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Executive SummaryCase management has been variouslyclassified as a skill group, a corefunction, service coordination, or anetwork of “friendly neighbors.” Although itdefies precise definition, case managementgenerally can be described as a coordinatedapproach to the delivery of health, substanceabuse, mental health, and social services, linkingclients with appropriate services to addressspecific needs and achieve stated goals. TheConsensus Panel that developed this TIPbelieves that case management lends itself to thetreatment of substance abuse, particularly forclients with other disorders and conditions whorequire multiple services over extended periodsof time and who face difficulty in gaining accessto those services. This document details thefactors that programs should consider as theydecide to implement case management ormodify 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 casemanagement is effective as an adjunct tosubstance abuse treatment. First, retention intreatment is associated with better outcomes,and a principal goal of case management is tokeep clients engaged in treatment and movingtoward recovery. Second, treatment may bemore likely to succeed when a client’s otherproblems are addressed concurrently withsubstance abuse. Case management focuses onthe whole individual and stressescomprehensive assessment, service planning,and service coordination to address multipleaspects of a client’s life. Comprehensivesubstance abuse treatment often requires thatclients move to different levels of care orsystems; case management facilitates suchmovement.Any definition of case management will becontextual, depending on who is implementingthe program. Perhaps a more helpful way tounderstand it is to examine the functions thatgenerally comprise case management: (1)assessment, (2) planning, (3) linkage, (4)monitoring, and (5) advocacy.Case Management andSubstance AbuseTreatmentWhen implemented to its fullest, casemanagement will enhance the scope ofaddictions treatment and the recoverycontinuum. A treatment professional utilizingcase management will Provide the client a single point of contact formultiple health and social services systems Advocate for the client Be flexible, community-based, and clientoriented Assist the client with needs generallythought to be outside the realm of substanceabuse treatmentxiii

Executive SummaryTo provide optimal services for clients, atreatment professional should possess particularknowledge, skills, and attitudes including Understanding various models and theories of addiction and other problems related tosubstance abuseAbility to describe the philosophies,practices, policies, and outcomes of the mostgenerally accepted and scientificallysupported models of treatment, recovery,relapse prevention, and continuing care foraddiction and other substance-relatedproblemsAbility to recognize the importance of family,social networks, community systems, andself-help groups in the treatment andrecovery processUnderstanding the variety of insurance andhealth maintenance options available and theimportance of helping clients access thosebenefitsUnderstanding diverse cultures andincorporating the relevant needs of culturallydiverse groups, as well as people withdisabilities, into clinical practiceUnderstanding the value of aninterdisciplinary approach to addictiontreatmentIn addition to the above competencies,treatment professionals must have skills relatingto interagency functioning, negotiating, andadvocacy. CSAT’s Addiction TechnologyTransfer Centers classify referral and servicecoordination—basic case managementfunctions—as core competencies for substanceabuse treatment providers.The Substance Abuse TreatmentContinuum and Functions of CaseManagementThe continuum of substance abuse treatmentranges from case finding and pretreatment toprimary treatment to aftercare. Although therexivare distinct goals and treatment activities at eachpoint on the continuum, rarely do clients’ needsfit neatly into any one area at a given time; casemanagement serves to span client needs andprogram structure. Substance abuse treatmentand case management functions differ in thattreatment involves activities that help substanceabusers recognize their problems, acquire themotivation and tools to stay abstinent, and usethe acquired tools; case management focuses onhelping the substance abuser acquire neededresources. Case management supports a clientas he moves through the recovery continuumand reinforces treatment goals.Interagency CaseManagementThe goal of interagency case management is toexpand the network of services available toclients. All organizations have boundaries towhat they can do, and case managers or“boundary spanners” transcend them tofacilitate interactions among agencies. In thefield of substance abuse, three interagencymodels have been identified. In the single agencymodel, the case manager personally establishesa series of distinct relationships on an as-neededbasis with counterparts in other agencies. In theinformal partnership model, staff members fromseveral agencies work as a collaborative team,often constituted case by case; the formalconsortium binds case managers and serviceproviders through formal written agreements.Clearly defined roles are essential to all threemodels to ensure that services are coordinatedand relevant gaps addressed.Although informal exchange or “socialservice bartering” among different agencies isintrinsic to case management, a more formalizedconnection among agencies sometimes may berequired. Examples include memoranda ofunderstanding and interagency agreements andcontracts; each of these methods for formalizing

Executive Summaryexpectations can be used in single agencymodels, informal partnerships, and formalconsortia.To be successful, a case management planmust thoroughly and critically examinecommunity resources to determine what formsof assistance are available and how casemanagement efforts can help clients attainnecessary assistance. Many communities havepublished directories of social, health, welfare,housing, vocational, and other serviceorganizations to help case managementprograms identify resources, possible providerlinkages, and potential gaps in services for theirclients. Although such directories are a goodstarting point, it is important to follow up on thelistings to ensure they are still accurate and willbe of use to the client.The Environmental AssessmentExploring the environment in which an agencyoperates is crucial to determining the feasibilityof an interagency effort. Analysis of thecommunity environment will enhanceunderstanding of the changes that occur amongclients, within the program, and in thecommunity. Case management takes placewithin a dynamic social service environment inwhich agencies are in constant flux. Programsconsidering interagency efforts must devisestrategies to respond to change while providingcontinuity for the client. Regular reevaluationhelps ensure continued relevance; communityservice provider networks or consortia areparticularly effective in sharing informationabout changes and developments.Potential ConflictsWhenever agencies or service providers worktogether, the potential for conflict exists. Areasof tension may be present from the very onset ofthe collaboration. For example, a new projectmay be viewed by established social serviceagencies as competition for scarce resources.Sometimes social pressures or the need tomaximize resources can force public agenciesinto joint ventures even if they do not mesh wellor have a history of being service competitors.Tensions can also develop in the course ofdelivering services; for example, interagencycollaboration may result in a client having twocase managers. Recognizing potential triggersfor conflict is a necessary first step in developinga system to handle them. When problems doarise, case managers and other agency personnelcan use both informal and formalcommunication to clarify issues, regainperspective, and refocus the interagency casemanagement process.Evaluation and QualityAssurance of CaseManagement ServicesSubstance abuse treatment programs, includingthose that receive public funding, areincreasingly operating in a managed careenvironment. In such an environment, policyand clinical decisionmaking rely on outcomedata that traditionally describe the impact ofcase management and substance abusetreatment interventions in the context of servicesused and money spent. An additional demandfor data comes from public and private payerswho want services linked to specific outcomes.To gauge the effectiveness of casemanagement, indicators of “success” must bedefined by the substance abuse program and itsstakeholders (including funding and regulatoryagencies). In documenting a case managementeffort, it is necessary to establish benchmarks tomeasure the case management process, forexample, recording how often a client shows upat treatment. Once the benchmarks are definedin measurable terms, the next step is to developand implement a method for measuringpractice; that is, to answer the questions, “Whatare case managers doing, and how does theirxv

Executive Summarypractice conform to the benchmarks?” Methodsof such documentation include Maintenance of a simple staff log procedurethat measures case managers’ activities bycontact Reviews of case manager client records toevaluate how service planning and referralsadhere to benchmarks Interviews or surveys of case managers orclients and their family members to collectinformation on activities in which casemanagers engage, to identify how clients’and case managers’ views of casemanagement activities differ Analysis of data from the agency’smanagement information system (to examinepatterns on type, number, and duration ofcase manager contacts with different targetpopulations).Measuring System OutcomesSystem outcomes are particularly important in amanaged care environment, where overall useof expensive services such as hospitalization andresidential treatment is strictly monitored.System outcomes can measure cost savings andquality of care: For example, continuity of care isan appropriate measure for a client at risk forrelapse after detoxification and before entry intooutpatient treatment. Tracking clients within acomprehensive service agency or analyzing dataon costs and encounters within a network ofagencies are two methods for measuring systemoutcomes. For such analyses, a computerizedmanagement information system (MIS) isessential.Measuring Client OutcomesAlthough “evaluation” is generally consideredworthwhile, there is little agreement about themeasurement and documentation of specificoutcomes for individual clients. Some view asingle measure such as sobriety to be the onlymeaningful indicator of success; others believexvisuccess should be gauged against a range offactors, including reduced substance use,improved family functioning, and fewerencounters with the criminal justice system.Until the debate is resolved, programs shouldidentify treatment objectives and extrapolatefrom them the outcome variables they want tomeasure.Anticipating Quality AssuranceData NeedsThe types of data required for an evaluation ofcase management, how the data are collected,and the manner in which data are put to usevary among different stakeholders. It isimportant to understand the types of data thatvarious stakeholders need to evaluate theprogram. Structured feedback loops should beestablished to ensure that the gathered data arereturned to various stakeholders in somemeaningful way so that they have an impact onshaping future program development (andfuture data needs). One of the benefits of thecase management approach is that it can beadapted to meet the sometimes contradictorynee

Case Management for Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. . HHS Publication No. (SMA) 12-4215. Rockville, MD: Author, 2012. Originating Office Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental