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Comprehensive Case Management for Substance Abuse TreatmentTreatment Improvement Protocol (TIP) Series 27
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 National Clearinghouse for Alcohol and Drug Information (NCADI) by phone (1-800-729-6686) or online (ncadi.samhsa.gov).
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.
Establish and maintain relations with civic groups, agencies, other professionals, governmental entities, and the community-at-large to ensure appropriate referrals, identify service gaps, expand community resources, and help to address unmet needs
The mission, function, resources, and quality of services offered by such entities as the following
civic groups, community groups, neighborhood organizations; and religious organizations governmental entities health and allied health care systems (managed care) criminal justice systems housing administrations employment and vocational rehabilitation services child care facilities crisis intervention programs abused persons programs mutual and self-help groups cultural enhancement organizations advocacy groups other agencies Community demographics The community's political and cultural systems Criteria for receiving community services, including fee and funding structures How to access community agencies and service providers State and Federal legislative mandates and regulations Confidentiality regulations Service gaps and appropriate ways of advocating for new resources Effective communication styles
Networking and communication Using existing community resource directories including computer databases Advocating for clients Working with others as part of a team
Respect for interdisciplinary service delivery Respect for both client needs and agency services Respect for collaboration and cooperation Patience and perseverance Continuously assess and evaluate referral resources to determine their appropriateness
The needs of the client population served How to access current information on the function, mission, and resources of community service providers How to access current information on referral criteria and accreditation status of community service providers How to access client satisfaction data regarding community service providers
Establishing and nurturing collaborative relationships with key contacts in community service organizations Interpreting and using evaluation and client feedback data Giving feedback to community resources regarding their service delivery
Respect for confidentiality regulations Willingness to advocate on behalf of the client Differentiate between situations in which it is most appropriate for the client to self-refer to a resource and instances requiring counselor referral
Client motivation and ability to initiate and follow through with referrals Factors in determining the optimal time to engage client in referral process Clinical assessment methods Empowerment techniques Crisis intervention methods
Interpreting assessment and treatment planning materials to determine appropriateness of client or counselor referral Assessing the client's readiness to participate in the referral process Educating the client regarding appropriate referral processes Motivating clients to take responsibility for referral and follow-up Applying crisis intervention techniques
Respect for the client's ability to initiate and follow-up with referral Willingness to share decision-making power with the client Respect for the goal of positive self-determination Recognition of the counselor's responsibility to carry out client advocacy when needed Arrange referrals to other professionals, agencies, community programs, or other appropriate resources to meet client needs
Comprehensive treatment planning Methods of assessing client's progress toward treatment goals How to tailor resources to client treatment needs How to access key resource persons in community service provider network Mission, function, and resources of appropriate community service providers Referral protocols of selected service providers Logistics necessary for client access and follow through with the referral Applicable confidentiality regulations and protocols Factors to consider when determining the appropriate time to engage client in referral process
Using written and verbal communication for successful referrals Using appropriate technology to access, collect, and forward necessary documentation Conforming to all applicable confidentiality regulations and protocols Documenting the referral process accurately Maintaining and nurturing relationships with key contacts in community Maintaining follow-up activity with client
Respect for the client and the client's needs Respect for collaboration and cooperation Respect for interdisciplinary, comprehensive approaches to meet client needs Explain in clear and specific language the necessity for and process of referral to increase the likelihood of client understanding and follow through
How treatment planning and referral relate to the goals of recovery How client defenses, abilities, personal preferences, cultural influences, presentation, and appearance effect referral and follow through Comprehensive referral information and protocols Terminology and structure used in referral settings
Using language and terms the client will easily understand Interpreting the treatment plan and how referral relates to progress Engaging in effective communication related to the referral process
negotiating educating personalizing risks and benefits contracting
Awareness of personal biases toward referral resources Exchange relevant information with the agency or professional to whom the referral is being made in a manner consistent with confidentiality regulations and generally accepted professional standards of care
Mission, function, and resources of the referral agency or professional Protocols and documentation necessary to make referral Pertinent local, State, and Federal confidentiality regulations, applicable client rights and responsibilities, client consent procedures, and other guiding principles for exchange of relevant information Ethical standards of practice related to this exchange of information
Using written and verbal communication for successful referrals Using appropriate technology to access, collect, and forward relevant information needed by the agency or professional Obtaining informed client consent and documentation needed for the exchange of relevant information Reporting relevant information accurately and objectively
Commitment to professionalism Respect for the importance of confidentiality regulations and professional standards Appreciation for the need to exchange relevant information with other professionals Evaluate the outcome of the referral
Methods of assessing client's progress toward treatment goals Appropriate sources and techniques for evaluating referral outcomes
Using appropriate measurement processes and instruments Collecting objective and subjective data on the referral process
Appreciation of the value of the evaluation process Appreciation of the value of inter-agency collaboration Appreciation of the value of interdisciplinary referral The administrative, clinical, and evaluative activities that bring the client, treatment services, community agencies, and other resources together to focus on issues and needs identified in the treatment plan.
Service coordination, which includes case management and client advocacy, establishes a framework of action for the client to achieve specified goals. It involves collaboration with the client and significant others, coordination of treatment and referral services, liaison activities with community resources and managed care systems, client advocacy, and ongoing evaluation of treatment progress and client needs.
Initiate collaboration with referral source
How to access and transmit information necessary for referral Missions, functions, and resources of community service network Managed care and other systems affecting the client Eligibility criteria for referral to community service providers Appropriate confidentiality regulations Terminologies appropriate to the referral source
Using appropriate technology to access, collect, summarize, and transmit referral data on client Communicating respect and empathy for cultural and lifestyle differences Demonstrating appropriate written and verbal communication Establishing trust and rapport with colleagues in the community Assessing level and intensity of client care needed
Respect for contributions and needs of multiple disciplines to treatment process Confidence in using diverse systems and treatment approaches Open-mindedness to a variety of treatment approaches Willingness to modify or adapt plans Obtain, review, and interpret all relevant screening, assessment, and initial treatment-planning information
Methods for obtaining relevant screening, assessment, and initial treatment-planning information How to interpret information for the purpose of service coordination Theory, concepts, and philosophies of screening and assessment tools How to define long- and short-term goals of treatment Biopsychosocial assessment methods
Using accurate, clear, and concise written and verbal communication Interpreting, prioritizing, and using client information Soliciting comprehensive and accurate information from numerous sources including the client Using appropriate technology to document appropriate information
Appreciation for all sources and types of data and their possible treatment implications Awareness of personal biases that may impact work with client Respect for client self-assessment and reporting Confirm the client's eligibility for admission and continued readiness for treatment and change
Philosophies, policies, procedures, and admission protocols for community agencies Eligibility criteria for referral to community service providers Principles for tailoring treatment to client needs Methods of assessing and documenting client change over time Federal and State confidentiality regulations
Working with client to select the most appropriate treatment Accessing available funding resources Using effective communication styles Recognizing, documenting, and communicating client change Involving family and significant others in treatment planning
Recognition of the importance of continued support, encouragement, and optimism Willingness to accept the limitations of treatment for some clients Appreciation for the goal of self-determination Recognition of the importance of family and significant others to treatment planning Appreciation of the need for continuing assessment and modifications to the treatment plan Complete necessary administrative procedures for admission to treatment
Admission criteria and protocols Documentation requirements and confidentiality regulations Appropriate Federal, State, and local regulations related to admission Funding mechanisms, reimbursement protocols, and required documentation Protocols required by managed care organizations
Demonstrating accurate, clear, and concise written and verbal communication Using language the client will easily understand Negotiating with diverse treatment systems Advocating for client services
Acceptance of the necessity to deal with bureaucratic systems Recognition of the importance of cooperation Patience and perseverance Establish accurate treatment and recovery expectations with the client and involved significant others including, but not limited to
nature of services program goals program procedures rules regarding client conduct schedule of treatment activities costs of treatment factors affecting duration of care client rights and responsibilities
Functions and resources provided by treatment services and managed care systems Available community services Effective communication styles Client rights and responsibilities Treatment schedule, time frames, discharge criteria, and costs Rules and regulations of the treatment program Role and limitations of significant others in treatment How to apply confidentiality regulations
Demonstrating clear and concise written and verbal communication Establishing appropriate boundaries with client and significant others
Respect for the contribution of clients and significant others Coordinate all treatment activities with services provided to the client by other resources
Methods for determining the client's treatment status Documenting and reporting methods used by community agencies Service reimbursement issues and their impact on the treatment plan Case presentation techniques and protocols Applicable confidentiality regulations Terminology and methods used by community agencies
Delivering case presentations Using appropriate technology to collect and interpret client treatment information from diverse sources Demonstrating accurate, clear, and concise verbal and written communication Participating in interdisciplinary team building Participating in negotiation, advocacy, conflict-resolution, problem solving, and mediation
Willingness to collaborate
Summarize client's personal and cultural background, treatment plan, recovery progress, and problems inhibiting progress for purpose of assuring quality of care, gaining feedback, and planning changes in the course of treatment
Methods for assessing client's past and present biopsychosocial status Methods for assessing social systems that may affect the client's progress Methods for continuous assessment and modification of the treatment plan
Demonstrating clear and concise written and verbal communication Synthesizing information and developing modified treatment goals and objectives Soliciting and interpreting feedback related to the treatment plan Prioritizing and documenting relevant client data Observing and identifying problems that might impede progress Soliciting client satisfaction feedback
Respect for the personal nature of the information shared by the client and significant others Respect for interdisciplinary work Appreciation for incremental changes Recognition of relapse as an opportunity for positive change Understand terminology, procedures, and roles of other disciplines related to the treatment of substance use disorders
Functions and unique terminology of related disciplines
Demonstrating accurate, clear, and concise verbal and written communication Participating in interdisciplinary collaboration Interpreting written and verbal data from various sources
Comfort in asking questions and providing information across disciplines Contribute as part of a multidisciplinary treatment team
Roles, responsibilities, and areas of expertise of other team members and disciplines Confidentiality regulations Team dynamics and group process
Demonstrating clear and concise verbal and written communication Participating in problem solving, decision making, mediation, and advocacy Communicating about confidentiality issues Coordinating the client's treatment with representatives of multiple disciplines Participating in team building and group process
Interest in cooperation and collaboration with diverse service providers Respect and appreciation for other team members and their disciplines Apply confidentiality regulations appropriately
Federal, State, and local confidentiality regulations How to apply confidentiality regulations to documentation and sharing of client information Ethical standards related to confidentiality Client rights and responsibilities
Explaining and applying confidentiality regulations Obtaining informed consent Communicating with the client, family and significant others, and with other service providers within the boundaries of existing confidentiality regulations
Recognition of the importance of confidentiality regulations Respect for a client's right to privacy Demonstrate respect and non-judgmental attitudes toward clients in all contacts with community professionals and agencies
Behaviors appropriate to professional collaboration Client rights and responsibilities
Establishing and maintaining non-judgmental, respectful relationships with clients and other service providers Demonstrating clear, concise, accurate communication with other professionals or agencies Applying the confidentiality regulations when communicating with agencies Transferring client information to other service providers in a professional manner
Willingness to advocate on behalf of the client Professional concern for the client Commitment to professionalism
Maintain ongoing contact with client and involved significant others to ensure adherence to the treatment plan
Social, cultural, and family systems Techniques to engage the client in treatment process Outreach, follow-up, and aftercare techniques Methods for determining the client's goals, treatment plan, and motivational level Assessment mechanisms to measure client's progress toward treatment objectives
Engaging client, family, and significant others in the ongoing treatment process Assessing client progress toward treatment goals Helping the client maintain motivation to change Assessing the comprehension level of the client, family, and significant others Documenting the client's adherence to the treatment plan Recognizing and addressing ambivalence and resistance Implementing follow-up and aftercare protocols
Professional concern for the client, the family, and significant others Therapeutic optimism Recognition of relapse as an opportunity for positive change Patience and perseverance Understand and recognize stages of change and other signs of treatment progress
How to recognize incremental progress toward treatment goals Client's cultural norms, biases, unique characteristics, and preferences for treatment Generally accepted treatment outcome measures Methods for evaluating treatment progress Methods for assessing client's motivation and adherence to treatment plans Theories and principles of the stages of change and recovery
Identifying and documenting change Assessing adherence to treatment plans Applying treatment outcome measures Communicating with people of other cultures Reinforcing positive change
Appreciation for cultural issues that impact treatment progress Respect for individual differences Therapeutic optimism Assess treatment and recovery progress and, in consultation with the client and significant others, make appropriate changes to the treatment plan to ensure progress toward treatment goals
Continuum of care Interviewing techniques Stages in the treatment and recovery process Individual differences in the recovery process Methods for evaluating treatment progress Methods for re-involving the client in the treatment planning process
Participating in conflict resolution, problem solving, and mediation Observing, recognizing, assessing, and documenting client progress Eliciting client perspectives on progress Demonstrating clear and concise written and verbal communication Interviewing individuals, groups, and families Acquiring and prioritizing relevant treatment information Assisting the client in maintaining motivation Maintaining contact with client, referral sources, and significant others
Willingness to be flexible Respect for the client's right to self-determination Appreciation of the role significant others play in the recovery process Appreciation of individual differences in the recovery process Describe and document treatment process, progress, and outcome
Treatment modalities Documentation of process, progress, and outcome Factors affecting client's success in treatment Treatment planning
Demonstrating clear and concise oral and written communication Observing and assessing client progress Engaging client in the treatment process Applying progress and outcome measures
Appreciation of the importance of accurate documentation Recognition of the importance of multidisciplinary treatment planning Use accepted treatment outcome measures
Treatment outcome measures Understand concepts of validity and reliability of outcome measures
Using outcome measures in the treatment planning process
Appreciation of the need to measure outcomes Conduct continuing care, relapse prevention, and discharge planning with the client and involved significant others
Treatment planning process Continuum of care Available social and family systems for continuing care Available community resources for continuing care Signs and symptoms of relapse Relapse prevention strategies Family and social systems theories Discharge planning process
Accessing information from referral sources Demonstrating clear and concise oral and written communication Assessing and documenting treatment progress Participating in confrontation, conflict resolution, and problem solving Collaborating with referral sources Engaging client and significant others in treatment process and continuing care Assisting client to develop a relapse prevention plan
Therapeutic optimism Patience and perseverance Document service coordination activities throughout the continuum of care
Documentation requirements including, but not limited to
addiction counseling other disciplines funding sources agencies and service providers Service coordination role in the treatment process
Demonstrating clear and concise written communication Using appropriate technology to report information in an accurate and timely manner within the bounds of confidentiality regulations
Acceptance of documentation as an integral part of the treatment process Willingness to use appropriate technology Apply placement, continued stay, and discharge criteria for each modality on the continuum of care
Treatment planning along the continuum of care Initial and ongoing placement criteria Methods to assess current and ongoing client status Stages of progress associated with treatment modalities Appropriate discharge indicators
Observing and assessing client progress Demonstrating clear and concise written and verbal communication Participating in conflict resolution, problem solving, mediation, and negotiation Tailoring treatment to meet client needs Applying placement, continued stay, and discharge criteria
Confidence in client's ability to progress within a continuum of care Appreciation for the fair and objective use of placement, continued stay, and discharge criteria
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