to treat the many special needs she confronts, but this is unlikely - understanding the ramifications of even one special need can be a staggering task. In the absence of such comprehensive knowledge, a case manager should have a basic foundation of attitudes and skills for delivering services to "special needs clients." The case manager should
Make every effort to be competent in the special circumstances that affect clients typically referred to a particular substance abuse treatment program
Understand the range of clients' reactions to the challenges associated with particular special circumstances
Remain aware of the limits of his own knowledge and expertise
Evaluate personal beliefs and biases about clients who have special problems or needs
Maintain an open attitude toward seeking and accepting assistance on behalf of a client
Know where additional information on special problems can be accessed
Whatever treatment providers' attitudes toward managed care, they will have to accept that it is the new paradigm for health care. Well over one-half of the States are currently in the process of adopting some form of managed care for providing public-sector behavioral health care services. Many have already received Federal waivers to implement Medicaid managed behavioral health programs, and other waivers are planned or pending. Managed care has changed the context in which substance abuse treatment services are delivered, and substance abuse programs must prepare to function within this new environment if case management is to survive.
Treatment providers using case management may not only survive but actually thrive under managed care.
Many managed care organizations (MCOs) reimburse for case management, so it behooves providers to prove that their brand of case management should be covered. The program should develop a comprehensive case management system with the flexibility and resources necessary to eventually show tangible savings.
To adapt to this new way of doing business, treatment programs must assess how they use case management and appraise their readiness to operate in a managed care environment. One way providers can thrive under managed care is to position themselves and their case management services in a competitive market by identifying market niches, such as clients with HIV/AIDS, criminal justice clients, or older clients.
As MCOs increasingly reimburse for case management, licensing requirements are becoming stricter. The trend is toward case managers who have advanced degrees.
Accreditation standards will also tighten under managed care.
In short, there are many reasons for substance abuse treatment providers to adopt case management or to formalize their existing case management activities. This will not necessarily mean an upheaval, as many programs are already helping clients navigate their other, non-substance abuse problems. This TIP equips providers with the knowledge they need to fully serve their clients at the same time they conform to the changing health care system.
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