National Institute on Drug Abuse

RESEARCH

MONOGRAPH SERIES

Progress and

Issues in Case

Management

U.S. Department of Health and Human Services • Public Health Service • National Institutes of Health

127
Progress and Issues

in Case Management

Editor:

Rebecca Sager Ashety, D.S.W.

NIDA Research Monograph 127

1992

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, MD 20857
ACKNOWLEDGMENT

This monograph is based on the papers and discussions from a technical

review on “Progress in Case Management” held on February 4-5, 1992, in

Bethesda, MD. The technical review was sponsored by the National Institute

on Drug Abuse (NIDA).

COPYRIGHT STATUS

NIDA has obtained permission from the copyright holders to reproduce certain

previously published material as noted in the text. Further reproduction of this

copyrighted material is permitted only as part of a reprinting of the entire

publication or chapter. For any other use, the copyright holder’s permission

is required. All other material in this volume except quoted passages from

copyrighted sources is in the public domain and may be used or reproduced

without permission from the Institute or the authors. Citation of the source is

appreciated.

Opinions expressed in this volume are those of the authors and do not

necessarily reflect the opinions or official policy of the National Institute on Drug

Abuse or any other part of the U.S. Department of Health and Human Services.

The U.S. Government does not endorse or favor any specific commercial

product or company. Trade, proprietary, or company names appearing in this

publication are used only because they are considered essential in the context

of the studies reported herein.

NIDA Research Monographs are indexed in the “Index Medicus.” They are

selectively included in the coverage of “American Statistics Index,” “BioSciences

Information Service,” “Chemical Abstracts,” “Current Contents,” “Psychological

Abstracts,” and “Psychopharmacology Abstracts.”

DHHS publication number (ADM)92-1946

Printed 1992

i i
Contents

Page

Executive Summary 1

Rebecca Sager Ashery

Application of Case Management to Drug Abuse Treatment:

Overview of Models and Research Issues 12

M. Susan Ridgely and Mark L. Willenbring

Managed Care and Case Management of Substance

Abuse Treatment 34

Albert Woodward

Accessing Additional Community Resources Through

Case Management To Meet the Needs of Methadone

Clients 54

Michael L. Dennis, Georgia T. Karuntzos, and J. Valley Rachal

A Strengths-Based Model of Case Management/Advocacy:

Adapting a Mental Health Model To Practice Work With

Persons Who Have Substance Abuse Problems . . . . . . . . . . . . . . . . . . . . . . . . 79

Richard C. Rapp, Harvey A. Siegal, and James H. Fisher

Case Management: An Alternative Approach to Working

With Intravenous Drug Users 92

Peter J. Bokos, Cheryl L. Mejta, Judith H. Mickenberg, and

Robert L. Monks
Transitional Case Management: A Service Model for AIDS

Outreach Projects 112

Victor Lidz, Donald A. Bux, Jerome J. Platt,

and Martin Y. lguchi

Delivering Case Management Using a Community-Based

Service Model of Drug Intervention 145

Judith A. Levy, Charles P. Gallmeier, William W. Weddington,

and W. Wayne Wiebel

Case Management To Enhance AIDS Risk Reduction

for Injection Drug Users and Crack Cocaine Users:

Practical and Philosophical Considerations 167

Russel S. Falck, Harvey A. Siegal, and Robert G. Carlson

Case Management Services for HIV-Seropositive IDUs 181

H. Virginia McCoy, Sally Dodds, James E. Rivers,

and Clyde B. McCoy

Case Management Models for Homeless Persons With

Alcohol and Other Drug Problems: An Overview of

the NIAAA Research Demonstration Program 208

Harold I. Perl and Mary Lou Jacobs

Integrating Qualitative and Quantitative Components

in Evaluation of Case Management 223

Mark L. Willenbring

Case Management Systems Represented in the

NIDA-Supported “Perinatal-20” Treatment Research

Demonstration Projects 251

Elizabeth R. Rahdert

Case Management: A Telecommunication Practice

Model 261

Farrokh Alemi, Richard C. Stephens, and John Butts

Aftercare for Formerly Homeless, Recovering Women:

Issues for Case Management 274

Deborah McMillan and Rose Cheney

i v
Intensive Case Management for Youth With Serious

Emotional Disturbance and Chemical Abuse 289

Mary E. Evans and Norin Dollard

Case Management as a Mechanism for Linking Drug

Abuse Treatment and Primary Care: Preliminary

Evidence From the ADAMHA/HRSA Linkage

Demonstration 316

William E. Schlenger, Larry A. Kroutil,

and E. Joyce Roland

Development and Implementation of an Interorganizational

Case Management Model for Substance Users 331

Ellen P. McCarthy, Zoila Torres Feldman,

and Benjamin F. Lewis

Assertive Community Treatment With a Parolee Population:

An Extension of Case Management 350

James A. Inciardi, Howard Isenberg, Dorothy Lockwood,

Steven S. Martin, and Frank R. Scarpitti

TASC: Case Management Models Linking Criminal

Justice and Treatment 368

Foster Cook

Case Management Community Advocacy for Substance

Abuse Clients 383

Rebecca Sager Ashery

List of NIDA Research Monographs 395

v

Executive Summary

Rebecca Sager Ashery

INTRODUCTION

A technical review on “Progress and Issues in Case Management” was held on

February 4 and 5, 1992. The purpose of the technical review was to examine

research studies on case management and substance abuse and to consider

future research directions. The review represents the cutting edge in research

on case management and substance abuse. Although several studies have

been conducted in the past on case management with chronically mentally ill

persons, the research presented in the technical review and in this monograph

represents first-time endeavors to conduct studies on case management with

substance abusers. Several case management models are being used in a

variety of settings with different substance-abusing populations. The studies

are in various stages-some have been completed, whereas others are in their

first year, and still others are in the middle. All the studies are collecting both

quantitative and qualitative data, and they represent randomized clinical trials

and evaluation studies. Some of the studies are comparing case management

alone to a standard intervention, whereas others are testing case management

plus an additional intervention(s) to a standard intervention. Participants

discussed both research and service delivery issues, such as barriers to

accessing resources, gaps in services, community linkages development,

model development, case manager/client ratio, cost-effectiveness and costcontainment, instruments and measurements, and background and education

of case managers.

The presentations were divided into several parts, which included (1) an

overview of case management; (2) case management and drug treatment;

(3) case management and outreach; (4) case management and special

populations, including persons with the human immunodeficiency virus (HIV),

homeless people, women, and youth; (5) case management and linkages; and

(6) case management with the criminal justice population. Below is a summary

of the chapters that resulted from the technical review.

i
OVERVIEW OF CASE MANAGEMENT

Application of Case Management to Drug-Abuse Treatment: Overview of

Models and Research Issues

M. Susan Ridgely and Mark L. Willenbring. Ridgely and Willenbring emphasize

that case management remains a loosely defined service, lending itself to many

adaptations to achieve a variety of objectives. They propose a typology looking

at the interaction among the functions and dimensions of case management

across programs. Four aspects of evaluation that are necessary to improve

the state of the art are discussed: (1) precise description of the intervention,

(2) implementation analysis, (3)implementation timetable, and (4) description

of the environment in which the program functions. Ridgely and Willenbring

also discuss potential problems in field research and measurement.

Managed Care and Case Management of Substance Abuse Treatment

Albert Woodward. Woodward states that no single, widely accepted definition

of managed care exists; however, many definitions share the same elements.

Managed care, as distinct from case management, is a cost-containment

strategy. Case management may often be used as part of a managed-care

plan. Issues in the managed care of drug treatment include tension between

quality of care vs. cost savings and cost-containment, the influence of financial

incentives in terms of quality of care, the lack of uniform explicit and relevant

criteria for assigning and monitoring patients in drug treatment, difference in

impact of managed care on public- and private-sector drug treatment programs,

and questions of cost benefits and savings. Woodward states that although

the primary goal of case management is not cost savings (like managed care),

with contracting public budgets it is paramount that case management show

itself to be cost-effective or cost-beneficial.

CASE MANAGEMENT AND TREATMENT

Accessing Additional Community Resources Through Case Management

To Meet the Needs of Methadone Clients

Michael L. Dennis, Georgia T. Karuntzos, and J. Valley Rachal. Dennis and

colleagues present data from two studies that the Research Triangle Institute

is conducting to examine the unmet needs of methadone clients and the extent

to which the case management approach can be used to improve treatment

outcomes. Both studies identify two major gaps in the existing service system:

(1) unavailability of local resources to help clients meet small and immediate

expenses to cover things such as car repairs, license exams, and initiation fees

2
and (2) operation shortfalls that prevented immediate intakes but not long-term

commitments (i.e., vocational programs that had slots but were out of funds for

child care). Data from one of the studies indicate that case managers were able

to reduce the application time for most benefit programs by 50 to 80 percent.

Dennis and colleagues recommend specific design features that should be

incorporated in future studies and in assessing the validity of the experiment.

A Strengths-Based Model of Case Management/Advocacy: Adapting a

Mental Health Model To Practice Work With Persons Who Have Substance

Abuse Problems

Richard C. Rapp, Harvey A. Siegal, and James H. Fisher. Rapp and

colleagues report on the initial model of the Enhanced Treatment Project,

which is in the beginning stages. The premise of the project is that case

management activities will improve treatment retention and compliance by

assisting patients in acquiring necessary resources and also by serving as a

therapeutic intervention. The project plans to recruit 600 veterans who apply

for substance abuse treatment at the Veterans Affairs Medical Center (VAMC)

in Dayton, OH. Veterans will be randomly assigned to one of the following: (1)

pretreatment induction (weekend intervention program) and case management/

advocacy, (2) case management/advocacy alone, (3) pretreatment induction

alone, or (4) no pretreatment induction and no case management/advocacy.

All veterans will participate in the standard inpatient or outpatient VAMC

programs. The case management/advocacy used in the project is based

on the strengths approach developed by Rapp and Chamberlain (1985).

The model is predicated on five principles, of which the foremost focuses on

assisting the client to utilize his or her strengths and assets as the vehicle for

acquiring needed resources. Case management/advocacy activities may

continue for up to 6 months. All veterans in the project will be reinterviewed

at 6, 12, and 18 months after intake to determine the effects of project

interventions. Rapp and colleagues address the role of therapist vs. case

manager and the potential conflict between the disease concept of substance

abuse and the strengths perspective.

Case Management: An Alternative Approach to Working With Intravenous

Drug Users

Peter J. Bokos, Cheryl L. Mejta, Judith H. Mickenberg, and Robert L. Monks.

The Interventions research study was designed to evaluate the effectiveness of

a case management approach compared with standard treatment in improving

intravenous drug users’ (IVDUs) access to and retention in treatment, treatment

completion, and reduction in posttreatment relapses. A total of 300 matched

IVDUs seeking publicly funded treatment will be enrolled in the study and

3
assigned to the case-managed condition or to the standard-treatment

condition (150 people in each) and followed for 3 years. Clients assigned

to the standard-treatment condition receive the names, addresses, and

telephone numbers of three substance abuse clinics within the client’s

geographical vicinity. Clients assigned to the case-managed condition are

referred to a case manager who completes an initial client assessment,

facilitates the client’s entry into treatment, and addresses other immediate

needs of the client such as housing and transportation. So far, 204 clients

have been admitted to the study (102 in each group). Ninety percent of the

case-managed clients and 35 percent of the control clients have entered a

substance abuse treatment program. The average length of time to admission

into a substance abuse treatment program was 6.19 days for the casemanaged clients and 31.69 days for the control clients. Within 15 days, 76

percent of the case-managed clients were admitted into a substance abuse

treatment program compared with 7 percent of the control clients.

CASE MANAGEMENT AND OUTREACH

Transitional Case Management: A Service Model for AIDS Outreach

Projects

Victor Lidz, Donald A. Bux, Jerome J. Platt, and Martin Y. Iguchi. Transitional

case management (TCM) aims at time-limited or short-term service to make a

quick, effective intervention in the lives of clients. The project, which was part

of an outreach demonstration project, emphasized the brokerage element of

case management-the attempt to place clients with agencies that can deliver

services matched to their needs with some monitoring of the service delivered.

IVDU and sexual partner subjects obtained through street outreach were

compared in Jersey City, NJ, and Newark, NJ. The study had three comparison

protocols. Only 38 percent of clients starting TCM completed the standard four

sessions. However, in spite of this, 83 percent of clients received service from

the TCM referral procedure compared with 13 percent for the standard care

group. Most clients wanted specific help only and tended not to be looking for

more comprehensive care. Lidz and colleagues suggest several enhancements

to reduce attrition.

Delivering Case Management Using a Community-Based Service Model of

Drug Intervention

Judith A. Levy, Charles P. Gallmeier, William W. Weddington, and W. Wayne

Wiebel. Two hundred active drug abusers in Chicago are being recruited for

the Neighborhood Outreach Demonstration Project. Subjects are randomly

assigned to the standard (control) or the enhanced group. The standard group

4
receives a referral list of agencies, and the worker will set up an appointment

by telephone. The community-based service (enhanced) model group receives

case management and peer support. The professional case manager meets

on a regular basis with the client and sets goals, discusses difficulties,

makes linkages, and monitors the clients progress, The indigenous outreach

worker provides on-the-street support, which includes helping clients find

transportation, providing followthrough on appointments, and serving as a

source of encouragement. Therefore, in this model, the professional case

manager and the indigenous outreach worker work as a team. Levy and

colleagues describe difficulties in carrying out the research and four sets

of findings related to programmatic issues.

Case Management To Enhance AIDS Risk Reduction for injection Drug

Users and Crack Cocaine Users: Practical and Philosophical

Considerations

Russell S. Falck, Harvey A. Siegal, and Robert G. Carlson. The DaytonColumbus AIDS Prevention Research Project employs a service-broker

case management model nested in an acquired immunodeficiency

syndrome (AIDS) educational program. This is a street outreach project

aimed at injection drug users (IDUs) and crack users. These subjects will be

randomly assigned to one of three intervention tracks. Subjects randomized

into the enhanced intervention track will receive AIDS educational sessions

and case management. The uniqueness of the intervention is that it blends

two different approaches to modifying human behavior: (1) a cognitive

behaviorally oriented educational program coupled with (2) a service-broker

model of case management. The total intervention has a 2-month time limit.

The model was being pilot-tested at the time of the presentation.

SPECIAL POPULATIONS

Case Management Services for HIV-Seropositive IDUs

H. Virginia McCoy, Sally Dodds, James E. Rivers, and Clyde B. McCoy.

McCoy and colleagues report on a 1-year demonstration program that involved

collaborative efforts between the University of Miami Comprehensive Drug

Research Center and the South Florida AIDS Network on an evaluation of

AIDS prevention education and case management services for HIV-seropositive

IDUs. Participants were randomly assigned to either the case management or

the control group. Participants in the case management group were assigned

to a case manager and received HIV prevention/education services and basic

case management services. The project has documentation on the cost of

services and on the time and efforts to maintain contact and monitor those in

5
the enhanced group. Data suggest that attention to engagement and

interaction with a client is a critical task of case managers working with IDUs.

Case Management Models for Homeless Persons With Alcohol and Other

Drug Problems: An Overview of the NIAAA Research Demonstration

Program

Harold I. Perl and Mary Lou Jacobs. Perl and Jacobs report on the Cooperative

Agreements for Research Demonstration Projects on Alcohol and Other Drug

Abuse Treatment for Homeless Persons funded by the National Institute

on Alcohol Abuse and Alcoholism. Thirteen of the fourteen projects have

proposed to provide case management services to meet the goal of increasing

linkages and cooperation among local social service agencies. Each project

has conceptualized the structure and intensity of its case management model

in a different way. Perl and Jacobs review some of the structural and functional

dimensions across which the different programs vary, including barriers to

program implementation. All the projects will be conducting outcome and

process evaluations. Perl and Jacobs also describe the Quarterly Report Form

used by the projects, which forms a matrix that gives information about services

rendered.

Integrating Qualitative and Quantitative Components in Evaluation of

Case Management

Mark L. Willenbring. Willenbring discusses the importance of integrating

qualitative and quantitative approaches to case management. The Community

Treatment for the Chronic Public Inebriate project was a randomized,

controlled trial comparing the effectiveness of three levels of intensity of case

management. Subjects consisted of 260 male public inebriates. Willenbring

discusses qualitative methods used in the collection of information, including

narrative logs, interviews, and observation. He emphasizes that whenever

possible multiple quantitative and qualitative methods should be used, which

can reduce the chances for biased conclusions based on distorted data or for

missing a critical factor.

Case Management Systems Represented in the NIDA-Supported

“Perinatal-20” Treatment Research Demonstration Projects

Elizabeth R. Rahdert. Rahdert reports on the Perinatal-20 grant program,

which comprises 20 treatment research demonstration projects offering

comprehensive, therapeutic, and adjunct services on a long-term basis to

addicted women of childbearing age and to their children and other family

members. Most of the projects include case management and represent

6
various models and components. Rahdert gives examples of functional

components associated with traditional case management systems that

are incorporated into at least one of the Perinatal-20 projects. These

components include outreach, home visiting, the use of screening and

diagnostic assessment instruments, service planning, the linking and

coordinating of services, the monitoring of service delivery and utilization,

and advocacy. By collecting a common set of defined data, the Perinatal-20

projects will be able to critically examine each case management functional

component in terms of its contribution to enlisting and retaining addicted

women in treatment.

Case Management: A Telecommunication Practice Model

Farrokh Alemi, Richard C. Stephens, and John Butts. Alemi and colleagues

focus on the potential impact of talking computers on case management.

They believe that telecommunications can radically improve the productivity

of case managers and help clients directly. Alemi and colleagues will be

testing the use of computers in a variety of ways for both clients and providers.

One method consists of a telephone support group that enables patients to

participate in group discussions from their homes without revealing their

identity, A randomized trial has been designed that divides volunteer, drugaddicted pregnant women into two groups: a control group with traditional

case management and an experimental group with telephone-assisted case

management. One hundred and fifty patients will be assigned to each group.

Aftercare for Formerly Homeless, Recovering Women: Issues for Case

Management

Deborah McMillan and Rose Cheney. The Aftercare project, which is in the

beginning stages, focuses on 200 formerly homeless recovering women with

children. The target population will be randomized into two groups. One group

will receive peer support and case management, and the other will receive case

management alone. Subjects will be followed for 18 months. The caseload

will consist of one case manager to 15 families. The case management model

incorporates a philosophy of empowerment. McMillan and Cheney identify

several barriers in working with the target population, including the need for

life and parenting skills, manipulative coping behaviors, transportation, and

the potential for relapse. They also identify roles for the case manager,

including advocate, treatment coordinator, educator, and therapist. Major

gaps in services, such as the lack of affordable housing, affordable child care,

and material goods, will require advocacy by the case manager.

7
Intensive Case Management for Youth With Serious Emotional

Disturbance and Chemical Abuse

Mary E. Evans and Norin Dollard. Evans and Dollard report on a New York

State Children and Youth Intensive Case Management (CYICM) program

that has the goal of maintaining children and youth with serious emotional

disturbances in the natural home. The program has a 24-hour-per-day, 7-dayper-week response capability. The child-to-worker ratio is 10:1. The intensive

case managers have access to flexible service dollars that can be used to

facilitate the client’s access to needed services and supports. Although

chemical abusers displayed a greater number of and different constellation

of problem behaviors and symptoms than nonabusers, the outcomes for both

abusers and nonabusers after the intensive case management program were

similar, with the abusing group spending significantly fewer days in State

inpatient hospitals and having fewer numbers of admissions than they had

experienced in the year prior to enrollment. The chapter discusses barriers

to model development and implementation and identifies impediments to

interagency cooperation and gaps in services. The chapter also outlines

several research strategies, including descriptive studies, program evaluation,

and funded research, that are used in assessing the effectiveness of CYICM.

CASE MANAGEMENT AND LINKAGES

Case Management as a Mechanism for Linking Drug Abuse Treatment and

Primary Care: Preliminary Evidence From the ADAMHA/HRSA Linkage

Demonstration

William E. Schlenger, Larry A. Kroutil, and E. Joyce Roland. Schlenger and

colleagues report on a National Evaluation of the ADAMHA/HRSA Linkage

Demonstration program. The goals of this program were to (1) recognize and

treat the health care problems of drug abuse treatment clients, (2) recognize

and treat substance abuse in the context of the primary care system, and (3)

identify feasible approaches to the provision of integrated health care in the

context of existing community-based services. Twenty-one grantees located

in 19 cities and 15 States across the country were funded. The purpose of the

National Evaluation is to identify and describe promising models whose efficacy

could be studied more rigorously in subsequent demonstrations, All 21 projects

proposed to use case management as a mechanism for achieving linkage.

Schlenger and colleagues give descriptive information about the linkage

program. Findings indicate that those who are identified through drug abuse

treatment are more likely than those who are identified through primary care

to receive drug abuse treatment (90 percent vs. 30 to 60 percent, respectively).

Clients identified in centralized model projects (nurse practitioners onsite at the

8
drug treatment facility) were nearly twice as likely to receive treatment than

those identified in decentralized models (services offered at different locations)

(65 vs. 31 percent for any treatment). Findings suggest that those who receive

more case management receive more services of all kinds. The relationship is

particularly strong in decentralized models. A second phase of the National

Evaluation will address the issue of models, characteristics of the case

managers, and service delivery.

Development and Implementation of an Interorganizational Case

Management Model for Substance Users

Ellen P. McCarthy, Zoila Torres Feldman, and Benjamin F. Lewis. McCarthy

and colleagues report on an interorganizational effort (part of the ADAMHA/

HRSA Linkage Demonstration program) to develop and evaluate a model for

the provision of primary health care services to substance abusers and for

the referral to appropriate substance abuse services of individuals in need of

treatment. The program has a central organizing and coordinating entity, which

is a federally funded community health center serving a predominantly Hispanic

population but also provides services citywide. A system of interorganizational

case management was designed and implemented to accomplish linkage

objectives to primary health care and substance abuse programs and HIV

services. Thirteen key agencies participate in the model. A linkage case

coordinator is employed by each of these agencies and is considered a point

of entry into the linkage program. He or she acts as an intermediary to link the

services of agencies in the community together so that the client has access

to a comprehensive range of care. Agency coordination takes place at multiple

levels. The evaluation component of the program focuses on the extent to

which linkages have been accomplished between the substance abuse and

primary health care systems.

CRlMlNAL JUSTICE

Assertive Community Treatment With a Parolee Population: An Extension

of Case Management

James A. Inciardi, Howard Isenberg, Dorothy Lockwood, Steven S. Martin, and

Frank R. Scarpitti. lnciardi and colleagues report on the University of

Delaware’s Assertive Community Treatment program, which combines case

management services with an intensive outpatient treatment regimen for druginvolved parolees. The focus of the model is on helping the client reenter the

community by providing “in vivo treatment.” Components of the model include

active face-to-face contact between counselor and client and the availability of

staff to clients at all times. Counselors have access to instrumental support for

9
clients (e.g., job training, rent and food money, and transportation) and more

traditional forms of treatment, rehabilitation, and support group services. As

applied to parolees, the model has time limits and success goals. There are

five phases for drug treatment, varying in intensity. During the course of the

study, 200 study subjects will be randomized into treatment and control groups.

A third comparison group includes parolees who have graduated from a prisonbased therapeutic community. lnciardi and colleagues discuss the barriers in

conducting research with a parolee population and problems in conducting

research on case management.

TASC: Case Management Models Linking Criminal Justice and Treatment

Foster Cook. The Treatment Alternatives to Street Crime (TASC) programs

provide a structured linkage between the justice and treatment systems. There

are 185 TASC programs in 24 States and 2 territories. TASC is capable of

intervening from the time of arrest through parole, with juveniles or adults and

with all types of offenses. TASC programs routinely serve offenders who use

alcohol or other drugs as they move forward through the justice system,

coordinating services throughout the process. TASC programs surveyed by

the National Consortium of TASC Programs in 1987 reported that the majority

of TASC clients were adults between the ages of 25 and 40; 82 percent were

male, and 53 percent were minorities. Seventy-eight percent were charged with

a felony arrest, and 75 percent had prior arrests. Cook points out that recent

studies have documented the success of coerced treatment for drug-involved

offenders. TASC clients have been found to remain in treatment 6 to 7 weeks

longer than other criminal justice-referred or voluntary clients. Cook discusses

the 10 critical elements and accompanying performance standards upon which

the TASC programs have developed their assessment protocols. More than

40 local program evaluations took place between 1972 and 1982. Most

evaluation studies found TASC effective in linking the criminal justice and

treatment systems. There has never been a national evaluation of the entire

TASC effort; however, three representative studies are under way.

REFERENCE

Rapp, C.A., and Chamberlain, R. Case management services for the chronically

mentally ill. Soc Work 30:417-422, 1985.

AUTHOR

Rebecca Sager Ashery, D.S.W.

Senior Social Work Specialty Consultant

Community Research Branch

10
Division of Applied Research

National Institute on Drug Abuse

Parklawn Building, Room 9A-30

5600 Fishers Lane

Rockville, MD 20857

11
Application of Case Management to

Drug Abuse Treatment: Overview of

Models and Research Issues

M. Susan Ridgely and Mark L. Willenbring

INTRODUCTION

There is growing interest in case management in the drug abuse treatment

field. Changes in the way drug abuse is viewed, problems in the current

delivery of drug abuse treatment, and cost containment pressures have all

converged to heighten curiosity about the usefulness of case management.

First, over time, practitioners and researchers have acquired a more complex

and complete view of the phenomenon of drug dependence. Rather than

viewing drug abuse as a single phenomenon, drug abuse has come to be

viewed as a multifaceted problem with presentations ranging from acute abuse

to chronic dependence, with high potential for relapse and recidivism. Rather

than there being a single effective approach to treatment, multiple approaches

are required. Patient-treatment matching has become a preoccupation.

There are identified subgroups of drug-dependent persons who are less

responsive to currently available treatments or who have special access

problems. Some of these subgroups are human immunodeficiency viruspositive intravenous drug users, poor and homeless drug users, and people

with concomitant mental illness and drug dependence. These people, defined

as having complex needs, require continual rather than episodic drug abuse

treatment and human services beyond drug abuse treatment. This constellation

of needs is similar to that presented by other populations with complex needs

such as people with chronic mental illness, frail elderly persons, and people

with acquired immunodeficiency syndrome (AIDS). Mental health, social

welfare, and medical programs have been used as case management

interventions in the delivery of care to these groups.

The presence of complex needs implies that multiple agencies will be providing

services to individuals over time, requiring coordination for care to be delivered

12
in the most efficient and effective manner. However, public treatment systems

are often fragmented and lacking in structures for continuous care. Although

the problems of many drug-dependent people are chronic in nature, many

conventional drug treatment programs provide treatment only for a limited

time. Although some drug-dependent persons need support and treatment

(continuously or intermittently) for months to years, public treatment systems

offer them acute intervention on an episodic basis, at best. In addition, even for

those who require acute care, few drug treatment agencies have the staff and

programmatic resources to provide critical ancillary services and opportunities

such as job training and access to alcohol- and other drug-free housing. Yet

many drug-dependent persons have difficulty accessing mainstream social

service, health, and human service agencies. Case management is appealing,

then, because it often involves coordinating the care of individuals over long

periods. In addition, case management, depending on its design and

implementation, can address problems of accessibility to services outside

the drug treatment system.

Another important trend that has led to the current interest in case

management in drug treatment is the increasing focus of public and private

payers on accountability and cost reduction. Although not all case

management programs are specifically designed to reduce costs, it is widely

believed that case management will have an effect on overall costs of

intervening in the lives of drug-dependent individuals if it (1) results in the

substitution of less expensive forms of treatment or (2) results in substitution

of drug abuse treatment for incarceration or hospital care.

Case management has become such a popular notion that, despite the lack

of agreed-on operational definitions, Federal and State Governments are

considering mandating case management services for a variety of human

service target populations, including recipients of Medicare and Medicaid,

high-risk recipients of Aid to Families with Dependent Children, AIDS victims,

elderly persons, and persons with mental illness and mental retardation (Ashley

1988). Government-funded demonstrations, designed to evaluate the utility

of case management with these at-risk populations, are under way in many

localities. For example, many of the National Institute on Alcohol Abuse and

Alcoholism-National Institute on Drug Abuse (NIDA) Community Demonstration

Projects for Alcohol and Drug Treatment of Homeless Individuals have

employed case management (Argeriou and McCarty 1990).

This chapter briefly reviews the conduct of case management in drug abuse

treatment by, first, defining case management and discussing prevalent

models. Second, barriers to the development of case management in drug

abuse treatment are discussed. Finally, challenges faced in the design and

implementation of field research on case management are examined.

13
DEFINING CASE MANAGEMENT

Many commentators have noted, and most experts agree, that traditional

social casework is the predecessor of case management (Schilling et al. 1988).

The functions of social casework typically include (Johnson and Rubin 1983):

the development of new resource systems to meet the needs

of people, the establishment of initial linkages between people

and resource systems and between resources themselves to

make them accessible to each other, the facilitation and

improvement of interaction between people within resource

systems to promote the effective and humane operation of

these systems and to make them responsive to people’s

needs, and the assistance to people to develop and effectively

utilize their own internal problem solving and coping

resources.

Several themes are apparent in the definition of social casework. Depending

on its philosophy and implementation, social casework emphasizes the

development of new resources, linkages to existing service agencies,

coordination of care, advocacy, and teaching. Casework typically includes

increasing the individual’s self-reliance and independence as well as

coordinating and integrating care. To formulate a case plan properly,

caseworkers need to consider the client’s personality, family and other

relationships, the applicable service agencies and their various policies and

procedures, and pertinent legal issues. This information IS then integrated

into a rational and practical plan, which is implemented, and the results are

monitored (Leiby 1978).

Those aspects of casework that focus on coordinating and linking service

delivery are the ones that most typify case management interventions.

Providing continuity of care may be the single most important rationale for

usinq case management.

Within the mental health field, Bachrach (1978, 1981) defines continuity of

care as “a process involving the orderly, uninterrupted movement of patients

among the diverse elements of the service delivery system.” The “service

delivery system” was broadly conceived to include not just treatment for the

presenting disorder (in this case mental illness) but also access to other

service systems designed to provide poor people with subsistence and services

(including housing, food, jobs and job training, medical services, legal services,

and the like). In addition, to the extent that mental health clients are also clients

of other service agencies (including welfare, criminal justice, alcohol and other

14
drug treatment), continuity of care involves efforts to coordinate with the staffs

providing services within those agencies. The dimensions of continuity of care

as conceptualized by Bachrach (1981) are:

Longitudinal: Treatment parallels patient’s progress, even though the

specific site and caregivers may change.

Individualized: Care is planned with and for the patient and family.

Comprehensive in nature.

Flexible: Pressures to progress or move forward along a continuum are

relieved. Service flow corresponds to changes in the patient’s needs,

Personal: Relationship.

Accessible: Barriers are removed or reduced.

Cohesive: Link among all service providers.

Note that flexibility of and adaptability to the individual are hallmarks of the

case management approach focused on continuity of care. These aspects are

considered to be a strength of the case management approach and yet account

for some of the difficulty in arriving at a consensus on the operational definition

of case management. According to Bachrach (1981), some of the barriers to

continuous care that provoked the development of the case management

concept are:

Absence of mandate

Time lags between services

Inadequate tracking and followup

Geographical impediments, especially in rural areas

Budgetary constraints

Personnel shortages

“Quantitative overload of care system” (i.e., inadequate resources to meet

the need)

Failure to fully appreciate the complexities of a problem

15
Much case management in human service settings is provided to a vulnerable

population with multiple needs, believed to be unable (or unwilling) to negotiate

their care among multiple service providers. The case manager serves as sole

agent (Kirk and Therrien 1975), responsible for coordinating care to meet the

needs of the individual client. Depending on the particular “incarnation” of

case management, the case manager may be expected to provide the bulk of

services or may be responsible for ensuring that the client is receiving services

from a variety of agencies. Regardless, the case manager is the one (maybe

the only one) who views the individual comprehensively and addresses the

individual’s needs from this perspective. Case management is believed to be

especially useful in the context of treating severe and complex problems that

involve multiple service agencies.

Although there is widespread acceptance of case management, it remains a

loosely defined service that is less understood than one might expect, given its

popularity. This is because case management lends itself to many adaptations

to achieve a variety of objectives and because it is not the province of one

discipline or service field. Several authors have suggested definitions of case

management. Most definitions include a discussion of some combination of its

purposes, functions, client needs, and the context in which case management

occurs. Perhaps the most useful yet simple enumeratron of the goals of case

management was proposed by lntagliata (1982):

Enhancing continuity of care (the most fundamental goal)

Cross-sectional (at any time, the services provided to an individual are

comprehensive and coordinated)

Longitudinal (services continue over time, responsive to ongoing changes in

the person’s needs)

Enhancing accessibility: assist in overcoming the administrative barriers

(multiple categorical programs, each with its own eIigibility criteria,

regulations, policies, procedures)

Enhancing accountability: designation of a single point of responsibility for

the overall effect of the system when multiple agencies are involved in

meeting a client’s needs (sole agency)

Enhancing efficiency: increasing the likelihood that clients will receive the

right services, in proper sequence, and in a timely fashion; may or may not

result in cost savings

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Controlling costs is another important goal in many case management

applications. Costs can be controlled by providing the least costly services

necessary, either by substituting less costly for more costly services, by

decreasing duplication of services, or by denying high-cost services deemed to

be of little benefit.

Case managers engage in discrete interventions to achieve these goals.

Another way to define case management is by its functions-the discrete

groupings of activities engaged in by case managers. There is remarkable

agreement among professionals and across fields on the basic functions of

case management. As articulated by the Joint Commission on the Accreditation

of Hospitals (1979), these functions are (1) assessment: determining an

individual’s current and potential strengths, weaknesses, and needs; (2)

planning: developing a specific service plan for each individual, with provisions

for day, evening, and night linkages to needed functions; (3) linking: referring

or transferring individuals to all required services in the formal and informal

caregiving systems; (4) monitoring: continuous evaluation of individual

progress; and (5) advocacy: interceding on behalf of an individual to ensure

equity, both in the specific case and for any larger group or class to which the

individual might belong. To these can be added identification and outreach in

recognition that many case management programs attempt to enroll clients not

using customary services. These six key functions have been widely accepted

(Phillips et al. 1988; Levine and Fleming 1987; Ontario Ministry of Health 1985;

Austin 1983; Schwartz et al. 1982; Lamb 1980; Marshman 1978; Agranoff

1977). Most functions identified by other authors are either modifications of

these primary functions or could be characterized as additional functions, such

as direct service provision, crisis intervention, system advocacy, and resource

development.

Functions describe what case managers do. Willenbring and colleagues

(1991) have proposed that the enumeration of functions does not sufficiently

differentiate among case management programs. Dimensions or operational

features indicate how case management functions are delivered. Table 1

outlines some of the dimensional characteristics of case management, giving

examples of the ends of the continua.

The authors propose that a typology or categorization system can be

developed by looking at the interaction among the functions and dimensions

across programs. This approach could be used to compare programs without

regard to the particular conceptual or philosophical framework on which the

program is based. This typology is a work in progress, but agreement on a

common set of functions and dimensional characteristics would facilitate

understanding how, why, and for whom a particular case management

approach might be expected to work.

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TABLE 1. Dimensional characteristics of case management

Characteristic

Duration

Pole A

Indefinite (defined by

client needs)

Intensity

Frequency of contact Frequent (daily contact)

Staff ratio

Focus of services

Availability

Site of service

Consumer direction

Advocacy

CM training

CM authority

Team structure

CM=case manager

High (1:10)

Infrequent (quarterly

contact)

Low (1:75)

Broad, inclusive Narrow, exclusive

24 hours Office hours

In vivo Office only

Consumer directed Professionally directed

Advocates for client

(to gain access to

services)

Gatekeeper for system

(finds alternatives

to requested services)

Advanced professional

degrees

On-the-job training

Broad authority,

administrative control

No authority,

persuasion only

Full team mode:

All CMs share all clients

Primary CM with

individual caseload

Pole B

Time limited

MODELS OF CASE MANAGEMENT

The goal of creating a typology useful across fields is to provide a

categorization system that will facilitate program planning, implementation,

and evaluation. In particular, it is necessary to categorize case management

programs accurately so that the results of research studies can be generalized

to other programs. A multiplicity of models have been proposed (Ross 1980;

Merrill 1985; Robinson and Bergman 1989), and each makes a contribution to

understanding case management within its respective field. However, none has

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received uniform acceptance within a field, nor are any generic enough to be

useful across human service fields.

In this short discussion, rather than enumerating the variety of models, a few

of the functions and dimensions mentioned earlier are useful in making

broadbrush discriminations. For example, one of the most important in the

mental health field has been the differentiation between case management

designed to deliver mental health and social support services and case

management designed to coordinate the provision of those services. In

one of the most well-researched applications of case management across

the fields, the Program for Assertive Community Treatment (PACT) model

of case management combines case management and direct mental health

treatment within one case management program characterized by intensity

of service, very low caseloads, and multidisciplinary team structure (Stein

and Test 1980). Studies have found the PACT model of case management,

in which direct service delivery is a primary function, to be effective in meeting

its goals (Morlock et al. 1988), and replications of the model have also found

favorable results for the most difficult, most needy clients (Mulder 1985; Bond

et al. 1988; Hoult et al. 1983). This model of case management is often

targeted to individuals who have chronic mental disabilities and do not make

use of the mental health treatment system or use it dysfunctionally-that is, by

preferring emergency room, detoxification, and acute psychiatric care to longterm treatment and rehabilitative services. Emergency rooms and acute care

without followup have not been found to be effective mechanisms to deliver the

care these individuals need.

By contrast, many applications of case management have focused on the

coordination of services provided by other treatment and service agencies,

with minimal, if any, direct service provided by case managers. Although this

model of case management is more dominant, fewer empirically sound

research studies have focused on the coordination or linkage model of case

management. These applications of case management (with higher caseloads

and less direct service provision) showed mixed results, with some case

management programs improving quality of life without interrupting patterns

of psychiatric hospitalization and others showing, for instance, both increased

use of services and increased cost without any concomitant improvement in

the lives of clients (Morlock et al. 1988).

Another simple (or simplistic) discrimination among case management

models is the differentiation between case management programs primarily

aimed at facilitating access to services from those aimed at gatekeeping or

managing access to services to increase the use of cost-effective alternatives

to expensive services. The facilitator model predominates in the public sector

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(among social service and alcohol and other drug and mental health agencies).

The primary goal of facilitator case management is to increase the likelihood

that individuals will receive the right services, in proper sequence, and in a

timely fashion. To achieve this, the case manager plans a comprehensive

service package and negotiates barriers that prevent clients from accessing

needed services. Cost savings may or may not be an explicit goal but may

be expected as the case manager facilitates better access to cost-effective

alternatives, achieves better coordination (and thus less duplication of services

across agencies), reduces utilization of more expensive and less effective

emergency room and acute inpatient services, and diverts clients from

detoxification and jail admissions.

Case managers used as gatekeepers to produce cost savings are

predominantly seen in the context of medical services and care for elderly

people and in some private agencies in the other fields. These gatekeepers

can produce cost savings by managing care, including substituting less

costly, more appropriate services and sometimes simply by not authorizing

higher cost services. Rather than facilitating access, gatekeepers must restrict

access to control utilization and thereby costs. The ability of gatekeeper case

managers to create savings depends on the availability of appropriate costeffective alternatives, case manager authority within the care system, and

case manager ability to control financing for the care they deem appropriate.

Specific strategies designed to avoid use of high-cost services must be built

into the program, along with proper incentives for the case managers. One

of the primary barriers to this kind of program is the absence of alternative

services.

Finally, in addition to the treatment/linkage dichotomy discussed above, the

authors predict that at least three of the other dimensions enumerated in table 1

are likely to be important in discriminating among types of case management.

These are team structure, intensity (caseload size), and case management

training (credentials). It is important that these dimensions of the program be

adequately described and documented in evaluations of case management.

Because the focus of most evaluations is on the question, “Does it work?,” it is

important to know what “it” is.

For example, many, if not most, case management programs describe

themselves as employing a team structure, but team structures vary

considerably. In some programs, all case managers on the team are

interchangeable and serve the total group of clients. Other programs

consist of multidisciplinary teams where each professional provides specific

services to the clients assigned to the team (e.g., nurses dispense disulfiram

[Antabuse], social workers complete entitlement paperwork). In still others,

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“teams” of individual case managers carry individual caseloads but provide

backup assistance to one another. These differences may be papered over by

the use of the descriptor “team,” yet the specific configuration may be critical to

the program’s success and, thus, to its replicability.

BARRIERS TO COORDINATION USING CASE MANAGEMENT

There are significant barriers to the coordination of services for drug-dependent

individuals. These barriers can be characterized as those most amenable to

intervention at the client level and those barriers that represent larger structural

or financial impediments. The former include the fact that service agencies

often do not recognize the authority of a case manager, that agencies differ in

practice and philosophy of drug (and other) treatment, and that most agencies

feel the need to make treatment decisions about the services required by a

client under their care. Case management directly confronts territoriality among

services agencies.

Among the barriers encountered and described in the few limited studies

of case management in the alcohol and other drug field, communication

problems and problems dealing with inflexible agency admission requirements

predominate. Within the alcohol and other drug treatment field, perhaps more

dramatically than in other human service fields, philosophical conflicts about

the nature of addiction and the goals of treatment increase the barriers that

case managers face in finding services for their clients. Many agencies simply

refuse to deal with clients with multiple or complex problems. If stabilization

rather than abstinence is the case manager’s goal, treatment programs may

refuse their clients entry. The end result is that case managers expend much

time and energy finding service providers within the drug treatment system. In

addition, the stigma associated with drug dependence makes access to other

human service agencies difficult. The philosophical debate over whether drug

dependence is a choice (and thus deserves consequences) or is a disease

(and thus deserves treatment), as well as the association of drug dependence

with criminality, can be used as rationales for denial of services. Considerable

advocacy may be necessary to see that the more difficult and deteriorated

client is served, and the case manager on the front lines will have to confront

this directly. This confrontation may have a positive effect of its own, by going

against the pessimism often identified with alcohol and other drug dependence

(Willenbring et al. 1990).

The level of optimism that the case manager has about the value of specific

interventions (or the positive nature of any intervention) is influenced by the

case manager’s training and expertise. There are problems with “naive” case

managers who are either too pessimistic or too optimistic, potentially impairing

21
their credibility with other providers and thus their ability to link clients to

services.

It has also been observed that the popularity of case management may be

explained by the desire of agencies and bureaucracies not to disturb the status

quo. Kane and associates (1991), describing case management as “this

ubiquitous, rapidly growing but poorly defined phenomena,” point out that “its

short-run political advantage is that it can be overlaid on existing systems of

health and human services without requiring basic organizational change.” This

has been the frustration of many line workers-that they are assigned to the

impossible task of making organizations behave differently toward their clients

or making and implementing rational care plans within irrational systems of

care.

CHALLENGES TO RESEARCH ON CASE MANAGEMENT

Many have commented that the popularity of case management is out of

proportion to evidence of its effectiveness as an intervention. Only recently

has the implementation of case management programs in the human service

fields been accompanied by research about its effectiveness. Although

evaluation in the mental health field has been developed further than in most

others, the findings there are neither comprehensive nor widely generalizable

Although there is general agreement that case management serves a set of

functions, there is no consensus about the operational definition of those

functions, Until the past few years, most program evaluations did not even

measure the behavior of case managers, leaving unanswered the question

of how case management is carried out in individual programs.

In discussing the state of the art in drug abuse treatment research, Ball and

Ross (1991) have referred to this phenomena as the “black box” in research

on treatment interventions. Ball and Ross attribute the phrase “black box” to

Lipton and Appel and, quoting from their contribution to a 1984 NIDA

monograph on drug abuse treatment evaluation (Lipton and Appel 1984),

state:

One concern expressed repeatedly had been that treatment is

largely a “black box.” The people, events, and interactions

subsumed by such labels as “therapy,” “counseling,” “refer for

services,” and “remediation” remain largely undescribed in

drug programs. As a result, variations in delivery and efficacy,

which are crucial to treatment evaluation, are also unspecified.

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Again, quoting other colleagues (Gottheil et al. 1981), Ball and Floss refer to a

“pervasive lack of knowledge about treatment factors”:

There are also many treatment factors that may be related to

outcome, although few have been identified. It is not enough

to know that more treatment is better than less without

knowing more about the effective components of treatment . .

there is an even greater need for basic and systematic

description, classifications, and measurements of treatment

factors than of patient characteristics.

Ball and Ross theorize that the black box continues to exist for both practical

and empirical reasons. First, with the emphasis of drug abuse research on

pharmacology, there was a lack of interest in treatment research, especially

program evaluation in contrast to the “hard sciences.” Field studies of drug

abuse programs are costly and difficult compared with laboratory research.

Second, Ball and Ross (1991) point to methodological impediments to the

study of treatment programs. They propose a schema for evaluation of

treatment programs that would focus equally on four domains: addict patients,

programs, services provided, and patient outcomes.

Finney and Moos (1989), in their discussion of design of research on alcohol

and other drug treatment, talk about the decisions that researchers face in

designing evaluations. Allowing that researchers usually choose experimental

designs for their methodological superiority, they state that there is nothing

inherent in experimental designs that precludes an indepth evaluation of

treatment itself; however, evaluators often find themselves short of funds to

undertake an exploration of treatment. The majority of the resources are

usually committed to “the logistical demands of implementing and monitoring a

true experiment in a field setting.” Nevertheless, Finney and Moos report an

expansion of the “traditional” black box approach to evaluating treatment

programs, including a new emphasis among treatment providers and

researchers on (1) implementation analysis, (2) review of the amounts and

types of specific services received by each client in the program, and (3) the

life context factors that can mediate the effects of the program on clients

(Finney and Moos 1989).

Both Graham and Birchmore-Timney (1989) in the alcohol and other drug

field and Brekke (1987) in the mental health field have focused the attention

of evaluators on the need to specify the treatment program, in this instance,

case management, beyond general descriptions. Focusing on the issue

of replicability, Graham and Birchmore-Timney assert that the focus on

experimental design in evaluation is too heavyhanded at this stage of case

23
management development. They question the value of adherence to strict

experimental designs when the intervention is as vaguely designed as are

many case management interventions. Rather than choosing sides between

the “academically funded evaluators” who continue to use outcome-oriented

research and “applied evaluators” who have abandoned effectiveness

questions in favor of evaluations more focused on program improvement,

Graham and Birchmore-Timney advocate that “the appropriate use of the

experimental method requires a reorientation away from administratively

defined ‘programs’ to operationally defined and evaluable program components”

(Graham and Birchmore-Timney 1989). Brekke (1987) has described a method

for specifying these program components in an application of case

management in the mental health field. As described in more detail below,

program implementation monitoring is an important part of an overall attempt to

specify the intervention being tested.

IF X IS EFFECTIVE, WHAT IS X?

Much of the effort to improve research design in the human service field is

focused on evaluation of the client or recipient of services. Research design

utilizing the randomized clinical experiment has become the “gold standard,”

some have argued, to the exclusion of attention to questions other than

effectiveness. Ball and Ross (1991) have pointed to an additional problem

in using the results of such research-the evaluation of poorly defined

interventions is not particularly useful to the field because the findings have

little generalizability and the interventions are difficult to replicate. To improve

the state of the art in evaluation of case management interventions, attention

to four aspects of evaluation are necessary. (The order of discussion is not

meant to imply an order of implementation of these aspects of evaluation.)

Precise Description of the Intervention

As many commentators have pointed out, there is no one thing called case

management (Bachrach 1989); rather, there are many things called case

management. Rather than attempting to study a modality, it is important

that individual programs within that modality are studied. The first step is to

generate a precise description of the case management intervention. Ball

and Ross (1991) advocate that the program be broken down into its operational

components and then each component described carefully. For example,

within a case management program, “outreach” may be a program component

encompassing specific activities.

The original proposal for a program is a place to start but is often unreliable as

a description of the implemented program. In addition, experience teaches that

24
service providers, often caught up in the implementation of an innovative

program, are not keen observers of the programs they implement. Ball and

Ross (1991) recommend that outside observers (more than one) interview

the program administrators, staff, and patients and observe and review

records. The requirement of multiple observers is supported by those

advocating methods to increase the rigor of qualitative research methods

(Silverman et al. 1990). Another method is to have an outside observer

collect qualitative data on the program (interviews and observation) and

prepare a “program manual” in an iterative process with the program staff.

This method asks staff members to describe the program in such detail as

necessary to replicate the program and, it is hoped, focus their attention away

from articulating philosophy and toward describing activities and functions.

A precise description of the program is the beginning but is not enough.

A qualitative description based on observation or interviews will be enhanced

by a more quantitative picture of the program. Measurement of time spent

performing discrete activities is one way to quantify program description, and

Brekke’s (1987, 1990) program implementation monitoring (described below) is

one method.

Implementation Analysis

This aspect of program evaluation focuses on the question, Does the

intervention that is described actually get implemented? Cargonne (1983),

in a comparison of case management activity for the Texas Department of

Mental Health and Mental Retardation, has observed, “a case management

system that has not been designed to accommodate the existing contextual

variables (for example, geographic inaccessibility and inadequate resources)

may be implicitly redesigned by the case managers to fit these demands.”

For example, a case management program may be explicitly designed to

coordinate care. Case managers, faced with a lack of appropriate treatment

facilities, begin to provide care to their clients, rather than to coordinate care,

resulting in a program completely different from that intended. Because of the

possibility that case managers will make significant alterations in the program

(unrecognized by management staff) or that program managers will allow

program interventions to evolve over time, it is important to monitor program

implementation.

Brekke (1987, 1990) has proposed a method for “model-guided” monitoring

of program implementation that has both descriptive and evaluative functions

(Brekke 1990):

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Descriptively they [implementation monitoring evaluations]

result in an empirical profile of the types, or major

components, of service delivered in a program. When

data are collected over time they can also provide a profile

of the longitudinal form of service delivery. Other program

processes can also be examined.

This method of program implementation monitoring makes use of a daily

contact log, which is a self-report checklist used to collect information about

case management interventions. Brekke (1987) notes that such instruments

are useful only to the degree that they are reliable and presents data on the

psychometric properties of the instrument. Brekke also achieved compliance

with the reporting on the daily contact log by agreeing to feed information back

to the program case managers on a regular basis.

Implementation Timetable

The next two aspects of program evaluation address the concern that there

may be changes in the environment that affect the intervention. Creating an

implementation timetable by recording dates of specific alterations in the

program or in the program’s environment is useful to help describe the context

for the program’s development and explain changes in client outcomes. For

example, if programs are evolving and a major new component is added to the

ongoing program, it would be important to note such events in a chronological

sequence. Other important events include major staff changes, changes in

administration in the host agency, temporary increases in case manager

caseloads due to intermittent turnover, and the like. In addition, important

events in the environment can be expected to have an impact on program

operations, including, for example, changes in the organization and financing

of alcohol and other drug abuse services and passage of laws concerning the

use of alcohol and other drugs (e.g., decriminalization of public inebriety,

mandatory sentencing laws for drug offenses).

Describing the Environment in Which the Program Functions

Case management programs do not exist in a vacuum. Although poor

coordination of services is often blamed for the discontinuity that case

management programs address, these problems equally may be the result

of insufficient resources or inappropriate services, problems usually not under

the control of case management programs. As Morlock and colleagues (1988)

noted in a review of case management research in the mental health field, the

effectiveness of case management may have more to do with the environment

than with the functions of the program per se. Because this is true, it is

26
important to document the environment in which programs operate. Issues

such as the adequacy or inadequacy of the service system, the support of

the host agency, and changes in the service system over time that affect

the operation of the program should be fully described. Changes in the

service environment explain why in some experiments the differences between

the control and experimental groups narrow over time. If agencies serving

clients in the “usual care” system begin to adopt programs that look more

like experimental case management interventions, it is unlikely that the

experimental program will create large enough effects to be found statistically

significant in small samples of clients.

POTENTIAL PROBLEMS IN FIELD RESEARCH AND MEASUREMENT

Finally, there are problems in field research and measurement that seem

to be common among demonstration research programs yet have not

been explicated fully in the literature. Addressing these in the design and

implementation of the demonstration and evaluation of case management

programs will make research in this area stronger and the findings ultimately

more useful. Under the heading “problems in field research,” the authors

suggest attention to three questions: (1) Is there a significant difference

between the experimental and control interventions? (2) Is there a single

experimental intervention, and does it stay stable over time? (3) When

is the intervention mature enough to begin client data collection?

The first question is often left unaddressed by those who propose case

management demonstration programs. The intuitive assumption is that the

experimental condition is different and superior to the control condition.

One example in case management evaluation illustrates this problem. In a

comparison of case management vs. usual care in bringing alcohol and other

drug abuse services to homeless individuals, the outcomes of homeless clients

receiving case management services plus shelter were compared with those

receiving shelter services alone. What was not fully appreciated at the start of

the demonstration was the impact of the shelter “coordinators.” These staff

members had typically been associated with the shelter and the larger service

system for some time and had developed extended referral networks among

the substance abuse treatment and other providers. Several case managers

working in the experimental program, by contrast, were new to the system

of care and new to case management as an intervention. It was not surprising,

then, that some measures of usual care would show better coordination

of services by shelter coordinators than by case managers. In addition,

sometimes rivalry develops between the new intervention and the old program

so that control condition staff members either intensify or change what they are

doing to compete with the new intervention (the so-called “John Henry” effect).

27
The next question has to do with the fidelity of the intervention. This is actually

a two-part question. First, is there a single experimental intervention? That is,

are all the case managers doing the same thing? Often, experimental programs

are based on broad notions of the functions of case management, and those

functions are not operationally defined. Case managers bring their own

professional and experiential backgrounds to the task and, in the absence of

precise delineation of activities, have a tendency to adjust the program model

to their experience, to what they are comfortable doing, or to their unique

understanding of what they are supposed to be doing. These problems can

be addressed by continual supervision of the implementation of the program.

Developing a program manual will help concretize the intervention and provide

a standard against which their activities can be measured. The second part of

the question, which has already been mentioned, concerns the tendency for

there to be “drift” of the interventions toward one another. The control condition

becomes more like the experimental condition (discussed above) or the

experimental becomes more like the control condition as case managers settle

into their jobs and the initial enthusiasm for a new project gives way to the

tendency to standardize and bureaucratize human service programs.

The third question-When is the intervention mature enough to begin client

data collection?-is often ignored because demonstration program funding is

most often limited to 2 or 3 years. Programs do not have the luxury of an

extended startup time and must enroll clients immediately into the evaluation.

Early enrollment ensures that there will be a sufficient number of clients for

the statistical analyses, but it ignores the fact that innovative programs often

evolve in the early stages of their implementation. Later in the demonstration,

clients could be receiving a different intervention than clients early in the

demonstration if startup problems delay implementation or if the program

goes through successive approximations before it finally settles into a mature

program. These problems seem to be the norm rather than the exception in

demonstration programs.

Potential Problems in Measurement

One of the first issues in evaluating case management is how to measure a

case management intervention. Part of the problem is that case management

is difficult to define, and the functions are often difficult to operationalize.

Most evaluation research uses some kind of time logging system on either a

daily, weekly, or episodic sampling basis. The forms used are most often

designed by researchers and not by the people who do case management.

Case managers often complain that they do not provide an accurate

representation of what case managers do. Also, unfortunately, few of these

instruments have been evaluated as to their validity or reliability.

28
To get precise information to characterize what case managers do,

researchers often create forms that require the case manager to differentiate

among activities in a wide variety of categories and report time spent in small

intervals. Researchers often believe that having a variety of possible service

categories will increase precision. Case managers, however, may find too

broad an array bewildering, and the lack of precision in the definition of service

activities (and consistency in reporting across case managers) raises questions

about the reliability of the data. Some have suggested that the professional

and experiential background of case managers affects their choice of certain

service categories over others more than a substantive difference in what they

provide to clients. These problems, along with the necessity of reporting on

small intervals of time, creates a paperwork burden that often is not balanced

by any clinical or administrative utility of the data. In rare instances, program

evaluators have found ways to make the data useful to the program as well as

to the evaluation (Brekke 1987), increasing the likelihood of compliance and

accuracy. Some balancing of the need for information with the demands of the

paperwork needs to be struck or the reliability of the data is in question. In

designing the data collection strategy, the careful evaluator will consider (1) the

difference between what he or she needs to know and wants to know and (2)

the difference between what he or she needs to get from the case manager

and what could be gotten (though possibly not as easily or reliably) from

another source.

Another cause of frustration is measuring usual care or the control condition.

Often, the experimental program is the only one receiving the enhanced

funding, so that usual care providers have less of a stake in the demonstration

and its evaluation. Having the staff of the control condition use the same

logging forms as the case managers would be optimal; however, management

information systems and reviews of institutional records often are used as

necessary substitutes. Also, although it may not be possible to have control

condition providers furnish the same level of detail, it may be possible to

design an abbreviated questionnaire asking a few general questions about

what services the control clients need (at some point) and then have received

(or not received) at a later point.

As Kane and colleagues (1991) have pointed out, “case management is hard

to extricate from the services being managed and, with few exceptions, this

disentangling had not been attempted.” Although Kane and colleagues had

other issues in mind when they made this observation, it is important to

evaluation that all services the clients receive are recorded, not just the services

provided by case managers. In fact, all services for both the experimental and

control condition clients should be detailed to make sure that effects attributed

to case management are not more attributable to other services being provided

29
in connection with case management. To the extent that the evaluation can

be said to be looking for the effect of continuity of care (caused by case

management) rather than for the effect of an intervention (case management),

the interpretation of client data is perhaps made more challenging.

CONCLUSION

Although research to date on case management suggests that it may be

an effective intervention, basic questions concerning case management in

general and its specific application to drug treatment remain to be answered.

These include questions about target populations; goals of case management;

and case management models (functions and dimensions) and their

relationship to population, goals, and outcome. Although research on case

management in drug treatment is in its infancy, much can be learned from

the work over the past two decades in other fields.

It is very likely that case management will be utilized more frequently as a

component of the drug treatment system. The challenge is to understand the

most effective and efficient way to use such an intervention. Researchers can

no longer afford to maintain the black box approach to treatment effectiveness

evaluation. Nor can practitioners continue to rely so heavily on intuitive beliefs

about what works.

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32
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ACKNOWLEDGMENTS

Anthony F. Lehman, M.D., M.P.H., and Howard H. Goldman, M.D., Ph.D.,

director and codirector, respectively, of the Center for Mental Health Services

Research, commented on an earlier draft of this chapter.

AUTHORS

M. Susan Ridgely, M.S.W.

Associate Director

Mental Health Policy Studies

Center for Mental Health Services Research

University of Maryland School of Medicine

645 West Redwood Street

Baltimore, MD 21201

Mark L. Willenbring, M.D.

Chief

Addictive Disorders Section

Minneapolis VA Medical Center (116-A)

One Veterans Drive

Minneapolis, MN 55417

33
Managed Care and Case Management

of Substance Abuse Treatment

Albert Woodward

INTRODUCTION

Managed care has gained increasing attention in the health care field,

including substance abuse treatment. Findings from health services

research on managed care, for health care in general and for substance

abuse in particular, will have relevance to the evaluation of case management

of persons with substance abuse problems.

DEFINITIONS OF MANAGED CARE

Managed care is a new concept widely discussed by health service researchers

and increasingly used by health care payers to control health care use and

costs. No single, widely accepted definition of managed care exists. Four

definitions obtained from a literature review share many similar elements but

offer different perspectives on the concept.

A recent definition from an Institute of Medicine report, “Treating Drug

Problems” (Gerstein and Harwood 1990, p. 286), may be the most

comprehensive definition extant:

A variety of strategies generically known as managed care

have been introduced to regulate more closely the use of

health services by beneficiaries or, alternatively, the supply

of health services to beneficiaries by providers. These

strategies include prospective certification or preadmission

review (PAR) of hospital stays, utilization review during

or after discharge, the use of preferred providers, and

specialized high-cost case management. PAR requires

that patients receive prior approval of admission to a

hospital from the insurer to be entitled to full reimbursement

of costs. Utilization review involves midtreatment or even

retrospective review by insurers (or their managed care

34
agents) of the “appropriateness” of services delivered,

with denial of insurance reimbursement for unapproved

services. Preferred providers often have contracts with

the insurers about the level and nature of care to be

delivered for a particular type of case. Under some

contractual arrangements, managed care providers have

explicit short-run financial (profit) incentives to reduce the

utilization of health care services of beneficiaries under

their supervision, although this arrangement is not true

under fee-for-service contracts. Yet under fee-for-service

contracts, a managed care contractor must eventually

demonstrate success at controlling costs or risk losing the

contract.

As detailed as this definition is, it is probably incomplete. The term “strategies”

used in the definition includes case finding and case management services,

financing arrangements, incentives, and provider organization, but it contains

some ambiguities. The definition does not distinguish prepaid financing

mechanisms such as health maintenance organizations (HMOs) and preferred

provider organizations (PPOs) from the more loosely structured managed

care providers. It does not distinguish “financial case management” and

‘clinical case management.” One associates managed care with the term

“case manager,” although the two terms are distinct (Institute of Medicine

1990, p. 331). It is unclear from the definition whether managed care is a

type of treatment, a form of financing, an approach to cost management,

or a combination of these. Finally, the definition ignores differences

between public- and private-sector managed care of drug treatment.

A second definition of managed care comes from a recent Congressional

Budget Office (CBO) report (Langwell and Menke 1991, p. 37):

The term “managed care” encompasses a variety of

interventions in health care delivery and financing. The

major dimensions of managed care include:

Reviewing and intervening in decisions about

health services to be provided--either

prospectively or retrospectively;

Limiting or influencing patients’ choice of providers;

and

Negotiating different payment terms with providers.

35
Another, briefer definition has similar key elements: “a set of techniques

used by or for purchasers of health benefits to manage health care costs

by influencing patient care decision-making through case-by-case assessment

of the appropriateness of care prior to its provision” (Field and Gray 1989).

Irving Muszynski, the past general counsel to the National Association of

Addiction Treatment Providers (NAATP), offers a fourth definition: an

arrangement that offers or covers specified health care benefits and that

employs some or all the following financing and utilization review mechanisms:

(1) negotiated fees or capitation rates for providers, (2) negotiated premiums,

(3) preadmission testing for inpatient and outpatient services, (4) concurrent

and retrospective reviews, (5) bill audits, (6) statistical analysis of frequency

and duration of service use, (7) adjusted measurements of clinical outcomes,

and (8) quality assurance review. The third and fourth definitions emphasize

the key elements of managed care, but they neglect the details in the first

definition.

The four definitions are presented as examples of how definitions can differ;

they are not definitive but illustrative of the difficulty of defining the term

completely. Perhaps the difficulty in defining the term is due to the pervasive

and all-encompassing role of managed care in health insurance. Today, pure

(as distinct from hybrid) indemnity or fee-for-service plans are the only health

insurance organizations without some aspects of managed care. Every other

derivative or hybrid has some level of managed care embedded in the plan,

whether through the requirements of precertification and case management

or through the complete or partial restriction to specific providers within a

network. Managed care is sufficiently broad to include reimbursement of

providers under fee-for-service, case rate, and capitation.

Most observers of health financing agree that managed care developed out

of payers’ concerns over rising health care costs, that is, as a cost-containment

strategy. Mental and substance abuse disorders have been the fastest rising

component of the health care premium (Frank et al. 1991). Employees with

drug and other related problems have increasingly used health insurance

coverage for substance abuse treatment. Since the advent of private health

insurance, the industry has not considered behavior disorders as appropriate

for coverage, but many employers have not shared this view. In the 1980s

employers added coverage for substance abuse treatment benefits, only now

to find them too costly (Jensen and Morrisey 1990). Managed care is one

way that payers have tried to deal with these rapidly rising costs. In the

private sector, health insurers frequently have “carved out” drug abuse (and

alcohol and mental health) coverage benefits from general medical coverage

and placed these benefits under managed care programs.

36
Managed care plans have several organizational forms or types. One is a

private company serving as an external review agent or a broker of case

management and preferred provider services for an insurer or a corporation.

Others include a subsidiary of a health insurer or a personnel department of a

company; each of these types may offer case finding and management, peer

review, or preferred provider services. HMOs and PPOs provide managed

health care and are viewed by some as managed care plans. In the public

sector, the Civilian Health and Medical Program of the Uniformed Services

and Medicaid have managed care programs, but they are not as common as

in the private sector (Prottas and Handler 1987; Temple and Kron 1989; Fant

and Pool 1990). Managed care plans claim to save health care costs by

negotiating with providers for discounted rates on services and by limiting the

treatment choices available (Institute of Medicine 1990, p. 435). Presumably,

only unnecessary care is eliminated.

The managed care plan usually has the responsibility for establishing initial

assessment and case management criteria for patients, recruiting and

organizing participating providers or treatment programs, and negotiating

contracts with payers and providers. Almost all managed care plans have

pretreatment assessment, which assigns individuals seeking treatment to

providers. Almost all also monitor the patient during treatment. This monitoring

frequently goes beyond quality assurance, peer review, and second opinion

techniques to involve the external reviewer of the primary counselor or

physician.

In the private managed care of drug abuse treatment, the emergent leaders

(such as American Biodyne, U.S. Behavioral Health, Preferred Health Care,

and American Psych Management) offer full-risk arrangements in which they

manage all aspects of a substance abuse case for a capitated rate. They

include alcohol and other drugs under substance abuse coverage; often the

problems and disorders caused by alcohol and other drugs are part of mental

health coverage. These managed care companies preprocess or pay claims

as part of their service, just like a traditional indemnity or fee-for-service health

insurance plan. Also, these companies encompass managed mental health

and substance abuse models that cut across provider reimbursement

arrangements, from fee-for-service, to case rate, to capitation.

ISSUES IN MANAGED CARE

A literature review reveals many important issues in the managed care of drug

treatment. Among them are the following:

Perhaps the foremost issue is a perceived tension between appropriateness

and quality of care vs. cost savings and cost-containment.

37
Managed care seeks to influence both provider practices and patient

behavior without sacrificing quality of care. How provider practices for drug

treatment have changed under managed care, how financial incentives have

influenced patterns of care, and how quality has been affected are unknown.

Some observers claim that patients with drug problems may not fare as well

under managed care programs as under more traditional programs because

the greater scrutiny of managed care may increase patients’ hesitancy to

seek or continue treatment.

No uniform, widely accepted, explicit, and relevant criteria for assigning and

monitoring patients in drug treatment apparently exist. Also, what managed

care does and what effect it has on outcomes and costs are not completely

understood.

The impacts of managed care on public- and private-sector drug treatment

programs may be different, but these impacts are not well known.

Finally, questions of cost benefits and savings from managed care cannot be

answered: Is it cost-effective in comparison with traditional alternatives? To

whom do the cost savings accrue-the employer, the insurer, the managed

care firm, or the patient? Or does managed care lead to cost shifting to the

consumer? How do public and private benefits derived from managed care

coincide or conflict?

This list is more illustrative than exhaustive, and it is not meant to favor or

reject managed care for substance abuse treatment. Each of these issues

is discussed briefly in the following material.

Managed care has generated controversy about the tradeoffs among cost

savings, access, and quality of care (for examples, see the October 1990

issue of Hospital and Community Psychiatry [Zusman 1990] and the fall 1990

issue of The Journal of Mental Health Administration (Docherty 1990]). This

controversy has centered on limitations for inpatient or residential drug

treatment. The Institute of Medicine report, “Treating Drug Problems”

(Gerstein and Harwood 1990, p. 287), states:

As managed care strategies have matured, they have come

under increasing scrutiny and criticism from alcohol and

drug treatment providers following aggressive moves by

managed care companies to cut the costs of treating drug

and alcohol abuse. Taking cues (that is, preadmission and

utilization review protocols) from the reviews by Saxe and

colleagues (1983) and Miller and Hester (1986), which

38
focused on alcohol and not drug treatment, managed

care reviewers have attempted to direct all drug clients

away from the inpatient programs and toward outpatient

services, because they are certifying shorter and shorter

inpatient stays. This trend is viewed with particular alarm

by employee assistance program (EAP) staff, chemical

dependency programs, and therapeutic communities

that have received accreditation and recognition but are

increasingly being asked to shorten treatment plans in

ways that defy all their therapeutic experience.

If managed care is in essence a policy to substitute outpatient care for inpatient

care, questions arise regarding outcomes of treatment and cost shifts in the

short and long run.

Substance abuse treatment providers express concern with the rapid

development of managed care programs. A survey of 130 members of

NAATP found that 90 percent of respondents had been exposed to managed

care programs and that such care “. . . has created an array of problems for

private providers, primarily with regard to the efforts of managed care systems

to control their clients’ general access to treatment and, for those clients

who gain access, the level of treatment provided” (Kite 1989, p. 16). State

legislatures are considering legislation to restrict managed care review;

increasing numbers of doctors and patients are suing managed care

companies (Freundenheim 1991).

Managed care seeks to direct or give incentives to providers to deliver care

more cost-effectively than under more traditional approaches. Whether drug

treatment providers have changed their practice under managed care is largely

unknown. If they have, the influences of financial incentives on their practice

is likewise unknown. Anecdotal evidence suggests that the implementation

of managed care may have unintended and undesired effects on provider

behavior. Some practitioners report spending so much time on the telephone

with managed care staff that they find their time for client treatment is cut back.

The profit margins of 28-day chemical dependency programs and the effect of

managed care on their profitability and pricing of services are other unknowns.

Most persons with drug problems will need medical, psychological,

pharmacological, or other ancillary treatment (Institute of Medicine 1990,

pp. 56, 75). Health insurance has “. . . favored hospital-based inpatient

stays over outpatient visits and continues to encourage the ‘gold standard’

medical model rather than more explicitly psychological or socially oriented

treatment” (Institute of Medicine 1990, pp. 294-295). Almost no studies have

been done on the effects of managed care on hospital drug abuse treatment.

39
Cutting costs by restricting access to types and amounts of service may lead

to relapse among drug users. The substitution in a managed care program

of outpatient care in those cases where inpatient care is more appropriate

(Institute of Medicine 1990, p. 251; Frabotta 1989) may merely lead to

patients’ later relapses.

Persons with drug problems may be less accepting of managed care

programs than the traditional approaches, but this has not been studied.

In both public and private health insurance where there is choice among

financing approaches, there is a question of whether parsons with drug

problems remain with fee-for-service approaches because they find these less

threatening than managed care and other newer approaches. Also unknown

is whether dependents especially adolescents, get treated differently under

managed care than primary insured persons. The questions cannot be

answered with the existing health services research.

No uniform, widely accepted, explicit, and relevant criteria for managed

care programs exists. Pretreatment assessment and patient monitoring

apparently are not comprehensive for most programs. Also, apparently

no uniform standards for admission criteria, length of stay, and treatment

procedures exist. Providers and, to a lesser degree, employers and patients

perceive managed care more as a cost-cutting mechanism than a treatment

approach for matching a person to the most appropriate treatment regimen

at each treatment stage (Institute of Medicine 1990, p. 476).

If a managed care program has implicit criteria (not publicly stated), outcomes

and cost-effectiveness of care are almost impossible to evaluate. Because

most managed care firms have not made their criteria public or reported

their results in peer-reviewed journals, no consensus can be reached on

outcome measures of managed care programs. Accepted outcome and quality

measures, control groups, and criteria for intervening in patient treatment are

frequently missing in published articles about cost savings and other results

of managed care programs. Without explicitly stated criteria on treatment

process and outcomes, quality and appropriateness of care also are difficult

to evaluate.

Managed care may produce different effects in public- and private-sector

programs. Some public advocates have argued that clients under managed

care in publicly financed programs such as Medicaid may receive services

insufficient to meet their needs. If public managed care programs curtail use,

quality of care may be adversely affected. Quality of care may be improved

by expanding or intensifying public drug treatment, whereas managed care

may inhibit persons with drug problems from gaining access to treatment. In

40
private health insurance without managed care, however, patients may receive

inappropriate care, for example, inpatient care when outpatient care may be

equally effective. The public and private sectors intersect for those privately

covered patients who exhaust their private health insurance for drug treatment

and have to rely on public programs for continued treatment. The public and

private sectors also intersect in legislatively mandated drug treatment services.

How such legislative requirements for health care benefits affect substance

abuse coverage and managed care has not been studied: Do small employers

drop health insurance coverage or institute managed care because of State

mandates? Do State mandates add to costs of substance abuse services,

including those under managed care?

Little is known about the cost-effectiveness of various developments in drug

treatment (McAuliffe 1990). This lack of knowledge extends to managed care

for drug treatment. Concerning cost savings, a recent CBO study found that

the cost savings of managed care programs were limited (Langwell and Menke

1991). This finding contrasts with the reported savings in many articles in the

trade press on health care of interest to business. Many articles by managed

care firms proclaim cost and utilization savings, but most are not based on

reliable health services research. What is also unknown is whether the savings

accrue to the payer and the provider or just to the managed care plan. The

CBO study noted that many cost savings findings come from HMOs where

financing and service provision are integrated, which is different from the more

loosely structured PPOs and managed fee-for-service plans. The study offers

three reasons for the limited costs savings from managed care programs

(Langwell and Menke 1991, p. 39):

Not all managed care arrangements are equally effective-in fact, there is

little evidence that loosely organized managed care produces any savings,

and much of the growth in enrollment in managed care organizations has

been among loosely organized types of arrangements.

Substantial administrative costs are associated with managed care,

and these costs may be sufficiently high to offset savings generated by

modest reductions in hospital admissions or length of stay. In addition,

administrative costs are higher the smaller the insured group. Since HMOs

tend to enroll a somewhat small proportion of the employees from any one

employer, their per capita administrative costs are high.

The fragmented system of health care financing in the United States

may make it possible for providers to expand the number of services and

increase prices for other types of patients when managed care is successful

in reducing utilization and expenditures for some groups of patients.

41
MANAGED CARE AND CASE MANAGEMENT

Managed care probably provides some useful insights for case management,

or at least some useful parallels. Before such insights can be presented,

managed care and case management should be defined.

Managed care has no single, widely accepted definition, as has been

indicated above. The four definitions given present certain common elements

or components of managed care. These include various types of utilization

review activities, assessment and referral to treatment, treatment monitoring,

financial incentives to influence provider practices, and provider arrangements

that direct patient choice. Managed care comes from an acute care, medical

model of treatment, which partly distinguishes it from case management.

Case management is a term that is used in both the health care treatment

and social services sectors. In the latter context its definition includes

longitudinal, individual, comprehensive, flexible, personal, accessible, and

cohesive interventions (Willenbring et al. 1991). As defined by the Joint

Commission on the Accreditation of Health Care Organizations, case

management functions include identification and outreach, assessment,

planning, linkage, monitoring and evaluation, and client advocacy (Willenbring

et al. 1991).

The health care treatment field uses case management in a different sense.

Case management in health care includes intake assessment, referral

to appropriate treatment, monitoring during treatment, discharge planning,

and coordinated followup care (Franklin et al. 1987). It literally refers to

the management of a “case.” It is frequently used in the long-term-care

field, where a variety of medical and related problems with activities of

daily living are present and require coordinated attention. In long-term

care, case management includes needs assessment, care planning, service

coordination, monitoring, and client advocacy (Kemper 1990). In health care,

case management is broader than managed care in that it refers to a full range

of health and related services, such as home care, often for chronic, debilitating

conditions.

In the arena of substance abuse treatment, there is a growing recognition of

the importance of treating more than just the disorder of substance abuse.

Willenbring and colleagues (1991, p. 4) explain this as follows:

Some of these groups (for example, public inebriates,

poor and homeless people, people with concomitant

serious mental illness and alcohol and other drug

42
dependence) share certain characteristics and problems

that are related to a poorer treatment response. These

seem to be related both to the nature of the illnesses

(for example, suffering a more virulent form of the illness)

and to the nature of the public treatment systems available

to serve them (fragmented, lacking in structures for

continuous care). Lack of socioeconomic resources, or

other social disadvantage, may contribute in many cases.

Recognition of the variety of problems has promoted the development of

social service interventions associated with case management to supplement

the medical model of treating the substance abuse problem. It is this attempt,

according to Willenbring and colleagues (1991, p. 5),

. . . both to modify alcohol and drug treatment and to

present it in conjunction with other treatments, that case

management has received its recent, and often favorable,

review. Case management, which has long been utilized

and felt to be effective in a variety of social welfare

programs and in psychiatric treatment, is appealing to

program designers confronted with complex problems

and fragmented systems of care.

Drug abuse providers now attempt provision of or reference to social services

for pregnant women with drug problems, homeless families and youths with

substance problems, and human immunodeficiency virus substance abuse

patients, groups of patients who have not benefited from the customary medical

care.

Case management is becoming increasingly important for providing care

to pregnant women with substance abuse problems. The Health Care

Financing Administration has instituted a Medicaid Demonstration titled

Treatment Services for Drug-Addicted Pregnant Women, which will provide

“coordinated care” for combined substance abuse and prenatal care (for

an explanation of coordinated care, see Managed care: Key 1991). The

demonstration is designed to include such services as outreach to identify and

recruit Medicaid-eligible women; integration and coordination of comprehensive

services (e.g., prenatal care, substance abuse treatment, other ancillary

services, including social support services for the family); assessment,

management, and followup of the mother and infant; and followup and

monitoring for a period of time following treatment services to help women

remain drug-free.

43
Substance abuse is a growing problem among homeless families, and

treatment providers recognize that these families require more than just

treatment services (Weinreb and Bassuk 1990). Despite the lack of sufficient

services across the Nation, there are several model programs that have

begun to offer both health and social support services. For problems faced

by homeless and runaway youth with drug problems, there are insufficient

services to meet their needs, but there are model programs that have had

some success in meeting youth’s needs (Pires and Silber 1991).

In the social services sector, case management includes much more than

treatment for substance abuse problems. This definition includes outreach

and services such as job counseling, training, and placement (Nishimoto et al.

1991). It frequently deals with a family rather than the individual (Neenan and

Bowen 1991). In addition, case management makes use of a facilitator, not just

a “gatekeeper,” in many managed care programs. Thus, managed care can

be included under the umbrella of activities that constitute case management,

whether in the health care or the larger social services context. Although

managed care practitioners frequently use the term case management, they

mean by it the management of a particular patient’s care, not a type of grouped

activities to treat and provide social services to an individual. There is an

intertwining of the use of terms that requires careful definition of each term in

the specific context to avoid confusion.

There are two issues in managed care that are particularly relevant to case

management. These are the lack of explicit, widely accepted criteria for

managed care and the lack of demonstrated cost savings attributable to

managed care.

The goals of case management and managed care appear to be different.

The former is concerned with providing coordinated care and social services,

patient advocacy, and a range or network of support systems; on the other

hand, managed care is concerned primarily with cost control, albeit without

sacrificing the quality of care. Despite the differences in their goals, however,

both case management and managed care are affected in similar ways by the

lack of criteria in assessment, referral, intervention activities, and followup as

much as by the lack of documented cost-effectiveness.

In managed care there are no uniform, widely accepted criteria for pretreatment

assessment and matching, patient monitoring, length of stay and appropriate

placement by modality and setting, and treatment procedures. There appears

to be the same lack of criteria within case management. The effect of this lack

in both areas makes it difficult to compare different interventions. Therefore,

in both managed care and case management, it is critical that evaluators state

44
explicitly and in detail “what it is” that the intervention or activity under analysis

does. That is, Are cost savings attributable to the financial incentives for the

providers, to changes in procedures such as shorter lengths of stay in

rehabilitation units, to changes in types of therapies, or to some combination

of these?

In managed care the health business literature is replete with articles

proclaiming the cost savings of the authors’ particular approaches to

managed care. These cost savings do not stand up to scrutiny for the most

part because the authors do not provide sufficient detail on the “what it is”

that their managed care program does (also, they frequently do not use

random assignment study methods or statistically adjust for self-selection

bias [Sechrest et al. 1990]). In case management, cost savings is not a

primary goal. Nonetheless, in an era of contracting public budgets, it is

paramount that case management show itself to be cost-effective or costbeneficial. The same difficulties encountered in demonstrating costeffectiveness or cost-benefits in managed care apply to case management.

Of particular importance in case management is the issue of cost-offset

(Holder 1987; Holder and Blase 1986; Holder and Schachtman 1987); that

is, Does an aspect of case management, such as job training and placement,

lead to a savings (an offset) in the costs of public welfare? The offset issue

presents methodological difficulties in evaluation, but it is not an insurmountable

barrier to research.

SUMMARY

Managed care has become an important subject for health service research

and is used increasingly by health care payers to control health care use and

costs. Health services research on managed care has relevance to the

evaluation of case management of persons with substance abuse problems.

Two issues in managed care that are particularly relevant to case management

are the lack of explicit, widely accepted criteria for managed care and the

lack of demonstrated cost savings attributable to managed care. Thorough,

systematic evaluative research needs to be done before these issues are well

understood.

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AUTHOR

Albert Woodward, Ph.D., M.B.A.

Public Health Analyst

Financing and Services Research Branch

National Institute on Drug Abuse

Parklawn Building, Room 9A-42

5600 Fishers Lane

Rockville, MD 20857

53
Accessing Additional Community

Resources Through Case Management

To Meet the Needs of Methadone

Clients

Michael L. Dennis, Georgia T. Karuntzos, and J. Valley Rachal

INTRODUCTION

The end of the 1980s saw renewed interest in expanding and improving the

effectiveness of methadone-assisted rehabilitation as a tool for stopping the

spread of infectious diseases, specifically human immunodeficiency virus (HIV),

the known cause of acquired immunodeficiency syndrome (AIDS) (Ball et al.

1989; Dennis et al. 1991 a; Haverkos 1991; Haverkos and Lange 1990; Hubbard

et al. 1989; Gerstein and Harwood 1990; Watkins et al. 1988). Injecting drug

users (IDUs), one of the fastest growing group of people with AIDS, account for

32 percent of all AIDS cases (National Commission on AIDS 1991). Unlike the

rate of new AIDS cases among homosexuals, the rate of new IDU-related AIDS

cases is increasing; 25 percent of all IDU-related AIDS cases have been

reported since July 1990 (Centers for Disease Control 1991).

Recent studies suggest that methadone treatment programs increasingly are

offering fewer services despite the complex needs of their clients and existing

Federal mandates to do so (D’Aunno and Vaughn 1992; Dennis et al. 1991 a;

Frances 1991; General Accounting Office 1990; Food and Drug Administration

1972). As programs employ fewer specialists and offer fewer direct ancillary

services, they must increasingly rely on existing community resources to meet

their clients’ needs, ensure their continued treatment, and support them on the

road to recovery. Unfortunately, clients and existing staff are not consistently

adept at accessing these existing resources. Recent evidence, reviewed later

in this chapter, suggests that increased attention to rehabilitation and ancillary

services improves retention and decreases the injection of heroin, speedball,

cocaine, and other drugs (Dennis et al. 1991 a; Fairbank et al. 1991; McLellan

et al. 1988).

54
This chapter reviews the literature and presents data from two randomized

field experiments that the Research Triangle Institute (RTI) is currently

conducting to examine the unmet needs of methadone clients, the availability

of community resources to address those needs, the utilization of these

resources, and the extent to which a case management approach can be used

to improve treatment outcomes. Information from these preliminary studies is

then used to recommend a model for accessing community resources through

case management to meet the needs of methadone clients. The proposed

model includes the authors’ definition of case management, suggested

qualifications for the case manager and how that manager should interact

with the existing staff and service system, and methodological considerations

in evaluating the proposed model.

BACKGROUND FROM THE LITERATURE

To identify related information and references on case management for

methadone clients, the authors searched the literature for the past 10 years

in five computer databases: MEDLINE, Psychlnfo, Mental Health Abstracts,

Health Planning and Administration, and Nursing and Allied Health. Each

database was searched for the following strings: Case management and

treatment; drug abuse or substance abuse or alcohol or methadone; case

manage and link; link and drug abuse or substance abuse or alcohol or

methadone; case manage and link or linkage and treatment; and service or

provider. We then reviewed recent issues of the National Institute on Drug

Abuse’s (NIDA) Treatment Research Monograph Series, NIDA’s (1990)

“Training for Methadone Treatment Professionals” draft manual, the Bureau

of Health Care Delivery Assistance’s “National Resource Guide: Primary

Health Care and Linking Drug Abuse Treatment” (Cox et al. 1991), volume

3 of the “Oxford Textbook of Public Health” (Holland et al. 1990), and RTl’s

extensive library of technical reports on drug abuse treatment.

Although the combined search identified more than 85 unique references

on case management, no published evaluations of case management were

identified that met the following criteria adapted from Chamberlain and Rapp

(1991, pp.172-173):

Case management defined as the independent variable rather than as an

element of the independent variable

Independent variable described

Dependent variables defined as client outcomes

55
Experimental or quasi-experimental designs used

Unique to this review, outpatient methadone or drug-free clients in the

sample

This finding is not surprising given that Chamberlain and Rapp (1991) had been

able to identify only six studies in the much larger field of mental health that

met these criteria. However, numerous reviews of the issues involved, surveys

of existing practices in addiction treatment, and detailed data on the other types

of client problems were identified.

Case Management Issues

During the past 10 to 20 years, case management has become an increasingly

common technique for providing some or all of the services in human services

agencies as clients have been transferred from institutions with centralized

services to the community where services are typically decentralized (Sanborn

1983; Weil et al. 1985). This chapter offers only a brief reprise of some of

the major recurring issues because the literature already provided several

models and reviews of case management in general (Bachrach 1981; Bond et

al. 1989; Chamberlain and Rapp 1991; Cohen et al. 1980; Forchuk et al.

1989; Franklin et al. 1987; Harris and Bergman 1988; lntagliata 1982; Levine

and Fleming 1987; Modrcin et al. 1985; Sullivan 1981; Perlman et al. 1985;

Pincus 1987; Stein and Test 1980; Texas Department of Mental Health and

Mental Retardation 1985; Willenbring et al. 1991). These issues include:

Should the case manager serve as a therapist/direct service provider, a

service broker, or an advocate?

Should case management be provided by someone located within a specific

program working with a specific type of client or by someone working in the

larger social service system matching clients to programs?

Which services should be provided directly by the program, and which

should be provided through case management of other community

resources?

Who should receive case management services, and how much assistance

should they receive?

Should case managers work directly with clients, as part of a treatment

team, or only through existing treatment staff?

To what extent should case management focus on client empowerment?

56
At one extreme, Lamb (1980) and Deitchman (1980) have argued that case

management should be part of the normal duties of a conscientious therapist

and that a nontherapist is unable to effectively work with the client without

knowing the client’s special needs. Under this conception, the therapist

would be a generalist and provide a variety of services to a presumably small

caseload of clients. Unfortunately, few of the primary counselors in methadone

programs have the qualifications for this role, raising the question of rationing

the services of those who do or spending resources to train those who do not.

At the other extreme, Rapp and Chamberlain (1985), lntagliata and Baker

(1983), and Kurtz and colleagues (1984) support a model of case managers

as brokers of services. Although they recognize the inherent problems of

using nontherapists, they cite evidence that staff members dedicated to case

management are more able and willing to do more of the work necessary to link

services. Furthermore, they believe that centralizing the networking process will

make it more effective by creating continuity in communication and building

stronger networks. Deitchman (1980) argues that centralization reduces the

confusion and competition that could result from multiple people calling the

same community provider.

Case Management Practices in Addiction Treatment

Although the need for case management in addiction treatment has been

recognized for more than a decade, there is little consensus about what it is or

who should provide it (Graham and Timney 1990; Pearlman 1984; Schlenger et

al. 1990). In a review of 21 demonstrations to link primary and drug abuse

treatment, Cox and colleagues (1991) found that every linkage program

proposed some form of case management, but the type of person providing

case management ranged from health education nurses to social workers to

paraprofessionals. Furthermore, their roles ranged from education to service

delivery and from working directly with clients to supporting the existing staff.

Timney and Graham (1989) reported that virtually all the 268 addiction

programs they surveyed in Ontario, Canada, provided some form of case

management, but what they provided ranged from health education or

counseling to service brokerage or referrals. More than half the programs

in the survey reported providing case management before and during

treatment; 75 percent reported providing some kind of case management

as aftercare; and 26.7 percent reported providing case management instead

of treatment.

Ogborne and Rush (1990) surveyed 167 addiction treatment programs to

study the impact of a new assessment and referral system in Alberta. The

57
26 programs that focused on assessment and referral to other programs served

as a form of centralized intake with treatment matching but did not attempt to

interfere with direct recruitment by existing programs. Thus, Ogborne and Rush

found that the “service brokerage” style of case management provided by these

programs supplemented the existing referral network rather than replaced the

primary providers’ informal referral process.

Barriers to Effective Methadone Treatment

There are numerous client-, program-, and community-level barriers to

effective treatment. Foremost of the client problems is the continued use

of heroin, cocaine, marijuana, and alcohol while in treatment. Methadone

programs originally were designed for people whose primary problem was

opiate addiction. Most clients entering programs now, however, are likely to be

dependent also on cocaine or another drug (Chaisson et al. 1989; Condelli et

al. 1991). Clients are also likely to have comorbid problems with mental illness,

criminality, unemployment, poor training or education, inadequate family/social

support, and AIDS and other infectious diseases (Cooper et al. 1983; Ginzburg

et al. 1984; Haverkos 1991; Hubbard et al. 1989; Rounsaville et al. 1986;

Woody et al. 1985). These additional problems create complex

and heterogeneous treatment needs that are beyond the scope of what most

methadone treatment programs can provide on their own.

Programs have several structural problems, including high caseloads and

poor pay and working conditions that lead to high turnover, low and fixed

dosage policies, and a shrinking number of ancillary services (Dennis et al.

1991 a). D’Aunno and Vaughn (1992) found enormous variation in clinical

practices in a national probability sample of methadone programs. Many

treatment units continued in practices that the majority of previous studies

had found to be ineffective. Among these common less effective practices

were low-methadone dosage policies and little or no client involvement in

dosage setting.

Existing community resources are scattered over a variety of agencies,

each with its own eligibility criteria and application process. Ex-addicts must

compete with many different populations for employment services (Hollister

et al. 1984). Groups such as displaced workers, unemployed youths, or

chronically unemployed nonoffenders are often viewed as more “deserving”

of social services than former drug users. The complexity of the employmentrelated problems of the various disadvantaged populations, including exaddicts, has led to the development of a variety of Federal, State, and local

programs designed to assist such individuals in obtaining and maintaining

employment. The two most relevant programs for this discussion are the

58
Job Training Partnership Act (JTPA) program and the State Division of

Vocational Rehabilitation (DVR) programs.

A major problem for methadone treatment clients is that the cost-per-client

standards generally used in the $3.8 billion JTPA program, the principal funding

agent for general employment services programs, stack the odds against the

ex-addict’s obtaining employment services. The JTPA-sponsored programs

primarily focus on preparing economically disadvantaged people or displaced

workers to enter the labor market through training, job development, and job

placement. During preparation and after placement, JTPA clients must rely

on their own skills and resources to either succeed or fail. Services such as

adjustment counseling, social service referrals, and crisis intervention

assistance are minimal or nonexistent in JTPA programs. The dropout rates

from JTPA programs for ex-addicts and other disabled populations are very

high because these programs are poorly suited to meeting their needs

(Hollister et al. 1984).

The more intensive training and employment needs of ex-addicts should and

can be met through State DVR programs, just as they are for many other

disabled people (e.g., persons with visual, hearing, or cognitive impairments).

DVR programs can cover the cost of everything from going back to school to

the cost of drug treatment for 5 to 10 years. In a national probability sample of

State DVR client records, Hayward (1989) found that 9.8 percent of the clients

reported substance abuse as their primary disability. Unfortunately, these

records do not distinguish clients by the substances they abuse (e.g., alcohol,

heroin, cocaine) or the type of treatment they receive (e.g., 12-step, residential,

methadone, outpatient drug-free). Later sections of this chapter suggest that

several barriers will continue to deter methadone clients from using these

programs.

PRELIMINARY STUDIES

This section reports the results of several preliminary studies that were done in

the context of two ongoing efforts to answer the following questions:

What are the needs and problems of methadone clients in the Methadone

Enhanced Treatment (MET) and Training and Employment Program (TEP)

studies?

Are community resources available to address these needs?

To what extent are community resources being used to meet client needs?

59
What kinds of services did clients receive through case management in MET

and TEP?

Were these services more effective or less effective than standard

treatment?

The MET and TEP trials are two independent studies, each with four

methadone programs in four different cities. Although two methadone

programs participated in both studies at the same time, there is no overlap in

the clients who participated. Before addressing the specific questions, the

following section briefly summarizes the MET and TEP studies and the extent

to which they involve case management.

Overview of the Two Studies

Methadone Enhanced Treatment Trials. The MET study is a randomly

controlled trial being conducted from 1988 to 1992 across four programs:

Sisters of Charity in Buffalo, NY; William C. Segaloff Substance Abuse Center

in Camden, NJ; Desire Narcotics Rehabilitation Center in New Orleans, LA;

and PBA, The Second Step, in Pittsburgh, PA. In this study, existing

methadone treatment is being compared with an enhanced protocol that

includes standardized needs assessment, increased problemsolving

counseling, more treatment planning, more frequent urine monitoring, and

use of a community services coordinator (CSC).

The CSC provides case management through MET counselors by locating

services to meet client needs identified by the counselor. The CSCs each have

3 to 10 years’ experience in either drug abuse or mental health counseling and

are very familiar with the social service system in the community in which they

work.

The study and sample were described in detail elsewhere (Bonito et al., in

press; Dennis et al. 1991a, 1991b; Fairbank et al. 1991; Wechsberg et al.

1991). In brief, the client sample represents more than 86 percent of the new

intakes to the four programs and includes 661 people in the main trials and

approximately 750 in two preexperimental baseline control conditions.

Depending on the site, the clientele is 60 to 80 percent male, 40 to 60 percent

ages 30 to 40, and 38 to 78 percent African-American. Data are available from

baseline, 6-month, 12-month, and 24-month interviews; service logs; record

abstractions; urine test results; and HIV test results for 540 to more than 1,300

clients.

60
Training and Employment Program Pilot Study. The TEP pilot study is a

randomly controlled trial being conducted from 1990 to 1992 across four

programs: Sisters of Charity in Buffalo, NY; Milwaukee County Mental Health

Complex in Milwaukee, WI; PBA, The Second Step, in Pittsburgh, PA; and

Santa Clara County Bureau of Drug Abuse Services in San Jose, CA. In this

study, existing methadone treatment is being measured against a protocol that

includes vocational needs assessment, financial assistance, and use of a

vocational specialist (VS).

The VS works directly with the counselors and clients to identify client needs

and provides case management services to identify community resources to

meet these needs. The VSs have master’s degrees in counseling or bachelor’s

degrees in social work and at least 10 years of experience in alcohol and other

drug rehabilitation with hard-to-serve populations. The VSs are very familiar

with the social services system in their communities.

The study and sample were described in detail elsewhere (Dennis et al. 1991c ;

French et al., in press; Karuntzos et al. 1991). In brief, the client sample in this

study represents more than 83 percent of the new intakes in two programs

(San Jose and Milwaukee only), 90 percent of the people recommended by

their counselor, and 74 percent of the people randomly sampled from the

existing caseload. Depending on the site, the clientele is 50 to 64 percent

male, averages 36 to 39 years of age, and is 2 to 39 percent African-American

(San Jose clientele is 44-percent Hispanic). Data are available from initial

interviews, 3-month interviews, service logs, and 12-month record abstractions

from approximately 360 clients.

What Are the Needs and Problems of Clients in These Two Studies?

Although the MET trials are still under way, several analyses have already

been conducted on the needs of the clients who are entering treatment and

how these needs compare with those of other IDUs identified through

community outreach by programs in the same communities and those

represented in NIDA’s (1991) 1990 National Household Survey on Drug

Abuse (NHSDA) conducted by RTI. Some of the client needs and problems

that were consistently identified across the four programs include:

From 70 to 90 percent are regularly injecting cocaine as well as heroin

(Wechsberg et al. 1991).

From 71 to 87 percent have a criminal record (Bonito et al., in press).

From 2.3 to 10.1 percent already tested positive for HIV using an ELISA

screen and Western blot confirmation (Dennis et al. 1991a).

61
More than 26 percent have gonorrhea, hepatitis, pneumonia, syphilis,

tuberculosis, or some other infectious disease (Bonito et al., in press).

IDUs entering these programs were more likely to be older, unemployed, use

more different drugs, and have longer drug use histories than IDUs identified in

the 1990 NHSDA (Wechsberg et al. 1991).

Although the report of cocaine injecting was high at intake, virtually none of

the current use involved crack cocaine. Unlike IDUs identified through

outreach in the same four communities, the chronic daily injectors of cocaine

were predominantly using speedballs, not cocaine alone.

The TEP interviews focused more on earnings, employment, training, and

services. Some of the relevant findings to date include:

Illegal earnings at intake often exceeded legal earnings by 2 to 1 (Dennis et

al. 1991c).

More than 66 percent were not employed in the week before treatment

admission, with 32 percent lacking a high school diploma and 33 percent

reporting at least one disability that would interfere with their ability to work

(French et al., in press).

Virtually all clients reported problems with paying for transportation, despite

the fact that 94 percent had access to some form of public transportation

and 65 percent had a reliable vehicle (French et al., in press).

Focus groups with counselors and clients further revealed that both groups

had problems locating and accessing services in the community (Dennis et al

19916).

Are Community Resources Available To Address These Needs?

Both the MET and TEP experimental protocols called for the development

of community resource directories in each community. Such directories were

successfully created in Buffalo, Camden, Milwaukee, New Orleans, Pittsburgh,

and San Jose (Arnesen 1990; Brown 1989; Garrett 1991; Goodman 1991;

Heath 1991; Hurley 1989; Norman 1991; Vargo 1991). The list below

summarizes the existing resources targeted and found in the community

in MET and TEP.

62
MET

—Housing

—Family services

—-Dental care

-—Medical care

—Transportation

—Food services

—Mental health services

—Physical rehabilitation

—Educational counseling

—Legal aid

• TEP

—Job preparation

—Assessment/evaluation

—Basic educational programs

—On-the-job training referrals

—Vocational counseling

—Vocational/technical programs

—Displaced worker programs

—Resources for vocational needs

Both MET and TEP

—Employment placement

—Job skills training

—Vocational rehabilitation

—Psychological rehabilitation

—Child care/day care

—Drug treatment

—Housing

—Minority opportunity programs

—Transitional needs programs

—Social service organizations

Several of the programs and resources identified can also provide long-term

assistance for medical problems, housing, vocational rehabilitation, job training,

and financial assistance to pay for treatment. Although many providers and

employers have had misconceptions or know little about methadone clients,

they have been willing to work with the TEP and MET staffs to try to meet the

complex needs of the clients.

Both studies identified two major gaps in the existing service system. First, the

unavailability or inaccessibility of local resources to help clients meet small and

63
immediate expenses to cover things such as car repairs, license examinations,

initiation fees, deposits, and tool belts were important short-term barriers to

treatment retention, employment, housing, training, and service use. Second,

many programs had operating shortfalls that prevented immediate intakes but

not long-term commitments. This included many vocational programs that had

slots but were temporarily out of funds for child care and others that had open

slots but no money for the required intake testing to establish eligibility.

To What Extent Are Community Resources Being Used To Meet Client

Needs?

An analysis of the topics being discussed during individual counseling sessions

in MET showed client concern about educational and employment issues in

more than 25 percent of the counseling sessions during the first 6 months of

treatment (Fairbank et al. 1991). Unfortunately, this analysis also showed that

the counselors made virtually no referrals to people inside or outside a program

who might address those issues. Furthermore, the CSCs in MET repeatedly

complained during the trial that they had a hard time getting the counselors to

identify these cases so that the coordinator could help locate the necessary

community resources. A major problem appears to be that many counselors

think that the client should first focus on his or her drug problems and that

issues such as employment or housing should be dealt with later.

In preparation for the TEP trials, RTI staff conducted focus groups with clients,

staff, and local providers in each of the four participating sites. Dennis and

colleagues (1991a) found that counselors and clients were largely unfamiliar

with the available agencies and resources in the community. Although many

knew of one or two agencies, they typically related horror stories about how

long it took to be accepted. For instance, many clients reported being rejected

by State vocational rehabilitation offices for incorrect reasons (e.g., being on

methadone would violate the Drug-Free Workplace Act; treatment clients who

were currently drug-free no longer faced barriers to employment) or having their

applications take more than 12 months to process (Karuntzos et al. 1991).

Many of the local training and JTPA providers said they did not actively recruit

ex-addicts and other disabled populations because such clients are more

expensive to serve than people without addictions or disabilities and reduced

the performance measures on which they were being judged (Dennis et al.

1991c). It should be noted, however, that the treatment staff knew of several

local programs that (probably unwittingly) had methadone clients in their

programs, although they reported they did not. Furthermore, most of the local

providers and employers were willing to work with methadone clients as long as

they were assured of the clients’ qualifications to do the work and their progress

in treatment was monitored.

64
What Kinds of Services Did Clients Receive Through Case Management?

Unfortunately, the MET trials were designed around enhanced counseling and

did not provide detailed measures of the case management services that were

provided. The authors know from site visits and progress notes that the CSCs

were able to identify many resources in the community for clients and to provide

transportation assistance through miscellaneous funds provided under the

grant. We also know that the CSCs helped many clients to speed up their

applications for welfare benefits by getting the forms and helping the clients

“walk them through” the application process.

In TEP, the vocational specialists maintained detailed logs of the services they

provided to clients, both in terms of direct work with specific clients and general

activities. The data Dennis and colleagues (1991c) collected from the client

service logs during the first 6 months of the pilot reveal that the vocational

specialists:

Directly provided clients with vocational assessments (24 percent),

vocational counseling (55 percent), and/or job placements (7 percent)

Brokered or arranged for motivational/self-esteem workshops (56 percent),

job development assistance (29 percent), support services (19 percent),

and educational or training services (29 percent)

Arranged for 32 percent of the TEP clients to be reviewed by a State

vocational rehabilitation agency and/or JTPA offices

Furthermore, they were able to reduce the application time for most benefit

programs by 50 to 80 percent, This was done largely by having all the forms in

advance, ensuring that the clients had all the necessary information, helping to

collect many of the required signatures and reports, walking the client through

the system, and following up on the clients as they proceeded through the

application process (Karuntzos et al. 1991).

Were These Services More Effective or Less Effective Than the Standard

Treatment?

The number of counseling sessions involving vocational and educational

issues in MET has been one of the single greatest predictors of reduced drug

injections, explaining 28 to 33 percent of the variance in subsequent abstinence

and 18 to 23 percent of the variance in chronic daily injecting when combined

with other treatment data (Dennis et al. 1991 a). The TEP interventions were

designed to identify clients with needs in these areas and to have those needs

addressed through existing local resources.

65
Although data on the long-term impact of TEP have yet to be collected, there is

already early evidence suggesting that existing community resources are being

reached and services are being received by the clients. Table 1 summarizes

the vocational outcomes of the clients randomly assigned to TEP with those

assigned to the standard level of services. After only 3 months of the program,

the TEP clients were receiving significantly more referrals, assessments, and

direct services (72 vs. 32 percent). Every vocational outcome, including

enrollment in long-term school/college programs, was higher for the TEP

group.

TABLE 1. Relative frequency of vocational outcomes at 3 months by level of

vocational services (n=218)

3-Month Standard TEP

Vocational Outcomes (N=111) (N=107)

Received classes/education 0.02 0.3

Referred to classes/education 5.8 13.8

Enrolled in school/college 8.6 12.2

Received job skills services 0.64 5.512

Referred to job skills services 1.71 5.41

Received vocational assessment 4.61 8.91

Referred to job training 1.1 3.3

Received help looking for job 7.5 9.8

Received job support services 7.42 1.1

Received financial help 0.6 6.5

Level of Services* Main Effect

(1,208, Significance

28.92 .0001†‡§

1.77 .1850

0.02 .8778

1.42 .0001†‡§

3.01 .0004†

1.32 .0009†

0.22 .6393

1.01 .3154

6.01 .0150†‡§

6.14 .0140†

Mean number of outcomes (1-10)

Percentage with any outcome (%)

0.46 1.73 45.56 .0001†‡**

0.32 0.72 36.61 .0001†‡

* Only services offered through standard treatment vs. the same services plus those

offered by TEP

† Significant main effect of the level of services at P

‡ Also a significant main effect of site at

§ Also a significant interaction between the level of service and client sample type (i.e.,

counselor recommended, intake sample, randomly sampled) at

**Also a significant main effect of client sample type at

SOURCE: Adapted from Dennis et al. 1992

66
There were also consistent patterns of reduced drug use during the first 3

months while the TEP clients were receiving the additional TEP services

(Dennis et al. 1991 c). Although the reduced pattern of drug use did not reach

statistical significance at 3 months, it does suggest movement in a positive

direction.

DISCUSSION

When the MET study began, the authors were planning to use primarily a very

administrative form of case management in which a CSC would identify local

community resources and then indirectly help clients access those resources

through their counselors. Although the CSC became an integral part of the

drug treatment team, few of the counselors were using the CSCs to access

community resources for their clients. This appears to have occurred, at least

in part, because counselors simply did not always understand the role of the

CSC. However, as meetings with the counselors continued, it became apparent

that many of them believed that progress on drug use issues should precede

services, rather than go hand in hand, as we were proposing.

The authors tried to address this problem in TEP by having the VSs work

directly with clients, focusing their efforts on a service broker type of case

management. Although this dramatically increased the number of clients who

were able to receive services, it was not without drawbacks. The camaraderie

and team approach in MET were largely missing, and several clients attempted

to play the VSs and counselors off each other for sympathy and services. Also,

as time progressed, it was apparent that, to address vocational and

employment issues, the VS had to deal with the full range of client needs and

problems, acting more and more like the original CSCs as time progressed.

Based on this experience and the preliminary studies to date, the authors

therefore recommend returning to the classic three-pronged approach to

methadone treatment:

Methadone to reduce the side effects of withdrawal and stabilize the client

Counseling to address the underlying psychosocial problem(s) of addiction

Support services to address logistical problems such as employment,

transportation, child care, and medical care

In this approach, case managers would be responsible for addressing the last

set of issues both in terms of immediate threats to treatment retention and longterm needs for rehabilitation. They would cover the full range of issues that

67
the MET CSCs did, while working directly with clients as part of an integrated

treatment team. Although the treatment team certainly may try to temper overly

ambitious plans, case management will be largely client driven.

The Case Manager and Case Management

In the authors’ approach, the case manager should be someone who is

familiar with both the clinical issues related to the client population and the

local service system. Because the focus is on accessing community resources

outside the treatment program, the case manager must be able to represent

both the clients and the program in general to outside agencies and potential

employers. Typically, he or she would have the equivalent experience of a

senior counselor, have worked with multiple service agencies, and have

credentials akin to a master of social work.

The role of the case manager would change as the client progresses through

the phases of treatment. The case managers would:

Have the primary responsibility for locating services outside a program and

collecting eligibility and application information

Build a network with the major local providers/employers and educate them

about methadone clients and programs

Work with the existing staff to assess a client’s immediate and long-term

needs and to develop a treatment plan to address them

Have the primary responsibility for getting immediate assistance to prevent

early dropout and for facilitating long-term placements with outside agencies

that can provide sustained assistance to address ongoing needs.

During the startup period of a new case management component, the case

manager will need to develop the resource directory and network with the

community’s existing agencies. A major component of this initial effort and

subsequent contacts with providers and employers will be to educate them

about methadone clients and treatment issues for ex-addicts in general. To

create the proposed integrated team approach, the case manager and primary

counselors will be cross-trained to understand critical issues in each area and

to learn how to coordinate their efforts, The counseling and medical staffs

will also be asked to help identify common unmet needs for which the case

manager should try to identify local resources. Table 2 shows how the roles of

case managers and the existing counseling and medical staff change during the

three phases of treatment: the first week, the first 3 months, and long-term care

68
TABLE 2. Model of case management roles by type of staff, client, and phase of treatment

Phase of Treatment

Staff and Client Roles

Case manager

Case manager and

counseling/medical

Staff

Counseling/

medical staff

startup

Development of resource

directory and network;

community education

Cross-training and

creation of treatment

teams

Identification of common

unmet needs

First Week

Determination of eligibility

and readiness for

other programs

Identification of

immediate unmet needs

Determination of drug

and other primary care

problems

Identification of needs

First 3 Months Long-Term Care

Provision of ancillary

services directly or

through referrals to

meet immediate needs

Treatment planning,

provision of in-house

services, identification

of long-term needs

Long-term placements

(e.g., job, DVR.

Medicaid) to provide

continued services

Treatment and ancillary

service followup

Primary care Primary care

Client

Participation in treatment Increased self-reliance

planning and obtaining and working directly with

services outside providers
During the first week of treatment, the client, primary counselor, and case

manager will identify immediate unmet needs that might cause the client to

stop coming to treatment, including adequate transportation, ability to pay for

treatment, housing, or social support. During this process, the case manager

will work with the client to determine the client’s eligibility and readiness for

existing programs and resources that might be used to address these needs.

The case manager will use internal resources and, if feasible, outside resources

to address needs that might prevent clients from returning the following week

(e.g., provision of bus tokens). During this time, the counseling and medical

staffs will proceed, as usual, to determine drug problems and other primary

care needs.

During the first 3 months of treatment, the primary counselor and case manager

will work with the client to develop a treatment plan, provide in-house services,

and identify long-term care needs. This plan will focus on short-term (i.e., now

to the next session) objectives to move the client along in treatment and to

access the community services. The case manager will work with the client to

access ancillary services directly or through referrals to meet immediate needs

that might cause the client to drop out during the first 3 months. As usual, the

counseling and medical staffs will provide primary care for drug treatment

problems.

During the remainder of treatment, the focus will be on long-term rehabilitation.

The client, primary counselor, and case manager will work together to follow up

on treatment and ancillary services. The case manager will try to place the

client into long-term programs that can provide continued services and support

(e.g., job, State DVR, Medicaid). The counseling and medical staffs will provide

primary care for drug treatment problems.

The start of case management services in the preceding model was at client

intake. However, the case management protocol also should address the

needs of clients already in treatment. For them, there will be less focus on

immediate treatment retention and more on barriers to their progress in

treatment. Thus, clients who achieve abstinence must then develop new

and productive lifestyles to avoid relapse. Getting clients into jobs or training

programs helps them feel as though they are making progress and rebuilding

their lives.

The timing and amount of services provided or obtained through case

management are integral to the success of the model. The authors believe

that treatment progress and the provision of service are mutually reinforcing

and should proceed in a spiral fashion. People without housing may need

immediate assistance before they can cognitively deal with their addiction.

70
However, services requiring long-term client and resource commitments, such

as training, should probably not be delivered until the client has made at least

some progress in treatment.

Methodological Considerations

Because there is much variability of both the type and quantity of client

needs, as well as expected differences in what will be received through

case management, future studies should be careful to incorporate several

important design features, including (1) replication in more than one service

system, (2) blocking on some measure of client need before randomization,

(3) standardized client needs assessments, (4) detailed measurement of the

services provided to individual clients, and (5) client-level outcome measures.

Based on the experience in the mental health field (Chamberlain and Rapp

1991, p. 186) client outcome measures should go beyond simple service use

and broad pathological classification measures. They also should include

measures that are sensitive to changes in levels of functioning and cognitive

perceptions of self-efficacy.

Future studies that involve community-based experiments should carefully

assess the validity of the experiment. Based on methodological work in MET,

Dennis (1990) suggested that this should include (1) assessing the integrity

of the case management protocol, (2) measuring treatment contamination,

(3) estimating case flow and statistical power requirements, (4) analyzing the

integrity of the random assignment process, (5) accounting for changes in the

environmental context during the experiment, and (6) accounting for changes in

the case management protocol during the experiment. Through this process,

the following queries must be answered:

To what extent has the planned case management protocol been

implemented?

To what extent does the case management regimen differ from standard

treatment?

To what extent does the randomly controlled trial represent a “fair” or valid

test of any observed differences?

This approach acknowledges past problems with implementing communitybased protocols and the importance of unexpected findings.

71
CONCLUSION

Using the information collected to date, the authors can already conclude that

methadone clients have many unmet needs for ancillary services. Furthermore,

in many cases existing community resources could be used to address both

immediate and long-term client needs. Although it should be evaluated further

in a controlled trial, case management appears to be a promising approach to

accessing many of these community resources. Provision of these ancillary

services, when combined with a small amount of discretionary funds to cover

small immediate needs (e.g., car repairs, rent deposits, test fees, tools) and

operational gaps in the service system (e.g., admission testing, first 1 to 2

months of services), is likely to improve client retention, treatment outcomes

(e.g., drug use, criminal activity, health risks), and longer term rehabilitative

outcomes (e.g., education, employment, and a productive lifestyle).

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ACKNOWLEDGMENTS

This chapter was developed with support from NIDA grants DA-7262-01

and DA-06383-02. This research would not have been possible without the

cooperation, hard work, and in-kind financial contributions of the participating

community providers. LaVerne Carpenter, Paul Ingram, Lou Mattia, Jim

Nowak, Vernon Shorty, Dick Wiesen, and their respective staffs and clients

at the William C. Segaloff Substance Abuse Center in Camden, NJ; PBA, The

Second Step in Pittsburgh, PA; Santa Clara County Bureau of Drug Abuse

Services in San Jose, CA; Sisters of Charity Hospital in Buffalo, NY; Milwaukee

County Health Complex in Milwaukee, WI; and Desire Narcotics Rehabilitation

Center in New Orleans, LA, collaborated in the MET and TEP trials on which

this research is based.

AUTHORS

Michael L. Dennis, Ph.D.’

Senior Research Psychologist

Georgia T. Karuntzos, M.S.I.R.

Human Resource Specialist

J. Valley Rachal, M.S.

Director

Center for Social Research and Policy Analysis

Research Triangle Institute

P.O. Box 121941

Research Triangle Park, NC 27009-2194

77
*Requests for reprints may be sent to Dr. Michael L. Dennis at the above

address.

78
A Strengths-Based Model of Case

Management/Advocacy: Adapting a

Mental Health Model To Practice Work

With Persons Who Have Substance

Abuse Problems

Richard C. Rapp, Harvey A. Siegal, and James H. Fisher

INTRODUCTION

A review of past efforts in the case management field and the body of

literature that has resulted reveals a seemingly endless discussion of many

fundamental aspects of this often imprecise, yet apparently timeless, social

service intervention. Discussions have focused extensively on describing

and defining case management (Roberts-DeGennaro 1987; Sullivan 1981)

and implementing the intervention, that is, deciding what profession should

implement case management in what setting and with what target population

(Moore 1990; Johnson and Rubin 1983; Baker and Weiss 1984). Recent

efforts have attempted quantitative measurement of outcomes (Fisher et al.

1988; Franklin et al. 1987; Borland et al. 1989), provided guidelines for utilizing

specific case management models (Stein and Test 1980; Knoedler 1979),

and attempted systematic comparisons of models (Reinke and Greenley

1986). Practice models have been general (O’Connor 1988) or specific to

populations who are experiencing chronic mental illness (Rapp 1988; Kanter

1989), homelessness (Rog et al. 1987) and advanced age (Goodman 1987).

One population that has received little attention is people with substance

abuse problems.

A scarcity of theoretical and practice work has existed relative to case

management with persons experiencing substance abuse problems.

Graham and Birchmore Timney (1990) have translated some of the generic

issues pertinent to case management into the field of substance abuse

treatment, and Ogborne and Rush (1983) discussed issues of linkage and

interagency cooperation in treatment services for problem drinkers as long

ago as 1983. Although useful in establishing a theoretical base, these efforts

still do not speak directly to a specific practice model of case management.

79
To help fill this void, a 1987 National Institute of Mental Health initiative

funded 13 demonstration projects targeted at young adults with coexisting

mental health and substance abuse problems. Of these 13 projects, 10

identified some form of case management as a primary service and provided

a general description of the case management intervention (Teague et al.

1990). Given the target population of these projects, the case management

services that are employed may have utility for work with substance abusers.

While the findings of these projects are being compiled, the substance abuse

field lacks a practice model of case management.

PROJECT BACKGROUND

An opportunity to explore case management with persons experiencing

substance abuse problems presented itself in the form of a recent National

Institute on Drug Abuse (NIDA) initiative. In response to that initiative,

the Wright State University School of Medicine, through its Substance

Abuse Intervention Programs, developed a demonstration project that

would address the interrelated problems of early withdrawal from substance

abuse treatment, noncompliance with treatment regimens, and resulting

poor treatment outcomes. The Enhanced Treatment Through Induction and

Case Management Project (Enhanced Treatment Project) uses a continuum

of complementary enhancement techniques that include (1) pretreatment

induction procedures in the form of a weekend intervention program and

(2) intensive case management/advocacy (CM/A) strategies utilizing a

strengths perspective. The latter enhancement technique, CM/A, is the

focus of this chapter.

CM/A was chosen as an enhancement in this project because it appears

that many patients quit drug abuse treatment and/or do not comply with

treatment regimens for reasons that can be addressed through CM/A services.

The causes of poor retention rates, noncompliance with treatment regimens,

and overall poor treatment outcome are complex and include both patient

and system dimensions. Patient issues include an interplay of physiological,

psychological, and social factors; system dimensions include the types of

treatment models employed, staff-to-patient ratios, and the comprehensiveness

with which patient dimensions are addressed during treatment. By definition,

CM/A interventions (e.g., coordination, advocacy, planning) are structured to

affect the interface between clients and (treatment) systems.

The traditional emphasis that treatment programs place on substance abuse

as a primary, almost exclusive, condition is an example of an issue that may

benefit from CM/A intervention. The often repeated notion of substance abuse

as a “primary condition” has merit when attempting to focus a patients attention

80
on treatment and impress on him or her the serious nature of the problem.

However, many patients entering treatment have other needs (e.g., housing,

employment, and education) that may affect their ability to engage in the

treatment process. Frequently, these other needs are neglected in the push

to “get people straight.” CM/A strategies are designed to bridge the ground

between “therapeutic” and “resource acquisition” interventions and to assist

directly with resource acquisition.

Despite the use of CM/A with similar populations and evidence that case

management and patient advocacy activities serve a powerful function in

helping to encourage substance abusers to stay in treatment and to realize

treatment goals (Kofoed et al. 1986), little systematic work to determine the

connection has been undertaken. It is a premise of the Enhanced Treatment

Project that implementation of CM/A activities will improve treatment retention

and compliance by assisting patients with acquiring the necessary resources

and also by serving as a therapeutic intervention. Coincidentally, this project

will provide an excellent forum in which to begin a systematic exploration of

the larger issues involved with CM/A work with substance abusers.

THE ENHANCED TREATMENT PROJECT

The project will recruit 600 veterans who apply for substance abuse

treatment at the Polysubstance Rehabilitation Program (PRP), a service

of the Department of Veterans Affairs Medical Center (VAMC) in Dayton,

OH. To determine the effectiveness of the project’s CM/A (and pretreatment

induction) approaches, veterans will be randomly assigned to (1) pretreatment

induction and CM/A, (2) CM/A only, (3) pretreatment induction only, or (4) no

pretreatment induction and no CM/A. After assignment, all veterans will

participate in standard inpatient or outpatient treatment programs at PRP.

During initial screening for the project and again during the intake interview,

veterans review informed consents that outline their potential participation in

the project. Veterans receive a stipend of $30 in return for their participation

in several hours of interviews at intake and at 6-, 12-, and 18-month followup

sessions. All veterans in the project have the opportunity to participate in

human immunodeficiency virus (HIV) education and testing.

To date, 77 male substance abusers have been recruited into the project.

Seventy-seven percent are African-American, 24.6 percent have a trade or

skill, and 52.8 percent worked 5 or fewer days in the month prior to entering

treatment. Only 35 percent are married, but most live with a significant other

and children (72.7 percent). Many have chronic medical problems (e.g., lower

back problems, hypertension, ulcers) that require treatment (42.1 percent), have

been convicted of a serious crime (57.5 percent), or have a comorbidity that

81
required psychiatric treatment (27.3 percent). Sixty-one of the seventy-seven

subjects have used cocaine in the 30 days before treatment, 55 of

whom describe cocaine as their drug of choice. Ninety-five percent of the

cocaine-using veterans have used crack cocaine.

CM/A IN THE ENHANCED TREATMENT PROJECT

The model of CM/A used in this demonstration project is based on a

strengths approach developed by Rapp and Chamberlain (1985). In its

original application, the Strengths Perspective of Case Management/Advocacy

was employed to assist a population of persons with mental illness to make

the transition from institutionalized care to independent living. The model is

predicated on five principles, foremost of which are allowing individuals direct

control over their search for crucial resources and assisting individuals to

use their strengths and assets as the vehicle for acquiring those resources.

Adaptation of the Strengths Perspective to work with persons experiencing

substance abuse problems seemed appropriate at theory and practice levels.

Persons with mental illness and those with substance abuse problems are

generally disenfranchised. Both groups generally suffer from a lack of needed

resources, such as housing, jobs, basic living skills, and education. Mention of

both groups generally provokes negative stereotypes, unflattering remarks, and

even fear.

Not coincidentally, the Institutions created to treat the two groups are similar.

Psychiatric and substance abuse treatment have generally been based on

control and conformity. Until the federally sanctioned and third-party payermediated deinstitutionalization of the 1970s and 1980s, respectively, most

treatment was conducted in hospitals, institutions, and other residential settings

The nature of the treatment is based on a medical model that emphasizes

the professional’s preeminence and the patient’s acquiescence. The most

prevalent theories of treatment have been problem-oriented models based

on an individual’s perceived pathology and resulting diagnosis.

Early research with the model was conducted with a small group of 19

patients in a noncontrolled trial (Rapp and Chamberlain 1985). In that initial

evaluation, more than 61 percent of resource acquisition-oriented client goals

were achieved with a client population generally seen as minimally capable

of independent living. This early indication of effectiveness, an emphasis on

the positive aspects of human behavior, and the commonalities implicit in the

two populations are attributes that formed the basis for adopting the Strengths

Perspective to work with persons who have substance abuse problems.

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Two supplements to the Strengths Perspective were made. First, the project’s

operational definition of CM/A was based on the work of lntagliata (1982) as

well as on the principles of the Strengths Perspective. In this project, CM/A is

defined as

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.

It is noteworthy that, when substance abusers are already in treatment,

the treatment system qualifies as a potential target of CM/A activities.

Second, the conceptual stages of CM/A that guide strengths-based

interventions are those elucidated by Ballew and Mink (1986) in “Case

Management in the Human Services.” In addition to guiding the order

of interventions, these stages (engagement, assessment, planning,

accessing, advocacy, and coordination) will be used as the basis for

differentiating and recording the time spent by case manager/advocates

in various functions. These supplements do not compromise the overall

intent or philosophy of the model.

THE CM/A PROCESS

Case manager/advocates receive notice of those veterans who are assigned

to one of the CM/A groups (CM/A only or pretreatment induction and

CM/A) on the same day that the veteran enters either inpatient or outpatient

treatment at PRP. The case manager/advocate’s initial contact with a veteran

is usually a brief meeting in which the overall project is once again explained

and the worker introduces the concepts of “case management” and “strengths

approach.” The case manager/advocate cites examples of the kinds of

activities that fall within the purview of CM/A, such as employment searches

and assistance with housing. Above all else, the case manager/advocate

leaves this first contact having offered to assist the veteran in some immediate,

tangible manner. Having just entered treatment, many veterans have important

matters that need to be put in order, such as retrieving clothing from a former

residence, contacting family members, or advising probation officers of the

veteran’s entry into treatment. This immediate and tangible offer of assistance

begins the process of engagement and models the action-oriented nature of the

relationship.

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During the next three to four contacts with the veteran, the case manager/

advocate completes a Strengths Assessment, not as a structured interview

but in an open-ended, discussion format. The exploration of past, often

forgotten personal assets is guided generally by an examination of nine “life

domains,” which include life skills, finances, leisure activities, relationships,

living arrangements, occupation/education, health, internal resources, and

recovery. However, one note about both worker and veteran expectations

during these early contacts seems in order.

Before their first contact with the veteran, case manager/advocates are

instructed not to read the veteran’s medical record and to avoid detailed

discussion of the veteran with treatment staff. This somewhat forced isolation

is intentional; case manager/advocates should strive to hear the veteran’s

goals and aspirations before they hear evidence of his past problems, mistakes,

or weaknesses. After these early contacts with the veteran, case manager/

advocates are unlikely to be sabotaged in their thinking by learning of the

veteran’s diagnosis or by hearing a recounting of the veteran’s “sordid” past.

Persons with substance abuse problems are programed by their own emotions

and society’s responses to their problems to focus on the negative. Veterans

who have been in treatment previously are especially used to the process of

doing fourth- and fifth-step work as is done Alcoholics Anonymous, that is,

making a moral inventory and admitting their “wrongs.” During their work with

veterans, case manager/advocates frequently will need to gently prod the

individual to stay focused on strengths and accomplishments instead of

recounting past problems.

As the case manager/advocate and veteran are nearing completion of the

engagement stage of their relationship, the veteran will begin to define those

goals on which he would like to work. The only structure imposed on the goalsetting process is the case manager/advocate’s refusal to participate in any

goals that are destructive to the veteran or to others, such as using drugs.

Work on goals is always guided by a written plan. The Case Management

Plan is straightforward in intent, yet elaborate in the functions that it can serve.

The plan provides the veteran and case manager/advocate with a format for

identifying broad goals, setting measurable objectives, and creating strategies

that can be implemented to accomplish the objectives. Target and review

dates are set for all objectives and strategies to prompt worker and veteran to

review progress toward completion, revise plans, and/or drop unwanted or

unsuccessful activities.

All plan goals are categorized as fitting into one of the nine life domains.

As veterans enter the project, most of their work centers on goals in the

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living arrangements, recovery, and occupation/education life domains. As the

CM/A relationship proceeds, relationships and internal resources (confidence,

problemsolving) issues begin to receive increasing attention. Although the

Case Management Plan’s primary function is as a goal-setting tool, it also

has utility as a research instrument and as an organizational and supervisory

device. These functions are described more fully later in this chapter.

CM/A activities may continue for as long as 6 months, during which time

veterans may move from inpatient or outpatient treatment to several other

modalities of care. Veterans who need long-term stabilization may enter PRP’s

extended care program; other veterans may reside in their own homes or in the

domiciliary (a transitional living environment at VAMC) while they participate

in aftercare treatment. In line with Strengths Perspective principles, case

manager/advocates provide aggressive outreach throughout the relationship

and assist veterans in networking with informal supports such as self-help

groups, neighbors, and friends.

During the course of CM/A activities, workers maintain close contact with the

veteran’s therapist and other VAMC staff members who are involved with the

veteran. As the veteran moves from residential status on VAMC grounds, the

case manager/advocate assumes a greater degree of contact with non-VAMC

services to assist the veteran with securing needed resources. It has been

the project’s experience at this juncture that many of the resources that

this population needs are available; what is problematic is the extreme

fragmentation of those resources.

MEASURING OUTCOME

Project participants undergo extensive interviews at intake that include

completion of the Addiction Severity Index, Enhanced Treatment Project

Intake Form, Symptom Checklist-90, and a readiness-for-treatment scale.

These instruments examine variables such as drug use, criminality,

psychological functioning, occupational and vocational performance, stability

of living arrangements, and HIV risk behaviors. All veterans in the project

are reinterviewed at 6, 12, and 18 months after intake to determine the effects

of project interventions. In addition, various process evaluations are used to

segregate and measure various pretreatment, CM/A, and treatment issues.

In addition to these broad measures of functioning, a variety of specific

techniques developed to analyze the CM/A interventions are being utilized.

Taking cues from the work of Austin and Caragonne (unpublished manuscript),

the amount of time spent on core case manager/advocate functions is

measured. Case manager/advocates also maintain “advocacy logs,” which

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illustrate their interaction with both VAMC and community agencies and

services. These documents assist in bringing research on CM/A with persons

who have substance abuse problems into the mainstream of research on case

management.

The Strengths Assessment and Case Management Plan are being used

with patients assigned to either of the two CM/A tracks. In addition to its

function as “roadmap” for case manager/advocate-patient interaction, the

Case Management Plan provides information useful to research, supervision,

and caseload planning goals. By receiving weekly printouts that highlight

uncompleted objectives and strategies, case manager/advocates and

supervisors can check on the status of individual veterans on their caseloads.

These reports also show the amount of work being conducted in the various

life domains, the frequency of goals being completed, and the relationship

between various patient profiles and their success in completing goals.

A Resource Database and Objectives/Strategies Database assist case

manager/advocates with their work with veterans. The Resource Database

holds a comprehensive listing of both VAMC and community resources that

is cross-indexed along several parameters to allow for ease of use. The

Objectives/Strategies Database is a comprehensive list of successful

objectives and strategies that can be used in working toward completion

of goals in any of the life domains.

TRAINING OF CASE MANAGER/ADVOCATES

All case manager/advocates in the Enhanced Treatment Project must have

at least a bachelor’s degree in a human services major such as social work,

sociology, psychology, or rehabilitation counseling and must possess at least

5 years of social service agency experience. Although they will be interacting

with persons who have substance abuse problems, project case manager/

advocates need not be extensively experienced in working with this population.

The project’s original contingent of three case manager/advocates ranged from

having a great deal of experience with persons who were substance abusers to

having no experience. Observations of those workers without prior substance

abuse experience have not revealed significant disparities in their delivery of

strengths-based interventions. The current uniformity of service delivery among

professionals with diverse backgrounds speaks to the nature of the training that

preceded initiation of the project.

Initial training focused on a detailed examination of CM/A. “Case Management

in the Human Services” (Ballew and Mink 1986) served as the primer for the

case manager/advocate’s review of CM/A. The detailed exploration of the

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stages of case management-engagement, assessment, planning, accessing

resources, advocacy, and coordinating-and the specific techniques available

to accomplish each stage are exemplary. Ballew and Mink’s work also devotes

an entire chapter and frequent commentary to “internal resources,” another term

for describing “strengths.” As a result of their description of the techniques

useful in accessing a client’s internal resources, this concept was incorporated

as a life domain in the Strengths Perspective.

After receiving a thorough overview of CM/A, case manager/advocates

were exposed to the Strengths Perspective of Case Management/Advocacy.

Training manuals developed by Modrcin and colleagues (1985) were utilized,

and works pertinent to the Strengths Perspective were reviewed (Kisthardt

and Rapp 1989; Rapp and Wintersteen 1989). Case manager/advocates

and other project staff members had the opportunity to spend 2 days with

Ronna Chamberlain, Ph.D., M.S.W., to clarify practice issues, which included

implementing a strengths perspective within a medical model-based treatment

program, avoiding reframing pathology into strengths, and maintaining morale

among case management staff and patients.

A great deal of training time was also spent on generic issues of confidentiality

and how confidentiality could be maintained as part of a research project

operating within a host institution. Case manager/advocates were also

introduced to research concepts and instruments. Treatment plan strategies

and goal-setting techniques were explored against a strengths-approach

background.

IMPLEMENTATION ISSUES

It was anticipated that project case manager/advocates would need to

eschew the role of “therapist” if they were to be effective in their role as

“case manager/advocate.” Past authors (Lamb 1980; Kanter 1989; Wiltse

and Remy 1982) have examined the debate over whether a client’s therapist

can function effectively as a case manager/advocate. In this project, the issue

would have been whether a case manager/advocate could function effectively

as a therapist. Given the time constraints, project mission, and treatment

system characteristics, it was necessary to resolve the issues at the outset

of the project. The likely result of not doing so would have been that CM/A

activities would have been neglected and role ambiguity would have resulted.

Resolution of this issue was difficult.

Given their training and professional experience, case manager/advocates

initially had difficulty in divorcing themselves from the role of therapist. This

difficulty seemed to be a response to the perception that veterans would

87
frequently be in crisis and, hence, would need crisis intervention and/or

longer term therapy as opposed to a focus on resource acquisition. Although

a thorough examination of this issue is beyond the scope of this chapter, brief

mention of two factors that led to resolution should be noted. First, therapists

at PRP are available to address those issues that are typically seen as central

to substance abuse treatment, for example, recognizing and admitting to

powerlessness over substances and developing a recovery plan focusing on

abstinence. Case manager/advocates are able to devote their full attention

to assisting veterans with pursuing necessary resources. As a result of this

exclusive focus on systematic implementation of Strengths Perspective

principles and resource acquisition activities, the number of crisis episodes

experienced by these veterans was significantly reduced.

An issue related to that of therapist vs. case manager/advocate arose over

whether and to what degree recovery issues were legitimate areas of work for

case manager/advocates. After lengthy discussions among scientific staff

members, case manager/advocates, and veterans who were part of the

project’s pilot phase, “recovery” was added as a life domain. Although case

manager/advocates do not function as substance abuse therapists, it is

inevitable that the issue of treatment will affect resource acquisition activities.

It was understood very early in the project that using CM/A interventions

based on a strengths approach would potentially create conflict in the

treatment environment. As with most substance abuse treatment settings,

PRP is oriented to a disease concept or medical model approach to treating

substance abuse problems. Although the relative merits and weaknesses

associated with this model have long been debated, one aspect of the model

quickly becomes apparent: Practitioners of the disease concept focus on

pathology, illness, and what is diseased, as defined by the name of the model,

an approach to substance abuse treatment that is the antithesis of the

Strengths Perspective of CM/A.

Two remedies to this tension seemed possible. Either case manager/

advocates would try and change the treatment system’s orientation to a

strengths approach or they would learn to integrate the approach into the

larger system. The latter course was chosen based on earlier experiences

with the model. R. Chamberlain (personal communication, June 1991)

described efforts to adapt the entire psychiatric treatment process (including

prescribing practices and use of restraints) in the Kansas State hospital system

to one based on a Strengths Perspective. Despite a legislative mandate to

implement a Strengths Perspective, at least as far as CM/A was concerned,

tensions between practitioners of the two models became more the focus of

attention than were the CM/A activities. Following the solution decided on in

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Kansas, the case manager/advocates in the Enhanced Treatment Project

operate on a “parallel course” to that of primary treatment. As might be

expected, these parallel interventions, disease-based primary treatment and

strengths-based CM/A, will occasionally come into conflict. It is at the point of

conflict that the need for advocacy is most acutely felt.

CONCLUSION

To some social service practitioners, the notion of applying a purely strengthsbased model of CM/A to any population might seem admirable, yet hopelessly

idealistic. To apply such a model to a population that is generally regarded

as intractable and hopelessly mired in problems might seem foolhardy. At

this point in the Enhanced Treatment Project, data are not available to either

support or refute the use of the Strengths Perspective with persons who have

substance abuse problems. What is available is anecdotal evidence that

indicates patient support of an approach that basically asks them, “What is

healthy about you and how can you use those assets to secure the resources

you need?” If outcome measures such as retention in treatment, reduction in

relapse rates, and improvement in accessing important resources support use

of the Strengths Perspective with this population, the substance abuse field

may need to rethink its longstanding preoccupation with disease and illness.

REFERENCES

Austin, D.M., and Caragonne, P. “A Comparative Analysis of Twenty-Two

Settings Using Case Management Components.” The Case Management

Research Project. Austin, TX: School of Social Work, University of Texas,

unpublished manuscript.

Baker, F., and Weiss, R.S. The nature of case manager support. Hosp

Community Psychiatry 35(9):925-928, 1984.

Ballew, T.R., and Mink, G. Case Management in the Human Services.

Springfield, IL: Charles C Thomas, 1986. 328 pp.

Borland, A.; McRae, J.; and Lycan, C. Outcomes of five years of continuous

intensive case management. Hosp Community Psychiatry 40(4):369-376,

1989.

Fisher, G.; Landis, D.; and Clark, K. Case management service provision and

client change. Community Ment Health J 24(2):134-142, 1988.

Franklin, J.L.; Solovitz, B.; Masson, M.; Clemons, J.R.; and Miller, G.E. An

evaluation of case management. Am J Public Health 77(6):674-678, 1987.

Goodman, C.C. The elderly frail: Who should get case management?

J Gerontol Soc Work 11(3/4):99-113, 1987.

Graham, K., and Birchmore Timney, C. Case management in addictions

treatment. J Subst Abuse Treat 7:181-188, 1990.

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Intagliata, J. Improving the quality of community care for the chronically

mentally disabled: The role of case management. Schizophr Bull 8(4):655-

674, 1982.

Johnson, P.J.. and Rubin, A. Case management in mental health: A social work

domain? Soc Work 28:49-55, 1983.

Kanter, J. Clinical case management: Definition, principles, components. Hosp

Community Psychiatry 40(4):361-368, 1989.

Kisthardt, W.E., and Rapp, C.A. Bridging the Gap Between Principles and

Practice: Implementing a Strengths Perspective in Case Management.

Lawrence, KS: University of Kansas School of Social Welfare, 1989.

Knoedler, W.H. How the training in community living program helps patients

work. New Dir Ment Health Serv 2:57-66, 1979.

Kofoed, L.; Tolson, R.; Atkinson, R.; Toth, R.; and Turner, J. Outpatient

treatment of patients with substance abuse and coexisting psychiatric

disorders. Am J Psychiatry 143(7):867-872, 1986.

Lamb, H.R. Therapist-case managers: More than brokers of services. Hosp

Community Psychiatry 31(11):762-764, 1980.

Modrcin, M.; Rapp, C.A.; and Chamberlain, R. Case Management With

Psychiatrically Disabled individuals: Curriculum and Training Program.

Lawrence, KS: University of Kansas School of Social Welfare, 1985.

Moore, S.T. A social work practice model of case management: The case

management grid. Soc Work 35(5):444-448, 1990.

O’Connor, G.G. Case management: System and practice. Soc Casework: J

Contemp Soc Work February:97-106, 1988.

Ogborne, A.C., and Rush, B.R. The coordination of treatment services for

problem drinkers: Problems and prospects. Br J Addict 78:131-138, 1983.

Rapp, C.A. The Strengths Perspective of Case Management With Persons

Suffering From Severe Mental Illness. Lawrence, KS: University of Kansas

School of Social Welfare, 1988.

Rapp, C.A., and Chamberlain, R. Case management services for the chronically

mentally ill. Soc Work 30:417-422, 1985.

Rapp, C.A., and WIntersteen, R. The strengths model of case management:

Results from twelve demonstrations. Psychosoc Rehabil J 13(1):23-32, 1989.

Reinke, B., and Greenley, J.R. Organizational analysis of three community

support program models. Hosp Community Psychiatry 37(6):624-629, 1986.

Roberts-DeGennaro, M. Developing case management as a practice model.

Soc Casework: J Contemp Soc Work 68(6):466-470, 1987.

Rog, D.; Andranovich, G.; and Rosenblum, S. Intensive Case Management for

Persons Who Are Homeless and Mentally Ill. Vol. I Washington, DC:

Cosmos Corporation, 1987.

Stein, L.I., and Test, M.A. Alternative to mental hospital treatment. Arch Gen

Psychiatry 37(4):392-397, 1980.

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Sullivan, J.P. Case management. In: Talbott, J.A., ed. The Chronic Mentally Ill:

Treatment, Programs, Systems. New York: Human Sciences Press, 1981.

pp. 119-131.

Teague, G.B.; Schwab, B.; and Drake, R.E. Evaluation of Services for Young

Adults With Severe Mental Illness and Substance Use Disorders. Alexandria,

VA: National Association of State Mental Health Program Directors, 1990.

Wiltse, K., and Remy, L. Conceptual Statement on Case Management for

Family and Children’s Services. Child Welfare Services Grant 426. Tempe,

AZ: Arizona State University School of Social Work, 1982.

ACKNOWLEDGMENTS

This project is being supported by NIDA research demonstration grant

DA-06944.

AUTHORS

Richard C. Rapp, M.S.W.

Project Director

Enhanced Treatment Through Induction and Case Management Project

Substance Abuse Intervention Programs

Wright State University School of Medicine

054 Biological Sciences Building

Harvey A. Siegal, Ph.D.

Director

Substance Abuse Intervention Programs

Principal Investigator

Enhanced Treatment Through Induction and Case Management Project

Wright State University School of Medicine

136 Biological Sciences Building

James H. Fisher, M.R.P.

Research Director

Enhanced Treatment Through Induction and Case Management Project

Substance Abuse Intervention Programs

Wright State University School of Medicine

054 Biological Sciences Building

3640 Colonel Glenn Highway

Dayton, OH 45435

91
Case Management: An Alternative

Approach to Working With Intravenous

Drug Users

Peter J. Bokos, Cheryl L. Mejta, Judith H. Mickenberg, and

Robert L. Monks

INTRODUCTION

The development of substance abuse treatment approaches that improve

treatment access and outcome for intravenous drug users (IVDUs) has

become critical in view of the increased risk and incidence of acquired

immunodeficiency syndrome (AIDS) within the IVDU population. Recent

national data indicate that 27 percent of people with AIDS are IVDUs (National

Center for Health Statistics 1991). Cumulative surveillance data on AIDS

cases within the city of Chicago indicate that IVDUs account for 21 percent

of the total AIDS cases (City of Chicago Department of Health 1992). In a

comparison of human immunodeficiency virus (HIV) seropositivity rates in a

2-year period across seven major cities in the United States, significant

increases in HIV seropositivity among IVDUs were found only in Chicago

(Battjes et al. 1991).

Within the IVDU population, HIV is transmitted primarily through the sharing

of needles and other drug paraphernalia (Battjes and Pickens 1988). In a

recent ethnographic study, Hopkins (1988) showed that 53 percent of IVDUs

still were sharing needles. He also found that more than 50 percent of IVDUs

either do not clean their needles or clean them ineffectively. Des Jarlais and

colleagues (1988) found that the more frequently a substance abuser was

injecting drugs, the more likely he or she was to share drug-using equipment

with someone else, and the more likely he or she was to be exposed to HIV.

One way of reducing the spread of AIDS within the IVDU population is to

increase their access to effective treatment. increased demand for substance

abuse treatment, coupled with reduced funding for these services, however,

has made it difficult for IVDUs to access needed treatment. Within the Chicago

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area, an IVDU may wait between 4 and 12 weeks for an available treatment

slot. Even if an IVDU enters treatment, risk for relapse remains high.

In recent years, there has been a resurgence in the use of a case management

approach to treat non-drug-using clients who have chronic, multiple problems.

Utilizing the core case management functions of assessment, planning, linking,

monitoring, and advocacy (Bagarozzi and Pollane 1984), clients receive

services that address their needs in a coordinated, integrated, and timely

fashion. IVDUs may be ideally suited to a case management approach

because they are characterized by chronic, multiple problems (e.g., drugrelated, AIDS-related, physical, psychological, economic, legal, housing). Thus,

extraordinary coordination is necessary with a variety of systems, including drug

treatment, medical, legal, welfare, vocational, and educational systems.

DESCRIPTION OF CASE MANAGEMENT

Several traditional social work and mental health case management models

exist. These models, some of which originated in the 19th century, have many

different constructs, ranging from the case manager being simply a referral

source, to the case manager being a broker of services, to the case manager—

after assessment and subsequent necessary steps-being a provider of

services.

The literature is replete with descriptions of what case management is, what

the case management functions are, what the roles of a case manager are,

and what appropriate caseload sizes are. Little empirical research exists,

however, as to the effectiveness of case management (Fisher et al. 1988).

According to Dybal (1980), the contemporary concept of case management

evolved in the 1960s. He indicated that the proliferation of categorical social

programs during this era had resulted in a fragmented and inefficient services

delivery system. Service integration was designated as a priority by then

Secretary of the U.S. Department of Health, Education, and Welfare Elliot

Richardson. Thus, Dybal defined case management as “a system of locating,

coordinating, and monitoring a defined group of services for a defined group

of people” and as a “process whereby a fixed point of responsibility within

a governmental agency, or its designee, is assigned to coordinate a

comprehensive, community-oriented plan of services and informal supports

for an individual or family.”

Others have defined the case management function in slightly different words,

but the definitions are variations on the same theme. Bagarozzi and Pollane

(1984) were somewhat more specific about the functions of a case manager

when they recognized case management as providing five basic services:

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(1) assessment, (2) planning, (3) linkage, (4) monitoring, and (5) advocacy.

Austin and Caragonne (1988) defined case management as a “systematic

problem-solving process, consisting of a series of sequentially related tasks

aimed at delivering a variety of services to a client.”

Some writers have expanded the definition of case management beyond

the function of the case manager to include the desired goal of case

management—a client’s independent living. Harris and Bergman (1987,

p. 296) presented this approach in writing:

The role of the case manager is generally seen as one of

coordinating and overseeing a patient’s overall treatment. In

this sense, case management, while integrally related to it, is

a set of functions independent of the treatment itself.

We are suggesting that the process of effective case

management can enhance patients’ own capacities to cope

and function in the world.

Roberts-DeGennaro (1987, p. 470) also talked about clients controlling

their own lives as a result of case management: “A successful case manager

enables clients to control their lives to the fullest extent possible. The case

manager must develop or have access to an existing network of available

resources to use on behalf of a client. Resources are often, however,

inadequately supplied, insufficiently comprehensive, or of poor quality.”

Anthony and coworkers (1988, p. 222) wrote:

Case management is viewed as a process by which the

person with severe psychiatric disability is supported in

negotiating for the various services that he wants and needs.

Four unique activities are identified as performed by the case

manager: connecting with clients; planning for services;

linking clients with services: and advocating for service

improvements.

Vintner (1969) looked at case management in terms of a three-step process.

The first stage is customarily termed intake, the process by which a potential

client achieves client status. On the client’s part, this often involves some kind

of presentation of himself or herself and his or her problem or “need.” On the

case manager’s part, this typically involves some assessment of the client and

the client’s problem-a preliminary diagnosis-and of the adequacy of

resources available to resolve this problem.

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The second stage may be identified as diagnosis and treatment planning.

It marks a more rigorous and exacting assessment by the case manager of

the client’s problem, of his or her capacities for help and change, and of the

various resources that might be marshalled in this effort. Diagnosis and

treatment planning involves a preliminary statement of the treatment goal

and also involves a preliminary plan of the general ways in which this helping

process will be undertaken and of the general directions in which it will be

guided.

The third stage is treatment. A treatment goal is specified; that is, that state or

condition that the case manager and client would like to achieve at the end of

a successful treatment sequence is determined. Treatment services that are

likely to result in this end state or condition are provided to the client often

through referral to appropriate agencies.

Because people who have disabilities and a variety of needs have difficulty

negotiating various service systems and because these people are usually

awed by the bureaucracy of such systems, “linking” becomes an extremely

important case management function. Anthony and colleagues (1988, p. 220)

supported the importance of this aspect of case management:

Case management services are activities aimed at linking the

service system to a consumer and coordinating the various

system components in order to achieve a successful

outcome. The objective of case management is continuity of

services Case management is essentially a problemsolving function designed to ensure continuity of services and

to overcome system rigidity, fragmented service, misutilization

of certain facilities and inaccessibility.

Cohen and coworkers made the point that linking does not just mean helping a

client to access a needed service, but it also means the ongoing monitoring of

the service delivery to ensure the service is available in the necessary degree

and quality (Cohen et al. 1988, p. 223).

The heart of case management is the linking activity. When

linking clients to services, the case manager arranges for the

client’s use of preferred service providers. The linking activity

is more than referring and forgetting. The case manager

presents the client’s assets and overcomes objections to

ensure the service provider’s acceptance of the client. After

the client has been accepted for services, the case manager

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monitors whether or not the client is being assisted and, if not,

implements action steps to remove any barriers to service

use.

Whereas linking seems to be an obviously needed and important case

management activity, locating and identifying services with which to establish

linkage is a difficult and time-consuming activity for case managers. Franklin

and colleagues (1987) speculated that “while the linking function of case

management is crucial, the number and types of community resources that

exist to which a case manager could link a client may well affect the extent

to which a case manager can impact on outcome measures.”

As stated earlier, case management has a long history of use in a variety of

social work conditions. Another application of this intervention might be in the

treatment of the substance abusers. Allison and coworkers (1985, p. 9) in a

National Institute on Drug Abuse research monograph said:

Dole and Nyswander (1965) have held that supportive social

services such as psychotherapy, vocational training, and

educational programs are essential parts of treatment for

heroin addiction. Newman (1977) agreed that methadone by

itself cannot be a complete treatment for heroin addiction, but

also pointed out that the kinds of services needed and the

special role of psychological services are still subjects of

considerable debate. Lowinson and Millman (1979) asserted

that “severe social and psychological disability is frequently a

product of the drug-dependent life” and appropriate services

are necessary to overcome these disabilities. Thus, the basic

approaches or policies of most methadone programs

emphasize physiological stabilization and the provision of

resources to permit rehabilitation.

CASE MANAGEMENT MODEL FOR SUBSTANCE ABUSERS

The case management model used in the Interventions Case Management

Study (ICMS) is an amalgamation of several social work and mental health

models; the project began in November 1989 and will be completed in

September 1994. (Interventions is an Illinois not-for-profit corporation that

provides a full continuum of treatment services to substance abusers.)

The Interventions model positions the case manager in the role of generalist.

In this role the case manager provides five basic functions: assessment,

planning, linking, monitoring, and advocacy (Bagarozzi and Pollane 1984).

More particularly, the case manager provides accurate needs assessment for

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the client, development of an individualized case management plan, linkage

with a variety of treatment providers and other services that are selected to

address individual client needs, monitoring of the process of treatment and

service delivery, and advocacy when needed.

To perform these functions, the case manager initiates an assessment of the

client’s strengths, needs, and potential solutions to his or her problems. Then,

a case management plan that addresses the client’s treatment and other

resource needs is developed. The Interventions model limits caseload size to

15 clients per case manager. This allows the case manager time for networking

with treatment and other resource providers. One goal of the project is to assist

the client with developing skills that he or she can use to access community

resource dependently.

Once treatment begins, the case manager works closely with the client’s

primary counselor to ensure that a treatment plan is developed. Part of the

function of a case manager is to monitor not only that the client is complying

with the treatment provider but also that the provider is fulfilling its role in

meeting the client’s treatment needs. If the “fit” between the provider and the

client is not appropriate, the case manager is responsible for seeking an

alternative treatment placement.

The case manager has access to service delivery dollars that allow the case

manager to expand services in the public sector as well as to purchase

treatment in the private sector if an appropriate publicly funded placement

is not available. The case manager also is concerned about nontreatment

issues that confront the client and inhibit his or her ability to make progress in

treatment (e.g., lack of housing, food, or transportation or poor health). Again,

on a short-term basis, the case manager has financial resources to purchase

services unavailable in the public sector that will ameliorate these conditions.

Service delivery dollars are distributed on the basis of clients’ service needs,

availability of services in the public sector to meet those needs, and the

clients’ ability to pay for the needed services. Some case-managed clients

never require service delivery dollars, whereas other clients initially depend

on service delivery dollars to meet treatment and some basic living needs.

The case manager uses available service delivery dollars only until the

service can be provided by a public-sector agency or until the client can

assume financial responsibility for services received. With the use of service

delivery dollars, the case manager attempts to capitalize on the client’s current

motivation for treatment by reducing any barriers (client, environmental,

and treatment systems barriers) that interfere with access to treatment.

97
The role of the case manager also is emphasized in relapse prevention,

relapse interruption, and recapture. Case managers attempt to provide a

unique continuity-in-care for clients. The case manager actively searches

for a client who is not attending treatment and attempts to reengage the

client in identifying current needs and developing a constructive plan of

action. The case manager attempts to work with the client in relapse to

develop a new solution to an old problem. The case manager’s process

of working with clients is directed at helping clients to empower themselves,

learn problemsolving skills, and develop new options for dealing with problems

in their full life context.

In summary, the Interventions case management model, as a process, is an

orderly, well-planned orchestration of individualized services needed to facilitate

a client in functioning as normally as possible.

RESEARCH STRATEGIES USED FOR ASSESSING THE CASE

MANAGEMENT MODE

The Interventions research study was designed to evaluate the effectiveness

of a case management approach compared with standard treatment in (1)

improving IVDUs’ access to treatment, retention in treatment, and completion

of treatment; (2) reducing AIDS high-risk drug behaviors among IVDUs; (3)

providing treatment experiences and services to IVDUs consistent with their

presenting needs and problems; (4) reducing posttreatment relapses and

improving responses to those relapses (e.g., reinitiate treatment); and (5)

increasing the cost-effectiveness of treatment.

In the ICMS, a longitudinal matched control design is used to test the

hypotheses. A total of 300 IVDUs seeking publicly funded treatment will

be enrolled in the study. IVDUs are matched according to gender, ethnicity,

and age; assigned to the case-managed condition (n=150) or to standardtreatment condition (n=150); and followed for 3 years.

Subject Recruitment and Enrollment

Subjects are recruited for participation in the study following US. Department

of Health and Human Services (HHS) guidelines from the Interventions Medical

Referral Services (IMRS). IMRS is a central intake program that provides initial

medical evaluations for about 95 percent of the IVDUs entering Chicago-area

publicly funded treatment. Approximately 8,000 new and reentering clients are

seen by the IMRS staff annually. Demographically, the IMRS client population

is similar to other national, large-scale substance abuse treatment outcome

samples (e.g., Hubbard et al. 1989; Simpson and Sells 1982). Minorities

98
account for 62 percent of the clients (54 percent are African-American, and

8 percent are Hispanic), and females account for 33 percent of the clients.

Furthermore, the IMRS client population includes groups (minority, male, and

female IVDUs) who especially are at risk for contracting AIDS. Cumulative

surveillance data on AIDS cases within the city of Chicago indicate that IVDUs

account for 21 percent of the total AIDS cases; minorities account for 56

percent of the AIDS cases; and females account for 10 percent of the total

AIDS cases (City of Chicago Department of Public Health 1992).

To reflect the demographic characteristics of clients entering treatment,

sampling is done to maintain about a 1:3 female-to-male ratio and about a

1:2 nonminority-to-minority ratio. Subjects are matched according to gender,

ethnicity, and age. Within the matched pairs, subjects are randomly assigned

to the standard-treatment condition (n=150) or to the case-managed condition

(n=150).

IVDUs who contact IMRS (in person or via telephone) seeking substance

abuse treatment are referred to a research interviewer for a prescreening

interview in which the client’s willingness and eligibility (IVDUs 18 and older)

to participate in the study are determined. Clients with a chronic physical or

psychiatric illness requiring medication and/or treatment that precludes their

ongoing participation in an outpatient substance abuse treatment program are

excluded from the study. Clients who are ineligible to participate in the study

or who choose not to participate in the study are given appropriate referrals

to substance abuse treatment through IMRS. Research interviewers

document the demographic characteristics of those clients not entering the

study along with the reason(s) for exclusion from the study to determine the

representativeness of the final sample. Clients who are eligible and agree to

participate in the study are scheduled for a subject enrollment interview. At

the interview, clients sign an informed consent form indicating that they

understand the purpose of the study and agree to participate in the study.

Clients who are actively in severe withdrawal or who are psychotic, intoxicated,

or demented are excluded because these clients cannot render an informed

consent.

After completing the research admission protocol (see table 1 for scales

administered), clients are randomly assigned to the standard-treatment

condition or to the case-managed condition. Clients assigned to the

standard-treatment condition receive from the research interviewer the

names, addresses, and telephone numbers of three substance abuse clinics

within the client’s geographical vicinity. This referral procedure is similar to

that used by IMRS in response to client inquiries about treatment. Clients

assigned to the case-managed condition are referred to a case manager who

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TABLE 1. Schedule of scale administration

Measure Admission Treatment Discharge

Preadmission Interview Form

(before admission)

Addiction Severity Index

Monthly Drug and Alcohol

Use Questionnaire

AIDS High-Risk Drug Behavior

Questionnaire

Treatment Service Cards/

Social Systems Tally Sheet

Monthly

Substance Abuse Problem Checklist Semiannually

Ease of Treatment Admission/

Treatment Status Questionnaire

Treatment Plans

Urine test results

Treatment discharge information

Semiannually

Monthly

Monthly

Monthly

Quarterly

Monthly

Posttreatment

Semiannually

Quarterly

Quarterly

Semiannually

Quarterly

completes an initial client assessment, facilitates the client’s entry into

treatment, and addresses other immediate needs of the client (e.g., housing,

transportation). The EMS intake flowchart describes the study enrollment

process (figure 1).

Instruments and Measures

To test the hypotheses regarding the effectiveness of a case-managed

approach in working with IVDUs, the ICMS staff administers a series of

research scales and instruments to monitor the client’s treatment status,

drug use, problems associated with drug use, needle use/sharing/cleaning,

and treatment goals and services.

All clients are tracked for 3 years. While clients are awaiting admission

to treatment or are in treatment, research interviewers monitor the clients’

progress on a monthly basis. On discharge from treatment, clients will be

interviewed 1 month posttreatment discharge and on a quarterly basis

thereafter. After 3 years, clients will be discharged from the study.

100
FIGURE 1. ICMS intake flowchart

101
Table 1 provides a list of the instruments and measures used in the study and a

schedule of their administration. Descriptions of the instruments and measures

follow.

Preadmission Interview Form. The Preadmission Interview Form is

used to determine the client’s eligibility to participate in the program.

Basic demographic information (age, gender, ethnicity), drug use and route

of administration, drug withdrawal symptoms, and previous treatment

experiences are obtained from the client.

Addiction Severity Index (ASI). The ASI (McLellan et al. 1980) is a wellknown treatment outcome tool that evaluates the seventy (defined as the need

for treatment) of seven common addiction-related problem areas: alcohol use;

other drug use; medical, psychiatric, legal, family and social, and employment

and support. For problem areas, two measures are obtained. The interviewer

rates the problem severity for each area using a lo-point rating scale (0=no

real problem, treatment not indicated and 9=extreme problem, treatment

absolutely necessary). For each problem area, a composite score based on

the sum of the individual objective items contained within the problem area

also is obtained. Reliability and validity studies conducted on the ASI indicate

good concurrent reliability (.92 or above for each scale) and good concurrent

and discriminant validity (McLellan et al. 1988).

Monthly Drug and Alcohol Use Questionnaire. The Monthly Drug and

Alcohol Use Questionnaire assesses clients’ drug use in the past 30 days.

Two measures of drug use are obtained-the average number of days the

drug was used in the past 30 days and the average number of episodes per

day on those days when the drug was used.

AIDS High-Risk Drug Behavior Questionnaire. The AIDS High-Risk Drug

Behavior Questionnaire is a self-report measure that examines clients’ needle

use, needle-sharing, and needle-cleaning behaviors and sex-for-drug-money

behaviors. Part A assesses these behaviors historically, and Part B assesses

these behaviors within the past 30 days. Parts A and B are administered at

study admission. Part B is administered monthly while the client is awaiting

treatment or IS in treatment, at treatment discharge, and quarterly during

posttreatment followup.

Treatment Service Cards/Social Systems Tally Sheet. On a weekly basis,

the primary counselor (and the case manager if the client was assigned to this

treatment condition) records the number of hours the client received each of the

listed treatment, social, and health services.

102
Substance Abuse Problem Checklist (SAPC). The SAPC is a self-report

inventory that assesses problems experienced by the substance-abusing

clients (Carroll 1984). The SAPC consists of 377 problems that are grouped

into the following eight categories: problems associated with motivation for

treatment, health problems, personality problems, social relationship problems,

job-related problems, problems associated with the misuse of leisure time,

religious or spiritual problems, and legal problems. The client reads each

problem statement and circles those that reflect a problem the client is

experiencing.

Ease of Treatment Admission/Treatment Status Questionnaire. The

Ease of Treatment Admission/Treatment Status Questionnaire is used to

determine whether the client is in a substance abuse treatment program,

when and where the client entered treatment, the ease or difficulty the client

had entering treatment, whether the client is on a clinic waiting list, whether

the client still is seeking treatment, and the client’s treatment discharge status

(when and why the client was discharged).

Treatment Plans. Treatment Plans are developed for clients by the assigned

substance abuse clinic counselor at treatment admission. Treatment plans are

reviewed and modified by the substance abuse counselor with the client every

90 days.

Urine Test Results. Urine samples are collected on a monthly basis from

clients while they are in treatment and on a quarterly basis while they are

awaiting treatment or during posttreatment followup. Urine samples are

tested for the presence of amphetamines, barbiturates, benzodiazepines,

propoxyphenes, and cannabinoids.

Treatment Discharge Information. Treatment discharge dates and reason(s)

are obtained by the research interviewers from the substance abuse treatment

clinics when it becomes known that the client is no longer in treatment.

Research interviewers are responsible for locating and contacting clients. At

study enrollment, clients are asked to provide their current addresses and

telephone numbers and those of three relatives or friends with whom they are

most likely to stay in contact. Changes in addresses and telephone numbers

are routinely checked at each client contact. This technique has been found to

reduce attrition in longitudinal research studies.

When a client has been contacted, the research interviewer either completes

the interview over the telephone or schedules an appointment for the client at

the research offices or at a mutually agreed-on place. If the client leaves the

103
study, reasons for leaving are recorded. To increase participation in followup,

clients are paid $5 for each completed quarterly interview and $10 for each

completed semiannual interview.

For clients who cannot be located, prison records and death certificates are

searched to determine whether the client is incarcerated or deceased. Death

certificates for deceased clients are obtained when possible, and the cause

of death is recorded.

RESULTS

Analyses of the data are divided into five major categories: (1) sample

description and comparison; (2) treatment access, implementation, and

description; (3) treatment outcome analysis; (4) treatment process analysis;

and (5) cost analysis. The primary questions addressed are what happened

and what works and does not work, with whom, and at what cost. Data

focusing on addressing these questions are collected across the 5 years of

the study. Preliminary data collected within the first 2 years of the study

address issues related to treatment access.

Sample Description and Comparison

A total of 204 clients have been admitted into the study; 102 subjects were

assigned to the standard-treatment condition, and 102 subjects were assigned

to the case-managed condition. The average age for the case-managed clients

is 41.39 years with a range from 27 to 69 years old. The average age for the

standard treatment is 39.88 years with a range from 21 to 67 years. In the

case-managed condition, 68 percent of the clients are male and 32 percent are

female. In the standard-treatment condition, 70 percent of the clients are male

and 30 percent are female. The racial distribution in the case-managed group

is 85 percent African-American, 10 percent white, 4 percent Hispanic, and 1

percent “other.” The racial distribution in the standard-treatment group is 87

percent African-American, 8 percent white, and 5 percent Hispanic. Table 2

presents the demographic description by treatment condition.

The majority of case-managed (86 percent) and standard-treatment (92

percent) clients have used multiple drugs for an average of 16 years. At the

time they entered the study, all clients had been injecting heroin an average of

19 years. Other commonly used drugs included alcohol, cocaine, and

marijuana.

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TABLE 2. Demographic description of clients in treatment conditions

Demographic Characteristics

Case-Managed

(n=102)

Gender distribution

Male

Female

Racial distribution

African-American

White

Hispanic

Other

Age (years)

Average

Range

Education

Eighth grade or less

Some high school

High school/GED

Some college

College graduate

Missing value

Employment status

Employed full time

Employed part time

Student

Retired/disability

Unemployed

Missing value

Marital status

Married

Remarried

Widowed

Separated

Divorced

Never married

Missing value

69 (68%) 71 (70%)

33 (32%) 31 (30%)

87 (85%) 89 (87%)

10 (10%) 8 (8%)

4 (4%) 5 (5%)

1 (1%) 0 (0%)

41.39 39.88

27-69 21-67

7 (7%) 13 (13%)

31 (30%) 31 (30%)

33 (32%) 32 (31%)

22 (22%) 18 (18%)

2 (2%) 1 (1%)

7 (7%) 7 (7%)

14 (14%) 18 (18%)

13 (13%) 14 (14%)

0 (0%) 1 (1%)

10 (10%) 15 (15%)

57 (56%) 47 (46%)

8 (7%) 5 (5%)

15 (15%) 15 (15%)

1 (1%) 1 (1%)

6 (6%) 1 (1%)

19 (19%) 14 (14%)

17 (16%) 18 (17%)

35 (34%) 48 (47%)

9 (9%) 7 (6%)

Standard-Treatment

(n=102)

105
FIGURE 2. Number of days between study intake and treatment admission

by group

Treatment Access

Ninety percent (n=92) of the case-managed clients and 35 percent (n=36)

of the standard-treatment clients thus far have entered a substance abuse

treatment program. The average length of time to admission into a substance

abuse program was 6.19 days for the case-managed clients (with a range of

0 to 59 days) and 31.69 days for the standard-treatment clients (with a range

of 0 to 163 days). Figure 2 depicts the range of time between study intake and

treatment admission by group. About 56 percent of the case-managed clients

entered treatment within 5 days. Within 15 days, 76 percent of the casemanaged clients were admitted into a substance abuse treatment program. In

comparison, only 7 percent of the standard-treatment clients entered treatment

within 15 days. Eight percent of the standard-treatment clients vs. 1 percent of

the case-managed clients were on a waiting list at a substance abuse treatment

clinic. Fourteen percent of the standard-treatment clients have stopped seeking

treatment. The long waiting lists at treatment clinics are most often cited as the

reason for deciding not to pursue treatment.

On a 5-point Likert scale examining clients’ perceptions of the ease with which

they entered treatment, 79 percent of the case-managed clients indicated that

it was “very” or “somewhat easy” for them to access treatment. The majority

106
of case-managed clients (74 percent) attributed their ease in accessing

treatment to having a case manager. Only 48 percent of the standard-treatment

clients indicated that it was “very” or “somewhat easy” to enter treatment. It is

interesting to note that 21 percent of the standard-treatment clients attributed

their ease in accessing treatment to their own contacts. Thirty-one percent of

the standard-treatment clients indicated that it was “very” or “somewhat difficult”

to enter treatment. The treatment clinic waiting lists were cited by 42 percent of

the standard-treatment clients as the reason it was difficult to access treatment.

DISCUSSION

These results indicate that case management is effective in facilitating IVDUs’

access to substance abuse treatment by reducing or eliminating obstacles to

treatment. The case managers have identified several barriers to treatment.

Through the referral, linking, and advocacy process, case managers reduce

obstacles and improve access to treatment. The limited availability of treatment

slots at publicly funded treatment programs is one of the major barriers to

accessing treatment. Case managers maintain an awareness of treatment

providers’ current ability to accept new clients. Clients are directed to those

treatment programs with available space or minimal waiting lists. A client also

may be placed on the waiting list of a preferred program (defined by matching

characteristics such as specialty in working with a particular cultural, ethnic,

racial, or gender group), temporarily enter a program with space available, and

transfer to the preferred program when space becomes available.

The lack of financial resources or health insurance to purchase treatment

services from the private sector IS another major barrier to treatment. When

publicly funded services are unavailable due to lack of space, case managers

can access funds to purchase care privately while the client is placed on the

waiting list of a publicly funded program. When space becomes available in

the appropriate publicly funded program. the client is transferred.

The lack of knowledge and/or skills to effectively traverse treatment delivery

systems also is an obstacle to accessing treatment. Case managers have both

the knowledge and skills necessary to negotiate the treatment system. Case

managers’ knowledge of admission criteria, admission process procedures,

and the organizational structure of the treatment system and individual

programs can assist clients with gaining access to treatment. Clients can be

directed to those clinics where they meet the admission criteria. In addition.

clients are guided through the admission/intake process. As a result, clients’

frustrations are minimized since they are better prepared for the intake

interview.

107
If a client lacks prerequisite treatment admission documentation or information

(e.g., identification, previous treatment records, laboratory results), his or her

admission to treatment may be blocked. Case managers assist clients with

obtaining the necessary treatment admission information to facilitate the

treatment admission process. This may involve paying photocopying fees to

duplicate previous treatment records, arranging for laboratory tests, and/or

arranging to have clients acquire an ID.

A client’s presentation and/or history may elicit an adverse reaction by

providers. Case managers may coach clients so that their conduct is

appropriate. Case managers also may negotiate a specific behavioral

contract addressing the provider’s concerns with the client as a prerequisite

to treatment admission. A treatment provider matched to the client’s

presentation or history (e.g., client placed in a program for criminal offenders,

people with AIDS) may be sought.

The coexistence of other problems (e.g., alcoholism, psychiatric issues, medical

conditions, financial difficulties, lack of housing, lack of transportation) may

interfere with access to substance abuse treatment. The case manager will

seek and coordinate the client’s treatment for each presenting problem. The

case manager also will help a homeless client locate and enter a shelter;

provide transportation assistance (e.g., public transportation tokens) to clients

with transportation problems; and help clients with financial problems to access

general assistance, unemployment compensation, or available jobs.

The client’s personal ambivalence about entering treatment and discontinuing

drug use is an additional barrier to treatment admission. The case manager

helps clients identify personal ambivalence, identify personal motivation

for change, establish goals, and seek appropriate treatment resources.

Throughout this process, the case manager remains supportive of a client’s

attempts at change.

CONCLUSIONS

National concern over the increased incidence of AIDS in the IVDU population

led to an emphasis on improved and innovative ways of engaging IVDUs in

drug treatment services. One such way is the utilization of a case manager to

assist the IVDU with negotiating the various systems related to drug treatment.

When this study was designed, it was anticipated that case management

would improve treatment access, would positively affect treatment outcome,

and would reduce relapse. After 2 years, preliminary data have demonstrated

that a case-managed approach is effective in assisting IVDUs with accessing

108
treatment with minimal delay (2 weeks or less).

The influence of case management on treatment outcome and relapse is still

under study. These results, combined with access data, will permit conclusions

to be drawn about the effectiveness of case management.

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AUTHORS

Peter J. Bokos, Ph.D.

President and CEO

Cheryl L. Mejta, Ph.D.

Division Chair

Health and Human Services

Governors State University

Research Consultant

Judith H. Mickenberg, M.S.W

Project Supervisor

Robert L. Monks, Ed.D.

Director of Research

Interventions Case Management Study

Suite 602

1313 South Michigan Avenue

Chicago, IL 60605

111
Transitional Case Management: A

Service Model for AIDS Outreach

Projects

Victor Lidz, Donald A. Bux, Jerome J. Platt, and Martin Y. lguchi

INTRODUCTION

In the mid to late 1980s, public health officials perceived that the acquired

immunodeficiencey syndrome (AIDS) epidemic in the United States had

entered a second, unexpected wave. Human immunodeficiency virus (HIV)

infection had spread to a new sector of the population, the injection drug user

(IDU) and the sex partner (SP) of the IDU. Designing public health measures

to contain HIV transmission among these newer at-risk groups loomed as a

difficult challenge. Other health-related programs directed to the same groups

had achieved only limited success. Street outreach projects, often tied to

mobilization of community organizations and services, were identified as a

promising way to make contact with and deliver health education to “hard-toreach” IDUs and SPs (Watters 1987a, 1987b; Des Jarlais and Friedman 1987;

Watters et al. 1988; Wiebel 1988). However, additional measures were needed

to recruit them from the streets and into formally organized programs. This

was especially true when IDUs and SPs were already infected and in need of

medical care or when they needed help from drug abuse treatment programs,

hospitals, and welfare agencies to initiate personal risk reduction. Case

management tied to an outreach program constitutes one approach to this

crucial recruitment function. This chapter reports on the development,

implementation, and preliminary evaluation of a specialized case management

program designed to operate as part of an outreach project in cities with high

prevalence rates of HIV among IDUs and SPs.

THE SETTING

Located near the AIDS epicenter in New York City, Newark and Jersey City,

NJ, are among the metropolitan areas with the heaviest concentrations of AIDS

cases in the Nation. The Jersey City metropolitan area ranked fourth in the

Nation in per capita AIDS cases for the year ending January 31, 1992, and

112
Newark ranked seventh. Through January 31, 1992, 7,581 cumulative AIDS

cases had been reported for the two metropolitan areas, nearly 60 percent of

New Jersey’s total (Centers for Disease Control 1992). The high rates of AIDS

can be attributed to widespread injection drug use in both cities. New Jersey is

the State with the highest per capita incidence of IDU-associated AIDS (Centers

for Disease Control 1989), and in Newark injection drug use has been linked

directly or indirectly (i.e., through heterosexual contact with an IDU or perinatal

transmission from mothers infected through injection drug use or sex with an

IDU) to more than 80 percent of all cases (New Jersey Department of Health

1990).

Heavily concentrated HIV infection among IDUs and SPs in Newark and

Jersey City is confirmed by the authors’ studies. As part of the National

Institute on Drug Abuse’s (NIDA) multisite National AIDS Demonstration

Research program, the authors, in collaboration with the New Jersey

Department of Health (NJDOH), established the Health Behavior Projects

(HBPs) in community offices in both cities to interview out-of-treatment IDUs

and SPs about AIDS-risk behavior and to collect samples of their blood for

HIV antibody testing. The HBPs operated from April 1989 through January

1992 and interviewed more than 5,600 subjects, more than 1 percent of the

total populations of the two cities, perhaps 2 percent of people between the

ages of 18 and 50. The investigators estimate that one-tenth to one-fifth of

all people at risk of HIV infection through injection drug use in the two cities

were recruited as subjects.

Although final results are not yet available, preliminary data show high rates

of infection in the sample.1 Among 2,774 IDU subjects in Newark, 1,137 (41

percent) were HIV antibody positive, In addition, 197 currently at-risk SPs

were tested, with 37 (19 percent) being HIV antibody positive. In Jersey City,

of 2,255 IDUs tested, 816 (36 percent) were HIV antibody positive. Of 185 SPs

tested, 27 (15 percent) were HIV antibody positive. Because many current SPs

are former IDUs, their rates of HIV infection are not indicative of risk for sexual

transmission.

Since April 1989, the HBPs have seen more than 2,000 people with HIV

infection. How many met diagnostic criteria for AIDS is unknown, as T-cell

counts were not performed nor clinical histories taken. The field staffs

impression was that only a modest proportion had progressed to AIDS or

received diagnoses that would generate NJDOH reports of AIDS cases.

Thus, public data on AIDS cases in the two cities may underestimate actual

prevalence. A majority of the HBPs’ 2,000 infected subjects probably belong

to a large pool of persons likely to develop AIDS whose impending illness

threatens the fiscal viability of the medical and social service systems (Young

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1988). In addition, most of the HBPs’ other 3,500 clients remain at substantial

risk of HIV infection. Seroconversion rates calculated from the HBPs’ followup

studies have varied, depending on city and cohort, from 2 to 11 percent per

person, per year (Iguchi et al. 1991). If they average to 5 percent per person,

per year, they correspond to roughly 175 additional infections annually in the

sample.

The setting of the HBPs’ case management program cannot be grasped in

demographic terms alone. It also involves a social class system typical of

many old industrial cities of the Northeast (Wilson 1987; Anderson 1990).

Since the 1950s, factories have been abandoned in large numbers, and

jobs that once supported families on a basis of manual skills have

disappeared. Stable working class communities have declined into

“underclass”2 neighborhoods where many households lack employment

or reasonable hope of it. Even men and women who have learned two or

three skills as welders, chemical mixers, or machine operators, as did some

of the HBPs’ older clients, have often been unemployed or intermittently

employed for two decades or more. Men in particular, demoralized by lack

of employment and incapable of supporting their families, have seen ties with

wives and children weakened (Liebow 1967). With the loss of the social

support that solidary family life commonly engenders, they are increasingly

open to criminal activities (Anderson 1978; Wilson 1987) and a drug-using

social life.

One-third of Newark’s residents receive welfare support (Nieves 1992).

The housing stock of both Newark and Jersey City has grown decrepit, and

large numbers of the poor cannot find decent housing. Public services have

been eroded by three decades of a declining tax base. Schools are poor, and

policing, sanitation, and other public services are inadequate. Street life in

many areas has fallen under the sway of drug dealers and muggers, often to a

point that police will not enforce routine maintenance of law in public places.

For many residents, the resulting insecurity affects nearly all routines of daily

life. Even IDUs complain about living and raising children in housing projects

dominated by armed drug dealers.

The anomie of the underclass community affects medical and social service

agencies as well. IDUs and SPs who become clients for AIDS services or riskreduction programs are often steeped in a culture of mutual distrust between

citizens and agencies. Predominantly members of minority groups, poor, and

relatively uneducated, they are accustomed to being treated with suspicion and

disrespect. Many have engaged in illegal activities for large parts of their lives

and become wary of all “established” institutions and professions. Most have

had years of discouraging experience with agencies such as welfare, parole

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and probation, public housing, and Medicaid, where they have met

bureaucratic tangles and disdainful attitudes more often than a service

orientation. Moreover, the routines of indigent IDUs, oriented mainly to the

daily rigors of obtaining drugs and the insulated social world of drug-using

groups, are generally incompatible with the world of formally organized

services and professions, where schedules and appointments predominate.

Thus, when IDUs encounter hospitals, medical practitioners, and social

workers, they tend to be cautious about extending trust. Their styles of

interaction may also reflect the manipulative, self-protective manner of people

hiding criminal activities, the impairment of individuals torn by emotional

conflicts, and the self-doubt that arises from failure in various spheres of life.

They are also likely to resist treatments that may lead to reduced drug use or

illegal income for buying drugs. And, hardly least, many are accustomed to

taking large risks on matters of personal health and well-being.

Thus, the present crisis in AIDS care and AIDS-risk reduction services for

IDUs and SPs involves much more than a large volume of unmet needs. It

also involves dilemmas about how to provide services to IDUs and SPs as

clients. Compared with AIDS patients in other risk groups, IDUs and SPs will

often be hard to reach and engage in stable treatment relationships (Rife et al.

1991). Unless especially effective programs are established to assist them,

they will fail more frequently than other client groups to keep appointments, take

medication, or report back when symptoms change. With these characteristics,

they are especially likely to suffer from fragmentation of care among specialized

and often competing agencies, many of which are understaffed and lacking in

resources (Willenbring et al. 1991). Nevertheless, the needs of IDUs and SPs

are as great or greater than those of other patient groups. Moreover, the HIV

epidemic will not be contained until effective ways of overcoming their

difficulties are developed.

HEALTH BEHAVIOR PROJECTS

HBPs conducted outreach to recruit community IDUs and SPs for interview

at the project offices in both cities. At the offices, subjects were introduced

to the interviewing and intervention staffs, screened for research eligibility,

and asked for written informed consent. Locator information was obtained to

facilitate subsequent contacts. Subjects were then interviewed at length with

the NIDA-sponsored AIDS Initial Assessment (AIA), Version 8. This instrument

covers demographic factors, drug use history, needle use practices, sexual

risk behavior, and AIDS knowledge. After completion of interviews, subjects

were given pretest counseling and asked to provide a blood sample for HIV

antibody testing. Subjects who indicated current injection of opiates were

offered a coupon for either 21-day or 90-day (randomly determined) methadone

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detoxification. Subjects were also invited to participate, after random

assignment, in either a risk-reduction health education program based on

interpersonal cognitive problemsolving theory or an attentional control group

(Platt et al., in press). Subjects were then offered a standard set of referrals

to a wide range of local agencies whose medical and social services might be

helpful to them. Finally, they were told how and when to return for results of

their HIV antibody tests and posttest counseling.

From early in the project, the HBP was able to place only a small minority of

its HIV-infected subjects for appropriate medical care. Even after the HBP

made several attempts at strengthening HIV pretest counseling and referral

procedures, only 8 percent of clients were returning for test results and posttest

counseling. Clients also were not following through on referrals to medical

clinics. Thus, only 5 or 6 percent of infected clients were likely obtaining

medical treatment (other than methadone treatment for drug abuse) directly

through HBP interventions. A large proportion of clients also were not securing

social services for their unmet personal needs, such as housing, food and

clothing, job counseling, psychological support in dealing with HIV disease,

family counseling, and legal services. Moreover, few of the uninfected subjects

were obtaining medical and social services (besides methadone treatment) to

help them avoid AIDS risks and maintain seronegative status.

These early findings made welcome an invitation from the Health Resources

and Services Administration and NJDOH, Division of AIDS Care and

Prevention, to apply for funds to develop a case management program

and conduct an evaluation of it. Dr. lguchi prepared a research design

for assessing the efficacy of a short-term, brokerage-type case management

service in comparison with the standard referral procedure and a third referral

procedure of intermediate intensity and cost. An application was submitted

and an award received. In June 1990 work began on developing a detailed

protocol for case management with IDUs and SPs.

TRANSITIONAL CASE MANAGEMENT

Several considerations shaped the design of the case management protocol.

First, it seemed desirable to assist large numbers of clients, even though

limited funding precluded a large staff. The HBPs were interviewing 1,000 or

more clients per city, per year. Following a classic model of intensive, long-term

case management would limit availability of the service to only 50 or 60 clients

per year, which seemed unresponsive to needs. Second, placing HIV-infected

clients for AIDS care was a principal purpose, but not the only one. Meeting a

public health need for stronger AIDS-risk reduction services to uninfected

clients was also a primary goal. Third, AIDS-risk behavior and resistance to

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treatment for HIV infection seemed for many clients to be embedded in

practical deprivations of everyday life. Enabling clients to meet a broad

spectrum of their everyday needs, thereby easing the acceptance of AIDSrelated services, became a major focus of service. Fourth, as outreach

projects, the HBPs were very limited service agencies, not clinics, welfare

agencies, or community-based organizations with broad constituencies. Nor

did the HBPs provide the kinds of services, such as drug abuse treatment, that

might keep large numbers of clients returning to the field offices on a routine

basis. On their own, the HBPs could supply only health education programs,

pretest and posttest HIV counseling, and similar low-cost services. Because

clients were unlikely to become dependent on these types of services, their

continued participation seemed problematic. Fifth, outreach projects

nevertheless presented a special strength as sites for case management,

namely, contact with large numbers of HIV-infected and at-risk people who

do not receive appropriate medical and social services. One way to exploit

this strength would be to concentrate on placing hard-to-reach or “hidden”

individuals with established agencies in the social service system.

After extensive discussion of these considerations, the model of transitional

case management (TCM) emerged. TCM aims at time-limited or short-term

service (compare Willenbring et al. 1991, pp. 18-22). Its goal is to make a

quick, effective intervention in the lives of clients. It emphasizes what is usually

termed the brokerage element of case management-the attempt to place

clients with agencies that can deliver services matched to their needs. When

matches are made, clients are to be “handed off” to the other agencies for

continuing services. In the ideal case, especially for HIV-infected clients, at

least one agency accepting a hand-off will provide case management on a

continuing basis. When hand-offs are completed, TCM staff gain time and

resources to attend to new clients.

TCM differs from AIDS case management as conducted in most other settings,

certainly from the San Francisco model (Benjamin et al. 1988). AIDS case

management often shades into managed care, with a goal of allocating scarce

treatment resources among patients in an efficient manner. Another goal is to

maximize patients’ opportunities to live independently in the community but

with appropriate supporting services (Rothman 1991). Case management of

this kind may be operated by a hospital, an insurance company or health

maintenance organization (HMO), or a community-based organization. Its

efficacy depends on the sponsoring agency having sufficient authority over

service providers, whether as employer or payor or indirectly through contracts,

to make allocations of resources (Mechanic and Aiken 1987). TCM does not

have the character of managed care, nor does its staff have authority over the

provision or coordination of primary services. TCM is a means of referring

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clients for services and advocates that they obtain services. Staff members

following TCM protocol seek to gain entry to the service system for clients and

attempt to reduce the burdens of confronting a fragmented system of care, but

do not operate from a position of authority in the system and hence cannot

make decisions regarding resource allocation.

TCM is also different by virtue of its time-limited nature (Willenbring et al. 1991).

With limited resources, an outreach project must avoid promising more services

than it can deliver. In contrast to programs that extend service for HIV-related

conditions until final hospitalization (Sonsel et al. 1988), HBP staff members

promise no more than four sessions of case management at a time. Extensions

of service are possible if the goals of TCM cannot be reached in this standard

sequence. Staff members have even invited clients to return for additional help

months after starting TCM if they lose services at programs where the HBP

placed them. Thus, the goal of TCM is to place clients with case managers

at other agencies and then support continuing use of their services. In this

respect, TCM brokerage is a type of followthrough on the outreach and

recruitment functions.

Similarly, TCM contains a monitoring component, but one sharply focused on

determining whether clients have established and maintained contact with

agencies to which they have been referred. If a client has not made contact

with an agency capable of meeting an urgent need, a repeat referral or an

additional referral will be made. If an agency rejects a client’s application,

TCM staff may inquire whether the reasons were appropriate. If not, an appeal

may be made to the agency. However, TCM does not involve extended, direct

monitoring of the client’s condition, in particular his or her medical condition.

Efforts are not made to interpret medical test results (other than HIV antibody

tests), visit the client’s home, assess his or her support network by interviewing

family and friends, arrange for home services to be provided, and so forth.

However, TCM’s scope of public health concerns is broader than many AIDScare programs. The HBPs have been as strongly oriented to risk reduction for

clients who are not infected as they are to care for HIV-infected clients. TCM

was designed to complement HIV counseling and health education services

and the coupon program for free methadone detoxification. Its rationale is to

encourage positive steps on risk behavior and health status by assisting clients

to meet a broad spectrum of personal needs. TCM has been provided to clients

without respect to HIV status to support whatever risk and harm reduction

efforts they can make.

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THE TCM PROTOCOL

TCM begins as soon after the AIA interview, the blood draw, and the standard

referral procedure as an appointment can be arranged. The staff tries to start

TCM immediately when AIA data indicate the clients are at high risk. However,

clients are often too tired after the AIA to begin another long interview, and

high-risk IDUs often feel the press of withdrawal symptoms. In such cases, the

interviewer introduces the case manager, who encourages the client to return

and tries to schedule an appointment.

The first session of TCM starts with an introduction to the service and its

purposes. The case manager then begins a comprehensive needs

assessment, evaluating the client’s level of psychosocial functioning (including

coping skills, problemsolving abilities, reality testing, and interpersonal efficacy),

current resources and support systems, immediate needs (e.g., psychiatric

care, food, housing, clothing, legal assistance, drug abuse treatment), and

possible obstacles to using services. Many clients return for TCM with a

critical need for food or shelter, intercession with probation or the Division of

Youth and Family Services, or referral to an inpatient detoxification program.

The case manager will then address the urgent need, postponing broader

assessment until the client is comfortable with a plan for the crisis at hand.

The needs assessment is based on a guide of 12 pages, listing questions and

probes for conducting the interview and recording pertinent data. The guide

ensures that key areas will be addressed and gives the case manager tactful

boilerplate for asking sensitive questions. For most clients, an initial needs

assessment can be completed in 40 minutes to an hour. As a result of the

assessment and taking into consideration a rating of needs completed by the

client, the case manager proposes potential courses of action. The case

manager ordinarily tries to make at least two key referrals during the initial

session so that the client will feel that TCM can produce concrete benefits.

However, the client should not be overwhelmed with too many referrals or

recommendations covering too many matters. Nor should referrals emphasize

issues that the client does not acknowledge to be important. The overwhelmed

or threatened client is unlikely to follow through on essential first measures.

The case manager must also avoid implying that the client’s problems are

easily solved or can be taken lightly. Finally, the client must be persuaded that

the care plan is realistic and likely to prove beneficial in proportion to efforts

expected from the client.

In most cases, the client’s and case manager’s perception of needs converge

closely on the more practical matters (e.g., food, shelter, welfare benefits).

However, they may have different perceptions of the chances that clients will

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receive help. In this study, case managers have generally been optimistic

that persistence will bring benefits, whereas clients have more often been

pessimistic about “the system” working. Yet, many HIV-infected clients

expect to qualify for disability benefits, although the case managers have

learned that clients are rarely approved until very ill. Clients seek places in

public housing when case managers know that obtaining an apartment takes

months or years. Or clients seek assistance for moving out of public housing

to the private market when case managers know that affordable apartments are

scarce. Occasionally, the case managers have seen possibilities for help that

clients have declined. One male IDU was advised to apply for welfare and food

stamps but declined: It was “no use” because he would “misspend” whatever

benefits he received. He was resigned to living homeless or in a shelter, eating

out of soup kitchens and food pantries, spending the proceeds of panhandling

on drugs. This client differed from several others primarily in being outspoken.

In general, case managers are more likely than clients to discern and

emphasize needs for mental health services, drug abuse treatment, longer

term medical care, and legal assistance. In the New Jersey study, clients

have resisted drug abuse treatment in two different ways. Some have stated

that they did not want or did not feel ready for such services. Others have

accepted referrals but never followed through in using them. In a few cases,

clients have passively avoided presenting themselves for an intake from week

to week through the course of TCM. Mental health services have been resisted

in similar ways, but apparently with a still stronger sense of stigma attached to

them. Nevertheless, several clients have made use of services in the mental

health field, often with good results even within the timeframe of TCM. Women

who entered counseling or family therapy to help children with emotional or

behavioral problems have made up a large proportion.

In TCM, presenting referrals to the client leads the case manager into the

brokerage and advocacy processes. Having identified the client’s priority

needs, the case manager must judge what services can address them. The

starting point for this task is a network of contacts at a variety of agencies. The

case manager must know not only what services agencies provide, but when

they will be available and for what types of clients, with what considerations

about payment, and with what difficulties of access. Clients often have urgent

needs and low thresholds of discouragement. They will then be lost to TCM if

they cannot be assisted quickly. A personal contact may be of key importance

if it helps to jump a client in crisis to the head of a queue. The case manager’s

role may also include making initial contacts with agencies, passing entry

information to the client, monitoring the client’s application process, and

intervening if the client encounters obstacles and becomes frustrated. The

HBPs encouraged many clients to call other agencies from the office to set

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up their first appointments. This procedure enables a case manager to prompt,

guide, and support clients as they enter negotiations for services.

TCM also involves supportive counseling as an adjunct to the referral and

placement function. The goal is to prevent clients from abandoning efforts to

obtain services when they encounter difficulty, including their own reluctance

to seek help. This may involve exploring with a client his or her needs for

services, including longer term counseling or therapy. However, the counseling

remains focused on the referral and placement goals of TCM. When a client

was in excruciating pain from an abscess undermining several teeth, yet had to

wait 5 weeks for the welfare office to consider his application for Medicaid and

then approve payment for oral surgery, fortitude was required of the case

manager as well as the client. After supporting the client through this ordeal,

the case manager was rewarded by seeing him give up not only the heroin with

which he had been managing the pain, but his belligerent manner toward the

world at large and some of his paranoia toward his family as well. The client

also placed himself in medical treatment for his HIV infection.

TCM thus involves supportive counseling as part of troubleshooting a client’s

difficulties in obtaining services. Focused counseling may also be required to

assist a client in managing an interpersonal crisis that emerges while progress

is being made on other problems. A woman who seeks family counseling or

therapy to deal with an abusive spouse or to persuade an HIV-infected partner

to use a condom may require strong professional support. Without counseling,

the impetus to follow through in using services may be lost. However, longer

term psychosocial counseling or therapy to help with, for example, depression,

interpersonal adjustment, coping strategies, or skills building, fall outside the

time-limited bounds of TCM. Needs for these kinds of help, when uncovered,

must be handled by services from other agencies. Similarly, TCM cannot

handle a complicated disability determination or other entitlement or legal

matter that may take months to resolve. When it is seen that an issue will not

be resolved by routine approaches, a case manager should refer the issue to

an agency providing longer term advocacy, such as a legal service.

One case manager counseled a client for more than 12 weeks to support her

in entering methadone treatment and psychotherapy for feelings of self-hatred,

including a fascination with masochistic sexual activity. With luck as well as skill

in maintaining focus on the transition to therapy, the case manager succeeded

in placing her with a qualified psychologist and in limiting her drug use to

occasional “slips.” A good outcome probably could not have been achieved

without the case manager’s willingness to hear unpleasant psychodynamic

issues associated with the client’s engaging in risky, humiliating prostitution.

This case pressed the limits of TCM somewhat farther than the supervisory

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staff had approved, even though the case manager skillfully maintained focus

on transition to care by a psychotherapist.

After initial needs assessment and referrals, the case manager ordinarily

plans to meet with a client for three additional sessions over 2 to 4 weeks.

Clients may also be encouraged to drop into the office for informal meetings

to report briefly on problems or progress with other agencies. During this

period, TCM focuses on monitoring a clients progress in obtaining help for

identified needs. If clients do not make contacts or keep appointments with

agencies, they will be encouraged to do so. Many clients need two or three

reminders before they keep first appointments with other agencies, especially

those whose services are stigmatized, such as HIV clinics or mental health

programs. If the services of a particular agency prove not to be available or

suitable, new referrals can be made. If changes in a client’s life have created

new needs, the initial assessment can be supplemented and agencies providing

appropriate services identified. When one need has been met, an underlying,

frequently more complicated need may become apparent. When a woman

obtains her HIV test results and resolves to make life changes to secure her

seronegative status, her husband’s attachments to drug use and sexual

dominance may be more clearly exposed, as may her own dependency and

passivity. Referrals for treatment of drug abuse and counseling on safer sex

may thus be inadequate without some form of couples therapy.

By the third or fourth session, the case manager can usually plan an end to

TCM service. At that point, the client should be making concrete progress with

the help of another agency or agencies. The primary focus of the last session

or two should be on monitoring progress with at least one other agency. When

progress is being made, the client should be encouraged in his or her efforts to

obtain useful services, When progress is insufficient, the client’s hope should

be supported and substitute referrals developed. However, judgment must be

exercised so that another agency is not undercut before its efforts have had

time to become effective. Care must also be taken not to give consensual

validation for a client’s complaints if they derive from ambivalence about making

life changes rather than from an agency’s shortcomings. The monitoring phase

may require an extension of TCM to assess a client’s progress with new

agencies. Clients should also be encouraged to plan over the longer term

for consolidation and continuation of their progress. If a client gives written

consent, the case manager may consult with another agency to confirm its

plans for continuing assistance. Ideally, TCM ends with a service plan

confirmed by other agencies.

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TCM AND POSTTEST COUNSELING

Difficulties in providing timely posttest HIV counseling sometimes created

problems in scheduling the end of TCM. From their start, the HBPs

emphasized placing HIV-infected individuals with medical clinics to be

assessed promptly for zidovudine (AZT), pentamidine, and other elements of

current AIDS therapy. In 1990 NJDOH launched its ambitious Treatment

Assessment Program (TAP) to furnish publicly supported triage, continuing

case management, and, as appropriate, AZT and pentamidine therapy for

infected persons. The efforts of TCM staff to coordinate with TAP soon

revealed consequences of the general scarcity of resources in the field of

AIDS services. To hand clients over to TAP’s case managers in an efficient

way, TCM staff needed timely results on HIV antibody testing. ELISA and

Western Blot tests for the HBPs were conducted by the NJDOH laboratory in

Trenton, NJ. Overburdened by a growing workload, the laboratory began to

lag in reporting results. For many clients, TCM had to be extended so that

final referrals could be made after their HIV statuses were known, often 6

weeks after blood had been drawn. Other clients were lost to TCM before

their test results had been returned. TAP in the meantime had also become

overburdened, so intake appointments were unavailable for 6 or more weeks

and, when missed by ambivalent clients, could be rescheduled for no sooner

than 2 months later. The TAP clinic at Jersey City Medical Center eventually

reduced its backlog sufficiently to accept HBP clients in a more timely manner.

For a period of several months, however, HIV-infected clients were sent to less

accessible hospitals. At best, clients were referred for HIV treatment later in

TCM and with briefer than ideal monitoring of their placements.

As the staff gained experience with TCM and learned to be flexible in managing

caseloads and schedules, the routine limit of four sessions was relaxed more

frequently. Greater emphasis was placed on achieving the original goal of

giving posttest counseling to all clients. To this end, TCM was routinely

extended until clients’ HIV test results were available. Although some clients

were still lost before receiving results, gains were made in the delivery of

posttest counseling. As a model, TCM thus encompasses posttest counseling

and support through at least the early phases of personal planning in

adjustment to HIV test results.

Posttest counseling was often a landmark event for high-risk seronegative

clients as well as seropositive ones. Many HBP clients assumed from the

experience of friends and family members that they would be seropositive.

After facing up to posttest counseling with anxiety and dread, they found deep

relief in their test results. One client, an IDU for roughly a decade as well as the

stable sex partner of another IDU for 5 years, had come to the HBP out of

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concern over her AIDS risk. She had lost one close relative to AIDS, and

another relative was receiving treatment for HIV in jail. She expressed anxiety

over her HIV status from early in TCM. After persuading her partner, himself

an HBP client from the previous year, to return for his HIV test results, and then

learning that he was seropositive, her dread mounted rapidly. After one delay

when results had not yet been returned to the HBP and another when the client

did not muster the courage to learn her results, the case manager could tell her

that her test had been negative. Over the next few weeks, her partner was able

to express his happiness over her good result, and the client expressed her

continuing love for him. She progressed in methadone treatment while he,

not able to afford treatment, succeeded in stopping drug use “cold turkey.” The

couple planned to marry as soon as they could. They also changed their social

life abruptly, breaking with drug-using friends and strengthening ties with her

father and extended family. With the case manager’s assistance, the client

obtained financial support and appropriate services for her household from

unemployment, Medicaid, food distribution agencies, a few medical clinics,

and a mental health program.

IMPLEMENTING THE TCM MODEL

The staffing plan for TCM included two case managers, one public health

assistant, and two outreach workers. The supervising case manager was

to monitor the routine referral services provided to all baseline and followup

subjects by HBP interviewers, supervise the second case manager, and serve

TCM clients herself. The junior case manager was assigned to full-time client

work. The public health assistant was to maintain records for the evaluation

of TCM, ensure that stocks of educational materials (including condoms for

distribution at all appointments) and office supplies were adequate, and remind

clients of appointments by telephone and mail. Early in the project, the public

health assistant also helped the case managers in updating referral lists of

service agencies and in meeting with agency representatives to introduce

TCM. The role of the outreach workers was to recruit clients for all HBP

programs on the streets and from welfare offices, emergency rooms, beauty

parlors, and other likely places. Outreach workers would also accompany

clients to appointments at other agencies and relocate clients who missed TCM

appointments, although the HBP was able to arrange this assistance only for

clients with special needs,

HBP contracted with a senior social worker experienced in AIDS case

management at hospitals and social service agencies to serve as TCM

consultant. For the first year and a half of TCM, he met weekly with

investigators and field staff for protocol development and revision, drafting

of manuals, and review of the assistance given to clients presenting unusual

problems.

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The formal staffing plan, following established standards in the case

management field, called for an experienced M.S.W. in the position of

supervising case manager and either an experienced B.S.W. or a newly

degreed M.S.W. for the second case manager. However, the North Jersey

market for social workers with experience in AIDS care proved to be extremely

tight. When staff members were first hired, 2 months of making contacts,

requesting resumes, advertising positions, and interviewing candidates did

not turn up a strong applicant with an M.S.W. and appropriate experience.

Only after almost a year of searching for a person with a professional degree

was an M.S.W. hired.

Although they did not have M.S.W. degrees, the first two case managers to

work at the HBPs were well qualified. The first one was a resident of Jersey

City who had experience as an intensive case manager with AIDS patients,

knew the community and its agencies, and related with minority individuals

and IDUs in a straightforward, respectful manner. The second case manager

had extensive experience with an IDU and SP clientele as a family planning

counselor. Combining energy in making placements with other agencies and

tolerance for the varied activities and interpersonal styles of clients, she was

especially successful in building supportive relationships with clients. The

scope and detail of her case records have made them a major resource in

assessing TCM. In staffing a research-oriented program, special consideration

should be given to candidates who can record the details of casework.

The TCM program gained its outreach workers by reassignment of two

already-employed members of the HBP staff. Under general arrangements

for the HBPs, all outreach workers were hired through two methadone clinics

in Jersey City and Newark, then supervised by NJDOH staff. In practice, the

TCM outreach workers were not effectively reallocated from the tasks of

recruitment for the HBPs in general to the case management effort specifically.

The arrangement proved efficient for primary recruitment of clients for intake.

However, when assistance was needed in walking clients to appointments with

other agencies or relocating them for TCM appointments, only occasional help

was received.

Staff turnover has been a notable problem for the TCM project. Two programrelated factors may have created difficulties, Both the first and second case

managers expressed discomfort with the research focus of TCM when they

resigned, commenting specifically on the extensive recordkeeping. They may

also have been disappointed by the turnover in clients under the TCM protocol,

which reduces continuity in client relations. When the second case manager

resigned, it appeared that the intensity she brought to her work had brought on

a temporary burnout. Supervisory staff members had noted her tendency to

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counsel clients more intensively than TCM requires, but they had not fully

perceived the emotional fraying that accompanied this extra effort. She has

since commented on the sense of relief she experienced after leaving the HBP.

Her experience serves as a reminder that staff members working in AIDSrelated service require emotional support.

STUDY DESIGN AND DATA COLLECTION

The research design called for a comparison of three ways of ensuring that

IDUs and SPs who are HIV infected or at risk of HIV infection receive referrals

for medical and social services:

TCM, as described above

Standard care (SC), the procedure that the HBPs had followed from the

start of field operations, with interviewers giving referrals after subjects had

completed AlAs

Case referral (CR), in which interviewers provide the basic referral service

as in SC but work under the supervision of a professionally trained social

worker who is familiar with the referral opportunities in the community and

who reviews the disposition of each case for appropriateness in terms of

client needs

All three protocols are methods of helping clients secure services from other

agencies for a wide range of personal problems common among IDUs and SPs,

including care for HIV infection. The study’s data collection has been designed

to show whether the TCM protocol produces a substantial increase, compared

with SC, in the numbers of infected and at-risk persons who obtain appropriate

medical and social services. A collateral issue has been to determine whether

the CR protocol increases referrals comparably to TCM, but at lower cost. By

comparing similar programs in Newark and Jersey City, the study was also

designed to suggest ways in which results might be site dependent.

Funded staff was not sufficient to operate three interventions in two cities at

the same time. Therefore, in phase one all Newark subjects received SC, and

Jersey City subjects were assigned to TCM or CR by odd or even project ID

numbers. In phase two, Jersey City subjects received SC, and Newark subjects

were assigned to TCM or CR by project ID number.

Phase one of TCM and CR was implemented in Jersey City on November 4,

1990, and maintained through September 27, 1991. SC had begun in Newark

under a revised protocol on July 2, 1990, with the early start possible because

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new staff members were not needed. Phase two began early in September

1991 and ran through January 1992.

Client data collected to assess the three protocols were keyed to the HBP

subject ID numbers so that they can be linked to data on demographics, risk

behavior, and serostatus. Data collected as part of the TCM assessment

were as follows:

For SC: (1) Checklists were prepared at the time of both baseline and followup

interviews to record every referral offered to each client; (2) at followup

interviews, clients were read lists of referrals they accepted at baseline and

were asked to report what use they had made of each one, with their reports

being recorded on a new form. These referral followup forms were completed

for about 750 of the SC study subjects in Newark who returned for timely

followup interviews; approximately 400 baseline SC clients did not return for

followup interviews. Data drawn from referral followup forms on 231 of the

SC clients in Newark provide the base of comparison for the assessment of

TCM below.

For CR: (1) The same instruments were used as for SC; (2) in addition, a brief

“areas of need” checklist was prepared for each client as part of the enhanced

CR service. This instrument reminded clients of needs in various areas in the

hope of encouraging them to accept appropriate referrals. In combination with

the referral followup form, the needs checklist should make it possible to assess

the relation between previously stated needs and actual use of referrals, Nearly

400 sets of baseline data and about 200 sets of followup data were collected

for CR clients in Jersey City. Data on CR clients have not yet been analyzed

and are not reported here. The field staff suggested that meaningful differences

between the SC and CR protocols were not maintained because, after learning

better referral skills as part of CR when working in Jersey City, or when

exchanging information with the Jersey City staff, interviewers used them

with Newark SC clients as well.

For TCM: (1) Checklists recorded offers of referrals at the baseline interview;

(2) complete case records reported all appointments and other client contacts

with TCM staff; (3) referral followup forms, completed in a way similar to those

for SC and CR, showed use of referrals during a period of approximately 6

months. Each case record, when complete, includes: the client’s own

indication of areas of chief need; the case manager’s assessment of the

client’s needs; the case manager’s case notes, including remarks on all

referrals made and, where subsequent appointments permitted, the clients

reports on use of referrals; monitoring and tracking sheets on which TCM staff

recorded all contacts with the client aside from appointments, including

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telephone and mail contacts and reports from family members or agencies;

and a termination form containing the case manager’s final assessment of

the client’s participation.

ASSESSMENT OF PARTICIPATION

From November 5, 1990, to September 4, 1991, 777 subjects in Jersey City

were interviewed with the AIA instrument. Of these subjects, 392 were provided

SC referrals and then offered the opportunity to receive case management

services under the TCM protocol. Of the 392 potential TCM clients, 287

agreed to participate, and case folders were created for all 287. Most of them

never returned to the HBP for a TCM appointment. The staff reported that 97

clients finished at least one session of TCM, with 91 completing the needs

assessment. In a review of all case folders, however, 103 clients were

identified as having had a TCM session with a case manager. The following

data on TCM are drawn from the case records on these 103 clients.

Referral sheets completed at baseline interviews were examined for clues

about why subjects refused TCM or failed to attend first appointments. Three

types of subjects could be identified, along with some others whose situations

were less clear. First, some subjects stated that they were employed and had

places to live, adequate food, and medical attention. Second, a larger number

of subjects rejected referrals saying that they were already receiving basic

services (e.g., welfare, food stamps, Medicaid, public housing). Although these

two types, together a considerable proportion, refused TCM on grounds of not

needing the service, a third and more common type of nonparticipant had high

levels of need but appeared to lack motivation for reducing drug use and other

risk behavior or may have distrusted the program.

TCM participants were thus a self-selected group of 26 percent of all subjects

assigned to the program. Compared with nonparticipants, they probably

constituted an intermediate group in terms of need and risk. On the average,

the first two types of nonparticipants likely had fewer, less urgent needs and

probably lower levels of current exposure to HIV risk. The third type likely had

greater needs and higher risks.

Of the 103 participating clients, 66 were IDUs, male and female; 36 were

female SPs; and 1 was a male SP seen in violation of HBP screening rules.

In all, 53 clients were women and 50 were men. Since AIA subjects during the

TCM study period were roughly 75 percent IDUs, SPs participated at higher

rates than IDUs. Similarly, among IDUs, women participated at higher rates

than men. This pattern may reflect the fact that the case managers, along with

key interviewers and outreach workers in Jersey City, were women and strongly

128
oriented to women’s issues. However, it may also reflect a reluctance on the

part of men to become recipients of help. Another likely factor is that men tend

to be more strongly engaged in the social role of IDU and hence are less likely

to accept help in recovery.

Client participation declined session by session. Of the 103 clients attending a

first session, 69 returned for a second, 51 for a third, and 39 for the fourth.

Thus, only 38 percent of clients starting TCM completed the standard four

sessions. Among those for whom the case managers obtained permission to

extend TCM, 15 attended a fifth session, 9 attended the sixth and seventh, and

4 attended for eight or more sessions. The session-by-session attendance data

also indicate that SPs attended longer than IDUs and women IDUs longer than

men. Among 15 clients who remained in TCM through the fifth session or later,

10 were women and 5 were men.

To encourage sustained participation, case managers were instructed to ensure

that clients completing an initial session received at least one helpful referral.

The case records document success in meeting this goal. They show that all

but 17 of the 103 TCM clients received at least one referral resulting in provision

of service. Some of the remaining 17 clients likely received help as well but did

not report it before dropping out of TCM. Thus, at least 83 percent of clients,

and likely more, received service from the TCM referral procedure.

The data on successful referrals also explain part of the session-to-session

decline in attendance. Many clients came to TCM for help of a specific kind,

such as a letter of referral to an agency distributing free food, placement in a

shelter or detoxification program, or an appointment at a medical clinic. These

clients tended not to be looking for more comprehensive care. If their specific

needs were addressed in one or two sessions, they often did not return. In

many cases, dropping out reflected a judgment, even if unwise, that urgent

needs had been met and TCM was no longer necessary. For other clients,

the records indicate the case manager’s agreement that reasonable goals set

in the initial needs assessment had been achieved after two or three sessions.

In these cases, early termination was made or the case manager informally

agreed that the client had completed TCM unless an unexpected need arose.

Only rarely, if the case records give fair indication, did clients drop out in

frustration that still another program had failed them.

Most attrition apparently resulted neither from TCM’s positive achievements

nor from pointed failures. Rather, clients simply did not return. Assuming that

clients who never returned were similar to ones who returned only weeks or

months after they had broken scheduled appointments, the main reasons for

dropping out of TCM were lack of resolve to make personal changes and

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embarrassment over not having followed through on referrals. This type of

dropout accounts for most of the attrition between the first and second

sessions, but progressively less for later sessions. This is consistent with

an overall picture that clients who participate only briefly are often similar in

motivation to nonparticipants. SPs showed less attrition than IDUs, and

women IDUs less than men, perhaps because they were less often conflicted

over making life changes.

OUTCOME ASSESSMENT

To assess TCM in terms of outcome methodology, case records from all 103

Jersey City TCM clients were examined and information bearing on the

following questions abstracted. First, what services were clients receiving at

the time of intake, as reflected in the initial needs assessment? Second, what

services did clients receive while participating in TCM? Third, what services

might clients continue to receive over a longer term after completing TCM?

Data bearing on these questions have been aggregated under categories

derived heuristically, that is, by grouping together similar services among the

ones supplied by agencies to which case managers referred clients.

A conservative summary of resulting data is presented in table 1. Entries have

been made under appropriate categories only where case records include clear

reports by clients or agency representatives that services had been or were

being received. Guesswork has been avoided whenever possible. Services

obtained by clients who did not subsequently keep an appointment, drop by the

office, or respond to a monitoring or tracking inquiry have not been recorded,

except where agencies or family members provided clear information. Because

of the frequency of attrition, this procedure likely underreports the achievements

of TCM.

Another reason for underreporting is that multiple referrals for a given client

within a single general category were not recorded. Second, third, or even

fourth referrals were often made because a first referral did not work out

satisfactorily. Thus, it seemed inappropriate to count substitute referrals.

However, many additional referrals grew out of a different circumstance. They

addressed needs that were different in substance, even if related to the same

general category-for example, medical referrals to a gynecologist, allergist,

and orthopedist or placements with both soup kitchens and food pantries,

followed by a referral for food stamps. It was often not possible to note these

additional referrals with confidence that they were not substitute referrals. To

keep the data “clean,” therefore, both additional and substitute referrals have

been omitted from the data set, with the consequence that the case managers’

efforts on behalf of many clients are substantially underenumerated. The

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TABLE 1. Referrals received by category-TCM clients (n=103)

Received Service Received Short- Received LongReferral Type Before Intake* Term Services*†

Term Services*†

HIV-related services

Medical

Support services

6

5

1

23 19

18 11

5 8

Alcohol and other drug

abuse‡

Inpatient treatment

Drug-free treatment

NA/AA

Other

Other medical services

Mental health and family

counseling

Housing and shelter

Food and clothing

Entitlements and financial

assistance

Legal aid

Employment and vocational

No documented service

14

1

1

12

0

37 42 16

9

18 19 4

42 40 9

42 44 24

8

7

18 17 57

34 10

11 1

2 0

21 9

0 0

17 11

10 1

31 8

*Does not reflect multiple services within category for invididual clients

Service obtained through TCM

‡Excludes methadone detoxification obtained through the HBP coupon program

referral data for TCM clients are thus best interpreted as indicating the broad

categories of need for which one or more referrals were made and utilized.

Table 1 shows that 5 clients were already receiving HIV-related medical care

at intake, 18 clients received placements for HIV medical care on a short-term

basis, and 11 seemed sufficiently well established in receiving care that they

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could be recorded as having continuing care. The clients recorded as obtaining

HIV care through TCM include two of the five who were initially receiving such

help. They gained additional referrals and service through TCM. Only one

client was recorded as having participated in nonmedical HIV care and support

programs before intake, whereas five received short-term care, and eight were

recorded as being securely placed for continuing care. Because of the delays

in posttest counseling and consequently in placing clients for HIV treatment,

care was just beginning for several clients as TCM was completed, which

explains why some are listed as receiving long-term service but not short-term

service. Probably additional clients among the 18 who were placed for medical

HIV care also ended up participating in support groups and obtaining other

psychosocial help but were placed by hospital-based case managers.

Because HBP serostatus data have not yet been linked to TCM client IDS,

the total number of seropositive participants is not yet known and success

in meeting their needs can only be estimated. Case records do not indicate

all the seropositives because many clients were lost to TCM before their

serostatus was reported. However, rates of seropositivity will be lower than

for the HBP as a whole because of the large percentage of SPs who took part

in TCM. If, in all, 30 TCM clients prove to have been HIV infected, help will

have been given to approximately two-thirds of them.

Treatment for drug problems (primarily drugs other than alcohol) was a focus

for TCM as for all HBP programs. Including all types of treatment, counseling,

or group support, the case managers made 34 successful referrals for

substance abuse problems. The 34 include additional placements for most

of the 14 clients who had already joined Narcotics Anonymous (NA), Alcoholics

Anonymous (AA), or another program before making contact with the HBP.

The 34 exclude 27 placements in methadone treatment through the HBP

coupon program, counted here as an independent intervention even though

the case managers actively supported it. However, several clients expressed

preferences for drug-free programs. Several others were exclusively or

primarily cocaine users who did not qualify for methadone treatment. A

few claimed to be opiate users and took methadone coupons but did not

qualify when their urine samples contained insufficient levels of opiates.

For all these types of cases, the case managers generally recommended

inpatient detoxification or rehabilitation programs. In 11 cases they succeeded

in making placements, although 2 patients would accept only outpatient drugfree programs. Most, but not all, of the 21 clients placed with NA or AA

received other forms of alcohol or other drug abuse treatment (including

methadone) as well. Referrals to NA or AA were usually suggested as an

additional support to people accepting another mode of treatment. However, a

minority continued in NA or AA without other treatment, in a few cases with

apparent success.

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Of the 103 clients, 37 had been receiving care for non-HIV medical problems

at the time of intake or shortly before. Their problems ranged from dental to

gynecological and included a large number of accidents and injuries. Most

of the care had been obtained in emergency rooms, with walk-in clinics also

being frequently used. Only a few clients received care from private physicians,

HMO staffs, or through other continuing doctor-patient relationships. A total

of 42 patients were placed for new medical care, and 16 were placed in

programs where longer term services had been initiated. These numbers

include some of the 37 who were previously obtaining treatment. In many

cases, referrals were made for serious medical conditions-epilepsy, diabetes,

sickle cell, cancer, liver or kidney disease, and painful dental conditions. In

most cases, clients were sent to family health clinics, walk-in clinics, family

planning services, and so forth for help under Medicaid, but often in

arrangements that would favor stable doctor-patient relationships.

At time of intake 9 clients were participating in programs that provide

psychosocial, psychological, psychiatric, or counseling services; 17 clients

received placements of this type through TCM, 11 of them on terms that

appeared stable and continuing. In many of these cases, the clients showed

frank and serious psychopathology. In others, relationships with spouses or

significant others were in turmoil. In several, children were having difficulties

at home, in school, or with the law, and placements focused on family

counseling or therapy for the children. Because TCM generally focused on

pressing practical difficulties, the case managers rarely made referrals for

therapy or counseling unless needs were intense. For most clients, matters

such as food, shelter, and income prevailed as focal concerns, and the service

did not progress to a point where psychosocial problems might become

foremost needs. Thus, psychosocial problems claimed primary attention only

if they had become urgent or threatened to become urgent, as was the case

for one young mother who had to plan for her children after learning that she

and her husband were both HIV seropositive. When the case managers

offered mental health referrals, they often encountered resistance from clients,

as would be the case in any population. Referrals in this area thus greatly

understate the psychosocial needs of the clientele as perceived by the staff.

The category of housing and shelter combines referrals for immediate shelter

with assistance in obtaining better long-term housing. Jersey City has many

homeless people, with IDUs and to a lesser extent SPs common among them.

Most of the 18 who were previously receiving help were living in large shelters

for the homeless. The 19 who received help through TCM include some people

who had been living on the streets or in abandoned houses and who were

newly placed in shelters. Others had been living in shelters and were helped

through TCM to move on to better housing. The four listed as receiving

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continuing help were placed in appropriate long-term housing, whether public

housing projects or privately owned apartments. More long-term help would

have been given in this domain were housing not so scarce and expensive in

North Jersey.

The large numbers who received help for food and clothing reflect the indigency

of many HBP clients. Yet, many IDUs have disposable income and spend it

on drugs, then approach a soup kitchen or food pantry for free meals. Many

SPs have the same hand-to-mouth subsistence imposed on them by their IDU

partners; others follow it to serve their own noninjection drug habits. Because

of the volume of demand for free food, the local soup kitchens and food pantries

do not give out food without letters of referral from a social service agency.

The case managers thus played a gatekeeper role by supplying referral letters

whenever clients came to them hungry. Indigent clients who continued with

TCM were assisted in obtaining food stamp allotments as well. The nine

clients listed as having received continuing help for food all obtained food stamp

allotments. The 40 clients receiving short-term help through TCM are fewer

than the 42 who previously received food, in part because many knew how to

obtain free food and did not need additional help. In several cases, clients

were ineligible for food stamps because of records of prior misuse of allotments.

The case managers could then only line up several pantries or kitchens to

sustain the clients. In many cases of assistance with food, children and

spouses benefited along with clients.

The case records show that at least 42 clients had been receiving some form

of entitlement before participating in TCM. Clients receiving help were primarily

women, SPs, and noninjection drug users. However, some male IDUs were

also receiving welfare, disability, or veterans’ benefits. Help in obtaining

entitlements or other financial support was successfully given to 44 clients,

24 of them apparently with relative permanency. Many of those helped were

people already receiving some assistance at intake. They often received

additional assistance (e.g., housing subsidies, welfare, transfers from welfare

to disability). However, 8 or 10 clients were taken off welfare (and/or food

stamps) during their period with TCM. The help they received from the case

managers was to gain reinstatement.

The impression of TCM staff was that welfare agencies try to remove drug

users, prostitutes, and other “undesirables” from their rolls. They undoubtedly

have good cause in many cases; fraud and misuse of funds are not uncommon

among IDUs and their families. Yet, the case records indicate that officials

sometimes act in the manner of police who arrest a person they “know” to be

a drug dealer whether he or she is holding drugs at the time (Gould et al. 1974).

On occasion, clients were dropped from welfare precipitously when they failed

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to keep an appointment or show a document, even after informing the officials

that a hospitalization or inpatient detoxification would make rescheduling

necessary. The cycling of clients on and off welfare rolls created extra work for

the case managers. Getting a client on welfare often proved to be an unstable

achievement, leading to additional effort after the welfare office imposed a

sudden change of status.

At intake, eight clients were receiving legal services for a variety of matters,

criminal and civil. The case managers assisted 10 clients in obtaining legal

help for problems ranging from divorce and child custody to theft and assault

to violations of parole or probation rules to pursuing injury claims. In one case,

extended legal help was needed for a complicated criminal matter.

The category of employment and vocational training or education is the one in

which TCM achieved the largest proportional increase in services. At intake,

7 clients were receiving help; 31 received additional short-term help; and 8

received extended help, such as placement in an educational program. Most

of the clients who benefited were unemployed men or women who sought

immediate jobs and would accept any work that could be found for them. A few

employed people sought training to upgrade their jobs. A few others registered

to continue college studies after succeeding in treatment for drug abuse. The

latter were among several clients who had been students but dropped out of

college when they started using drugs.

TCM provided the most concrete help when it sent clients to programs, such

as the Urban League’s, that placed people in direct contact with employers. In

almost all cases, the jobs obtained were for unskilled work, at warehouses, for

example, with little future and indefinite prospects for continuation. Several

clients were able to return to work they had performed earlier in their lives,

a few in skilled positions and one in long-haul truck driving. Two were

employed in what the HBPs gathered is a favorite line of work among unskilled

drug users, school bus driving. A number of the older men, now long-term

IDUs, had worked at a variety of skilled jobs earlier in their lives, several in

more than one field. With the region’s loss of industry requiring skills, unfulfilling

warehouse work was now the best they could find. Reading between the lines

of case reports, it appears that clients who had no job but asked for vocational

training or education were often not seeking long-term self-improvement but

simply declining practical help.

To place the data on TCM in perspective, table 2 presents data gathered from

the followup referral forms of 231 SC clients in Newark, which show overall a

much lower level of acceptance and use of referrals. Of the 231 clients, 123

accepted no referrals from their interviewers. The other 108 clients accepted

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TABLE 2. SC services—Newark clients (n=231)

Referral Type

HIV-related services*

Medical

Support services

Received Active at

Service Followup

0 0

0 0

0 0

Alcohol and other drug

abuse†

Inpatient treatment

Drug-free treatment

NA/AA (hotlines)

Other

1

0

0

1

0

Other medical services 0

Mental health and family

counseling

Appointment

Accepted Made

0 0

0 0

0 0

111 9

2 1 3

13 2

67 4

10 0

28 6

23 6

4 0

15 1

1 5 8

0 0

32 10

108 21

228 40

3

2

0

1

0

3

1

0

1

4

0

3

14

15

1

Housing and shelter

Food and clothing

Entitlements and financial

assistance

0

0

4

Legal aid

Employment and vocational

0

0

Totals

Clients accepting referrals

Referrals given

5

6

*HIV serostatus not known at time of referral

†Excludes methadone detoxification obtained through the HBP coupon program

an average of 2.11 referrals. However, only 14 clients followed through with

their referrals to the point of receiving service, and only 1 client obtained service

from two agencies. At the time of followup interview, approximately 6 months

after baseline, five clients were still receiving services from six agencies.

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In interpreting these data, three qualifications must be considered. First, they

have been collected differently from the data on TCM clients. They are derived

from questionnaires probing client memories and reports, not case records.

Second, although followup interviewees were in key respects a self-selected

group (rates of relocation and followup interviewing were approximately 65

percent for the cohorts involved), they may have been differently self-selected

than TCM participants. Third, the SC clients were recruited and received

service in Newark rather than Jersey City. Newark is both a larger, more

diverse city and a less closely knit community than Jersey City. However,

it is characterized by more service agencies and, on the whole, more active

and effective ones. On balance, how client opportunities compare in the two

cities is not fully understood by the investigators.

In reviewing the SC data more closely, the following patterns are noteworthy.

Among SC clients, no referrals were accepted for HIV-related medical treatment

or social support, although it must be emphasized that these referrals were

offered immediately after the AIA and before HIV test results were known. Had

the followup referral forms probed acceptance and use of referrals given at the

time of posttest counseling rather than baseline interview, some use of HIVrelated referrals might have been identified. However, during the period of this

study, only 12 to 15 percent of Newark subjects received posttest counseling

prior to returning for followup interviews.

The followup referral forms indicate, first, verbal “acceptance” of referrals

given after AIA interviews, In all, 28 clients accepted non-HIV-related medical

referrals and 23 accepted referrals in the domain of mental health or family

relations. Only 4 referrals were taken for housing or shelter, 15 for food and

clothing, 15 for welfare and entitlement matters, and 32 for employment or

vocational training. A larger response, 111 acceptances in all, was obtained in

the domain of alcohol and other drug abuse, even though, for comparability with

data reported above, HBP coupons for methadone detoxification are not

included in this count. However, most of these referrals (67) consisted merely

of accepting an NA or AA hotline number.

When clients were asked whether they had made appointments with agencies

to which they had been referred, their responses revealed the weakness of

SC as a form of client service. Only 6 of 28 claimed to have made medical

appointments, 6 of 23 to have made mental health or family relations

appointments, 1 of 15 to have obtained food distribution, 8 of 15 to have

made a welfare appointment, and 10 of 32 to have made a job or vocational

appointment. Of the 111 clients who accepted drug or alcohol abuse referrals,

only 9 made an appointment. This includes several who may have made

appointments for drug abuse treatment but only 4 of the 67 who accepted NA

or AA hotline numbers.

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When SC clients were asked whether they had received services through

their referrals, the numbers dwindled further: three for medical care, one for

mental health services, one for food and clothing, four for entitlements, three for

employment or vocational help, and three for alcohol or other drug assistance,

including two for hospital detoxifications and one for NA or AA. At time of

reinterview, no medical treatment was active. However, one client was still

receiving mental health care, four still had entitlements, and one remained

active at NA.

Table 3 arrays the data presented in tables 1 and 2 in a common format and

introduces percentage data to facilitate comparisons. It shows that, with a

lower threshold of participation, SC involved 46.75 percent of potential clients,

whereas TCM involved only 26.28 percent. However, SC resulted in concrete

help for only 12.96 percent, whereas TCM provided help to 83.50 percent of

participants.

Thus, SC assisted 6.06 percent and TCM assisted 21.94 percent of all assigned

subjects. Table 3 also shows the percentages of all assigned subjects and of

all participants who received service in each category through SC and TCM.

Whatever caveats are warranted by the preliminary nature of these outcome

data, they suggest that TCM provided a service that cannot be produced with

the lesser commitment of staff resources involved in SC. By this standard, TCM

has been a success. The core of its success is the high rate of 83.50 percent in

obtaining concrete service for active participants, a large improvement over

12.96 percent for SC. Nevertheless, the rate of success in helping all potential

clients remains lower than desirable at only 21.94 percent. As suggested in the

assessment of participation above, many of the 78.06 percent of potential

clients who did not obtain help had lower levels of need and greater resources

available to them than did TCM participants. Yet, others apparently had still

greater needs and fewer resources. TCM shares in the common difficulty of

interventions directed to IDUs and associated hard-to-reach or hidden groups;

namely, many potential clients with severe needs lack the will or motivation to

participate effectively. By enhancing TCM it may be possible to improve

participation modestly among these groups, but it would be naive to expect

dramatic improvement.

ENHANCEMENTS TO TCM

The experience with TCM in Jersey City suggests the need for several

enhancements to reduce attrition at various points in the program and even

increase initial client recruitment:

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TABLE 3. Comparison of outcomes for SC and TCM

Total participating*

Obtained services

HIV-related services

Medical

Support services

Alcohol and other drug abuse+

Inpatient treatment

Drug-free treatment

NA/AA

Other

Other medical services

Mental health and family

counseling

14 8 6 21.94 83.50

0 2 3 5.87 22.33

0

18 4.59 17.40

5 1.28 4.85

3 34 6.67 33.01

2 1 1 2.81 10.68

0 2 0.51 1.94

21 5.36 20.39

0 0 0.00 0.00

3 4 2 10.71 40.78

1 17 4.34 16.50

0 19 4.65 18.45

1 4 0 10.20 38.83

4 4 4 11.22 42.72

0 10 2.55 9.71

3 31 7.91 30.10

‘SC defines participation as accepting at least one referral for services, TCM defines participation as attending at least one appointment.

†Excludes methadone detoxification obtained through the HBP coupon program

Housing and shelter

Food and clothing

Entitlements and financial

assistance

Legal aid

Employment and vocational

6.06

0.00

0 00

0.00

1.30

0.87

0.00

0.43

0.00

1.30

0.43

000

0.43

1.73

0.00

1.30

12.96

0.00

0.00

0.00

2.78

1.85

0.00

0.93

000

2.70

0 93

0.00

0.93

3 70

0.00

2.78

N

108

Offered SC (n=231)

Percent of Percent of Clients

Sample Participating

46.75

Offered TCM (n=392)

Percent of Percent of Clients

N Sample Participating

103 26.26
Outreach staff should accompany clients to their initial appointments at

referral agencies. With moral support and practical assistance, clients

should attain higher levels of followthrough in keeping appointments.

Outreach staff might also be utilized to contact clients who fail to keep

TCM appointments and encourage continued participation.

The number of TCM sessions should be increased for clients who make

progress in dealing with their problems, but for whom a transfer to an

agency providing continuing case management has not been achieved.

Although TCM staff tried dutifully to make handoffs to other agencies, many

clients completed the program before securing ongoing service elsewhere.

Extending TCM until handoffs have been arranged should help to ensure

effective transitions to other agencies.

Clients should be invited to return to TCM for followup sessions when

they experience difficulties. This enhancement may keep adventitious

misfortunes from undoing the progress achieved by TCM, and it should

improve relations with clients by assuring them of the staff’s continued

interest.

Coupons redeemable in the community for groceries, public transportation,

clothing, or other necessities might be given to clients to compensate them

for participating in TCM. The HBPs enjoyed strong participation in their

interview programs because they paid subjects $10 for interviews and $5

for blood samples. Given the public health goals of TCM, the expense of

distributing coupons might be justified if rates of participation can be raised

above the 25-percent rate experienced to date. Such incentives would be

cheap compared with medical costs saved if they prevent one HIV infection

per year by involving more people in risk reduction. However, care should

be taken to ensure that coupon payments do not become coercive for

clients, subsidize use of illicit drugs, or degrade participation by creating

an incentive for false appearances of compliance.

DISCUSSION

The overriding goal of TCM as a service model is to complement the

recruitment function of an outreach project by efficiently placing clients

with established agencies in the social service and medical treatment systems.

Because of the limits of TCM, it may not be possible to address all the needs

identified in initial or subsequent assessments with a client. The case manager

must often accept placement for one or two key problems as a strong outcome,

especially if the placement is coupled with transferring responsibility for

continuing case management to another agency. When continuing care can

140
be arranged, TCM often takes clients from the fringes of the social service

system to new opportunities. Because disenfranchised citizens such as IDUs

and SPs often lack access to essential services, a short-term intervention

attempting mainly to place clients for help with their most pressing personal

needs represents a positive force. If performed thoughtfully and with sympathy

and energy, TCM may cumulatively help many people with serious needs.

The data presented above show that TCM is a promising, though improvable,

intervention for recruiting IDUs and SPs, especially women, into the medical

and social service system.

This conclusion addresses only the client service goals of TCM. The public

health goal of limiting HIV transmission is addressed only indirectly in this

chapter. The impact of TCM on reduction of AIDS risks and eventually on

incidence of infection is extremely difficult to assess. In the hope that TCM

has measurably affected rates of transmission, a next phase of evaluation

will link the program data reported above to data on risk reduction from HBP

followup interviews.

NOTES

1. For more complete analysis of seroprevalence data on the early cohorts of

the Newark and Jersey City studies, see lguchi et al., in press.

2. The term “underclass” is not used in a pejorative sense, as criticized by

Wilson (1987), for example, nor does it involve reference to race or

ethnicity. It is used in a technical sense deriving from well-established

theories of social class (Weber 1947). A social class is an extensive

social grouping that derives its solidarity from a common interest position

in the relations of production. An underclass is a grouping denied

participation in the system of production and whose interests are defined

essentially outside it. They may crystallize around opportunities for

entering or changing the economic system or around transfer payments,

illegal pursuits, and entirely extra-economic activities. Members of an

underclass commonly bear heavy psychosocial burdens due to the lack

of honor attached to their social positions. Many citizens of even the

poorest communities in Newark and Jersey City are members of the

working class and share the social honor and economic interests of that

class. However, local communities may be heavily burdened by the

prevalence of underclass membership and by outside perceptions that

all residents belong to the underclass.

141
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ACKNOWLEDGMENTS

Research reported in this chapter was conducted as part of the AIDS

Community Outreach Demonstration Projects of Newark and Jersey City,

operated in cooperation with NJDOH, Division of Alcoholism and Drug Abuse

with assistance from the Division of AIDS Care and Prevention. It was

supported by National Institute on Drug Abuse grants DA-05286 and DA-05289

and by the Newark AIDS Service Demonstration Project grant BRH-0000-70-02

from the Health Resources and Services Administration. Continuation of the

case management program is presently supported by a grant from the City of

Newark, Department of Health and Human Services, with Federal funding under

the Ryan White HIV Emergency Relief Act, Title I.

143
AUTHORS

Victor Lidz, Ph.D.

Assistant Professor

Donald Bux, M.S.Ed.

Instructor

Jerome J. Platt, Ph.D.

Professor and Director

Martin Y. Iguchi, Ph.D.

Assistant Professor

Division of Addiction Research and Treatment

Department of Mental Health Sciences

Hahnemann University

Mail Stop 984

Broad and Vine

Philadelphia, PA 19102-1192

144
Delivering Case Management Using a

Community-Based Service Model of

Drug Intervention

Judith A. Levy, Charles P. Gallmeier, William W. Weddington,

and W. Wayne Wiebel

Although case management is being widely adopted as an intervention

strategy to ameliorate a multitude of human problems, the philosophy and

practical application of the term vary widely by program, service provider, and

target population (Bachrach 1989). The authors’ study, the Neighborhood

Outreach Demonstration Project (NO DP), is engaged in longitudinal research

to develop and evaluate a community-based service (CBS) model for use with

drug-dependent populations. The CBS model incorporates two components

designed to stop or reduce drug dependency among active and recovering

substance abusers. The first strategy uses case management techniques to

promote drug-free living and prevent relapses to drug use. A service team

consisting of a case manager and an indigenous outreach worker provide

counseling, advocacy, and referral services; linkages to medical and social

service providers; and preventive materials and education for stopping the

spread of the human immunodeficiency virus (HIV). In the second strategy,

the team works with project participants to organize and facilitate the latters’

participation in a peer-support self-help group designed to encourage drug

abstinence and the adoption of patterns of behavior that reduce HIV

transmission.

Utilizing network outreach techniques, the study is recruiting a total of 200

active drug abusers in a northside and a southside Chicago neighborhood.

Individuals are eligible for inclusion in the study if they report having used

an illegal drug during the previous 6 months, have experienced physical or

psychological problems because of drug use, and express a desire to become

drug-free. Once enrolled, subjects are randomly assigned to a standard

(control) or CBS-enhanced group in their respective community settings for

comparison, using a blocked randomization procedure to ensure balance in

the number of allocations made to each group (Meinert 1986). The study is

designed to answer the question, “Does the CBS model, which combines

145
community-based case management and peer-support techniques, provide the

social support needed to assist active substance abusers in reducing or ending

drug use?”

THE CBS CASE MANAGEMENT MODEL

Although the delivery of social support through case management has

received renewed attention since the 1960s the concept has a long history

in the tradition of social work (Kanter 1985). Case management has been used

to intervene with such diverse human conditions as acquired immunodeficiency

syndrome (AIDS) (Froner and Rowniak 1989; Broadhead and Fox 1990;

Kotarba 1990; Cook et al. 1991), chronic illness (Wissow et al. 1988; Wool

et al. 1989), the Infirmities of aging (Seltzer et al. 1987; Kerr and Birk 1988),

and mental illness (Shueman 1987; Anthony et al. 1988; Kanter 1985; Borland

et al. 1989).

The CBS model of case management is designed to stop or reduce drug

dependency among active and recovering drug users by providing them

with the social support needed to adjust to the demands and to counter the

problems of living drug-free in the community. It draws heavily on the Chicago

model of community intervention that combines an innovative application of

medical epidemiology (de Alarcon and Rathod 1968; de Alarcon 1969; Hughes

and Crawford 1972; Hughes et al. 1972) with the established capabilities of

ethnography to offer insight into the social worlds of addiction (Lindesmith 1947;

Becker 1953; Finestone 1957; Shick and Wiebel 1981; Wiebel 1988). Under

the CBS model, the case manager meets formally on a regular basis to help the

individual set realistic goals for recovery, talk over difficulties that the person

faces, link the person to medical providers and social service agencies to meet

his or her physical and psychosocial needs, help the individual to effectively and

appropriately utilize existing services, and provide education on drug-related

problems, including HIV transmission. The case manager also monitors the

person’s progress and serves as an advocate when needed. Working in close

consultation with the case manager, the indigenous outreach worker assists the

participant on a less formal basis by providing on-the-street support. The duties

of the outreach worker include establishing ties between the program and

members of drug-using networks, informing prospective participants about the

CBS project, helping CBS participants find transportation and follow through on

medical and social service appointments, monitoring their health and well-being

through contact with them in the community and within drug networks, and

serving as a source of encouragement to the individual in undertaking the

changes needed to reduce or stop illegal drug use and its related activities.

146
A major strength of the team approach is that it combines the skills and

resource mobilization of a professional case manager with the outreach

capacities, insider’s knowledge, and network ties of the indigenous worker

within targeted drug populations. Two-person teams are ideal because each

member can check the other’s perception of a particular case and also draw

on independent experience with that person under differing conditions and

social environments (Froner and Rowniak 1989). When viewed as a unit,

the team functions to (1) help the person set realistic goals and determine

strategies to meet them; (2) identify resources, including service entitlements

and personal reserves available to bring about change: (3) link the person to

the social service system; (4) provide advocacy when necessary; (5) help in

the development of a network of supportive relationships; (6) monitor progress;

and (7) assist in resetting goals as appropriate.

In the second component of the model, the case management team mobilizes

the efforts of CBS group participants in the project to form and maintain

membership in a professionally assisted self-help group. These groups

provide encouragement, a system of beliefs that reinforces positive attitudes

and behavior, and practical suggestions for bringing about change through

the advice and social support of individuals who find themselves in similar

situations (Gartner and Riessman 1979).

The peer support component of the CBS model draws conceptually on the

community self-help movement that emerged during the late 1960s and early

1970s. Self-help groups have proven effective in helping people cope with a

variety of medical and social problems. Popularly known self-help organizations

include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Weight

Watchers, Widow to Widow, and Hospice. Groups such as AA and NA often

succeed in assisting individuals to manage the social problems related to

withdrawal from substance abuse.

Two features of the CBS model differ significantly from traditional peer-support

groups organized around issues of drug dependency. First, in contrast to

groups such as AA and NA that incorporate a singular philosophy of recovery

that members are strongly encouraged to endorse, CBS participants define the

philosophical ethos, agenda, and content of support-group meetings according

to what they perceive as appropriate for becoming drug-free. Thus, each group

tailors its efforts to meet the needs and interests of its particular membership

composition, and each differs somewhat in its behavioral norms and practices.

contextual properties, and collective beliefs, Second, unlike most groups

substance abusers attended during institutionalization for drug treatment or

as a means to stabilize recovery after release, CBS self-help groups initially

comprise active, on-the-street addicts who may or may not choose to

147
subsequently enter treatment. The project staff has found, however, that

participation in the group often acts as a stepping stone to treatment when

individuals see others select this option. In time, these individuals are expected

to return as recovering addicts who can act as stage models for others in the

group.

Despite initially accepting participants who are actively engaged in drug use,

the self-help concept appears to offer CBS peer-group participants many of

the same benefits experienced by recovering addicts in more traditional

settings. These include sustaining a common world view in relation to drug

use, helping members to live successfully in the “straight community,” making

advice available from more experienced members to those with lesser

experience in controlling drug dependency, providing successful role models,

discussing problems and coping devices, and developing a positive identity

and self-image (Nurco et al. 1983). During meetings, group interactions

reinforce and reward reduction and abstinence by providing the client with

non-drug-related interests and a network of new friends and acquaintances

to replace his or her “running mates.” As one project participant explained:

I know since I’ve been in this group, I’ve found other things

to do besides going on 53rd Street to find the dope man. I

ride the bus, I go down to the fountain and stick my feet in

the water on a hot day and just think. It feels good.

Under the CBS model, it is expected that as drug use decreases or ends,

group processes will motivate members to shifl their focus from managing the

problems of active substance abuse to meeting the challenges of successful

employment, community involvement, family participation, leisure activities, and

remaining drug-free. This goal is salient to group members for, as one woman

expressed, “I feel we are role models for the community. If we do well, we can

show the community there is hope for others.”

CHALLENGES AND BARRIERS IN MODEL DEVELOPMENT

One of the fundamental challenges of developing and testing a theoretical

model lies in the praxis of transforming the ideal into everyday practice. Hiring

staff members with the appropriate skills and values to implement their tasks is

essential. Also, educational and socialization guidelines and procedures are

needed to communicate the specifics and spirit of the model to those charged

with a particular staffing role. Despite careful screening and socialization,

however, all employees bring some level of task preferences, preconceived

notions, and entrenched beliefs about how a project ought to operate and their

role in this process. These biases and beliefs color their work performance

and have a critical impact on model development.

148
The effects of these personality characteristics become apparent when

comparing similarities and differences in the activity reports of the projects

two case management teams. The entries in one log suggest an emphasis

on providing brokering services, whereas the other reports a greater portion

of time devoted to counseling activities related to curbing drug use. Although it

is apparent that the project’s two subpopulations differ somewhat in their case

management needs, staff interviews reveal that these service allotments also

parallel the interests, formal training, and previous work experiences of the two

case managers. Over time, the performance of each team should be enhanced

by a cooperative exchange of skills and contacts as the goals of the project

become better articulated and understood. Inservice training and monitoring

of services clearly are needed to promote a better standardization of services

where appropriate.

Traditionally, the skills needed to fill the position of case manager have

been associated with the professional training of a social worker. In practice,

however, case managers have been drawn from a variety of fields, work

experiences, and levels of training (Leukefeld 1990). Although it has been

argued that case management requires only a “minimal level of skills” to be

effective (Ozarin 1978) experience with the multiple needs of the CBS

population indicates that an effective community-based case manager needs

a thorough understanding of the social service and drug treatment system.

Possession of this grounding, which may be gained in a variety of methods,

supersedes any single form of training or prior employment experience.

Case management can be taught (Anthony et al. 1988), and the authors’

experiences with outreach workers as members of the case management

team suggest that such skills can be acquired on the job and through inservice

training.

Outreach workers who are indigenous to the community are critical to

successful community-based intervention because they are familiar with the

subcultural mores and sociogeographic boundaries of a target population

and are perceived as credible by its members (Johnson et al. 1991). In

street-based drug and HIV intervention programs, outreach workers frequently

are former addicts. They have been conceptualized in the literature as the

“professional ex” (Brown 1991) because their occupational roles permit them

to use the experience, contacts, and knowledge gained through former

addiction to bring about change with others who are struggling with the

problems of recovery and active drug use.

The general lack of discussion in the outreach literature coupled with a diversity

of opinion among staff members in various outreach projects indicate that it is

not clear how long the individual should be an “ex” before being hired. Hiring

149
outreach workers with a relatively recent period of recovery can be an asset

because their network contacts and experiences are current. On the other

hand, outreach duties require the worker to interact closely with street addicts,

drug dealers, and possibly former running mates actively engaged “in the life.”

It is possible that individuals in recent recovery may be more likely to relapse

when occupationally reentering the social worlds of drug networks than workers

with longer histories of sobriety. Yet, the temptations of recidivism apparently

remain great at any stage. During an inservice training, one outreach worker

employed for several years on a project affiliated with NO DP once confessed

that "l still have dreams about fixing.” Other outreach workers in the room

admitted to having similar fantasies.

Relapse seriously compromises outreach workers’ abilities to carry out their

tasks (Johnson et al. 1991) and potentially jeopardizes project participants’

confidence and trust. Prevention strategies include holding stress-related

inservice training and helping staff members identify tactics to use when feeling

the pull to use drugs. One seasoned outreach worker who was asked to share

her method with neophytes at a recent workshop reported that she “listens to

her music” when she gets tempted; another worker reported seeing his “shrink”;

for another, stress reduction entailed talking to his coworkers. The project

also encourages workers to attend recovery meetings, even during working

hours, whenever they feel it is necessary. For example, outreach workers who

enter a shooting gallery or copping (drug-buying) area while helping a project

participant resist using drugs may need immediate social support for

themselves should temptations toward drug use resurface.

Experience in NO DP and observations of others indicate that not all individuals

will succeed in avoiding relapse. When such tactics fail, programmatic policies

are needed that assist employees with getting formal help and support when

necessary. Also, from a project standpoint, outreach responsibilities must be

organized in ways that permit a smooth and efficient transfer of duties when

necessary. A prime example is the need to keep locator forms current so that

project participants can be located should drug relapse force an outreach

worker to take time off or suddenly leave the project.

The ability of the case management team to link clients to needed services

is partly the function of the types, quality, and number of services available

(Franklin et al. 1987; Anthony et al. 1988). In the context of the current

economic climate, times are tough and communities are reducing programs,

entitlements, and the number of drug treatment slots. Meanwhile, governmental

funding for programs also is decreasing, thus reducing former levels of

services and making eligibility criteria more stringent and limiting. The

recession also has made finding and retaining employment more difficult,

150
with the result that it is harder for people to function without some form of

social support. As one frustrated CBS participant explained:

They got these big signs up there saying ‘I’m hiring’ but

they don’t hire me. It took my sister 2 years to find a job.

She sure walked a lot of places, lots of doors closed in her

face. And it was hot and cold out there, but she got one. I

just got discouraged a bit, but I ain’t given up.

Case management principles and practices cannot solve these system-level

problems (Wool et al. 1989), although they affect CBS outcome measures by

setting the opportunities and parameters for case management success. Thus,

current evaluation of the model occurs within a set of social and economic

forces that might prove more benevolent or less generous to success at

different times. The effects of such temporality on outcome are difficult to

tease out or resolve.

Because it is designed to reduce service overlap and ensure effective

coordination of services, case management is believed to be cost-efficient

when compared with other customary forms of service delivery (Franklin et al.

1987). Good case management, however, typically requires an expensive

investment per client. Therefore, it has been argued that “the choice of

cases should be made carefully to ensure they are the ones that benefit

most from intervention” (Shueman 1987, p. 316). Such selection, however,

is inappropriate for a research demonstration project whose recruitment

methods purposely avoid “creaming” a pool of prospective subjects and the

study design calls for random assignment to a standard or enhanced group.

Thus, attempts to evaluate the success and cost-effectiveness of the CBS

model as it might be implemented by a typical community agency or program

are constrained by adherence to the necessary research demand that all

participants receive equal effort and access to a randomly assigned level of

service.

CHALLENGES AND BARRIERS IN WORKING WITH THE TARGET

POPULATION

People with serious drug dependencies often face multiple health and

psychosocial problems. These include the need for adequate housing,

food, medical care, day care for their children, and health screening for

untreated illness. Typically, they have few social resources for meeting

these problems. Frequently, they are unemployed or work in a marginal

capacity. Many have little contact with their families or have severed family

ties completely. As one project participant explained, “I don’t have anyone.

I got a man to live with who beats me, who does drugs, and that’s all I got.”

151
Because of the enormous need of active substance abusers, working with

them constantly drains staff energy and project resources. What levels and

types of support to offer a particular client and how to avoid having the client

become dependent on the program present a difficult and nagging dilemma for

the project staff. Decisions typically are negotiated on a case-by-case basis

within the context and constraints of the project’s finite resources.

Although the CBS goal is to help the client set realistic goals, clients can

become disillusioned with the project when participation does not culminate

in some desired service such as finding a job or regaining custody of their

children:

I been getting so frustrated, I been looking for a job but

nobody calls. My baby asked me for a bag of potato chips

for 25 cents and I ain’t got that. It seems like the whole city

needs help but they don’t need my help. I just about to give

up but I can’t. But I’m furious. Every day when I come here

I want to get a damn bag because I’m mad.

Realizing such desired outcomes may be influenced by factors such as low

educational skills or a past history of drug arrests that are beyond the control

of the management team. Frustration and a sense of engulfment are not

uncommon feelings among management team members, particularly when

the pressures of personal and program expectations define success in ways

that create unrealistic expectations (Levy and Gordon 1987).

Although the CBS goal is to help the client set realistic goals and take

responsibility for achieving and maintaining drug-free living, such autonomy

takes time to develop, and the trajectory of progress frequently is punctuated

by instances and periods of relapse. One former cocaine abuser refers to this

process as a “roller coaster ride” in which the user travels along a psychological

fast track of highs and lows in motivation and recurrent drug use. Consistent

with this analogy, participants in the project often demand services at one point

and lose interest in them at other times, a practice that influences the person’s

progress and has implications for the functioning of the case management

team. For example, making appointments and setting up treatment plans can

be frustrating when clients fail to keep them. Strategies such as having the

outreach worker accompany the client ensure that the person carries through.

Even with peer support to encourage the maintenance of sobriety, the

temptation to return to drugs is an ongoing problem, as the following exchange

among self-help group participants attests:

152
Janet: I haven’t stuck myself for 10 days, I don’t feel good

today, but this program has saved my life. You use the

program to your advantage, but you have to be consistent.

I wanna shoot the stuff-you know-but I know I can’t. The

problem is when that train said 35th, my stomach started to

turn. I started thinkin’ about reaching.

Bill: Yeah, the same thing happens to me when I see 47th

Street. I think about some stuff. It’s up here [he points to

his head]; the neighborhood can trigger negative thoughts.

Jim: When I leave here, I got to get straight on the bus and

get out of here or I don’t know if I can resist the cop man.

Because of the roller coaster aspects of most drug use trajectories, monitoring

client progress is an important case management function. Although such

observation may be relatively easy when working with addicts in an institutional

setting, it is considerably more problematic when working with street addicts

who typically are difficult to locate unless they voluntarily and consistently

maintain contact with the project.

In general, the lives of most street addicts are characterized by poverty,

unemployment, and preoccupation with mere physical survival. As one

project participant confessed, “I live just one day at a time, that’s all I can

afford.” To generate sufficient money to maintain their drug habit, many

street addicts engage in illegal activities that carry severe negative sanctions

should they be caught (Johnson et al. 1991). The substance abuser’s need

to maintain a low profile to avoid attention from law enforcement or their

victims complicates followup (Wiebel 1990). Many street addicts disguise

their identity by using street names or aliases (Anderson 1990), change

addresses frequently, and “cop” in new areas to avoid troublesome contacts

that might lead to problems. For example, one of the northside participants

currently is hiding from his “connection” to avoid retribution for stealing the

latter’s stereo equipment to hock for drugs. Also, because drug addiction

can lead to serious health problems (Faupel 1991), unexpected hospitalization

or even death contributes to unexplained disappearances. Thus, the

unpredictability and hidden nature of being “in the life” pose a set of challenges

and barriers for the case management team in monitoring the progress of

project participants. Experience has shown, however, that once the team

earns a participant’s trust, most clients check in routinely on their own or

respond positively to attempts to find them.

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Meanwhile, even the task of mobilizing resources available through other

providers may require a level of investment that the project cannot provide.

The demand for bus tokens, for example, appears almost inexhaustible; clients

legitimately need them to attend self-help groups, get to doctor’s appointments,

go for job interviews, or come in to see their case manager, but tokens also

have a ready street value that permits them to be converted easily to cash or

traded at the local liquor store. A similar market exists for condoms dispensed

by the project to reduce HIV transmission—they are readily sold to the local

pornographic shops for a fraction of their cost. Some misuse of projectdispensed materials is to be expected because street addicts are astute

at finding ways to generate quick sums of money. In acknowledging this

inevitability, staff members must decide how to ration the project’s available

resources and to spot “scams” that conflict with project goals.

Currently in the CBS model, the emphasis has been on providing support to

the individual with an addiction problem. However, addiction seldom is a

socially isolated condition. Rather, friends, family members, “associates,”

and other participants in the person’s social network typically play a role in

creating and maintaining the addiction. It is not uncommon for these ties to

sabotage or undermine the person’s attempts at recovery and pull him or her

back into the abuser’s role. One client explained:

My boyfriend is so jealous of my coming here. He was

one of those once-in-a-while users, so I don’t think he

understands the way of a dope fiend. When I go home

from here, he is going to sit there and have an attitude, this

attitude he’s got. I just don’t get it. He’s not happy when I

get high or don’t get high. He always brings up my past.

He never lets me live it down. He won’t even talk about

using condoms. My mom thinks he’s afraid that I’m going

to become independent.

A limitation of the CBS model as it is currently being delivered is that its

case management thrust primarily intervenes at the individual level. Although

the philosophy of the model recognizes the need for the substance abuser to

develop and redefine existing relationships, this goal is difficult to assist without

directly interacting with the members of the person’s immediate social network.

Part of the CBS challenge, then, lies in helping the person identify resources

and means to build new relations and positively transform or withdraw from

relationships such as those described by one CBS participant:

Yeah, the hardest thing for me is all the people I know get

high. When I get around them, they are high and I’m not.

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And they are uncomfortable around me. So what I’m

working on is finding a new block, a new boulevard with

people who don’t get high, but it is hard to find ‘em down

here.

Family and friends constitute a potential source of family support that the

case management team can focus on building and better utilizing. Case

management time also is spent helping participants to develop more effective

parenting skills and to obtain and organize the resources needed to provide

their children with a more healthful, more nurturing environment.

DEVELOPING SERVICE LINKAGES

When setting up the NO DP project, the staff quickly discovered that, for

effective case management, other resource groups and agencies needed

to learn about the project and its goals. To accomplish this, the case

management teams developed short talks to deliver at churches and schools

along with brochures to hand out to prospective clients. Visibility also was

enhanced through participation on community social service boards and

committees, attendance at local events, and by inviting members of social

agencies to participate in the project’s inservice training. These actions

helped forge linkages and reciprocities at both the organizational and the

systems levels.

Overall, it can be difficult for individuals to navigate a pathway unassisted

through the various programs and agencies potentially available to them.

A function of case management is to “humanize a system that can otherwise

be pretty damaging and destructive” (Weisman 1987, p. 382). Experience

in dealing with the system has convinced members of the project’s case

management teams that gaps in services are the product of red tape and

bureaucratic processes. Case managers and outreach workers perceive a

high degree of insensitivity to client needs on the part of health care providers,

public aid facilities, and drug treatment centers. Interviews with project

participants reveal a similar perception of powerlessness and forced

dependency. For these reasons, a case manager or outreach worker may

choose to accompany a project participant on an initial service visit. As one

case manager explains, “Whenever possible, I like to take clients in and

introduce them to the staff person they will be seeing in the program. Next

time when they go in on their own, the person behind the desk will remember

who they are and that they have someone looking out for them.”

Although building organizational cooperation is crucial to the success of a case

management project, getting services rests strongly on the case management

155
teams’ knowledge of how to “work the system.” As one case manager

argues, “If I didn’t already know the networks of service agencies and the

people who work in them, my job would be much more difficult.” Working the

system requires accessing a fragmented and diverse system of organizations

and programs that include governmental and private agencies, methadone

treatment centers, food pantries, legal aid societies, nursing homes, and

residential living centers.

Typically, a case manager who has been working in the field for a while has

built up a history of reciprocities and favors owed to or by others. Case

managers and outreach workers who are former addicts often are familiar

with the intricacies of the health and treatment system through personal

experience. It is not uncommon for them to know each other from the street

or to have been in treatment with another ex-addict who now holds a position

of authority within the social service system. In some instances, getting

services for a client with special needs may require “using a chip” or in some

way trading on goodwill that has been previously established. Gaining service

also may rest on the unspoken promise that the case manager will assist if

problems arise (Kanter 1985). Such relationships have a downside, however

(Netting et al. 1990). The social service system also functions as a revolving

door with service providers moving in and out of specific agencies and

positions. Consequently, a potential always exists for the case management

team to expend considerable effort cultivating a personal relationship only to

have that person leave the agency, resulting in a loss of influence.

On the positive side, the revolving door also results in a service environment

in which new resources, programs, and personnel become available as others

dwindle or shut down. Consequently, building service linkages entails scanning

the community for new sources of help. Relationships with one program or

agency can produce a ripple effect that leads to service ties with others. For

example, personnel at one agency advised one of the project’s case managers

that money was available from a private trust administered by another program.

Contact with this second agency yielded money for a client’s back rent at a local

halfway house; this contact in turn laid the groundwork for future referrals

between the sheltered living facility and the project.

The street addict’s understandable distrust of social control agents and other

society “officials” leads to service barriers related to maintaining contact with the

client. Until a level of trust has been established, study participants may falsify

personal information or refuse to provide their legal names or addresses to the

project staff. At times, participants may not be purposely deceptive about their

whereabouts or associations but may forget to mention that the name that they

have listed on the mailbox or buzzer of a residence differs from their own

156
(Johnson et al. 1991). Friends or relatives may refuse to cooperate in tracing

a client to avoid becoming involved or placing the person in possible jeopardy.

Not having ready access to an individual makes it difficult to link clients to other

programs and agencies when ready access to or an immediate response from

the substance abuser is required or a stable living arrangement is needed.

In some cases, the work of the case management team partly entails helping

the client amass the various records and personal data required to prove

eligibility for service entitlements. The homeless street addict may not have

the birth certificate needed to establish eligibility or access to a safe place to

store important documents-a situation that sometimes results in the person

entrusting them to the project’s files for safekeeping.

Working in this capacity with local agencies creates a need for procedures

to govern the storage and movement of project-gathered information that

might prove harmful to participants if it becomes public. In this regard, all

study participants are asked to sign a consent form that outlines the specifics

of the study and the possible dangers of participation when joining the project.

In addition, all client information is kept in a locked file to which only the case

management team has access. Research data released to the University of

Illinois for the study’s analyses are transmitted with all personal identifiers

removed. Also, information about a client is never released to or requested

from an agency unless the client has given written permission specifying

exactly what information will be transmitted and the purpose for which it will

be used. When tracing clients through personal networks, staff members are

careful not to reveal the purpose of the project or the nature of the person’s

participation to those who are contacted.

EVALUATION OF THE MODEL

Few empirical or comparative data on the efficacy of case management are

available (Franklin et al. 1987), but agreement exists that assessing the

efficacy of case management is a difficult task (Collard et al. 1990). As Fisher

and colleagues (1988) note, few projects operationally define their concept of

case management, making comparisons across studies difficult. Studies tend

to have few subjects, and the timeframe for evaluation typically is less than a

year. The longitudinal design, power sampling techniques, and triangulation of

methods in this study are designed to offset these limitations. Measures and

data collection techniques are described below.

Each CBS participant has a clinical record that includes a written recovery

plan specifying the person’s personal goals and the strategies that have been

identified to meet them, progress notes compiled by the case management

157
team, and any documents or referral information needed to obtain services

from other service providers. Both the case manager and outreach worker

chart their interactions and activities on behalf of the study population. Daily

activity reports of the case management team include (1) number of sessions/

days an individual attended a self-help group, (2) numbers and types of

agencies contacted, and (3) admission to other treatment modalities (e.g.,

outpatient programs or NA). Analyses of these and other case management

statistics from the project provide a profile of what services are delivered and

to whom, change in patterns of service use over time, and the effects of

different levels and patterns of resource utilization in reducing or stopping

drug use and recidivism.

The Addiction Severity Index (ASI-1) used at intake is a reliable and valid

clinical/research instrument that assesses treatment problems found in

alcohol- and other drug-abusing individuals (McLellan et al. 1985). The

ASI-1 is a structured, 40-minute interview designed to evaluate problem

severity in seven areas commonly affected by substance abuse: medical

condition, employment, alcohol use, other drug use, illegal activity, family

relations, and psychiatric problems. The ASI Followup (ASI-2) is used at

followup and duplicates the ASI-1 except for items for which no change in

status or behavior occurs over time.

The Symptom Check List-90-Revised (SCL-90-R) is used to determine levels

of psychiatric discomfort at intake and followup. The SCL-90-R requires about

12 to 15 minutes to complete. Subjects score their distress with a symptom

from 0 (not at all) to 4 (extremely).

The Social Support Instrument, developed by the research team, measures

change in social support over time. The questionnaire records type of, use

of, and satisfaction with support received from various sources, including

family social service and medical providers, volunteer agencies, employers,

and friends. It also records project participants’ leisure activities, participation

in community organizations, and social network affiliations.

An ethnographic component of the project focuses on the activities of

participants at both field sites. The project ethnographer attends peer-support

meetings at each field station, talks informally on a regular basis with the staff

and participants in the program, and keeps a carefully written record of relevant

transactions that occur among group members and between staff and group

members before and after meetings. In addition, the ethnographer collects

contextual data about the life experiences and drug networks of project

participants by occasionally accompanying the outreach workers on their daily

rounds. These data provide a “natural history” (Gallmeier 1988; Becker 1970;

Circourel 1964) of the intervention and research process.

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PRELIMINARY FINDINGS

The standard and CBS-enhanced groups drawn from each of the two

community settings ultimately will contain 50 participants each, for a total

of 200 research subjects. Toward this goal, 140 subjects were recruited by

the end of the first 8 months in the field. Subjects’ ages range from 20 to

65, with a mean of 42 years. Fifty-nine percent are male, and 41 percent

are female. With the exception of one Hispanic participant, all subjects on

the southside are black. This composition parallels the racial mix of the

neighborhood. Examination of the demographic mix on the northside reveals

greater racial and ethnic diversity, again reflecting the characteristics of the

area. Few Hispanic subjects are enrolled in the project because they tend not

to live in either neighborhood.

Although they may be polydrug users, subjects are rather evenly divided in

perceiving either heroin or cocaine as their major problem of substance abuse.

Scores on the ASI report that subjects’ problems are mostly with drugs; all

areas of functioning demonstrate moderate levels of distress. Responses on

the SCL-90-R are mildly to moderately elevated, particularly somatic symptoms,

obsessive compulsive symptoms, depression, anxiety, and paranoid feelings.

Most subjects (82 percent) are not currently living with a spouse. Nearly 48

percent live in some form of living arrangement other than their own home or

apartment.

Early statistics and field notes from the ethnographic component suggest at

least four sets of findings related to programmatic issues. First, the reports

of street addicts indicate that they do have some social support available to

them should they need to borrow small sums of money, obtain a place to sleep

overnight, or talk to someone about their problems. About 75 percent reported

having at least one person to go to for help if needed.

A second programmatic finding is that the functions and activities of the case

management team at each site are shaped by (1) their service preferences

and prior work experiences and (2) the social environment and demographic

characteristics of the study participants that they serve. Participants in the

southside subsample confront a different set of barriers to drug-free living and

present a different profile of needs than their counterparts on the northside.

On the northside, for example, it is hard to go hungry because of the high

number of food pantries and soup kitchens that exist. Meanwhile, in the

absence of similar programs in their neighborhood, the almost exclusively

black study population on the southside is far more likely to rely on real and

fictive kin to obtain food when needed. For instance, the phrase “going for

the cousins” (Stack 1973) refers to tapping into social support networks of

159
nonblood relationships. This diversity underscores Weisman’s (1987)

observation that case management strategies that work with one population

or in a particular community setting may not work in another. Consequently,

the NO DP staff has discovered that case management techniques must be

tailored to fit the particular population and setting in which they are delivered.

Third, despite initial trepidation that no one would come, the staff was

pleased to find that a core of project participants voluntarily attend the

project’s self-help group. Currently, one group operates at the northside

station, and the southside offers four sessions weekly, including an all-women’s

group. Session attendance, which varies from as few as 3 people to highs

of 12 and 13, is influenced by participants’ self-perceived need and such

external factors as the weather, holidays, time of the year, and the availability

of resources to get there. Field notes indicate that participants use the groups

to discuss and develop strategies for addressing problems of living and

becoming drug-free. These coping devices and the encouragement of peer

support can result in reduced drug use:

I gave up $30 today by coming to group. I was asked to fix

a guy’s radiator but I said I had to go to group. Since I been

coming to group, I only use two times a week instead of

every day. For me, that’s good.

Or abstinence:

Since I been in this group, I haven’t got high at all. When I

leave here, I feel good, I don’t care what we talk about, I

always feel good.

And the encouragement to remain drug-free:

I have a question. I’m addicted. If I get clean, can I still

come to group? I’ve been clean for 2 months and I need

this group to stay clean.

Finally, the staff was surprised to learn the extent to which the field station

emerged as a critical way station on the road to sobriety. Project participants

often use the field station as their “home away from home” and, in some cases,

as their primary home base. Here they have access to a telephone to talk with

service agencies, utility companies, and relatives; the field station telephone

number also is given out to prospective employers to contact job applicants.

The field station provides the homeless with a mailing address, a service

that has proven particularly useful for one client who has her medications

mailed there. For many clients, the field station becomes a refuge, an urban

counterpart to an “oasis” or “island” in the street. Using ethnographic and

160
questionnaire data, the project staff intends to explore the role of the field

station as an unanticipated aspect of the CBS model.

RESEARCH CONSIDERATIONS AND CONSTRAINTS

Over the next 4 years, it is anticipated that followup will remain one of the

staffs most difficult challenges. Almost half the participants in this study live

with friends, relatives, or in transient living conditions. Thus, they may not

have “official” addresses. Street addicts also relocate geographically to avoid

the networks of users who might pull them back into using drugs. In this

regard, the project has continued to interview and follow the progress of a

study participant whose goals for recovery included moving out of the region

to be with her family.

Few street-level users have telephones (Johnson et al. 1991), a situation that

makes it difficult to find them except through face-to-face contact and word of

mouth. To offset this problem, many clients provide the telephone number

of a friend, relative, or neighbor through whom they can be reached if needed.

Some clients pool resources to share the cost of a telephone with a neighbor

or family member whose name is listed. Because all study participants are

promised confidentiality concerning their drug use and enrollment in the study,

staff members are careful not to reveal compromising information about the

person when contacting others.

Retaining participants in the study also involves tracking their whereabouts

through the medical and criminal systems. During the first 8 months of the

project, the staff maintained contact and conducted interviews with three

participants who entered prison and with one who was hospitalized in the

final stage of AIDS-related complications. Three participants died during this

period, including the person with AIDS. By holding interviews outside the field

station when necessary and by using locating tactics developed as part of a

community-based AIDS intervention project (see Johnson et al. 1991 for a

detailed discussion of these methods), the staff has managed to contact and

conduct regular followup interviews with all but 1 of the 140 participants

described previously.

A second research difficulty lies in developing the reporting framework and

procedures for documenting services delivered to project participants. The

case management teams perceive directing their efforts toward helping the

project participants as their first priority. Consequently, they tend to resist

reporting procedures that divert time from direct service activities. Moreover,

although it is important to chart all major activities, it is not clear at what level

of detail charting becomes dysfunctional. Recording every project-related

161
telephone call, including those where the person is not available, noting

each casual contact with a project participant, and reporting all aspects of

the person’s life that become known to the team are overwhelming tasks.

Consequently, the team has been experimenting with different techniques

and reporting forms. Current strategies include keeping individual case

management records, a daily activity form, and a bus token/transportation

log.

Ensuring that the intervention staff understands and adheres to the spirit of

the projects sampling design poses a third major difficulty. Staff members

report feeling resentful and disappointed when sample randomization results

in the assignment of a particularly promising individual to the standard group—

an outcome that they consider undesirable despite continual reassurance

that no one knows which group assignment ultimately will prove the more

efficacious. Similar discomfort occurs when staff members are forced to

redirect standard group requests for help to the project-prepared social service

directory instead of their providing services. Because of the value dilemmas

that maintaining a standard vs. enhanced group entail, the research staff must

be constantly vigilant about monitoring and offering support to intervention staff

and resist the temptation to unintentionally compromise the integrity of the

research design by offering inappropriate services and resources to the

standard group.

FUTURE DIRECTIONS

In summary, case management is more than a set of functional activities;

it is also a process. Conceptually, it begins with the case manager assisting

a person set realistic goals and identify the means to achieve them. Over time,

it entails drawing on and creating the social support and resources needed to

improve the person’s quality of life and bring about desired change. It ends

when the person has built sufficient social resources and skills to permit

autonomy and self-management of the problem and his or her life.

Although this scenario represents the ideal case management trajectory, the

drug intervention literature and experience with this project suggest that such

a smooth, linear path to recovery is more likely to be anomalous than routine.

Recovery from drug use is often marked by false starts and slippages; periods

of sobriety may be broken by “chipping” or bouts of recidivism. Both case

management and the route to recovery may vary significantly among project

participants. As the NO DP study progresses and longitudinal data become

available, it will be possible to chart the events that lead to success or failure

along with the influence of case management and peer support groups on such

outcomes.

162
As is true for case management, the role of social support in aiding people to

stay off drugs remains a much-understudied area. Future analysis will focus

on the roles and effects of social support and how its impact is modified by

the type, strength, situation, and demographic status of the provider or

user. For example, different types and uses of social supports have been

documented among blacks, whites, and Hispanics. Age and gender also

appear to be influencing forces. Some studies suggest that family members

provide obligatory, instrumental support and friends provide optional and

emotional support (Seeman and Berkman 1988; Antonucci and Jackson

1987). This study will be used to understand the nature and significance of

social support systems currently available to the street addict, taking into

account factors that influence differences in types and patterns of use. Based

on these and other analyses and data, the final goal of the project will be to

evaluate the efficacy of using the CBS model to reduce illicit drug use and to

limit the spread of HIV.

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ACKNOWLEDGMENT

The research reported here was supported by National Institute on Drug Abuse

grant DA-06994-02.

AUTHORS

Judith A. Levy, Ph.D.

Associate Professor

Charles P. Gallmeier, Ph.D.

Senior Research Ethnographer

W. Wayne Wiebel, Ph.D.

Associate Professor

University of Illinois at Chicago

School of Public Health, M/C 925

2121 West Taylor Street

Chicago, IL 60612

William W. Weddington, M.D.

Professor

Department of Psychiatry

University of Illinois at Chicago

513 MPI, M/C 913, P.O. 3921

Chicago, IL 60680

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Case Management To Enhance

AIDS Risk Reduction for Injection

Drug Users and Crack Cocaine

Users: Practical and Philosophical

Considerations

Russel S. Falck, Harvey A. Siegal, and Robert G. Carlson

OVERVIEW

Seventy years ago when Mary Richmond (1922), a pioneer in the field of

social work, said that social casework consisted of those processes designed

to affect adjustments between an individual and the social environment, she

could well have been describing case management. Thirty-five years ago

Helen Perlman’s (1957) problemsolving model of social casework consisted, in

part, of letting people identify their problems and then helping them to mobilize

“inner and outer forces” to deal with the problems (Skidmore and Thackeray

1982, p. 69). Case management as a conceptually distinct modality evolved

out of social casework in the early 1970s when people who had been released

from State mental hospitals returned to their communities and struggled to

function successfully. Case management provided a mechanism through

which recently released patients, with the assistance of case managers, could

navigate the often fragmented social service system to access the resources

that would enable them to live and function adequately in their communities

(Stein and Test 1980; Test 1981).

Several models of case management have been developed since this initial

effort. One type is the “mixed model” in which the case manager serves in a

clinical capacity as the client’s primary therapist and also as a service broker;

another model casts the case manager almost exclusively as a broker of

services (Rapp and Chamberlain 1985). In general, these models have

functioned by engaging the client in the case management process, assessing

the needs of the client, planning how to meet the identified needs, accessing

the resources to meet the client’s needs, coordinating the delivery of services;

monitoring the client’s progress in meeting his or her needs, engaging in

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advocacy on behalf of the client as appropriate, and eventually disengaging

the process (Sullivan 1981; Ballew and Mink 1986). These processes are

most often expected to take place over an extended period in the classic

case management model.

Since its initial application with chronically mentally ill individuals, case

management, in one form or another, has been applied to a variety of

different populations, including people being treated for alcohol and/or other

drug problems, people with developmental disabilities, elderly people, victims

of child abuse, homeless people, and people with acquired immunodeficiency

syndrome (AIDS) (Willenbring et al. 1991; Sensel et al. 1988). To this list may

now be added not-in-treatment injection drug users (IDUs) and crack cocaine

users who are at high risk for contracting human immunodeficiency virus (HIV)

disease.

The Dayton-Columbus AIDS Prevention Research Project employs a service

broker case management model and nests it in an AIDS educational program

to increase the adoption of HIV risk-reduction practices among IDUs and crack

cocaine users. The objective of case management in the Dayton-Columbus

project is to identify clients’ needs, come to a mutually agreed-on and realistic

prioritization of those needs, and then link clients with those community

resources capable of helping to meet those needs.

The impressions and experiences of people working in AIDS prevention

research suggest that effective responses by individuals to the AIDS threat

may be tempered by other issues having more immediacy and relevance.

These issues are diverse in nature and run the gamut from concern about

immediate needs, such as where the next meal is coming from and where to

find shelter for the night or clothes for the children, to the realization that they

are living in a neighborhood that is saturated with violence and that they could

well be the next victims (Mays and Cochran 1988; Weissman 1991; Carlson

and Siegal 1991). The case management component in the Dayton-Columbus

intervention is designed to address these issues, thereby allowing clients to

attend to and hopefully internalize the AIDS risk-reduction messages.

THE DAYTON-COLUMBUS MODEL

IDUs and crack users who enroll as subjects at the Dayton and Columbus,

OH, sites of the National Institute on Drug Abuse (NIDA)-funded Cooperative

Agreement Initiative are randomly assigned to one of three intervention tracks.

The tracks will be evaluated to determine which is more efficacious in reducing

the risk of HIV acquisition and transmission. Each subject participates in a

standard pretest counseling and education session that lasts about 20 minutes.

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On the second visit, subjects are randomized into one of the tracks. Two

tracks, one lasting about 30 minutes (the monitoring track) and the other (the

standard track) lasting 1 hour, consist of the didactic presentation of basic

information about AIDS as well as demonstrations and rehearsals of needle

cleaning and condom use. The third track, the enhanced intervention, consists

of four AIDS educational sessions coupled with six case management sessions

for a total of seven client contacts (figure 1).

The AIDS education program that serves as a backdrop for the case

management component is based on a modified version of the health

belief model developed by Rosenstock (1974) at the U.S. Public Health

Service in the 1950s. The original model postulates that a person’s health

behavior, in relation to a health threat, is dependent on four variables:

the person’s perceived susceptibility to the health threat, the perceived

seriousness of the threat, the perceived benefits of specific options to address

the health threat relative to the availability and effectiveness of those options,

and the perceived barriers to adopting actions to reduce the health threat

(Rosenstock 1974). To this theoretical model was added the variable of

se/f-efficacy as conceptualized by Bandura (1977) in his social learning

theory.

This theoretical framework has been translated into four educational sessions,

each lasting between 1 and 2 hours. (For more details on this model, see

Falck and Siegal, in press.) Topics include “An Introduction to the Relationship

Between Drug Use and HIV Disease,” “AIDS Facts,” “Drug Addiction,” and

“Safer Sex and Relationships.” The educational objectives are for attendees

to recognize (1) those behaviors that make them susceptible to contracting

HIV disease, (2) the severity of AIDS, (3) the benefits and response efficacy

of specific HIV risk-reduction behaviors, (4) the barriers that block the adoption

of risk-reduction behaviors, and (5) their capability (self-efficacy) to use riskreduction methods. A preliminary analysis of this approach has suggested

that those IDUs who complete the National AIDS Demonstration Research

(NADR) Project Dayton-Columbus enhanced intervention are more likely to

adopt needle-use risk-reduction behaviors than those people who receive less

intense interventions (Siegal et al. 1991).

The general structure of the case management protocol now being pilot-tested

incorporates six components delineated by Ballew and Mink (1986) in a model

originally employed in a child abuse and neglect project: engagement; needs

assessment; planning; accessing resources; monitoring, coordinating, and

advocacy; and disengagement. Two characteristics make the DaytonColumbus case management model unique. First, the intervention is a

blend of two fairly different approaches to modifying human behavior: a

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FIGURE 1. Dayton-Columbus client flowchart

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cognitive, behaviorally oriented educational program coupled with a servicebroker model of case management. The result is a “new” mixed model, one

that combines an educational-rather than a clinical-orientation with service

brokerage. Also, the mixing of the approaches may have an additive effect-an

effect greater than either approach alone would have-on changing behavior.

For instance, the educational sessions have the potential of increasing clients’

receptivity to the case management process because some of the sessions

employ fear arousal techniques to address the severity variable in the health

belief model. The case management process can help extinguish that fear by

helping clients get involved with services that can get them out of the lifestyle

that puts them at risk. Once engaged in the case management process, clients

may also be more attentive to the educational component because the sessions

will reinforce (and justify) their involvement in case management. In addition,

the educational model and case management process described herein attempt

to develop and enhance (empower) the clients’ skills in negotiating complex

social situations. The resultant model is therefore a broad-based, eclectic one.

Second, the case management process has been purposely compressed

into a period generally not to exceed 2 months in duration. This time limitation

accomplishes two objectives. One, it sets a fast-paced tone for the process.

The client knows he or she will not be involved in the process for a long time—

the end is in sight, even at the beginning-an important point for a population

that is generally not oriented to long-term goals. Also, in a more practical vein,

the time constraint limits the number of individuals on the case manager’s

caseload to a manageable number of 20 to 25.

IMPLEMENTING THE MODEL

Outreach workers recruit eligible IDUs and crack users to participate in the

research project. The potential participants present at the site office and

learn more about the project. If they are interested in participating, an informed

consent document is executed. Participants are then interviewed using the

NIDA-developed Risk Behavior Assessment (RBA) questionnaire to gather

extensive information on drug use and sexual and health practices. Afterwards,

on a one-to-one basis, the participants receive a brief, nationally standardized

HIV education and pretest counseling session.

Participants return for a second visit 7 to 10 days later, at which time they are

randomized into the monitoring track (which serves as a control group), the

standard track, or the enhanced track. Before receiving their test results, if

they chose to be tested, all participants are interviewed on a one-to-one basis

to gather baseline information on their past and present use of area human

service resources as well as their perceptions of their current needs for

services.

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Clients randomized into the enhanced track receive their HIV antibody test

results from the staff person who will serve as their case manager. Thus, the

engagement process is initiated. After divulging the HIV results in a posttest

counseling session, the case manager functions as an educator and conducts

the first educational session, an hour-long overview of the relationship between

drug use and HIV disease. Following the session, the case manager and the

outreach worker explain the case management process and its benefits to the

client. If the client agrees to participate, then the engagement phase has been

completed, and an appointment is scheduled for the next visit 1 week later.

The third visit occurs at the site. The case manager conducts a semistructured

interview to gather information on the client’s general life situation as well as

specific information on perceived problems, needs, and strengths. This is the

assessment stage.

The fourth visit occurs at the site about 1 week later and begins with the case

manager conducting an educational session focusing on facts about AIDS.

The session contains a slide presentation depicting various pathophysiological

manifestations of HIV disease. This material, which is fear arousing in nature,

is presented because it poignantly conveys the severity of the disease—a

necessary ingredient of the health belief model. Although the application

of fear-arousal techniques in health education programing is the subject of

some debate, its use in the context described here is consistent with what is

known about the appropriate use of such methods (Job 1988). Following the

educational session, the case manager engages the client in the planning

stage of the case management process. It begins with the case manager

asking the client to list what the client feels are his or her major unmet needs.

The case manager follows with his or her perceptions of the client’s needs.

This interchange results in dialog that culminates with a mutually agreed-on

priority list of needs and goals. Next, a plan is developed that details, in stepby-step fashion, who is to do what when to meet the needs necessary to attain

the goal(s).

The fifth visit occurs about 1 week later and begins with the case manager

conducting the educational session on addiction. After the session, the case

manager works with the client to begin implementing the plan and accessing

resources. The content of this session varies according to a client’s needs and

strengths, but the general philosophy is to have the client contact a targeted

agency. The case manager serves as a personal helper. Behavioral rehearsal

techniques are employed so that the client can learn how to interact effectively

with service agency personnel.

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The sixth visit occurs 1 to 10 days later when the case manager and the

outreach worker visit the client in the field. The visit has several purposes.

First, the visit allows the case manager to continue accessing resources and,

if necessary, to serve in an advocacy role. If more than one service provider

is involved, then the case manager may, with the client’s approval, engage in

a coordinating role if the situation warrants. Second, because the visit occurs

in the field, it allows the case manager to interact with the client in a natural

setting, thereby providing the opportunity to learn more about the clients

situation and the obstacles that may impede progress. Finally, visiting the

client in the field can have a positive symbolic impact. The visit demonstrates

that the case manager cares enough about the client to leave the confines of

the office to visit and work with the client on his or her own turf.

The seventh visit occurs a week later and begins with the case manager

conducting the final educational session that addresses safer sex and

relationships. This session is followed by what is scheduled to be the last

case management session in which accessing, advocacy, and coordinating

occur if necessary. This session is followed by client debriefing and then

disengagement.

MEASURING PROGRAM IMPACT

A variety of different measures, both formal and informal, are employed to

measure the process and outcome of the case management intervention

that is currently being pilot-tested.

Qualitative assessments of the case management process are achieved

through interviews with clients that are conducted by the project’s ethnographer,

feedback solicited from clients by the outreach workers, input from focus

groups, and journal entries by the case manager.

Two semiquantitative measures are used to assess the case management

process. First, a social service inventory, an instrument that captures selfreported information on past and present use of local area human service

agencies as well as present needs, is administered at baseline and again 6

months later. These data are compared with inventory data collected from

participants in the monitoring and standard tracks. This comparison provides

a reasonable indication of the effectiveness of the case management process

in successfully linking clients with needed services,

Another semiquantitative measure of the effectiveness of the case management

process involves assessing the attainment of the service acquisition objectives

specified in the clients’ planning sessions. At the disengagement session,

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clients are asked to sign releases of information that the case managers may

use to query those agencies the clients claim to have become linked with; if the

linkage (contact has been made and client is eligible for the service) is verified,

realization of the service acquisition objectives is determined to have occurred,

and the process is judged effective relative to the number of service linkages

realized. Determination of the success of the case management process for

any given client depends on whether the goals specified during the planning

process are attained.

Ultimately, the effectiveness of the enhanced intervention (AIDS education

coupled with case management) is determined by comparing it with the

monitoring and standard tracks at baseline and postintervention on a variety

of different variables, including self-reported drug use (corroborated by

urinalysis) and sexual practices, to determine which intervention brings

about significant reductions in HIV risk behaviors. This determination is

accomplished by administering the RBA and the Risk Behavior Follow-up

Assessment questionnaires in a pre/post fashion. (For an explanation of this

process, see Siegal et al. 1991.)

TRAINING AND BACKGROUND OF CASE MANAGERS

Minimum requirements for case managers in the Dayton-Columbus project are

a bachelor’s degree in a social science and at least 2 years of relevant human

service agency experience. Once on staff, a case manager must complete the

Ohio Department of Health’s HIV counselor education program, because the

case manager also serves as an HIV counselor. In addition, the case manager

also spends time learning how to conduct the project’s educational sessions.

The learning process is accomplished largely by self-instruction in the project’s

written protocols for the educational sessions, coupled with observations of

sessions conducted by experienced educators. The case manager is asked to

conduct the sessions to the satisfaction of the site director before the sessions

are conducted with clients.

Training in case management begins with the reading of “Case Management in

the Human Services” by Ballew and Mink (1986), because much of the material

in the text serves as the practical basis for the model employed in the project.

Familiarization with the text is followed by personal visits to those agencies to

which a significant number of referrals will be made. These agencies include,

but are not limited to, area drug treatment programs, homeless shelters,

public housing authorities, and major food pantries. The case manager

attempts to identify a liaison with whom future communication regarding

access of service might occur, the eligibiliiy requirements of the agency,

and the agency representative’s response to the explanation of the project,

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This information is recorded and becomes part of the case manager’s

resource file. In addition to the visits, the case manager also studies the

area social service directories (compendiums of area services compiled by

local United Way-type organizations) to become familiar with the array of

available services.

As warranted, the case manager attends workshops and continuing education

programs given by authorities in the field of case management.

CONFIDENTIALITY

Confidentiality is a major concern in any professional human service

endeavor, but it need not inhibit the case management process. Contact

with other agencies to request service on behalf of a specific individual is

made only with the written consent of the individual needing the service.

Similarly, contact with any agency to ascertain whether a specific individual

received service from that agency is never made without the written consent

of that individual. Requests for information about a client’s participation in this

project are honored only with a signed release of information that is consistent

with Federal law (Confidentiality final rule 1987).

PRACTICAL AND PHILOSOPHICAL CONSIDERATIONS

Although the compression of the case management process into a

2-month timeframe may seem like a corruption of the process to some

case management practitioners, the Dayton-Columbus approach is designed

to be flexible. This flexibility helps the process maintain its philosophical

integrity. For instance, if a client conveys to the case manager that he or

she has emergency needs for services, such as drug treatment, housing,

food, or medical care, the process as previously described is bypassed and

the case manager strives to meet the client-identified needs in a timely fashion.

Furthermore, if the process is not executed in the limited timeframe specified,

it may be extended up to a month longer until it is completed. Finally, the client

is not bound to limit contact with the case manager to scheduled appointments

and is free to make unscheduled contacts throughout the duration of the

process-generally about 2 months. What at first appears to be an unduly

narrow application is really a fairly well-rounded, somewhat traditional case

management model.

Although the Dayton-Columbus model was described earlier as a “new”

mixed model with an eclectic orientation, it is nonetheless oriented toward the

identification and solution of problems. It may, therefore, be labeled by some

as a “remedial” rather than a “strengths” model of case management. However,

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the assessment of a client’s strengths and the application of these strengths

to the planning and accessing stages of the model suggest that the “remedial”

label is not wholly descriptive of the process. A question to be answered is

whether the strengths model as described by Rapp and Chamberlain (1985)

could succeed with a not-in-treatment, street, drug-using population. The

amount of time and the nature of the contact required may preclude the

strengths model’s application in this venue, because the model is predicated

on the development of a companionship-type of relationship. The short amount

of time the Dayton-Columbus case managers have with the clients and the

fact that case managers do not “hang out” on the street mean the development

of such a companionship-type relationship is unlikely and, therefore, so is

application of the strengths model. Furthermore, an ethnographic study

suggests that IDUs and crack users move from crisis to crisis (Carlson and

Siegal 1991). Given this fact, it is incumbent that the Dayton-Columbus model

link people with services quickly. Although the strengths model can succeed

at this task if given time, time is a scarce commodity when working with active

users of street drugs.

Based on previous experience in the Dayton-Columbus NADR project and

knowledge of area drug-using networks, it is expected that “average” project

clients will be mostly African-American (75 to 80 percent) and males (60

percent) in their early thirties to midthirties with 10 to 15 years of serious

drug involvement. A very large number (65 to 70 percent) will have recent

experience with crack and injectable drugs. Of concern is whether potential

clients, other than the most highly self-motivated, will even give the process

a chance because it will require an average of 2 to 3-1/2 hours per visit

(including travel time). No financial or commodity incentives are being offered

for participation. Therefore, the project must compete with the “I need to take

care of business” ethos that is so much a part of the street drug culture.

Assessing the impact of the model is complicated by the clients’ preprogram

knowledge of the human service network. At least one AIDS prevention

project working with IDUs has found clients to be “system wise” (G. Rodriguez,

personal communication, July 1991). Indeed, preliminary data gathered from

59 Dayton-Columbus project participants revealed significant levels of past

involvement with the communities’ human service networks. For instance, 83

percent had previously received food stamps, 55 percent had received public

assistance, 34 percent had stayed in a homeless shelter, and 42 percent had

been involved in a drug treatment program at least once in their lives. These

data obviously suggest that project participants are familiar with aspects of the

community’s human service network. If this is the case, the question arises as

to whether a service broker model of case management is needed. The answer

is, “probably.” Past involvement with the system does not imply successful

176
interaction. Furthermore, the same dataset shows that 20 percent of the

participants are currently in need of food, 22 percent now want to get involved

in a drug treatment self-help group, and 12 percent are in need of medical care.

Serious consideration must also be given as to whether local human service

agencies are capable of serving more people than they do currently. For

instance, for the past 2 years, long waiting lists for drug treatment have

existed in both Dayton and Columbus. This fact raises the question of

whether it is appropriate to engage people in a process that engenders a

need for a service that the system may not be able to deliver in a timely

fashion. The answer is, “perhaps.” Furthermore, advocacy on behalf of

single individuals often succeeds. If advocacy can generate enough pressure

on the system to make it more responsive to the needs of people, the actions

may be justifiable at the local and even the national level. If advocacy fails,

then the process is quite dubious. This issue deserves careful monitoring

and consideration.

Consideration must also be given to the disincentives for service. For example,

some clients may thoughtfully decline employment opportunities because such

employment could result in the loss not only of their public assistance support,

if they are recipients, but also of medical support, something that is often

not attached to the employment benefit” packages of underclass people.

Clients may also question why they should go back to school or engage in job

training when the Nation is in the economic doldrums and experiencing a high

unemployment rate-a rate that does not approach the unemployment rate

people in impoverished inner-city areas have experienced for most of the past

two decades.

Not surprisingly, case management has its critics, and they also need to be

considered. Although case management has been offered as a panacea for

what ails the community mental health movement, Mechanic (1986) and

Mechanic and Aiken (1987) have noted that it has had limited success.

Mechanic (1986) also has argued that more faith has been placed in case

management than is warranted. In assessing case management, Mechanic

and Aiken (1987) said:

It is foolish to place so much hope on an intervention that is as

weak as this one and has so little supporting structure. If case

management is to be effective, it must be embedded in an

organizational strategy that clearly defines who is responsible

for care, that has in place the necessary service elements to

provide the full spectrum of needed services, and that can

control the range of resources so that balanced decisions can

be made.

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Mechanic and Aiken (1987) also point out that case managers are often

young, inexperienced, undertrained, and underpaid. Although these

criticisms apply specifically to case management within the community mental

health movement, those outside the mental health arena need to take note.

Expectations may be unrealistic and strategies poorly defined. However, in

partial answer to criticism, it is also unrealistic to expect social casework and

case management to correct the poor decisions of the past or to correct longlived social injustices.

Finally, one issue that will surely not be resolved soon, but that merits

mention, is the role that programs such as the one described here may have

in causing or inhibiting needed social reform. For years, social programs

have permeated the lives of people in the underclass, yet problems have

continued to grow, particularly among the still-disenfranchised minorities

whose neighborhoods are now plagued by spiraling murder rates, high levels

of unemployment, and general despair. It is useful to consider the ultimate

impact of some of the efforts detailed in this volume. Although professionals

involved in the provision of these programs believe they are humanistic,

altruistic agents working to relieve pain and suffering and helping people to

realize their potential, it must be considered that the opposite may be the

case: that they are agents of social control facilitating preservation of the

status quo. Of course, those people who have worked in the social work and

human services fields realize that sociopolitical conundrums such as this are

not new (Toren 1972).

SUMMARY

The AIDS intervention model described herein represents a new “mixed”

model of case management, one that combines AIDS risk-reduction education

with a modified version of the traditional broker of services model. The case

management component of the model is designed to heed and address those

immediate needs that may distract a person from attending to the AIDS riskreduction messages. The educational component of the model can help a

person develop interest in the case management services. The result is a

model that, theoretically, can have a greater impact than either component

alone would have.

The advantages of the model are its flexibility, its ability to quickly assess and

address clients’ concerns, and its short duration that enhances the likelihood

that drug users will complete the process.

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REFERENCES

Ballew, J.R., and Mink, G. Case Management in the Human Services.

Springfield, IL: Charles C Thomas, 1986.

Bandura, A. Self-efficacy: Toward a unifying theory of behavior change. Psychol

Rev 84(2):191-215, 1977.

Carlson, R.G., and Siegal, H.A. The crack life: An ethnographic overview of

crack use and sexual behaviors among African-Americans in a Midwest

metropolitan city. J Psychoactive Drugs 23(1):11-20, 1991.

Confidentiality final rule: 42 CFR, Part 2. Federal Register 52(110):21796-

21814, June 9, 1987.

Falck, R.S., and Siegal, H.A. HIV Risk Reduction for Injection Drug Users and

Their Sexual Partners; Intervention Manual. Rockville, MD: National Institute

on Drug Abuse, Community Research Branch, in press.

Job, R.F.S. Effective and ineffective use of fear in health promotion campaigns.

Am J Public Health 78(2): 163-167, 1988.

Mays, V.M., and Cochran, S.D. Issues on the perception of AIDS risk and risk

reduction activities by black and Hispanic/Latina women. Am Psychol

43(11):949-957, 1988.

Mechanic, D. The challenge of chronic mental illness: A retrospective and

prospective view. Hosp Community Psychiatry 7(9):891-896, 1986.

Mechanic, D., and Aiken, L.H. Improving the case of patients with chronic

mental illness. N Engl J Med 317(26):1634-1638, 1987.

Perlman, H.H. Social Casework: A Problem-Solving Process. Chicago:

University of Chicago Press, 1957.

Rapp, C., and Chamberlain, R. Case management services for the chronically

mentally ill. Soc Work 30(5):417-422, 1985.

Richmond, M. What Is Social Casework? New York: Russell Sage Foundation,

1922. pp. 98-99.

Rosenstock, I.M. Historical origins of the health belief model. Health Educ Q

2(4):328-335, 1974.

Sensel, G.; Paradise, F.; and Stroup, S. Case management practices in an

AIDS service organization. Soc Casework; J Contemp Soc Work 69(6):388-

392, 1988.

Siegal, H.; Falck, R.; Carlson, R.; and Li, L. Changes in needle risk behavior: A

preliminary comparative analysis of the Dayton-Columbus NADR program’s

standard and enhanced intervention tracks at six months. In: Research In

Progress. Rockville, MD: National Institute on Drug Abuse, Community

Research Branch, October 1991.

Skidmore, R.A., and Thackeray, M.G. Introduction to Social Work. 3d ed.

Englewood Cliffs, NJ: Prentice Hall, 1982.

Stein, L.I., and Test, M.A. Alternatives to mental hospital treatment. Arch Gen

Psychiatry 37(4):392-397, 1980.

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Sullivan, J.P. Case management. In: Talbott, J., ed. Chronically Mentally Ill.

New York: Human Service Press, 1981.

Test, M.A. Effective community treatment of the chronically-mentally ill. J Soc

Issues 37:71-86, 1981.

Toren, N. Social Work: The Case of a Semi-Profession. Beverly Hills: Sage

Publications, 1972. pp. 93-98.

Weissman, G. AIDS prevention for women at risk: Experiences from a national

demonstration research program. J Prim Prev 12(1):49-63, 1991.

Willenbring, M.L.; Ridgely, M.S.; Stenchfield, R.; and Rose, M. Application of

Case Management in Alcohol and Drug Dependence: Matching Techniques

and Populations. DHHS Pub. No. (ADM)91-1766. Rockville, MD: National

Institute on Alcohol Abuse and Alcoholism, 1991.

ACKNOWLEDGMENTS

This project is being supported by NIDA grant DA-07305 and the Ohio

Department of Alcohol and Drug Addiction Services.

AUTHORS

Russel S. Falck, B.S.S.W

Project Director

Harvey A. Siegal, Ph.D.

Professor and Principal Investigator

Robert G. Carlson, Ph.D.

Director of Ethnography

AIDS Prevention Research Project

Substance Abuse Intervention Programs

Department of Community Health

Wright State University School of Medicine

143 Biological Sciences Building

3640 Colonel Glenn Highway

Dayton, OH 45435

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Case Management Services for HIVSeropositive IDUs

H. Virginia McCoy, Sally Dodds, James E. Rivers, and Clyde B.

McCoy

INTRODUCTION

The annual acquired immunodeficiency syndrome (AIDS) incidence rate for

the Miami Metropolitan Statistical Area (MSA) is high, and the recent trend

is relentlessly upward-from 25.2 (per 100,000) (January 1988) to 38.1

(November 1988) to 49.6 (December 1989) and 81.4 (June 1991)—and

is consistent with earlier predictions of increases made from the best

epidemiological evidence available (Centers for Disease Control 1989, 1990,

1991). As might be expected, the Miami MSA’s recent total of 4,578 reported

AIDS cases constitutes a majority of the cumulative total in Florida. Moreover,

Miami ranks highly in comparison to other U.S. metropolitan areas in all

exposure categories (Shultz et al. 1991). Among the populations at highest

risk nationally for human immunodeficiency virus (HIV) infection are intravenous

drug-using men and women. Of the cases reported among adults in Miami,

26.6 percent occurred in injecting drug users (IDUs). Of the IDUs tested, 23

percent of the males were HIV positive; this is a high rate, but only one-half the

46 percent HIV-positive rate found in female IDUs (Dade County Public Health

Unit 1991).

Factors compounding the risk of HIV for IDUs are their tendency to be

isolated from mainstream society and to be unaware of and unable to easily

access health and social services. Agency barriers (e.g., philosophies, styles,

personalities, funding restrictions) are reported to create service gaps, some

of which may be specific or unique to IDUs. The consequences of these

psychological, lifestyle, knowledge, and agency barriers are decidedly not

trivial. It has been estimated that about half of AIDS-related deaths in IDUs

are not identified as such and thus are not so reported (Curran 1989). Because

of the numerous health and social consequences resulting from HIV infection,

concurrent attention is required to the primary prevention of viral transmission,

the provision of health and social services, and research about these issues.

The integration of these activities could translate into better and more informed

181
decisions about policies related to health service delivery in this epidemic

(Fineberg 1989).

COMPREHENSIVE DRUG RESEARCH CENTER AND SOUTH FLORIDA

AIDS NETWORK

A l-year demonstration program was conducted in Miami, FL, that involved

revising the established case management system of the South Florida

AIDS Network (SFAN) to better serve HIV-positive IDUs, to provide case

management of a sample from this population by SFAN, and to perform a

process or performance evaluation of the demonstration by the University of

Miami (UM) Comprehensive Drug Research Center (CDRC). This collaborative

effort was designed to integrate CDRC-conducted research and prevention

education with SFAN-provided case management services for IDUs.

SFAN is a program within the Public Health Trust of Dade County, which

operates major primary and tertiary health care programs, including-under

contracts with UM-the University of Miami/Jackson Memorial Medical Center,

the major provider of medical services for indigent AIDS patients and a national

leader in AIDS research. SFAN was established in 1986 as one of the first

national AIDS care and treatment demonstration projects. Enrollees in SFAN

receive case management services for a range of institution- and communitybased HIV-related services.

CDRC is a coordinating “matrix” center, embracing multidisciplinary basic,

clinical, and other applied research encompassing virtually all facets of

substance abuse etiology, epidemiology, and consequences. CDRC has a

20-year history and foundation at UM. Approximately one-third of more than

30 substance abuse research projects currently being conducted at UM by

CDRC faculty members or collaborating faculty involve IDU-related HIV. The

CDRC subcontract with SFAN for design, training, and evaluation services

extended from August 1, 1990, through September 30, 1991; an additional

8-month limited-activity period was appended to allow for followup. The

collaboration for this project, which involved a research-oriented academic

medical institution and a service-oriented primary and tertiary care public

hospital, required substantial consideration of different roles and responsibilities

in joint planning. Each organization has different ideologies, organizational

sanctions, and managerial structures. The attention to detail and accuracy

in data processes, the specificity, and the measured pace of research

undoubtedly seemed foreign and appeared constraining to the quickly and

urgently changing demands of patient care. Attention had to be given to the

establishment of mutually defined “common ground” to minimize-and, when

182
anticipated, to prevent-unnecessary and potentially counterproductive tension

in the program’s implementation.

ORGANIZATIONAL STRUCTURE

Leadership personnel from both CDRC and SFAN met together initially to

identify organizational domains. CDRC had responsibility for participant

recruitment; assignment of control and case management statuses; control

group referrals; all data collection that was unique to the evaluation; and all

data entry, analysis, and interpretation relevant to the evaluation of the

demonstration. SFAN had responsibility for case management services

and data collection related to services recommended, received, and billed

to SFAN. Frequent CDRC-SFAN meetings were held to modify the existing

SFAN case management program, adding outreach activities and health

education regarding sex and drug use risk-reduction activities, to ensure its

fit for the unique needs of IDUs. The meetings also were used to reach

consensual decisions regarding data required for evaluation purposes, their

definitions, mechanisms for maintenance and sharing, and the delineation of

staff functions and accountability. Program orientation meetings were held

with staff members of both organizations; in-service training programs were

held with the SFAN case managers to familiarize them with the relationship

between drug addiction and HIV transmission and to demonstrate risk-reduction

counseling and behavioral skills, such as needle cleaning, for this population.

Modifications of the SFAN Case Management Program for HIVSeropositive IDUs

The routine SFAN-defined case management program includes a sequence

of activities: an introduction to SFAN, program enrollment, patient and

participant needs assessment, service care plan development, plan

coordination and implementation, plan monitoring, and followup. Case

managers at SFAN are bachelor-level health educators, with no social work

training and little experience working with drug users. Their routine role is

to provide health education and referrals to services and to maintain contact

with SFAN clients.

The modifications in the case managers’ program to accommodate the unique

needs of HIV-positive IDUs were as follows:

Enrollment in SFAN, with an orientation to the continuum of HIV-related

services of SFAN’s provider agencies

Assignment of individual cases to specified managers

183
Needs identification through screening by the case manager to determine

medical status, economic status, social supports and family status, and

psychological functioning

Regular, ongoing HIV prevention education about knowledge and skills

required for behavior change to reduce HIV transmission, including the role

of addiction treatment in HIV transmission prevention, the adoption of

needle-cleaning practices, and the use of condoms during sexual activity

The identification and utilization of health and mental health care, social and

economic services, and addiction treatment services

The use of regular and frequent (every 2 weeks) monitoring of patients’ use

of the above-identified services to determine access, compliance with

treatment, and the reassessment of any needs or problems for treatment or

intervention

Low staff-to-patient case ratios (1:30 to 1:35)

An integrated research and evaluation component to assist with needs

assessment and determination of outcomes for HIV-seropositive IDUs in the

areas of service utilization, cost, HIV risk-behavior change, and further

program development

Barriers in Working With IDUs

Barriers often encountered when working with IDUs include homelessness,

denial of drug-related adverse consequences, continued drug use, and lack

of available treatment programs. Many of the IDUs in the demonstration

program were homeless. Living “on the streets” is undesirable from the

perspectives of the homeless individual and the larger society in that it creates

or exacerbates health and social problems. Less profound, but salient from

the perspective of this demonstration project, is the difficulty homelessness

presents for followup efforts and attempts to make “home” visits. Program

participants who were asymptomatic at enrollment found it difficult to focus

on risk-reduction strategies. Many of them continued risky sex and drug-using

behaviors. Drug abuse is characterized by denial of dependency, and drug

users were no less likely than those infected through other means to deny

their HIV infection. Even when IDUs chose to seek enrollment in a drug

treatment program, there were times when there was no program available for

demonstration program participants because they could not pay for the service.

184
METHODS

Research Design

HIV-seropositive IDUs who were involved in other studies at CDRC constituted

the participant pool for this demonstration project. All study participants had

received HIV testing, counseling, and prevention information. After signing an

informed consent and being assured of confidentiality, participants were

randomly assigned to either the case management or control group. Random

assignment was done using a table of random numbers; even numbers in the

table were assigned to the case management group, and odd numbers were

assigned to the control group. Monetary inducement was neither offered nor

given to members of either group to accept their assignment or to participate in

the evaluation aspects of the demonstration project. Participants in the case

management group received the services outlined above, with active, regular

contact with an assigned case manager. Participants in the control group

received the regular social work services of the CDRC. These services

consisted primarily of social, medical, and health service referrals on request by

study participants. See figure 1 for research design and activity flow chart.

Those randomly assigned to the case management condition, being voluntary

participants in the demonstration program, had-and sometimes exercised-the

option to refuse to participate in the program. Of those who were assigned but

opted not to enroll in SFAN, many were already receiving services from primary

health care clinics, Jackson Memorial Hospital, or the Department of Veterans

Affairs.1 An additional informed consent was required at SFAN for those

enrolled in the demonstration program because of access to medical records.

Randomization procedures were compromised somewhat by SFAN’s

continuing need to maintain a full caseload of 30 to 35 cases for each of

three case managers assigned exclusively to this demonstration program.

(This compromise to randomization procedures was partly in response to

complaints from case managers in SFAN’s regular program whose caseloads

were considerably higher.) Consequently, after CDRC had assigned about

20 HIV-positive subjects to the case management and control groups,

randomization was stopped to fill the caseloads. Once the caseloads reached

30 per case manager, randomization procedures were again instituted. This

process ultimately resulted in fewer participants being enrolled in the control

group (40) than the case management group (100); the project period expired

before the control group size could be equalized with the case management

group.

185
FIGURE 1. Research design and client flow

KEY: CM=case manager; JMH=Jackson Memorial Hospital; PHCC=primary health care centers

“Send to UM” refers to sending forms and data to evaluator.
Data Collection and Data Management

As noted earlier, the collaboration for this project required considerable

accommodation and patience between a research-oriented academic

medical institution and a service-oriented primary and tertiary care public

hospital program. This was particularly true with regard to perspectives on

data collection and data management. The priorities of the CDRC staff tended

toward attention to detail and accuracy in data processes, whereas those of

the SFAN staff were attuned to episodes of patient-staff interaction, affective

behavior and emotional states, and the mutable and sometimes idiosyncratic

demands of patient care.

Despite these differences in emphasis, extensive extant SFAN service and

CDRC research data were abstracted, and additional data were captured

expressly for the demonstration program evaluation. A wide range of data

collected on each participant provided multiple dimensions for the conduct of

process and outcome evaluation.

Baseline data were collected via two interview instruments, the AIDS Initial

Assessment from the National Institute on Drug Abuse’s (NIDA) National

AIDS Demonstration Research project and the questionnaire from the Centers

for Disease Control’s National Health Study, as these projects were the source

of participants for this Health Resources and Services Administration (HRSA)/

NIDA demonstration project. Each instrument captured drug-using and sexual

risk behaviors for HIV as well as demographic information. Comparable

variables were selected from these baseline data sets and merged into a

single data file. In addition, data files from participants’ admissions, needs

assessments, services received, medical and health status, and other status

change information were maintained throughout the program as 15 separate

files, then merged into a single master data set for analysis purposes.

The management of the data collected by separate organizations required

substantial planning and ongoing coordination to ensure compatibility of

systems, timely data entry, avoidance of redundant items, ability to merge files,

and quality control of the data. In CDRC, unique identifier codes were assigned

to each subject according to study type; SFAN maintained two participant

identifier codes that had to be reconciled with the CDRC codes. Data from

SFAN were edited onsite by a supervisor and edited for completeness at the

CDRC site. All data were maintained in locked files.

Research Strategies for Evaluating the Program

An adjusted random design procedure, described in the Research Design

section, was employed to compare the case management model with a

187
control (non-case management) model. The control group utilized the

services of a bachelor-level, experienced social worker on staff at CDRC

who, on request and without a formalized needs assessment, during a brief

intervention session, referred study participants to health and social services.

The major evaluation question (i.e., Is case management superior to one-time

referrals to services on demand as a methodology for ensuring that needed

services are received by HIV-positive IDUs?) was operationalized as, Will the

case-managed group receive higher numbers of services than the control

group? In addition, quantitative data were collected for process evaluation,

such as the amount of time spent with each participant, the number of contacts,

referrals, attempts at making contacts with participants, and type of attempts

(e.g., telephone, letter, outreach), and contact (e.g., routine followup, case

manager or participant initiated).

RESULTS

Baseline Characteristics

Table 1 shows the demographic characteristics of the study population.

There were no significant differences in characteristics of age, race, gender,

education, major source of income, and employment between the control and

case management groups. Similarly, there were few differences in drug and

sex risks for HIV at baseline between the two groups as shown in table 1A.

The case management group was more likely to have ever used cocaine

(powder) (p=.03) and to have received money or drugs for sex (p=.05) than

the control group. Additional baseline characteristics include medical status

and AIDS symptoms (table 2). HIV status did not differ significantly between

the two groups, nor did performance status. Most study participants were

asymptomatic and able to perform most daily activities without help (66.0

percent of the case management group, 67.5 percent of the control group).

Typical AIDS symptoms also did not differ significantly (data not shown).

There was no significant difference between the case management group

and the control group on the degree to which they believed they were at risk

for HIV. Because these baseline characteristics were similar for both groups,

the authors expected that any differences between the two groups at the

conclusion of the intervention could be attributed to the effects of the

intervention (i.e., the case management services).

Participant Needs Assessment

An assessment of subjects’ service needs (table 3) shows essential differences

between the case management and control groups. Financial assistance

186
TABLE 1. Characteristics of the study group, percent*

Case Management

Characteristics† (n=100)

Age

Control

(n=40)

<25 10.0 7.5

26-30 27.0 17.5

31-35 27.0 27.5

36-40 23.0 35.0

41+ 13.0 12.5

Race

Black 87.0 85.0

Hispanic 7.0 2.5

White/Native American 6.0 12.5

Gender

Male 61.0 67.5

Female 39.0 32.5

Education

<High school graduate 58.6 48.7

High school graduate 24.2 25.6

>High school graduate 17.2 25.6

Major source of income

Government sources 12.3 3.1

Other legal sources 43.2 68.8

Illegal sources 42.0 28.1

Other 2.5 0

Employment

Regular 15.4 32.4

Occasional 22.0 21.6

Unemployed/retired 62.6 45.9

* Percentages may not add to 100 due to rounding.

† The differences for HIV status, performance status, and perception of HIV risk

were not significant between the case management and control groups.

189
TABLE 1A. Drug and sex risk activities, percent*

Risk Behaviors Case Management

Drugs

Drugs ever used

Alcohol

Marijuana

Crack

Cocaine (powder)

Cocaine (injected)

Heroin

Other (injected)

Other (noninjected)

Not currently enrolled

in drug treatment program

Cleaned needles

Never

Half the time or less

More than half the time

Always

Shot drugs at shooting gallery

Never

About half the time or less

More than half the time

Always

Sex

Received money or drugs for sex

Never used condoms

No sexual risk behaviors

(No IDU partners, use condoms

always, no anal sex)

Number of sexual partners

None

One

More than one

89.0 95.0 ns

70.0 62.5 ns

70.0 57.5

56.0 35.0 .03

72.0 62.5 ns

58.0 55.0 ns

69.0 60.0 ns

70.0 62.5 ns

99.0 92.5 .03

13.8

6.2

7.7

72.3

49.4 52.9

38.3 32.3

7.4 5.9

4.9 8.8

42.0 22.5 .05

50.0 47.5 ns

23.5 15.8 ns

16.9

24.1

59.0

*Percentages may not add to 100 due to rounding

ns=not significant

Control p

0.0

10.7

10.7

78.6

ns

8.3

33.3

58.3

ns

190
TABLE 2. Medical status at baseline, percent*

Medical Status† Case Management

HIV status

AIDS only

AIDS-related complex only

HIV positive only

3.0

3.0

94.0

Performance status

Normal activity

No special care

Unable to work

Self-care

Some assistance needed

Hospital care needed

66.0 67.5

18.6 17.5

6.2 5.0

3.1 0.0

5.2 7.5

0.9 2.5

Perception of risk of HIV

No chance 11.2 7.5

Some chance 62.2 75.0

High chance 20.4 10.0

Sure chance 5.1 5.0

Unsure of chance 1.0 2.5

* Percentages may not add to 100 due to rounding.

† The differences for HIV status, performances status, and perception of HIV

risk were not significant between the case management and control groups

Control

2.5

97.5

(Supplemental Security Income [SSI] and Medicaid) and basic food needs

are significantly greater for the case management group, whereas basic shelter

needs are significantly greater for the control group. Because of the difficulty

IDUs have in accessing services, it was important to determine whether there

were others (e.g., family members, friends) who could provide assistance to the

HIV-positive IDUs. For both groups, a parent was overwhelmingly the choice as

caregiver.

The psychological assessment showed that for both the case management

and control groups the prevalence of low mental health was high, but not

significantly different. In the case management and control groups, the

participants scored in the medium-to-high range (43.2 and 45.0 percent,

respectively). The major implication of using a brief screen to detect

psychiatric illness in a case management program for HIV-seropositive

191
TABLE 3. Client needs assessment, percent

Characteristics Case Management

Receiving financial assistance

SSI 13.2

Medicaid 15.6

Needs food stamps 40.7

Has no place to go 13.0

Relationship of caregiver

Parent 89.0

Spouse 2.0

Sexual partner 1.0

Relative 4.0

Friend 1.0

Child 2.0

Other 1.0

Range of mental health

Low mental health 56.8

Medium mental health 35.8

High mental health 7.4

ns=not significant

Control p

7.5 ns

0.0 .001

2.5 .001

35.0 .000

ns

100.0

0

0

0

0

0

0

ns

55.0

42.5

2.5

IDUs is to enhance early referrals to necessary psychiatric, neuropsychiatric,

and mental health services. A brief screen is especially important when case

managers are nonprofessionals.

Services Provided

The SFAN case managers provided basic educational services such as AIDS

101 and HIV risk reduction.2 They referred clients to additional services in other

agencies, but followup data were recorded and available for analysis for only

some of those referrals (table 4). The services of greatest need were financial

assistance (23.3 percent) and outpatient medical services (22.8 percent).

Transportation services (21.8 percent) were provided to assist clients in

accessing services. Most clients (80 percent) came to the program only one

time after admission; other clients came 2 (3 percent), 3 (1 percent), 6 (1

percent), 7 (1 percent), or 13 or more times (14 percent).

192
TABLE 4. Services referred

SFAN Education N Percent

CMG* referrals for services

Outpatient

Inpatient

Medications

At-home medical

Financial assistance

Housing services

Meals

Drug abuse treatment

Mental health services

Transportation

Medical supplies

AIDS agency

Other social services

Total 193 99.9

Control group referrals for services

Medical treatment

Financial assistance

Housing

Food

Drug abuse treatment

Counseling on drug abuse

Employment

SFAN (AIDS agency)

8

5

9

5

2

3

4

6

Total 42

44 22.8

3 1.6

13 6.7

5 2.6

45 23.3

11 5.7

7 3.6

6 3.1

1 0.5

42 21 .a

1 0.5

2 1.0

13 6.7

*Case management group

19.0

11.9

21.4

11.9

4.8

7.1

9.5

14.3

99.9

Thirty-three research participants in the control group were referred to 42

services during the study period (table 4). The greatest needs of this group

were medical treatment and basic needs of food and shelter. Subjects in the

control group received fewer services, primarily because there were no active

attempts to reach them by the social worker.

193
The SFAN health educators counseled clients on various aspects of AIDS

sex and drug risk reduction, basic AIDS information, and nutrition. The average

amount of time spent providing education about HIV transmission during the

case management activities included 8.1 minutes on AIDS 101, 7.3 minutes

on safer sex, 8.0 minutes on drug use reduction, and 5.6 minutes on universal

precautions.

Status and Behavior Changes

Status changes that occurred during the study are listed in table 5. Status

changes, including changes in caregivers or dependents, financial assistance,

medical diagnosis, symptoms or care, and drug treatment, were noted by the

case manager at each contact. Few changes were seen in caregivers or

dependents, financial assistance, or drug treatment. The greatest change in

the case management group was an increase in medical care, including visits

to doctors and nurses, treatments, medications, and hospitalizations. This

increase may indicate that the patients had greater access to services, may

reflect an escalation in symptoms and more frequent instances of acute

problems, or both. In fact, two clients in the case management group died

during the study, and five changed their status from HIV positive to AIDS (data

not shown). The increase in treatments primarily included beginning AZT and

other medications (patients were unable to identify the type by name). Even

though data are incomplete in the control group, there was one death and no

changes from HIV status to symptomatic AIDS. It is interesting to note that the

greatest changes in the control group were also in medical care, primarily visits

to a doctor or nurse. The case management group members apparently

received greater attention to health care as a result of the case management

program. In addition, they also reported decreasing their drug and sex risk

behaviors, which may also improve their health and survival time. Without the

case management program, most would have been unaware of the availability

of AZT and other medications,

Preliminary data on behavioral changes-comparing baseline assessments to 6

months postentry into the demonstration program-are also reported in table 5.

Improvements in HIV-risk activities were noted for both case-managed and

control groups in most aspects of sex-risk and drug-risk behaviors measured.

The number of sex partners, the injection and noninjection use of cocaine, and

the use of alcohol and marijuana decreased; the use of condoms increased for

both groups. The case-managed group also decreased their use of crack

cocaine and increased their use of clean needles, whereas the control group

decreased their use of clean needles. Adversely, the case management group

194
TABLE 5. Status and behavioral changes*

Status Changes (Percent of Times Mentioned)

Changes in Case Management Control

Caregivers

Diagnosis

Treatment/medication

Visits to doctor/nurse

Hospitalization

Performance status

Risk behaviors

12

13

34

59

17

8

21

1

0

0

13

1

1

0

Behavioral Change—Mean Scores†

Sex behaviors

Number of sex partners

Use of condoms

Case Management Control

Baseline 6 Month Baseline 6 Month

12.3 3.8 15.3 4.3

.5 .6 .5 .8

Drug-using behaviors

Drug use

Alcohol

Marijuana

Crack

Cocaine (noninjecting)

Cocaine (injecting)

Heroin and cocaine

.9 .7 1 .0 .9

.7 .4 .6 .5

.7 .4 .6 .7

.6 .2 .4 .2

.7 .1 .6 .4

.6 .2 .5 .3

Use shooting gallery .8 1.2 1.0 .8

Clean needles 3.3 3.8 3.7 3.3

Number of injecting partners 4.3 2.4 1.9 2.7

195
TABLE 5. (continued)

Multiple R

§

.15

.38

Behavioral Change Differences Between Control and

Case Management Groups

Baseline to 6-Month Followup

Risk Behaviors Correlation Coefficients‡

Sex behaviors

Number of sex partners .07

Use condoms .24

Drug-using behaviors

Drug use

Alcohol .22

Marijuana .28

Crack .16

Cocaine (noninjecting) .09

Cocaine (injecting) .01

Heroin and cocaine (injecting) .30

Use shooting gallery .47

Clean needles .05

Number of injecting partners .57

* Incomplete data; pending completion of followup.

.35

.39

.37

.27

.36

.40

.51

.17

.62**

† Scores were computed on each variable by assigning a value of “0” to the

“Never” category, “1” to the lowest category (for example, use condoms less

than half the time), and adding “1” to each additional category in that variable.

‡ Pearson product-moment correlation.

§ Controlling for number of visits and time in program (months).

** p<0.01

increased their use of shooting galleries. These results show a trend in the

direction of improvement of HIV risk behaviors; however, as the data in the last

section of table 5 show, only one behavior change was significantly different

between the case management and control groups: The number of different

people with whom the study participant injected and had sex was significantly

different between the control and experimental groups.3

These preliminary findings are suggestive, given the pattern of difference

between the two groups, that case management may not only improve health

196
TABLE 6. Service costs for case-managed HIV-positive IDUs (n=38)

Number of Services Service Cost

Service Type

Per

Total Individual Mean ($) Low ($) High ($)

Inpatient 13 0.3 8,656 3,713 27,228

Outpatient 91 2.4 441 0 1,457

Pharmacy 136 3.6 16 0 133

Psychosocial 2 2 0.6 33 1 7 53

Other* 68 1.8 172 16 1,415

Percent

of Total

Total ($) cost

115,126 68

40,154 2 4

2,239 1

732 0

11,679 7

Totals 330 6.7 4,472† 169,930 100

* Includes emergency room (23), individual educational counseling (21) group residential (10),

supplies (10), and substance abuse counseling (4)

† For all services, per individual

care access and delivery of services to IDUs but also may improve their

situation for additional risks for HIV infections and, thus, survival time.

Cost of Services

The following are some descriptive cost data on services received by 38 of

the case management clients in the period August 1, 1990, through September

30, 1991. (All cost information in this analysis is based on extant operations

data from SFAN. Consequently, no service cost data are available for the

control group.) For all participants randomized into the case management

group, individual services received and their costs (when documented) were

abstracted from SFAN records and recorded in participant files maintained by

CDRC for evaluation purposes.

There were 330 instances of documented services identified that had billed

costs recorded; these were abstracted from the case files of 38 patients and

were grouped into categories as shown in table 6 for this analysis. The casemanaged participants averaged 8 to 9 services each (mean=8.7, median=7.5);

only 11 percent of the case-managed group had more than 15 service

transactions within the 13-month period reviewed. Pharmacy transactions

(mean=3.6) were the most common, but these services were not very

expensive according to the case management records: Pharmacy services

averaged only $16 per transaction and totaled only 1 percent of the aggregated

expenditures for all recorded services. Conversely, “inpatient” services were

the least frequently noted but by far the most expensive. The average cost

per instance for the 13 inpatient “services” reported was almost $9,000; these

197
services represented more than two-thirds of the aggregated expenditures for

all services recorded.

Given that the population of interest is IDUs, it is important to note that

“substance abuse counseling” services were recorded in 4 instances for these

38 patients (with group and individual psychosocial counseling services being

noted in another 22 instances). Because these few substance abuse

counseling services were combined with various other services (see table 6

note explaining “other” category), it was not possible here to assign cost figures

to these services.

Followup of Participants

Participants in the control group were seen for a followup assessment at 6

months after the date when baseline data were captured (at their initial entry

into the CDRC National AIDS Demonstration Research [NADR] study and

their assignment to the control condition for this HRSA case management

demonstration program evaluation). In the interim between initial assessment

and followup, the CDRC social worker was available to provide assistance on

request to all NADR research subjects (including those in the control group for

this HRSA project). The CDRC social worker received 33 contacts from control

group members and made 42 referrals to appropriate services (table 4).

Complete data from the 6-month followup assessments for the control group

will not be available until sometime later and when the last of the control group

will have been reinterviewed.

The schedule for contact with the case manager was every 2 weeks, and

most of the clients in the case management group were seen on a regular

basis. Following SFAN procedures, case managers first attempted contact

via telephone, followed by a letter, then a field visit. If all those attempts failed,

the case manager referred the case to the CDRC outreach worker for followup.

Table 7 shows the followup data for the case management group. For

each visit to SFAN, means of 1.5 attempts were made to reach the client

by telephone, 1.1 times by letter, and 1.2 times by field visit. An average

of 8.8 minutes (median=5) was spent on each telephone attempt. (The high

number of minutes used to reach clients can be attributed both to busy SFAN

telephone lines and the homeless or street-frequenting character of the HIVpositive IDU clients in this study.)

As described above, the CDRC social worker did not make active attempts to

contact the study participants, but CDRC outreach workers do make attempts

to maintain contact with study subjects to facilitate relocating and reminding

198
TABLE 7. Case management group: followup data

Case Manager Attempts To Maintain Contact

Number of attempts by

Telephone

Letter

Field visit

Mean Median

1.5 1.0

1.1 1.0

1.2 1.0

Mean number of minutes on telephone

in making attempts

8.8 5.0

Referrals to outreach 1.0 1.0

Minutes With Client

Time Spent Discussing Risk Reduction Mean Median

Risk-reduction topic

AIDS 101

Safe sex

Universal precautions

Drug reduction

8.1 10.0

7.3 6.0

5.6 5.0

8.0 7.0

the subjects of the scheduled followup assessments. It is instructive to note

that there is documentation that one-half of all attempted subject contacts

require an intermediary or referral by a friend, acquaintance, or relative before

direct contact is made.

These data reinforce the implications of the contact data reported for the casemanaged group in table 7: Maintaining frequent contact with IDUs is both time

and labor intensive. The data also suggest that attention to engagement and

interaction with a client is a critical task of a case manager working with IDUs,

a group that is alienated from most institutions. The data also seem to indicate

that the more ill the client is, the greater the number of visits he or she makes

to see the case manager.

For some case management clients, every contact made with the public health

and welfare system was reported to SFAN. Among those clients, the mean

number of contacts with the system was 8.14 (median=10), not controlling for

time in the program (data not shown). Sixty-two percent of clients were seen

199
on average at least once every 2 months; 15 percent were seen only once after

enrollment. The maximum number of system contacts was 35.

IMPLICATIONS FOR CONDUCTING FUTURE RESEARCH ON CASE

MANAGEMENT

Results from the authors’ study indicate that future studies of IDUs need to

compare different approaches to case management to determine the degree

to which they change HIV risk behaviors, increase compliance with treatment,

yield client satisfaction with services, and increase survival time. These

studies need to evaluate the kinds of systematic baseline status and client

service needs assessments, such as physical and mental status and social

support, that are required to determine a specific treatment plan. In addition,

investigation needs to be conducted on population-specific assessments

and case management models (e.g., gender-specific needs such as

gynecologic complications and reproductive issues). Finally, the effects

of case management approaches on case manager burnout and caregiver

burden also need to be studied.

The literature describes case management strategies as encompassing

three primary components: assessment of needs, coordination of services,

and monitoring of service delivery. Kane and colleagues (1989) discussed

several elements that are integral to a variety of case management models.

These basic elements include client screening, needs assessment, care

planning, implementing the service delivery plan, monitoring service delivery,

and reassessing the service delivery process. Two sources of variation that

may impinge on both case management costs and effectiveness are whether

the case management program performs all the functions listed above and

whether any case management functions within the case management

organization are delegated to one or more organizations in the community

(Kane et al. 1989).

Research on the effectiveness of case management with IDUs should also

evaluate outcomes in light of the availability of existing services. Communitybased case management has been employed in managing the delivery of

services to HIV-infected clients. Mor and colleagues (1989) examined case

management models that were utilized in the AIDS Health Service Programs.

These programs placed primary emphasis on satisfying the clients’ needs.

The four goals of community-based case management for HIV-infected

persons were the following: increasing access to service, identifying barriers

and gaps in service, improving continuity of care and service coordination,

and improving overall client satisfaction (Mor et al. 1989). Mor and coworkers

(1989) concluded that the major obstacle to providing case-managed care to

200
HIV-infected persons was the lack of many essential services, such as housing

options, transportation, and drug abuse treatment slots.

Research could be conducted on the use of professionals vs. nonprofessionals

in the delivery of case management with HIV-positive IDUs. The literature

provides discussion about the appropriate roles for case managers. Some

primary roles of the case manager are to act as an advocate and counselor

(Secord and Parker 1987), as a therapist (Rothman 1991), and as a gatekeeper

to a variety of medical care services (Hurley et al. 1989; Rothman 1991).

Nonprofessional case managers, like those in the current study, can be

advocates and gatekeepers but are not expected to be counselors and

therapists. Weil and Karls (1985) described three different types of case

management models differentiated by level of providers: professionals or

specially trained paraprofessionals, nonprofessionals, and multidimensional

staff of the comprehensive service centers. These researchers further describe

three variants of case management provided by professionals. In the first

model, the generalist case manager (or broker) model, the case manager takes

the client through the entire case management process. The second model,

the primary-therapist-as-case-manager model, may be utilized when the case

manager’s relationship with the client is primarily therapeutic. In the third

model, the interdisciplinary model, a team of managers is utilized to implement

specific case management functions. Although models using nonprofessionals

may prove most cost-effective, little information exists to guide development of

such models. Weil and Karls (1985) also describe three models in which case

management is provided by nonprofessionals who have a special relationship

with the client: The family-as-case-managers model enlists family members

as case managers; the supportive care model utilizes a support care worker,

usually from the community, to work as a client’s case manager; the volunteercase manager model assigns a volunteer to work as a client’s case manager.

A review of the literature on social support and HIV provides theoretical

considerations for case management with IDUs that move beyond service

delivery. Case managers can provide supportive roles to HIV-positive drug

users who may be lacking a large supportive network. Knowledge that one

is HIV seropositive has been shown to be a distressing life event (Casadonte

et al. 1990; Blaney et al. 1990; Antoni et al. 1990). Avoidance coping, a

response that may prevent individuals from reducing HIV risk or from receiving

early HIV intervention services, has been found in several studies of HIVseropositive persons (Ironson et al. 1990; Jacobsen et al. 1988). In addition,

several studies have shown that social support buffers the stress associated

with knowledge that one is HIV seropositive (Zich and Temoshok 1987; Noh

et al. 1990; Blaney et al. 1991). To study the effects of a case management

intervention with HIV-seropositive IDUs, Cobb’s (1976) theoretical model of

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social support includes several dimensions that are particularly useful. These

dimensions include the provision of emotional support, active support (defined

as reflecting the receipt of care), esteem support, material support, and

instrumental support (Cutrona and Russell 1990).

Mor and colleagues (1989) also noted that few studies have assessed the

cost-effectiveness of case management programs; cost-effectiveness usually

has secondary focus. Most studies indicate that case management may cost

more than traditional service delivery. Although it has been demonstrated

that case management may be as effective in the delivery of service as

traditional service delivery models, it is unclear whether case management

techniques improve the quality of life of clients (Franklin et al. 1987). In

addition, it is unclear whether appropriate use of services using case

management techniques will ultimately reduce total cost of care. Currently,

the financial benefits of case management remain largely undetermined.

Cost-effectiveness of case management programs depends on overhead,

levels of staff education and training, and the amount of client contact required

(Secord and Parker 1987) as well as other factors. Longitudinal studies are

needed to determine long-term effects of this methodology.

The determination of service costs was not one of the initial objectives of the

Miami case management project. After project implementation, it was decided

that an attempt would be made to capture whatever service cost data were

available or could be abstracted from current records. A preferable design

would minimally have included mechanisms to capture comparison data from

the control subjects, but the study had to proceed within the limits of its

resources.

As originally designed, this study had two sets of outcome objectives: Set 1

focused on “services,” that is, referrals made, placements, and specific services

delivered. The stated intent was to collect and compare data following the

more passive referrals made for those in the control group with more active

involvement, such as advocacy, transportation services, and followup, for

referrals made for those in the case management group. Set 2 focused on

drug use and sexual risk behaviors, with the interest being in the impact of

case management in securing services for IDUs that were instrumental in risk

reduction.

Logically, cost comparisons between the two groups should reveal greater

expenditures for the case-managed group if the calculations are simply the

sum of the costs for all services received (including the case management

service). After all, one of the objectives of case management is to improve

consumer knowledge and success in accessing appropriate services.

202
More sophisticated cost-benefit or cost-containment analyses require that some

putatively avoidable costs (e.g., hospitalization or other higher cost services for

treatment of patient problems) be quantifiable in dollars and contrastable to

services designed for problem and/or cost avoidance or prevention. This is

particularly true for the intervention objectives contained in Set 1. Cost-benefit

analysis refers to a family of procedures employed when both the costs and the

benefits of an intervention can be measured and compared monetarily. This

approach can be contrasted to cost-effectiveness analysis, an evolving, as yet

unstandardized, area of investigation that addresses the relationships between

program dollar costs and outcomes or impacts that are measured in units other

than dollars.

Cost-effectiveness analysis may be more appropriate for analyzing the

intervention objectives noted in Set 2. Either of these types of analysis

would seem to require at least some knowledge of “disease stage,” that is,

case management and control groups should not be compared where one

group is mainly asymptomatic at baseline whereas the other is mainly

symptomatic.

There are few cost analysis studies available that document the costs of HIV

diseases in the United States; Hardy and colleagues (1986), Scitovsky and

Rice (1987), and Bloom and Carliner (1988) are cited by Rice and coworkers

(1990) as documenting the direct and indirect HIV costs in macro terms. More

studies can be found that document the direct personal medical care costs of

AIDS (Andrulis et al. 1987; Green et al. 1987; Hellinger 1988, 1990; Sisk 1987;

Scitovsky 1988, 1989), but none of these cited studies provide estimates of the

direct and indirect costs of the AIDS-causing virus among people who inject

drugs intravenously. (This situation is similar to what Apsler and Harding

[1991], Cross and coworkers [1988], and Hubbard and colleagues [1989]

reported regarding the rarity-virtual nonexistence-of cost-effectiveness

studies for drug abuse treatment.) Thus, studies such as this one, but that are

specifically designed to ascertain the cost-effectiveness of case management

for HIV-positive IDUs, are recommended.

NOTES

1. An analysis conducted in August 1991 regarding nonenrollees found that

21 percent were uninterested and that 21 percent were already receiving

services elsewhere.

2. Case managers provided basic educational services such as AIDS 101 and

HIV risk reduction. In the first visit, this was done 17 times; second visit, 21

times; third visit, 18 times; fourth visit, 15 times; fifth visit, 16 times; and

sixth visit, 16 times.

203
3. Behavior change differences between the case management and control

groups were analyzed using Pearson correlation coefficients to determine

the relationship between the variable at baseline and the same variable at

followup. In addition, multiple linear regression analysis was conducted to

determine the change between a baseline variable and the variable at

followup, controlling for program assignment (case management or

control), the number of visits, and time in the program.

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Schneiderman, N.; and Fletcher, M. Psychological and neuroendocrine

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analyses of life events, hardiness, and social support. J Psychosom Res

35(2-3):297-305, 1991.

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distress, stress-related disruption and coping among healthy HIV-l positive

gay males. Psychol Health 4:259-273, 1990.

Bloom, D.E., and Carliner, G. The economic impact of AIDS in the United

States. Science 239:604-610, 1988.

Casadonte, P.; Des Jarlais, D.; Friedman, S.; and Rotrosen, J. Psychological

and behavioral impact among intravenous drug users of learning HIV test

results. Int J Addict 25(4):409-426, 1990.

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National Center for Infectious Diseases, February 1989.

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National Center for Infectious Diseases, June 1990.

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3449. Miami, FL: National Center for Health Services Research and Health

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Cutrona, C., and Russell, D. Type of social support and specific stress toward a

theory of optimal matching. In: Sarason, B.; Sarason, I.; and Pierce, G., eds.

Social Support: An lnteractional View. New York: Wiley, 1990. pp. 319-366.

Dade County Public Health Unit. AlDS Surveillance Report. November 1, 1991.

Fineberg, H. Application of health services research on HIV infection to the

formulation of health policy. In: LeVee, W., ed. New Perspectives on HIVRelated Illnesses: Progress in Health Services Research. DHHS Pub. No.

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Health Care Technology Assessment, 1989. pp. 13-17.

Franklin, J.; Solovitz, B.; Mason, M.; Clemons, J.; and Miller, G. An evaluation

of case management. Am J Public Health 77(6):674-678, 1987.

Green, J.; Singer, M.; Wintfeld, N.; Schulman, K.; and Passman, L. Projecting

the impact of AIDS on hospitals. Health Aff (Millwood) 6(3):19-31, 1987.

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economic impact of the first 10,000 cases of acquired immunodeficiency

syndrome in the United States. JAMA 255:209-211, 1986.

Hellinger, F.J. Forecasting the personal medical care costs of AIDS from 1988

through 1991. Public Health Rep 103:309-319, 1988.

Hellinger, F.J. Updated forecasts of the costs of medical care for persons with

AIDS, 1989-93. Public Health Rep 105(1):1-12, 1990.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; Cavanaugh, E.R.;

and Ginzburg, H.M. Drug Abuse Treatment: A National Study of

Effectiveness. Chapel Hill, NC: University of North Carolina Press, 1989.

Hurley, R.; Freund, D.; and Taylor, D. Gatekeeping the emergency department:

impact of a Medicaid primary care case management program. Health Care

Manage Rev 14(2):63-71, 1989.

Ironson, G.; LaPerriere, A.; Antoni, M.; O’Hearn, P.; Schneiderman, N.; Klimas,

N.; and Fletcher, M. Changes in immune and psychological measures as a

function of anticipation and reaction to news of HIV-1 antibody status.

Psychosom Med 52:247-270, 1990.

Jacobsen, P.; Perry, S.; Hirsch, D.; Scavuzzo, D.; and Roberts, R.

Psychological reactions of individuals at risk for AIDS during an experimental

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Management Costs: Conceptual Models and Program Descriptions.

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Mor, V.; Piette, J.; and Fleishman, J. Community-based case management for

persons with AIDS. Health Aff (Millwood) 8(4):139-153, 1989.

Noh, S.; Chandarana, P.; Field, V.; and Posthuma, B. AIDS epidemic, emotional

strain, coping and psychological distress in homosexual men. AIDS Educ

Prev 2(4):272-283, 1990.

Rice, D.P.; Kelman, S.; Miller, L.S.; and Dunmeyer, S., eds. The Economic

Costs of Alcohol and Drug Abuse and Mental Illness: 1985. San Francisco:

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Rothman, J. A model of case management: Toward empirically based practice.

Soc Work 36(6):520-528, 1991.

Shultz, J.M.; Elliot, L.; McCoy, C.B.; Greer, P.J.; Bock, A.; and Needle, R.

Acquired immunodeficiency syndrome-Dade County, Florida, 1981-1990.

MMWR 40(29):865-868, 1991.

Scitovsky, A.A. The economic impact of AIDS in the United States. Health Aff

(Millwood) 7(4):32-45, 1988.

Scitovsky, A.A. Studying the cost of HIV-related illnesses: Reflections on the

moving target. Milbank Q 67(2):318-344, 1989.

Scitovsky, A.A., and Rice, D.P. Estimates of the direct and indirect cost of

acquired immunodeficiency syndrome in the United States, 1985, 1986, and

1991. Public Health Rep 102(1):5-17, 1987.

Secord, L., and Parker, M. All about private case management. Health Cost

Manage 4(6):1-11, 1987.

Sisk, J.E. The costs of AIDS: A review of the estimates. Health Aff (Millwood)

6(2):5-21, 1987.

Weil, M., and Karls, J., eds. Case Management in Human Service Practice. San

Francisco: Jossey-Bass, 1985.

Zich, J., and Temoshok, L. Perceptions of social support in men with AIDS and

ARC relationships with distress and hardiness. J Appl Soc Psychol 17:193-

215, 1987.

ACKNOWLEDGMENT

The authors acknowledge the contributions of SFAN for implementation of the

project and data collection for evaluation purposes,

AUTHORS

H. Virginia McCoy, Ph.D.

Project Director

NlDA/HRSA Case Management Project

Sally Dodds, M.S.W., L.C.S.W.

Project Co-Director

NIDA/HRSA Case Management Project

206
James E. Rivers, Ph.D

Deputy Director

Clyde B. McCoy, Ph.D.

Director

Comprehensive Drug Research Center

University of Miami School of Medicine

Dominion Tower

1400 Northwest 10th Avenue

Miami. FL 33136

207
Case Management Models for

Homeless Persons With Alcohol and

Other Drug Problems: An Overview of

the NIAAA Research Demonstration

Program

Harold I. Perl and Mary Lou Jacobs

INTRODUCTION

Since 1987 the U.S. Congress has authorized and funded several Federal

programs to address homelessness under the Stewart B. McKinney Homeless

Assistance Act (Public Law 100-77) and subsequent amendments to that

act. Sections of this law authorized the National Institute on Alcohol Abuse

and Alcoholism (NIAAA) to establish programs of alcohol and other drug

treatment interventions for homeless persons. In fiscal year (FY) 1987,

NIAAA. in consultation with the National Institute on Drug Abuse (NIDA),

initiated a program of nine Community Demonstration Grant Projects for

Alcohol and Drug Abuse Treatment of Homeless Individuals (National Institute

on Alcohol Abuse and Alcoholism 1988). Several of these projects provided

case management as a component of their interventions; in fact, one project

evaluated a specific case management model (see Ridgely and Willenbring,

this volume).

In FY 1990, NIAAA, again in consultation with NIDA, initiated a secondgeneration research demonstration program that built on many of the lessons

learned through the first program. The Cooperative Agreements for Research

Demonstration Projects on Alcohol and Other Drug Abuse Treatment for

Homeless Persons required that projects provide extended interventions such

as comprehensive treatment, self-help group involvement, case management,

transitional and permanent housing, and vocational training. Fourteen projects

were funded in the following cities: Albuquerque, NM, Birmingham, AL,

Chicago, IL, Denver, CO, Evanston, IL, Los Angeles, CA, New Haven, CT,

New Orleans, LA, Newark, NJ, Philadelphia, PA, St. Louis, MO, Seattle, WA,

Tucson, AZ, and Washington, DC. Further information on the 14 projects is

presented in appendix 1.

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The Cooperative Agreement program contains six key design and evaluation

requirements, Each project is required (1) to spend at least 25 percent of its

direct costs on evaluation activities, (2) to employ an experimental or quasiexperimental evaluation design, (3) to evaluate the experimental intervention

against one or more comparison groups, (4) to measure outcome with a core

battery of assessment instruments specified by NIAAA, (5) to conduct process

and program implementation evaluations, and (6) to submit the process and

outcome evaluation data to NIAAA at specified intervals as part of a national,

multisite evaluation. The assessment instruments and evaluation plans are

discussed in more detail later in this chapter.

The interventions being implemented by each Cooperative Agreement project

are required to meet three primary goals: (1) reduce the consumption of

alcohol and other drugs by the project participants, (2) increase the participants’

level of shelter or residential stability, and (3) enhance their economic and/or

employment status. Two secondary goals are improving the participants’

physical and mental health status and increasing the linkages and cooperation

among the various local social service agencies in addressing the multiple needs

of homeless persons with alcohol and other drug problems.

Although the original Request for Applications (RFA AA-90-01) announcing

the availability of program funds did not stipulate a specific treatment protocol

to be implemented, 13 of the 14 projects proposed to provide case management

services to meet these goals. In addition, each project is providing services

in one or more of the following categories: outreach and engagement; alcohol

and other drug treatment programing; and a housing component such as shelter

care or supervised, supportive, or alcohol- and drug-free (ADF) housing. The

next section presents an overview of the case management models that these

projects are implementing and evaluating.

OVERVIEW OF CASE MANAGEMENT MODELS IN THE COOPERATIVE

AGREEMENT PROGRAM

The RFA defined case management as “an array of activities coordinated

through regular interaction with clients wherever they may be found to assure

service needs are met. These include, but are not limited to, assessment and

evaluation, continuous service planning, advocacy, benefits acquisition, and

service linkage and monitoring” (RFA AA-90-01, p. 8).

Each project conceptualizes the structure and intensity of its case management

model in a different way than the others, based in part on organizational

philosophy and in part on local resources. Consequently, this chapter is not

able to present a single model that adequately describes all the interventions

209
being implemented in this program; it does describe and define some of the

structural and functional dimensions across which the different programs vary.

More detailed descriptions of each project’s proposed intervention and

evaluation design can be found in “Synopses of Cooperative Agreements for

Research Demonstration Projects on Alcohol and Other Drug Abuse Treatment

for Homeless Persons”’ (National Institute on Alcohol Abuse and Alcoholism

1991a).

Dimensions of Case Management Models

Caseload refers to the number of clients for whom a given case manager is

responsible. In the Cooperative Agreement program, the caseloads tend to

average 14 to 15 clients per worker. However, in some projects caseloads

are considerably smaller, in anticipation that individual client needs will be

extensive. For example, case managers in the residential treatment component

at the Los Angeles project carry a caseload of two dually diagnosed clients, and

case managers in the New Haven project have a caseload of five cocainedependent individuals. In contrast, a case manager at the Newark project,

where a model of intensive case management is being compared with a public

welfare casework model, is responsible for 30 clients.

Duration refers to the length of time a case manager is responsible for serving a

particular client. This may be time limited or ongoing. Four of the Cooperative

Agreement projects provide duration of service for 3 to 4 months; and six

projects provide a case management duration of 12 months or longer. Several

of the latter were intended to be ongoing or indefinite interventions, but the

funding and evaluation constraints of a 3-year demonstration program forced

the determination of an endpoint for the case management services that may

be somewhat arbitrary.

Team structure refers to two aspects of the manner in which the case

management team works with the clients. The first aspect reflects whether

the case management staff takes an individual approach in which each case

manager works exclusively with a particular set of clients or takes a team

approach in which any client can be served by any staff member. Typically,

the Cooperative Agreement projects employ the individual approach. One

interesting variation occurs in the Denver project, which utilizes dyads

consisting of a primary case manager and a co-case manager; each dyad is

responsible for 17 clients. A second aspect of team structure highlights the

generalist vs. specialist dimension. In the generalist model, all case managers

perform the same types of activities with and for each of their clients, whereas

in the specialist model, certain staff members perform specific tasks in a

particular area for all appropriate clients, such as applying for entitlement

210
programs like Supplemental Security Income or food stamps and creating

linkages to housing or vocational training opportunities.

Direct provision of treatment is a dimension that reflects whether the case

managers’ responsibilities are limited to traditional case management functions,

such as treatment planning, linkage, and advocacy, or whether the staff

provides more direct services and treatment, either in addition to or in lieu of

the traditional tasks. The projects in the Cooperative Agreement program are

implementing models that draw on both variations of this dimension. About

half the projects employ case managers to provide direct services and about

half do not. In fact, the Washington, DC, project is comparing the effectiveness

of a model that calls for provision of alcohol and other drug treatment provided

by case managers with a model in which the case managers provide more

indirect linkage services.

Another important dimension concerns the qualifications of the workers.

Again, there is broad variation among the Cooperative Agreement projects.

For example, some projects require that case managers be professionally

trained, hold an advanced degree, or be otherwise credentialed, whereas other

projects do not want professionally trained staff members for these positions.

Other projects seek a balance between credentialed and noncredentialed

workers. Similarly, some projects prefer that the workers be recovering

persons, and some require that workers reflect the specific cultural and ethnic

background of the target population and setting. Other projects have no

preferences or requirements in those regards. The levels of previous case

management experience that are required or preferred by the project also vary

across the 14 Cooperative Agreement sites. In fact, one project finds that staff

members with no experience are easier to train to implement an innovative

model of case management.

The location of the client-case manager interactions is another dimension on

which the different models vary. For example, case managers may meet with

their clients out on the street, either by appointment or by happenstance, or

they may meet in an office setting. If they do meet in an office, it may be part

of the clients’ residential setting or it may be located in a facility that is physically

separate from the residential aspects of the project.

The dimensions described in the section above are representative of the case

management models being implemented by the 14 Cooperative Agreement

projects. As the evaluations progress over the course of the demonstration

program, other dimensions may prove to be key aspects of effective case

management models.

211
BARRIERS TO PROGRAM IMPLEMENTATION

The Cooperative Agreement projects received funds in September 1990. At

the time of this writing, they have spent approximately 18 months implementing

the case management models that they proposed in their original applications,

including up to 9 months for startup activities. The projects have encountered

obstacles to implementation, some of which have resulted in modifications to

the original program designs. Some of the more commonly experienced

obstacles are described below.

Inadequate Program Articulation

Because the Cooperative Agreement program provided support for new

treatment interventions only or for expansions of services to substantially new

populations, many project sites lacked prior experience in the provision of case

management services, especially for homeless persons with alcohol or other

drug problems. In addition, at that time the existing literature on the provision

of case management services pertained mostly to homeless persons with a

chronic mental illness. Consequently, few of the proposals specified a clear

and descriptive explication of what they really intended to do regarding case

management for homeless persons with alcohol and other drug problems.2

When the projects began to implement their models in the field, much time had

to be expended in operationalizing a concrete set of procedures and activities.

Staffing Issues

Staffing issues can have potent effects on program implementation. Projects

in the Cooperative Agreement program have encountered staffing problems in

several areas. Some projects have had difficulties with initial staff recruitment

due perhaps to relatively low salaries being offered for case managers or the

specification of certain requirements such as being in recovery or representing

a particular cultural background. Some have encountered problems with

staff training: Very few available staff members have had previous training

or experience both in homelessness issues and in alcohol and other drug

treatment. Excessive staff turnover, which is not uncommon in the highly

labor-intensive atmosphere of case management programs, especially during

the early stages of startup, can be disruptive, both in terms of the effect on the

morale and sense of well-being of both the clients and staff and in terms of the

need for constant training of new staff members. Some projects have found

staff members to be very uncomfortable working with homeless persons, or

they may have unrealistically high expectations of client behaviors and become

discouraged with their perceived lack of client progress, especially if they have

not had much exposure to this type of client.

212
Gaps in Existing Service Systems or Unanticipated Loss and Degradation

of Available Resources

In some instances, the Cooperative Agreement projects discovered that the

local, community-based service system did not resemble what had been

expected. For example, the Washington, DC, project originally proposed

implementing and assessing two different intensive case management models

for clients with a dual diagnosis of chronic mental illness and alcohol and other

drug abuse. Under the first model, the clients would receive alcohol and other

drug treatment from the case managers on staff at the project site; under the

second model, the project’s case managers would arrange for clients to receive

alcohol and other drug treatment services at outside agencies. Unfortunately,

the project discovered that, contrary to expectations, adequate alcohol and

other drug treatment services for dual-diagnosis clients could not be located

outside the host agency. The design quickly was modified, and the project

has implemented a program that compares a model of case manager-provided

recovery services with a model that concentrates on developing more intensive

social network support systems for the clients. Although this redesign was

executed very quickly, extensive program modifications can entail a timeconsuming delay in implementation.

In other communities, the level of existing services has been unexpectedly

reduced across the entire State, county, or locality. For example, the host

agency of another of the Cooperative Agreement project sites lost a substantial

portion of its State funding. This reduction did not affect the NIAAA-funded

project directly, but it did disturb many of the ancillary programs in which the

project clients participated. Future reductions are not unlikely, given the current

fiscal and political environment. Even if the cuts do not affect these projects

in a direct manner, they probably would serve to reduce the richness of the

service environments in which the projects are embedded and to lessen the

chances that fiscal support for the demonstration programs would be provided

by local sources after the Federal funding period has ended.

Systems Linkage Issues

As described earlier, one of the secondary objectives of the Cooperative

Agreement program was for projects to work toward increasing the

coordination and linkages among the various community agencies that

may be serving homeless persons with alcohol and other drug problems.

At the present time, the projects are typically at the stage of development in

which the basic internal startup issues have been mastered, and they are now

attempting to solidify viable working relationships with other local agencies and

institutions. Nevertheless, this has not proved to be as simple as anticipated.

213
For example, many of the projects are either new entities or more established

institutions expanding into an area that is relatively new for them, and therefore,

they may not be aware of local political conditions. Consequently, the entities

may act in ways that could cause the existing social service agencies to view

them as potential competitors for scarce local resources. Even a wellestablished and politically sawy organization may be perceived as encroaching

or expansive when it seeks to provide new services to clients whom it has not

previously served.

One ramification of the competition issue is that some of the Cooperative

Agreement projects have not been obtaining the number of client referrals

from other local social service agencies that they had predicted. Several

factors may contribute to this occurrence. In some cases, the Cooperative

Agreement project managers and line staff may be relatively unknown to,

and therefore not completely trusted by, the broader referral network that

deals with homeless persons. Thus, they receive few or no referrals. This

situation may be exacerbated by the reluctance of some service providers

and referral sources to accept the random assignment of clients to intervention

groups that is an integral part of the program design in the 14 Cooperative

Agreement projects. The possibility of assignment to a no-treatment control

group is perceived to be even less desirable when the level of available

services in the local community is very low. Furthermore, some of the

Cooperative Agreement projects have eligibility requirements that are very

narrowly focused, and they are finding fewer potential participants that meet

all the screening criteria.

In other cases, the Cooperative Agreement projects have found that certain

idiosyncracies of the existing referral and service system have a dampening

effect on their client flow. For example, one project discovered that one of the

shelters in which their program was being implemented had a reputation on the

street of being extremely intolerant of current or former alcohol and other drug

users. Consequently, potential clients were extremely reluctant to admit alcohol

and other drug use during their screening interview for fear of being judged

unacceptable for shelter placement. At the same time, this reluctance resulted

in clients being assessed as ineligible for the Cooperative Agreement project

when they were within the eligibility guidelines.

Whatever the reasons for the unexpectedly low flow of potential clients, nearly

all the projects in the Cooperative Agreement program have found that more

active outreach and engagement activities needed to be developed as part of

their program implementation. Typically, these have focused on the client level,

but many projects have also instituted interventions at the service system level

that would facilitate tapping into an already existing client base.

214
EVALUATION OF THE COOPERATIVE AGREEMENT PROJECTS

Evaluation is an integral component of the Cooperative Agreement program.

Each of the 14 projects is committed to conducting extensive outcome and

process evaluations at the individual site level and to participating in a national,

multisite evaluation. A major component of these evaluations will be tests of

the effectiveness of the various intervention programs, including the models of

case management that are being implemented. Details of the evaluation are

presented below.

Outcome Assessment

At the heart of the outcome evaluations, at both the individual and multisite

levels, is the core battery of assessment instruments that each project is

required to utilize. (A detailed explanation of the core battery is beyond the

scope of this chapter, but additional information may be obtained from the

primary author.) The battery comprises the Addiction Severity Index (ASI)

(McLellan et al. 1985), the housing portions of the Personal History Form

(PHF) (Barrow et al. 1985), and the Alcohol Dependence Scale (Horn et al.

1984). The ASI and the PHF both have been modified extensively by NIAAA

to make them more appropriate for use with the population of homeless persons

with alcohol and other drug problems and to better fit the requirements of the

Cooperative Agreement program. Reliability and validity studies of the modified

instruments are being conducted at both the individual and the multisite levels.

In addition, NIAAA has provided extensive training in the administration of the

core battery of instruments to research assessment staff members at the project

sites. A national training workshop was held for all the assessment supervisory

personnel, and an onsite training workshop was conducted for the assessment

line staff at every project site. At the time of this writing, additional followup

training workshops have been provided to two project sites.

Implementation Assessment

The implementation of the case management models at each project site is

assessed with several methods. One strategy is based on the development

of detailed logic models for all the components of each project. Several editions

of the logic models have been, or will be, prepared. The initial logic model

is based on the originally proposed program, and subsequent versions will

reflect the evolution of the program design as it is implemented over the course

of 3 years. Other methods of assessing program implementation include a

quantitative instrument developed by NIAAA, the Quarterly Report Form

(QRF) (National Institute on Alcohol Abuse and Alcoholism 1991b ), regularly

scheduled qualitative assessments (comprehensive investigative telephone

215
calls to each project site at least five times per year), and other episodic

formal and informal methods (conversations between project site-level and

national-level staff during regularly scheduled working group meetings of the

Cooperative Agreement investigators in Bethesda, MD, and requests from

individual projects for technical assistance on a particular issue). These

assessment methods are each well suited for a more focused examination

of the case management models being implemented by the projects.

The QRF is key to the implementation assessment. NIAAA expects that

both the quantitative and qualitative information gathered with this instrument

will be extremely valuable. The QRF should be able to reveal precisely what

components of the various case management models were implemented and

to what degree. These data then can be linked with the more quantifiable

outcome data being collected elsewhere and, ideally, will provide the

opportunity to isolate what are the “active ingredients” of case management

and determine their effectiveness in treating homeless persons with alcohol

and other drug problems.

The foundation of the QRF is the “Glossary of Service Activities for Alcohol

and Other Drug Abuse Treatment of Homeless Persons” (National Institute

on Alcohol Abuse and Alcoholism 1991 c). This glossary represents an

extensive revision of an earlier taxonomy of services (National Institute on

Alcohol Abuse and Alcoholism 1989) used in the first round of Community

Demonstration projects. The glossary was developed by staff of NIAAA

and R.O.W. Sciences, Inc., with major guidance and advice from a specially

convened expert technical advisory panel. The glossary defines 39

specific services that have been organized into 7 broad service categories:

(1) services planning and monitoring, (2) alcohol and other drug abuse

treatment services, (3) mental health services, (4) services and benefits

acquisition and coordination, (5) prevocational and vocational training,

(6) health care, and (7) other services. These services can be provided

in one or more of the following seven different service settings: (1) outpatient,

(2) street, (3) residential treatment, (4) ADF housing, (5) shelter,

(6) independent housing, and (7) other.

The QRF combines these service types and service settings to form a matrix

that can describe whether a particular client receives a particular service in a

particular setting. The matrix also designates the provider of the service, using

one of the following categories: case manager, addictions counselor, other

provider, case manager and addictions counselor, case manager and other

provider, addictions counselor and other provider, case manager and addictions

counselor and other provider, and provider unknown.

216
Another section of the QRF describes program implementation at the project

level. For each major project objective (including case management services)

this section describes progress toward achieving the objective during the

past quarter, the presence of any barriers to achieving the objective, and

approaches that were employed to overcoming the barriers. A final section

of the QRF presents a detailed and cumulative flow chart of the project’s clients

during the entire project period. NIAAA uses this flow information to track the

enrollment, retention, graduation, and followup rates of the project participants.

The QRF is completed by program and evaluation staff at each of the project

sites. QRF data are submitted to NIAAA on a quarterly basis. Nine of the

projects are submitting these data with the standard QRF, which records the

absence or presence of a particular service for a particular client in a particular

setting during the reporting period. The other five projects are employing a

more comprehensive, alternate version of the QRF, which records the units of

service that clients have received in each category of service type and setting.

An additional instrument, the Treatment Services Interview (TSI) (National

Institute on Alcohol Abuse and Alcoholism 1991 d), developed as an adjunct

to the QRF, is a brief client interview form designed to assess the client’s use

of treatment services from all sources during the preceding 60 days. All the

data in the TSI are based on the client’s self-report and are expected to

complement the data obtained with the QRF.

CONCLUSION

The NIAAA program of Cooperative Agreements for Research Demonstration

Projects on Alcohol and Other Drug Abuse Treatment for Homeless Persons

builds on the earlier round of Community Demonstration projects supported

by NIAAA and represents a more sophisticated effort to implement and

evaluate different models of case management interventions for this population.

The program provides a graphic example of how various models of case

management have been operationalized in different ways across the project

sites. Although at the time of this writing the projects are still in the early stages

of implementation, NIAAA expects to learn a great deal about the effectiveness

of case management interventions for homeless persons with alcohol and other

drug problems. A final multisite, national evaluation report is expected in fall

1994, but prior to that, NIAAA will sponsor various monographs, technical

papers, and research conferences to disseminate the important information

that this program will yield. In addition, each of the 14 Cooperative Agreement

projects will be publishing descriptions and evaluations of their individual

interventions in the scientific literature.

217
NOTES

1. This document and the other NIAAA publications cited in this chapter are

available through the National Clearinghouse on Alcohol and Drug

Information (1-800-729-6686).

2. This also was due in part to the limited page constraints of the application

form for US. Public Health Service funding.

REFERENCES

Barrow, S.M.; Hellman, F.; Lovell, A.M.; Plapinger, J.D.; Robinson, C.R.; and

Streuning, E.L. Personal History Form. New York: New York State

Psychiatric Institute, 1985.

Horn, J.L.; Skinner, H.A.; Wanberg, K.; and Foster, F.M. Alcohol Dependence

Scale. Toronto: Addiction Research Foundation of Ontario, 1984.

McLellan, A.T.; Luborsky, L.; Cacciola, J.; McGahan, P.; and O’Brien, C.P.

Guide to the Addiction Severity Index: Background, Administration, and Field

Testing Results. DHHS Pub. No. (ADM)85-1419. National Institute on Drug

Abuse. Washington, DC: Supt. of Docs., US. Govt. Print. Off., 1985.

National Institute on Alcohol Abuse and Alcoholism. Synopses of Community

Demonstration Grant Projects for Alcohol and Drug Abuse Treatment of

Homeless Individuals. Rockville, MD: National Institute on Alcohol Abuse

and Alcoholism, 1988.

National Institute on Alcohol Abuse and Alcoholism. Services for Homeless

People With Alcohol and Other Drug Problems: A Taxonomy for Reporting

Data on the Utilization of Services and on Systems Level Linkage Activities.

Contract No. (ADM)281-88-0003. Rockville, MD: National Institute on Alcohol

Abuse and Alcoholism, 1989.

National Institute on Alcohol Abuse and Alcoholism. Glossary of Service

Activities for Alcohol and Other Drug Abuse Treatment of Homeless Persons.

DHHS Pub. No. (ADM)91-1847. Rockville, MD: U.S. Department of Health

and Human Services, U.S. Public Health Service, Alcohol, Drug Abuse, and

Mental Health Administration, 1991c.

National Institute on Alcohol Abuse and Alcoholism. Quarterly Report Form.

Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1991b .

National Institute on Alcohol Abuse and Alcoholism. Synopses of Cooperative

Agreements for Research Demonstration Projects on Alcohol and Other Drug

Abuse Treatment for Homeless Persons. DHHS Pub. No. (ADM)91-1763.

National Institute on Alcohol Abuse and Alcoholism. Rockville, MD: U.S.

Department of Health and Human Services, U.S. Public Health Service,

Alcohol, Drug Abuse, and Mental Health Administration, 1991a.

218
National Institute on Alcohol Abuse and Alcoholism. Treatment Services

Interview. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism,

1991 d.

AUTHORS

Harold I. Perl, Ph.D.

Public Health Analyst

Homeless Demonstration and Evaluation Branch

Division of Clinical Prevention Research

National Institute on Alcohol Abuse and Alcoholism

Parklawn Building, Room 13C-06

5600 Fishers Lane

Rockville. MD 20857

Mary Lou Jacobs, M.S.W.

Programmatic Area Task Leader

R.O.W. Sciences, Inc.

Suite 500

5515 Security Lane

Rockville, MD 20852

219
APPENDIX 1. List of Cooperative Agreement sites, by site location, project

title, and principal investigator

ALBUQUERQUE, NM

Substance Abuse Treatment

Programs for Homeless Persons

Sandra Lapham, M.D.

Director

Substance Abuse Research Programs

Lovelace Medical Foundation

Suite 302

1650 University Towers Building

Albuquerque, NM 87102

(505) 246-2403

BIRMINGHAM, AL

Comparative Substance Abuse

Treatments for the Homeless

Jesse Milby, Ph.D.

Professor of Medicine and Psychology

University of Alabama at Birmingham

Medical School

700 South 19th Street

Birmingham, AL 35205

(205) 934-8960

CHICAGO, IL

Demonstration of Case Management

and Supported Housing

Michael Sosin, Ph.D.

Professor

University of Chicago

School of Social Service

Administration

969 East 60th Street

Chicago, IL 60637

(312) 702-1129

DENVER, CO

Intensive Case Management for

Homeless Substance Abusers

G. Nicholas Braucht, Ph.D.

Professor and Chairman

Department of Psychology

University of Denver

2155 South Race Street

Denver, CO 80208

(303) 871-3701

EVANSTON, IL

Case-Managed Residential Care for

Homeless Addicts

Kendon Conrad, Ph.D.

Research Assistant Professor

Northwestern University

629 Noyes Street

Evanston, IL 60208

(708) 491-2192

LOS ANGELES, CA

Evaluation of Treatment Options for

the Dually Diagnosed

M. Audrey Burnam, Ph.D.

Senior Behavioral Scientist

The RAND Corporation

1700 Main Street

Santa Monica, CA 90407-2138

(301) 393-0411, ext. 6370

220
NEW HAVEN, CT

Research on Services for Homeless

Substance Abusers

James F. Jekel, M.D., M.P.H.

CEA

Winslow Professor of Epidemiology

and Public Health

Yale University School of Medicine

P.O. Box 3333

60 College Street

New Haven, CT 06519

(203) 785-2849

PHILADELPHIA, PA

Assessing Treatments for Homeless

Poly-Addicted Men

Thomas E. Shipley, Jr., Ph.D.

Professor

Department of Psychology

Temple University

Broad Street and Montgomery Avenue

Philadelphia, PA 19122

(215) 787-7458

NEW ORLEANS, LA

New Orleans Homeless Substance

Abuse Project

James D. Wright, Ph.D.

Charles A. and Leo M. Farrot

Professor of Human Relations

Department of Sociology

Tulane University

Newcomb Hall 220

New Orleans, LA 70118

(504) 865-5820

NEWARK, NJ

Homelessness, Substance Abuse: An

Investigation of Two Interventions

John Franklin, M.D.

Assistant Professor

Department of Psychiatry

University of Medicine and Dentistry

ADMC-1408

30 Bergen Street

Newark, NJ 07103-7000

(201) 456-6431

SEATTLE, WA

Intensive Case Management for

Chronic Public Inebriates

Gary Cox, Ph.D.

Research Associate Professor

Department of Psychiatry and

Behavioral Sciences,

XD-45

University of Washington

Seattle, WA 98195

(206) 543-3555

ST. LOUIS, MO

Substance-Abusing Homeless

Families: Breaking the Cycle

Elizabeth M. Smith, Ph.D.

Associate Professor

Washington University School of

Medicine

4940 Audubon Avenue

St. Louis, MO 63110

(314) 362-2587

221
TUCSON, AZ

Southern Arizona Alcohol/Drug

Program for the Homeless

Sally Stevens, Ph.D.

Director

Amity Settlement Services

47 East Pennington

Tucson, AZ 85701

(602) 741-7574

WASHINGTON, DC

Washington, DC, Homeless

Dual-Diagnosis Project

Robert Drake, M.D., Ph.D.

Associate Professor

Department of Psychiatry

Dartmouth Medical School

Suite 202

Two Whipple Place

Lebanon, NH 03756

(603) 448-0126

222
Integrating Qualitative and Quantitative

Components in Evaluation of Case

Management

Mark L. Willenbring

INTRODUCTION

Social workers are fond of pointing out that case management is a rediscovery

of the casework they have been doing all along, and in many ways this view is

correct. As the complexity of human problems society confronts has increased,

service providers have turned to case management in an attempt to coordinate

and organize an often-fragmented system of care. Something similar can be

said about a recent shift toward qualitative program research, especially applied

ethnography. Although not so long ago the emphasis seemed to be more on

quantitative outcome methods, program evaluations have been turning more to

qualitative methods to try to bring some order and meaning to what may be

incomplete or incomprehensible quantitative results. Although anthropologists

and other social scientists may understandably complain about the belated

nature of this attention, it is nevertheless a welcome change.

However, integrating data from an ethnography performed coincidentally

with a randomized, controlled treatment comparison is not a simple task.

Unfortunately, qualitative and quantitative researchers have tended to divide

into competing camps, so this kind of integrated approach is not commonplace.

It is to the credit of the National Institute on Drug Abuse and the National

Institute on Alcohol Abuse and Alcoholism (NIAAA) that they have encouraged

this recent development in a variety of research demonstration projects. Having

recently participated in such a project in which the investigators attempted to

integrate qualitative and quantitative approaches (and being a recent convert to

qualitative approaches), the author would like to share some observations on

this process. In doing so, I shall illustrate more general points with specific

examples from our project.

Before describing the project, however, I wish to emphasize the important

distinction between program philosophy as articulated by the planners and staff

223
of the program and a description of the program activities that the staff engages

in. As noted elsewhere (Willenbring et al. 1991; Ridgely and Willenbring, this

volume), this distinction is not always obvious, and program philosophy is often

described in lieu of measurement of the intervention process itself. Because it

is in describing program interventions that a combination of quantitative and

qualitative methods is particularly helpful, this chapter begins with a brief

discussion of this contrast. Readers impatient with this more conceptual

discussion may wish to skip to the following, more pragmatically oriented

sections and return to this section as needed for clarification.

OVERALL EVALUATION STRATEGY

The Importance of the Program Concept

As Ridgely and Willenbring (this volume) point out, the first step in quantitative

measurement of case management involves separating program philosophy

and goals from the daily activities engaged in by case managers. Although

this may seem obvious to some, in practice it may be difficult to keep the two

separate. Program philosophy, principles, and goals (the term “program

concept” will be used hereafter to refer to this combination) should ideally direct

the implementation of the program. The program concept is the “blueprint” that

will be used by managers to direct the implementation of the program. Because

program concept includes a statement of the goals of the program, it is the

reference point for determining how closely the program that is eventually

developed fits what was planned. Program concept also must contain some

direction (in the form of principles or values) concerning how these goals should

be met. A program might have a goal of providing drug abuse treatment

services to homeless women and children. The program principles may specify

further that these services are to be provided in a way that maximizes client

input and preference and minimizes any coercive components.

Values and goals are usually articulated by funders and policymakers. For

example, program managers within human service organizations take direction

from administrative superiors, who in turn answer to a board of directors, a city

council, or legislators (figure 1).

Program concept cannot be simply a statement of principles, although principles

constitute an important part of the concept. Like a blueprint for a building, the

concept must include structural details, including what resources (e.g., staff)

will be needed and how they are to be assembled to achieve the final structure.

This blueprint must include not only the characteristics of the staff members to

be recruited for the case management team, but also a clear description of

what kind of activities they will engage in and how they will do so. That is,

224
FIGURE 1. The process of program development, modification, and

evaluation

program concept should be the guide that is used to decide which primary

case management functions will be stressed and which additional functions

will be used. It should guide the team structure (individual primary caseloads,

full-team sharing of caseload, mixed models) as well as the more continuous

dimensions of intensity (caseload, visit frequency), scope (broad, narrow),

and length (brief, indeterminate). (Functions and dimensions referred to here

are discussed at greater length in Willenbring et al. 1991 and Ridgely and

Willenbring, this volume.) Program concept, then, is the key factor in program

design, and an understanding of the concept is essential for evaluation as well

225
Unfortunately, program concept is often too brief or incomplete. A common

mistake is to focus on philosophy or goals without articulating the relationship

between them and program structure. Another mistake is failing to take into

consideration the existing system of care and how the new program will fit into

it. A third mistake is failing to articulate how the program as conceptualized is

expected to result in the goals desired.

Although it is the role of the program manager to develop the concept, it is

the role of the evaluator to determine what the program concept is in the

minds of the managers or planners. This includes determining how complex

or sophisticated it is and whether it contains both statements of principle and a

structural “blueprint” for the team(s) as well as the goals of case management.

For experimental or quasi-experimental designs, the evaluator must clearly

have in mind the program concepts of all comparison interventions. Only

through understanding the program concept can the evaluator determine (1) the

similarity of the program implemented to the one planned and (2) the success

of the program in achieving its goals. For experimental designs, a related issue

is whether the comparison interventions differed and, if so, whether they

differed in the ways planned.

Evaluators can often help program planners and managers to articulate their

programs more clearly, especially if the evaluators are included in the planning

process and if they are aware of what questions to ask. Filling out a table

similar to table 1 (discussed below) may prove beneficial. For a more complete

discussion of classification of case management models, the reader is referred

to Willenbring and colleagues (1991).

Elsewhere in this volume, Ridgely and Willenbring emphasize the importance of

describing and measuring the program as implemented, specifying the activities

engaged in by the case managers, without reference to program philosophy or

concept. The foregoing discussion of program concept might be taken to

suggest that such measurement could be supplanted by explication of the

program philosophy. This should not be the case, however, because a good

program concept includes reference to the structure and function of the program

as well as to its goals and principles. Although it is possible to describe a case

management program without any knowledge of the program concept, it is not

possible to determine program success (i.e., outcome) without reference to the

original goals of program development. Therefore, a well-articulated program

concept helps both program implementation and evaluation.

226
The CTCPI Program Concept

The Community Treatment for the Chronic Public Inebriate (CTCPI) project

began in 1983 in a subcommittee of the Minneapolis Advisory Committee

on Alcohol and Drug Problems. During a 2-year fellowship at the University

of Wisconsin, Madison, the author had been exposed to the Program for

Assertive Community Treatment/Training in Community Living (PACT/TCL)

approach to community treatment of persons with severe and persistent mental

disorders (Stein and Test 1980). After moving to Minneapolis, I became

involved with the Minneapolis Advisory Committee, and several members

of this committee met over a period of 2 years to develop some ideas about

adapting the “Madison Model” to treat chronic public inebriates, or skid row

alcoholics. In 1985-86, with the financial support of the Minnesota Department

of Human Services Chemical Dependency Division, the Minneapolis Mayor’s

Office, the Minneapolis Police Department, and the Minneapolis Foundation

and with the cooperation of the Hennepin County Chemical Health Division,

the committee asked the Minnesota Institute on Public Health to study the

feasibility of providing case management to public inebriates, using a prepaid

capitation model (similar to health maintenance organizations). Service

utilization patterns, costs of service, and attitudes and beliefs of a random

sample of 43 subjects were examined in this study. The results of the feasibility

study were published as “Borrow Me a Quarter” (Neuner and Schultz 1986).

The study concluded that the concept of intensive case management for public

inebriates was feasible and should be explored further. It was estimated that

a 10- to 15-percent reduction in service utilization (a reasonable goal) would

offset the cost of case management. A capitation approach to payment was not

considered feasible because of the very high and unpredictable costs of service

for this population and the lack of an offsetting large group of low-use clients.

The “Borrow Me a Quarter” study formed the basis for application first to the

Robert Wood Johnson Foundation and then to NIAAA for funding for a largescale demonstration project. In the first application, the intent was to compare

the efficacy of intensive case management against episodic care only, using a

randomized trial design with two groups. For the NIAAA application, two major

changes were made in the design of the study. The first concerned eligibility of

subjects; the Request for Proposal specified that the target population had to be

homeless or imminently homeless persons. In making this change, the extent

of homelessness in the public inebriate population was miscalculated as higher

than it actually was. This error had the effect of selecting for the most severely

disordered subjects and also narrowed the range of clients served. The

feasibility study had focused on frequent utilizers of detoxification centers, not

all of whom were homeless. Thus, although it was not immediately apparent,

this selection change altered the applicability of our model of case management

227
to the subject population. The second change followed on the first: Under a

Health Care for the Homeless Program grant, three case managers were

available to start at about the same time as the NIAAA grant, so this group was

added as a third comparison group, intermediate-level case management.

Funding by NIAAA was granted to the Hennepin County Chemical Health

Division under the Stuart B. McKinney Act for research demonstration projects

for homeless persons with alcohol and other drug problems in 1987. Funding

was initially for a 2-year period; a third year was eventually awarded under a

competitive renewal process.

The final CTCPI project was a randomized, controlled trial comparing the

effectiveness of three levels of intensity of case management: intensive (ISV)

(caseload=12), intermediate (IMD) (caseload=40 to 50), and control (CTL). CTL

group members received whatever services were generally available. These

typically included an opportunity to talk with a counselor when admitted to the

detoxification center and minimal levels of case management if they were

receiving economic assistance payments of some sort. In the CTL group, case

management, if provided at all, tended to be episodic, brief, and minimal in

scope. Effectiveness was defined as a reduction in service utilization and costs

and an improvement in quality of life. Subjects consisted of 260 male public

inebriates; public inebriety was defined as having 15 or more admissions to the

Hennepin County Alcohol Receiving Center, being unemployed and/or on public

welfare, and having a history of failure to respond to conventional alcohol and

other drug treatment. Subjects also had to meet the Federal definition of

homeless or imminently homeless.

Both the ISV and IMD case management programs were designed to be

comprehensive in scope, tolerant of continued drinking, focused on providing

subsistence needs and improving overall function, and indeterminant in length.

The ISV program, modeled after the PACT/TCL case management model,

was also designed to be street-oriented, assertive case management. Case

managers were encouraged to be creative in providing whatever they felt their

clients needed and to spend considerable time in the field with clients. The IMD

group used the standard Hennepin County guidelines for case management,

which emphasized comprehensive scope, coordinating care, providing care in

the least restrictive way possible, and maximizing client input and choice. The

IMD group, although doing some work in the field, was by necessity and design

meant to be more office based than the ISV group. Because American Indians

constituted a significant proportion of chronic public inebriates in Hennepin

County, both programs made an effort to hire American Indian case managers.

Case managers generally were trained at the bachelor’s degree level or

somewhat less; some had social work backgrounds; and others were trained as

chemical dependency counselors. All case manager positions were entry-level

228
TABLE 1. Characteristics of comparison groups in the CTCPl program

Characteristic

Intensity

Staff:client ratio

Typical visit

frequency

Contact time

Scope

Site

Team structure Modified Team

Case manager

training

Duration

Availability

Consumer direction

Treatment goals

ISV

Intense

High (1:12)

Daily-weekly

High (up to several

hrs/wk)

Comprehensive

Field oriented

BA or CD certificate

Indefinite

M-Sat, day hours,

walk-ins

Maximize client

input, professional

decides

Improve function,

reduce morbidity

Functions Primary’ plus help

with daily living

and alcohol/other

drug counseling

IMD

Moderate

Moderate (1:45)

Weekly

Moderate (several

hrs/mo)

Comprehensive

Office based

Modified team

BA

Indefinite

M-F, less open

to walk-ins

Maximize client

input, professional

decides

Improve function,

reduce morbidity

Primary only

CTL

Minimal

Low (1:75 to 100,

when available)

Infrequent

Low

Narrow

Specific site and

program

Varies

Varies

Time limited

Varies

Unknown

Varies

Varies

*Primary functions include outreach, assessment, planning, linkage, monitoring, followup,

and client advocacy. Additional possible functions include direct service provision,

system advocacy, and so on. See Willenbring and colleagues (1991) for a full

discussion of these concepts.

KEY: BA=bachelor’s degree; CD=chemical dependency

229
positions. The ISV program had five case managers and a full-time, master’slevel unit supervisor. The IMD program had three case managers and a parttime, master’s-level unit supervisor. The three groups are compared and

contrasted in table 1.

CTCPI Evaluation Strategy

Once the program concept has been clearly elaborated, the evaluation

strategy can be planned. The goal of the process evaluation is to describe

the implementation process and the intervention(s); the outcome evaluation

determines how well the project met its goals.

Based on the program concept and the overall study design, an evaluation

strategy was developed in which the goals were to (1) describe program

implementation, including any changes made in the programs during the

course of the study; (2) describe and compare the two case management

programs implemented both quantitatively and qualitatively; and (3) compare

program outcomes. A brief overview of the strategy is shown in table 2 and

in the following paragraph. A more detailed discussion then follows.

The initial process evaluation consisted of a quantitative time log for case

managers, specifying the client, location, amount, and type(s) of service

provided; a significant events daily log for case managers; implementation logs

for the principal investigator (PI), evaluation director, and project director; a

case study performed by the national evaluation team assembled by NIAAA;

quarterly implementation analyses by the evaluation director; and interviews

with case managers and unit supervisors by the evaluation director. At the

suggestion of NIAAA staff members, an ethnographic component was included

in the third-year competitive renewal application. Primary outcome evaluation

consisted of examination of agency records regarding detoxification center

use, medical services, economic assistance, use of court services, and

costs or charges for such services. Secondary outcome measures included

an Addiction Severity Index (ASI) (McLellan et al. 1980) interview every 6

months for the case management groups and an interview by the ethnographer

for a subsample of all three groups.

UNDERSTANDING THE PROCESS OF CASE MANAGEMENT

Qualitative Process Measurement

Based on the program concept (the blueprint), a program IS implemented or

“constructed.” For the purpose of describing this development, qualitative

methods, such as implementation logs, interviews, and observation, are best

230
TABLE 2.

Goal

Process

Evaluation

Outcome

Evaluation

Evaluation strategy for the CTCPI project

Qualitative Measures

Implementation logs (PI, ED, PD)

Quarterly implementation reports (ED)

Significant events logs (CM)

Interviews of CM staff (ED)

Observation of CM-client dyad and

CM teams (ETH)

Interview with clients and CMs (ETH)

Interviews with clients (ETH)

Quantitative Measures

Time logs (CM)

Structured interviews

(ETH)

Service agency

records of utilization

and charges (ED)

ASI (CM)

KEY: PI=principal investigator, ED=evaluation director, PD=project director,

CM=case manager, ETH=ethnographer, ASI=Addiction Severity Index

(implementation analysis) (Brekke 1990). Such methods should emphasize

the process of implementation itself, especially any barriers encountered,

responses to these barriers, the effectiveness of the responses, and ways in

which the implemented program differed from the original program concept.

These techniques will be contrasted below, using specific examples from the

CTCPI project.

In CTCPI, implementation logs were to be kept by the PI, evaluation director,

and project director and were to reflect the day-to-day experience of program

implementation. In practice, it proved difficult to keep the logs. People were

not in the habit of keeping logs, and there was no way to build in an external

incentive (like tying log completion to evaluations or paychecks). Weekly

interviews were easier to obtain (they could be scheduled), and these resulted

in regular data collection. Minutes from other regularly scheduled meetings

were also useful. Minutes were often written during a meeting (whether with

two or several people) by one of the participants and then copied or otherwise

shared with others. Finally, the single most useful type of ongoing narrative

was a quarterly implementation analysis required for the national evaluation

by the funding agency and written by the evaluation director. Based primarily

on interview notes and meeting minutes, a draft was shared with the other

participants, and their comments were incorporated prior to submission. These

quarterly reports were then available for the final implementation analysis at the

end of the project.

231
As noted above, interviews with other project managers were very useful as

substitutes for logs kept by each participant. Interviews of case management

staff members also proved helpful. First, interviews could determine whether a

program concept was shared by members of a team. If so, this “actual” concept

could then be contrasted with the original concept, as well as with the “actual”

concepts in comparison groups. Second, a working model of a particular case

management method could be developed. That is, through the descriptions of

each case manager, it could be determined how each approached an individual

case and how each manager saw the team working together (or not, as the

case might be). These interviews also provided a longitudinal history of various

changes that occurred. For example, unit supervisors in both programs were

replaced during the project. In both cases, the replacements were experienced

by case managers as changing the working model or method in significant

ways. Interestingly, both teams experienced the changes as resulting in loss of

freedom and creativity in favor of greater bureaucratization. On one team, what

had been a disparate group of case managers working more or less individually

became a unified team that felt united against the new unit supervisor, who was

viewed as enforcing new, “rigid” rules.

The interviews with staff members were supplemented with interviews

with clients about services received, including case management. Additional

data were collected from both case managers and clients concerning their

perceptions of a particular interaction that was also observed by the

ethnographer. Structured interview schedules were used to facilitate

standard data collection practices and data analysis. These data generally

confirmed that the top priorities for both case managers and clients were

meeting subsistence needs, particularly shelter (table 3). However, case

managers typically saw themselves as providing more services than the

clients saw themselves receiving. In the ISV and IMD groups, case managers

saw themselves as providing more chemical health services than clients

reported receiving. However, ISV case managers saw themselves as

providing psychological and social services more often than did IMD case

managers. Clients saw themselves receiving these services relatively

infrequently from both groups. These data seemed to fit well with interview

data from the case managers, suggesting that ISV case managers had spent

much more time talking to clients and helping them in the field, especially in the

early stages of the project. It is less clear why there is a discrepancy between

the perceptions of ISV case managers and clients in terms of what services

were provided. It may be that case managers identified certain interactive

behaviors as therapeutic (e.g., counseling, social services) but that clients

defined services in a more concrete way. Whether the apparent ineffectiveness

of this service differential (that is, the fact that the additional ISV services did not

appear to yield much change) is related to the client-case manager discrepancy

is not clear.

232
TABLE 3. Assistance received from case manager, by client interview and by

case manager interview. Differences nonsignificant by analysis

unless otherwise noted. (n=20)

Variable Client

ISV

Case Manager

IMD

Client Case Manager

Shelter

Yes

No

Not applicable, not a problem

Money

Yes

No

55%

30%

Not applicable, not a problem 15%

Legal

Yes

No

Not applicable, not a problem

Physical

Yes

No

30%

50%

Not applicable, not a problem 20%

Psychological

Yes

No

Not applicable, not a problem

Chemical

Yes

No

Not applicable, not a problem

Social

Yes

No

Not applicable, not a problem

=8.5, df=2, p=0.014

=7.66, df=2, p=0.023

13 (65%)

7 (35%)

0 (0%)

11

6

3

5 (25%)

5 (25%)

10 (50%)

6

10

4

6 (30%)

9 (45%)

5 (25%)

5 (25%)

15 (75%)

0 (0%)

6 (30%)

11 (55%)

3 (15%)

15 (75%)

2 (10%)

3 (15%)

13 (65%)

5 (25%)

2 (10%)

6 (30%)

1 (5%)

13 (65%)

13 (65%)

6 (30%)

1 (5%)

13 (65%)

4 (20%)

3 (15%)

5 (25%)

6 (30%)

9 (45%)

9 (45%) 2 (10%)

6 (30%) 14 (70%)

5 (25%) 4 (20%)

9 (45%)*

3 (15%)

8 (40%)

7 (35%)

8 (40%)

5 (25%)

14 (70%)

4 (20%)

2 (10%)

12 (60%)†

3 (15%)†

5 (25%)†

9 (45%)

11 (55%)

0 (0%)

2 (10%)

14 (70%)

4 (20%)

1 1 (55%)

5 (30%)

3 (15%)

13 (65%)

1 (5%)

6 (30%)

4 (20%)

2 (10%)

14 (70%)

3 (15%)

9 (45%)

8 (40%)

1 (5%)’

6 (30%)’

13 (65%)’

12 (60%)

6 (30%)

2 (10%)

4 (20%)†

3 (15%)†

13 (65%)†

Although it was expected that Indians and whites would be significantly different

in their subsistence adaptation patterns, the interview data did not confirm

that expectation (table 4). Meeting subsistence needs appeared to be such a

pressing and urgent task that it tended to reduce the influence of other factors

that might be important under other circumstances. The ethnic matching of

233
TABLE 4. Subsistence adaptation in American Indian and white public

inebriates. Unless otherwise indicated, analysis is not

significant.

American Indian

Variable (n=25)

Sources of shelter

No answer 1 (4%)

Independent living 14 (56%)

Shelter or other non-CD placement 8 (32%)

Chemical health placement 9 (36%)

With family or friends 13 (52%)

In detox or other nonsanctioned institution 4 (16%)

Incarceration 2 (8%)

Camping out 9 (36%)

Other (e.g., “carrying the banner”) 0 (0%)

Sources of food

No answer 6 (24%)

Drop-in centers (multipurpose sites) 13 (52%)

Food lines (single-purpose sites) 11 (44%)

Food shelves 2 (8%)

Informal strategies (e.g., dumpster) 1 (4%)

Institutions 2 (8%)

Sources of money

No answer 6 (24%)

Formal sources (e.g., temp labor) 4 (16%)

Personal sources (e.g., friends, family) 5 (20%)

Informal sources (e.g., “junking,” stealing) 14 (56%)

Sources for hygiene needs

Not applicable 19 (76%)

Formal sources (e.g., drop-in centers) 5 (20%)

Personal sources (e.g., friends, family) 3 (12%)

Informal sources (e.g., outdoor bathing, sponge baths) 0 (0%)

Sources for clothing needs

Not applicable 11 (44%)

Free stores 8 (32%)

Thrift stores 6 (24%)

Case manager 4 (16%)

Other (e.g., personal) 1 (4%)

White

(n=20)

0 (0%)

10 (50%)

7 (35%)

14 (70%)

11 (55%)

7 (35%)

5 (10%)

8 (40%)

3 (15%)

3 (15%)

7 (35%)

9 (45%)

3 (15%)

4 (20%)

3 (15%)

3 (15%)

4 (20%)

3 (15%)

10 (50%)

13 (65%)

6 (30%)

1 (5%)

3 (15%)

8 (40%)

6 (30%)

5 (30%)

3 (15%)

3 (15%)

234
case manager and client similarly did not appear to be related to response to

case management.

The process of client-case manager interaction was chosen as the focus of

our interviews, and multiple perspectives were obtained on this process.

Through the use of multiple perspectives, the more individual or idiosyncratic

observations were separated out, leaving a framework of core observations

that were taken to fairly represent the case management methods used in

this study. Although it is true that other methods, such as coding of videotapes

or audiotapes, might yield more consistent results, it is often difficult in practice

to carry out this type of process research. Case management tends to be an

imprecise process, involving multiple parties in a complex process over time,

that does not lend itself to rigorous process research methods. Besides, use of

these other methods does not eliminate the possibility of biased measurement; it

merely raises a series of somewhat different questions. One never fully knows

whether the true phenomenon is being described. The use of multiple structured

or semistructured interviews with different participants in a process is one way to

control for observer bias and one that may be more feasible in field research.

Observation of case manager activity is another method that complemented the

interviews well. Observation was especially useful in comparing characteristics

of the two programs. For example, on the basis of narrative logs and interviews

alone, it was not clear that the two case management programs differed in

overall atmosphere or in presentation to the clients. There was a concern that

the two interventions might not be very different in practice. It was argued that

the IMD group might be providing intensive services to only a portion of their

clientele, rather than less service to a larger clientele.

Observation showed that the two groups differed in their overall atmosphere.

The ISV group, although located on the second floor, maintained an open, walkin type atmosphere. Coffee was available, and clients who were not severely

intoxicated or belligerent were encouraged to stop by, have coffee, and visit.

Contacts with clients were more informal and longer, and staff members other

than the primary case manager were often involved in these interactions.

Observations of case management activity confirmed that considerable time was

spent in the field. In the IMD program, on the other hand, staff offices were

located behind a closed and locked door marked “Staff Only.” Interactions with

clients were briefer and more instrumental, and drop-in, informal visits were not

encouraged. Much less time was spent in the field.

Observational data thus added new information (e.g., the atmosphere was

different between the two programs; more time was spent in the field in the

ISV program) as well as validating information obtained in other ways (e.g.,

235
most interactions were focused on subsistence needs; the representative

payee relationship served as the “glue” holding the case manager-client dyad

together). Observational data allowed for more confidence in the program

descriptions and countered erroneous beliefs by staff members who had

personally observed one team but not the other.

It is always difficult to know which of many interactions or behaviors are the

important or determining ones in a human process as complex as case

management. It is possible, for example, that the information obtained or the

contrasts noted were not relevant concerning client outcome. Similarly, there

could be important aspects that were overlooked or could not be measured,

such as the personality styles of the case managers and clients. These types

of problems are always present in some degree but should not be used to

justify not attempting to measure the interventions. The use of multiple

qualitative measures helps ensure against missing a truly significant factor.

Programs can be designed to be different in certain definable and measurable

ways. In this case, ISV was to be more intensive and field oriented, whereas

IMD was less intensive and more office based. Qualitative methods of narrative

logs, interviews, and observation confirmed that they differed in these ways

but suggested a similar focus on meeting subsistence needs. Determining

whether the focus was, in fact, similar required a quantitative method, described

below. Observation also suggested that the two groups differed in the overall

atmosphere of the team milieu, an unexpected difference that occurred as a

result of the way these particular teams developed. There was still uncertainty

about how much the time spent (intensity) differed.

Another question is whether the presence of an observer alters the phenomenon

observed to such a degree as to bias the findings. An ethnographer always

must deal with this problem and does so partly by becoming familiar to the

participants, as a “fly on the wall.” The use of interviews as well as observation

helps, because interviews do not take place concurrently with the interaction.

Because memory is often selective, however, multiple perspectives are

necessary to decrease distortion. Greater consistency of findings across

methods gives a basis for more confidence in the findings.

It is often difficult to convince clinical and administrative staffs to fill out logs

or questionnaires. Scheduling interviews has the advantage of ensuring

completion of the task and fits better with busy clinical schedules. Staff

members often have little chance to reflect on their work and usually enjoy the

opportunity to discuss it. Methods requiring writing, especially in an ongoing

way, simply do not seem to fit well with the way most staff members work.

Maintaining written records frequently requires persistent nagging by the

236
evaluator, which can have a detrimental effect on the quality of the data

obtained.

Qualitative methods are particularly helpful in defining some of the dimensional

characteristics of case management, that is, in defining how it is carried out. In

conjunction with quantitative methods, qualitative methods may help determine

characteristics such as intensity of program, qualities of interaction, attitudes

toward clients, team functioning, and attitudes toward supervision. Because

they tap into the inner experience and thoughts of the participants in a relatively

open-ended fashion, they allow for unexpected findings to emerge more readily

In this project, for example, only the qualitative methods were able to discern

the differences in atmosphere of the two programs. A variable such as this

can potentially be very important in determining outcome, yet it would have

been missed if only quantitative methods had been used.

The evaluator is in many ways dependent on the subjects and staff of a

case management project to integrate an enormous amount of data and

to formulate hypotheses concerning factors influencing effectiveness or its

lack. For example, the case managers were virtually unanimous in voicing

the opinion that conventional alcohol and other drug counseling techniques

were ineffective in this particular sample. Similarly, they all felt that obtaining

monetary benefits and becoming the representative payee for clients was

very effective. Clients generally agreed. Although these are uncontrolled

observations, they are excellent for hypothesis generation and can serve as a

basis for more detailed research later. These observations also may prove

valuable to others designing similar interventions elsewhere, especially if the

findings are broad based and corroborated by other data. Research of this

type is difficult and time consuming, and program managers often must make

decisions without the benefit of carefully constructed quantitative research.

Besides, these models are simply not sophisticated enough to integrate all

potential factors simultaneously, and researchers must rely on the human brain

to do so. In this way, decisions can be guided by carefully done qualitative

research and often much more quickly than is possible with quantitative

research.

Open-ended inquiry also lends itself to testing whether a program concept is

shared among the staff members. Although other methods are more effective

at determining whether such a shared concept leads to a specific program

implementation, it is useful to determine independently whether case managers

have a common program concept. Sometimes some elements of a program

concept are shared and others are not, and determining which elements are

shared can be important. Assessing the staffs perceptions of program concept

is not sufficient, of course, and must always be accompanied by more direct

measurement of case manager activities.

237
Quantitative Measurement of Case Manager Activities

Time logs offer the easiest method of describing the activities or functions of

case managers in quantitative terms. In contrast to qualitative methods, time

logs are best at describing the “what” of a case management intervention as

opposed to the “how” of qualitative approaches. Some dimensional aspects,

such as field orientation, may also be captured with time logs. Logs give a

day-by-day account and can be more or less detailed, depending on the

specific needs of the project. The fact that case managers fill out the logs

themselves is an advantage in that only they know precisely how they spend

a day. Time logs also help determine how much service a particular client

received and may reveal differences in the way individual case managers work.

On the other hand, case managers may not be willing to specify time spent

on some activities (e.g., talking with colleagues or other “down” time) or may

pad the clinical service time. Case managers may interpret a category

(“assessment” vs. “counseling” vs. “care planning”) differently, in spite of

repeated instructions. Measures must be taken to prevent double recording,

where a mixed activity is logged twice. For example, if a case manager drives

a client to a court hearing and talks about the housing situation of the client on

the way, the time could be logged as “transporting,” “counseling,” “housing,” or

perhaps all three.

Because of these problems, evaluators must attempt to be as clear and simple

as possible in creating logging instruments. If at all possible, it is helpful to build

in time for instrument development and pilot testing in the field prior to study

data collection. Line staff should be included in this process of instrument

development whenever possible.

Even when the development of an instrument is done well, however, its use

represents a significant burden to case managers. It would be unusual for staff

members not to experience some resentment of the paperwork burden in a

research demonstration project, even if they strongly believe in its goals. Case

managers typically like to be doing something active and often have many

competing tasks to do, some of them urgent. Keeping track of their time in an

obsessive manner may not be a pleasant task and can significantly distract

from pressing clinical duties. Thus, evaluators will do well to compromise on

asking for details in favor of obtaining some data with greater accuracy. In our

first log (figure 2), case managers were asked to account for their time in

increments of 6 minutes (0.1 hour) and to record the client, location of service,

and how much time was spent on each activity with that client. This log was

used for about 15 months and resulted in the accumulation of some helpful

data. However. we discovered over time that we were asking too much of our

238
staff. It was necessary to collapse categories for purposes of analysis because

of overlap and different interpretations among staff members. It was also

suspected that some case managers, who had to turn in logs before they could

receive their paychecks, were filling them out very quickly and inaccurately.

After working with the case managers over a period of months, we arrived

at a compromise (figure 3). The number of categories was reduced, and the

requirement of specifying the time on each activity for each client was dropped

in favor of specifying the total time per client contact and simply checking off all

activities that took place. This compromise worked well, and it seemed to result

in improved accuracy for the data being collected.

Qualitative and quantitative methods worked in a complementary fashion in

helping to describe the interventions. Integrating the data from observations,

interviews, and time logs produced a comprehensive and cohesive picture of

each intervention. Based on the first time logs, both programs appeared to be

providing a similar quantitative mix of services, and the overall direct service

time was about the same as well. However, ISV case managers spent more

time in the field, and the total service time per client was much greater in the

ISV group. Put a bit differently, ISV and IMD clients received similar service

types, but ISV clients received more of them and received more service in the

field than did IMD clients. Interview data confirmed these figures, as did

observation, suggesting that it was a robust finding.

However, interviews suggested that the ISV program became more like the

IMD program in some ways over time. ISV case managers repot-ted that

many interventions they tried initially, such as helping clients set up households,

teaching them how to shop for subsistence items, and intensive one-to-one

counseling, did not seem effective,’ and they began to de-emphasize them

in favor of benefit acquisition, money management, and housing support.

These latter activities were also stressed by the IMD program, and the

program philosophy espoused by both staffs was similar in stressing tolerance,

improving function in whatever way possible, and accepting that not everyone

was going to be able to achieve abstinence. Some ISV staff members, perhaps

feeling defensive or competitive, even suggested that many of the IMD group’s

clients were in fact receiving intensive services, because some clients were

receiving very few whereas others appeared to be receiving more. The ISV

staff members suggested that with the latter clients there might be little

difference in outcome between groups.

In this case the observational data concerning the differences in atmosphere

proved crucial. Because the case managers were not involved in each others’

programs, they were not in a position to compare and contrast them. Thus,

239
FIGURE 2. Daily Activity Log
FIGURE 3. CTCPI/HCH Grant Activity Log
interview data alone were misleading. Quantitative data were helpful in

determining the range and mean amount of time and type of service per client

(which differed significantly across groups) but did not address issues of style.

Ethnographic interviews with clients also suggested that the services clients

received did not vary much between programs. Ethnographic observation, on

the other hand, revealed the differences in atmosphere discussed previously.

Observation was also helpful in validating the differences in amount and

location of services that were shown by the quantitative logs.

Thus, through a combination of quantitative and qualitative methods, a

comprehensive picture of each intervention emerged. Distortions that were

present in any one viewpoint were canceled out by other information until

only the core stood out. Information confirmed by two or more methods was

considered more likely to be valid. Findings consistent across several methods

could be considered quite robust. Surprisingly, none of the methods appeared

to have any intrinsic overall advantage or to be free from distortion. Perhaps

the most common failure of any one method is that it presents a partial picture,

and what is not seen may not be known. With multiple methods, missing

something important becomes less likely (table 5).

Given the fact that such extensive evaluation is not always possible, the

evaluator is left with the dilemma of which method(s) to choose. It might be

best to utilize at least one quantitative and one qualitative method if possible.

Alternatively, using several methods but in a less intense way may give some

reassurance that nothing critical is being missed. For example, a sampling

strategy could be used with time logs, or observation could be done for a few

brief periods to help inform the interview process. If only one or two methods

are used, however, evaluators should be cautious in interpretation of findings

In particular, an evaluation that relies primarily on interviews alone must be

considered preliminary.

OUTCOME EVALUATION OF CASE MANAGEMENT IN DRUG ABUSE

Most outcome evaluation is by nature at least semiquantitative. Qualitative

methods serve mainly to inform the quantitative findings, which is a useful

process, especially in attempting to understand what an intervention consists

of, how it works, and the perceptions of staff and clients of the program.

Consumer satisfaction may be measured in part by qualitative methods as well.

However, determining whether case management works better than another

type of intervention, or which of two case management interventions works

better, requires quantitative outcome measurement.

242
TABLE 5. Data collection methods in case management research

Goal

Process

evaluation

Method

Interviews

Time logs

Observation

Outcome

evaluation

Structured

interviews

Information

systems

Type

Qualitative

Quantitative

Qualitative

Semiquantitative or

quantitative

Quantitative

Most Helpful For: Trouble Spots

• Obtaining participants’ viewpoints

• Open-ended exploration

• Hypothesis generation

• Providing guidance to other program

managers re: what works

• Assessing shared program concept

• May not reflect activities accurately

• Distortion and bias possible

• May be too speculative

• Participants may be unaware of

important factors

• Describing and comparing case

manager activities

• Determining type, quantity, and

location of services provided

• Statistical comparisons

• Attempt to obtain too much detail may

result in loss of validity

• Categories may overlap or be interpreted

differently by case managers

• Numbers may give illusion of validity

• Comparing and contrasting programs

• Determining overall “atmosphere”

• Validating time log and interview data

• Observer bias

• Presence of observer may alter behavior

of participants

• Obtaining personal information

• lndepth interviewing

• Psychiatric diagnosis

• Statistical comparisons

• Dropout rate high

• Instruments not validated or reliable

in study population

• May not measure relevant variables

• Tracking service utilization

• Longitudinal evaluation

• Statistical comparisons

• Superficial information

• Administrative barriers
This requirement poses significant problems for evaluators. Case management

is often utilized to assist persons with one or more complex, difficult conditions,

such as substance abuse, mental and physical illnesses, and social problems

(e.g., homelessness and domestic abuse). Because case management is a

complex intervention, it may be difficult to conceptualize what specific changes

in client outcome are expected. Which of so many potential variables should be

measured? How should they be measured? Furthermore, many instruments

have not been validated in target populations. Especially in substance abuse,

lengthy followup periods are necessary to ensure that changes are meaningful,

yet this poses the risk of a high dropout rate. These and other technical

problems can jeopardize an entire project and leave its findings open to

question.

There are several things that can be done to diminish these problems.

Once again, a clear conceptualization of the intervention and the target

population can help guide the evaluation strategy. What are the precise

goals of the program? How is success measured? In substance abuse in

particular, outcomes tend to be thought of in dichotomous ways, such as

“using” or “sober.” However, the reality is much more ambiguous. Success

may need to be thought of in more gradual or continuous terms. For example,

in the feasibility study for this project, it was estimated that a reduction in

service utilization of 10 to 15 percent might fully offset the cost of case

management. From a clinical standpoint, a change of 20 percent in key

indicators may be thought of as a “rule of thumb” concerning what constitutes

minimal evidence of change. Of course, whether 20 percent change makes

sense in a particular situation must be considered in view of the degree of error

of the method of measurement and the clinical significance of variation in a

particular variable. Working to achieve a clear understanding of the intervention

process, how it is expected to result in change, and the type and amount of

change that is to be considered significant will help all aspects of the project,

not only the evaluation.

Is case management expected to result in a reduction in substance use? Or

are other aspects of the client’s life, such as physical or mental health, nutrition,

or housing status, more clearly targeted? It may be important to examine the

assumptions about the relationship between substance use and other areas

of life function. Although it may seem that improvement in other life areas will

follow from a reduction in substance use, these areas may vary independently

(McLellan et al. 1981).

244
Structured Interviews

Once these conceptual issues have been dealt with to some degree, a method

of measurement must be chosen. In recent years, there has been a trend to

move beyond simple determinations of abstinence from drug use, to more

complex outcome determinations relating to multiple areas of life function. In

an effort to improve interrater reliability and to make studies more comparable,

structured interviews or questionnaires have been advocated (Vuchinich et al.

1988). Although use of these questionnaires has for the most part improved

outcome evaluation, there are certain inherent limitations to their use as well

as some avoidable pitfalls.

Structured interviews consist of a series of standard questions asked of each

participant in a more or less standard way. Answers are generally coded into

numerical form, either by asking a question that requires a number for the

answer (How many times have you received treatment for drug abuse?) or

by creating a multiple-choice type of question (Q: How do you feel today?

A: 1. Very well; 2. OK, but not great; 3. Unwell). Examples of structured

interviews or questionnaires that are commonly used in drug treatment research

include the ASI (McLellan et al. 1980) the Beck Depression Inventory (Beck

1961), and the Symptom Checklist (Derogatis et al. 1974).

The structure imposed by these instruments has indeed improved the overall

quality of outcome research in drug abuse. As more studies report results using

one of the instruments, there is created a large, more cohesive and comparable

literature than was the case without them. Their use also facilitates statistical

analysis.

Structured interviews may lead to a false sense of security, however. It

becomes very easy for a numerical answer to appear to mean more than it

does. With this reification of the numerical answer, statistical analysis can

proceed without much awareness of how the results relate to the phenomenon

under study. Statistical significance can be mistaken for clinical or social

significance. Many instruments that have been developed and validated

within one population are later used within others without regard for questions

of validity and reliability. For example, when the ASI was used in the study

described in this chapter, almost all subjects received extremely low ratings for

“Employment/Financial Problems,” even though they all were unemployed and

many were receiving public welfare. A large proportion literally did not have

enough money to live on and scavenged in dumpsters for food. However, the

instrument, which was developed as a treatment planning tool for alcohol and

other drug treatment centers, was more sensitive to conflict and distress about

work, and because our subjects had long since given up hope of working, no

245
distress was reported. Similarly, low scores on “Family/Social Problems”

reflected the fact that, although these subjects had very little social support,

they reported little or no conflict or “problems” with others. The instrument

could pick up distress about family and social relationships but was not

sensitive to the social disengagement of skid row inhabitants.

This is not to say that the ASI is not a good instrument or that it should not

be used. To the contrary, its use is often advocated because it provides a

relatively easy and clinically relevant way to organize data about subjects with

alcohol and other drug dependence. It is important, however, to be aware of

its limitations and to consider them during data analysis. The same could be

said for many other interviews or questionnaires.

Another vexing problem is the dropout rate. Alcohol and other drug populations

are notorious for being hard to find at followup. Case management itself

significantly improves followup rates because case managers are determined

to know where their clients are, and clients are often motivated to make contact

with case managers. This advantage of case management must be taken into

account if there are differences between groups in dropout rates. It is tempting

to reduce the length of followup because the dropout rate increases with longer

followup periods, but this flies in the face of evidence suggesting that minimum

followup periods of 1 to 2 years are necessary in alcohol and other drug

dependence (Vaillant 1983). Even with a relatively stable population and

intensive case management, however, we were able to interview only slightly

more than 50 percent of subjects after 2 years. Other homeless demonstration

projects had similar problems. Subject payment may improve these rates

somewhat, but even then, dropout rates are likely to remain high, especially

in poor populations. Another form of structured or semistructured interview

involves more ethnographic methods. We created a structured interview for

our investigation of resource networks in homeless inebriates and also used

structured interviews to examine the process of case management. The

structured interviews were embedded in an ethnographic participant

observation study, however, and as often as not, participant observation

was the more useful approach. At the same time, the use of interviews did

allow more direct comparison of responses from the two case management

groups, including some statistical analysis. Construction of the interviews also

stimulated the study group to focus more clearly on the type of information

desired and offset potential biases in the observer.

Service Utilization and Information Systems

An alternative to structured interviews has emerged with the development of

computerized data storage. It is now possible to track an individual’s use of

246
services within a service area or system over time. Data on the number of

contacts, agencies involved, billings, diagnoses, and service time provided

may be readily retrievable. Because these services, such as those that supply

subsistence resources or medical care, often are essential to the clients, there

may be less loss of contact with clients over time (that is, fewer dropouts). In

the CTCPI study, the dropout rate over 2 years was only 5.5 percent by this

method, compared with 10 times that with structured interviews and case

management. Furthermore, many agencies now operate in such a way that

a client cannot receive services unless an entry is made in the information

services database. It also becomes possible to track different patterns of

service utilization as well as use of one agency or service.

These advantages are offset by several disadvantages. The information

available is often superficial, consisting of those data elements most useful

to system managers for tracking workload and submitting billings to a funding

agency. Demographic information, primary problem or diagnosis, and type

and extent of services provided are typical elements included in an information

system. Although this information can prove useful, it is limited and most often

does not include ratings of function or clinical history. Thus, data from the

information system are most useful if system utilization itself is a relevant

outcome variable (which was the case in the CTCPI study). System utilization

may also be used as a somewhat distant surrogate for severity of problems,

assuming that greater utilization results from more severe problems. Of

course, increased utilization may result from case management, reduction

of barriers, improved access, or greater recognition by the client as well.

Nevertheless, the dropout problem with interviews is so difficult that it may

be better to obtain fewer data more completely and reliably.

However, there are other barriers even to this use of information systems.

Although it is possible to overcome these barriers, given enough time, it can be

a taxing process. Barriers may be both intentional and inadvertent. Intentional

barriers to this information are constructed in response to data privacy issues.

Alcohol and other drug and human immunodeficiency virus information, in

particular, is closely guarded against unauthorized disclosure. This problem

can be addressed by obtaining the appropriate release forms from subjects,

but this is not always possible.

There are often barriers constructed against disclosure across bureaucratic

boundaries as well, even within the same overall organization. For example,

information systems in place in a public hospital may be different from those in

the mental health services area. Some of these barriers are intentional and

pertain to data privacy. Access to data is restricted to those with a bona fide

need to know. Other barriers result from the way the information systems are

247
structured, where data sets, hardware, and software may be incompatible. For

example, there may even be a different unique identifier (an identifier, such as

Social Security number, that applies for only one individual) for a particular

client in different agencies.

Another bureaucratic barrier is the difficulty of obtaining data from an existing

set, particularly from a set of data elements that are not routinely collated and

analyzed, or if data on a particular subset of agency clients are wanted. It may

be necessary to create a program to do this, which can be a time-consuming

process. Research projects (especially someone else’s) typically do not have

a high priority on staff time in service agencies, and the budget constraints of

recent years have exacerbated this problem.

More mundane bureaucratic barriers may prove to be some of the hardest to

overcome. Turf issues, petty infighting, and bureaucratic sloth all take their

toll and can be exacerbated by envy evoked when a new demonstration project

displaces employees who have thanklessly toiled in the trenches for years.

Unforeseen problems may arise that are due to “history,” that is, compensation

for debts from old favors or defeats in old battles within the organization.

All these barriers taken together can be daunting and may stall the most

competent evaluation. Thus, it is important to anticipate and remove as

many as possible prior to initiating the project. Administrative support at all

levels is often required to move the project along. Embarking on a new project

should not be rushed if the administrative support staff is ambivalent or lacks

enthusiasm. However, given enough time and strong administrative support,

barriers can be overcome. Moreover, the result may be worth the effort,

because it may yield data of excellent quality with a very low dropout rate.

CONCLUSIONS

There is a significant need for evaluation of case management applications

in alcohol and other drug treatment as well as in other settings. Yet, the

obstacles to conducting and evaluating demonstration projects are daunting

and may discourage both program managers and evaluators from embarking

on new ventures. This is unfortunate, because it is possible to carry out

an excellent evaluation by simply following some careful steps. The first

requirement is to establish clarity concerning the aims of a particular project

and how case management is expected to result in the desired outcome.

Evaluators can assist managers in the process of clarification of program

concept, which helps ensure the success of both program development and

evaluation. Once the program concept is clear, the evaluation process can

proceed from the questions that arise concerning program process and

outcome.

248
It is essential to measure both the nature of the intervention (process

evaluation) and its effectiveness (outcome evaluation). Whenever possible,

multiple qualitative and quantitative methods should be used. Use of multiple

methods reduces the chances for biased conclusions based on distorted data

on the one hand or missing a critical factor on the other. When resources or

time is limited, the use of one qualitative and one quantitative method is

recommended, using a sampling strategy if necessary.

Given some good administrative support within the service agency, persistence,

and attention to detail, evaluation of case management programs can help

future program planners construct more finely tuned and effective programs.

NOTE

1. This was one example of how the original model did not fit with the study

population. As mentioned earlier, this resulted from the change in selection

to include only homeless individuals, which resulted in a more impaired and

homogeneous population than that originally planned.

REFERENCES

Beck, A.T.; Ward, C.H.; Mendelson, M.; and Erbaugh, J. An inventory for

measuring depression. Arch Gen Psychiatry 4:561-571, 1961.

Brekke, J. Program implementation analysis. In: Morrissey, J., and Dennis, D.,

eds. Homelessness and Mental Illness: Toward the Next Generation of

Research Studies. Proceedings of an NIMH-Sponsored Conference.

Rockville, MD: National Institute of Mental Health, Office of Programs for the

Homeless Mentally Ill, 1990.

Derogatis, L.; Lipman, R.; and Rickels, K. The Hopkins Symptom Checklist

(HSCL)—A self report symptom inventory. Behav Sci 19:1-16, 1974.

McLellan, A.; Luborsky, L.; O’Brien, C.; and Woody, G. An improved evaluation

instrument for substance abuse patients: The Addiction Severity Index

J Nerv Ment Dis 168:26-33, 1980.

McLellan, A.; Luborsky, L.; Woody, G.; and O’Brien, C. Are the addiction-related

problems of substance abusers really related? J Nerv Ment Dis 169:232-239,

1981.

Neuner, R., and Schultz, D. Borrow Me a Quarter: A Study of the Feasibility of

the Prepaid Case-Management System for the Chronic Recidivist Alcoholic.

St. Paul, MN: The Minnesota Institute of Public Health, 1986.

Stein, L.I., and Test, M.A. Alternative to mental hospital treatment. I: Conceptual

model, treatment program, and clinical evaluation. Arch Gen Psychiatry

37:392-397, 1980.

249
Vaillant, G. The Natural History of Alcoholism. Cambridge, MA: Harvard

University Press, 1983.

Vuchinich, R.V.; Tucker, J.A.; and Harllee, L.M. Behavioral assessment. In:

Donovan, D.M., and Marlatt, A.G., eds. Assessment of Addictive Behaviors.

New York: Guilford, 1988.

Willenbring, M.L.; Ridgely, M.S.; Stinchfield, R.; and Rose, M. Application of

Case Management in Alcohol and Drug Dependence: Matching Techniques

and Populations. National Institute on Alcohol Abuse and Alcoholism. DHHS

Pub. No. (ADM)91-1766. Washington, DC: Supt. of Docs., U.S. Govt. Print.

off., 1991.

ACKNOWLEDGMENT

This chapter was prepared with support from NIAAA grant #1, RI AA-07930-01.

AUTHOR

Mark L. Willenbring, M.D.

Associate Professor of Psychiatry

University of Minnesota

Chief

Addictive Disorders Section

Minneapolis VA Medical Center (116-A)

One Veterans Drive

Minneapolis, MN 55417

250
Case Management Systems

Represented in the NIDA-Supported

“Perinatal-20” Treatment Research

Demonstration Projects

Elizabeth R. Rahdert

INTRODUCTION

Identifying effective strategies for enlisting and retaining drug-abusing women

of childbearing age in treatment continues to be a difficult problem facing this

Nation’s health care service providers (Lewis and Phelan 1992). Currently,

case management (CM) systems offer promise in that they include functional

components that are designed to facilitate a treatment program’s chief aims,

that is, to enlist and retain addicted women for a sufficient amount of time to

see beneficial change (Finnegan et al. 1991). Yet with rising national health

care costs (Rice et al. 1991), CM must also be cost-efficient. To determine

whether a program’s CM strategies are effective and cost-efficient requires

that a program objectively define those functional components that support its

clinically relevant enlistment and maintenence activities. Furthermore, the

program must define those components in specific analytic units such that the

cost to deliver all components of an effective CM system can be calculated.

Collaborative efforts on the part of the “Perinatal-20” offer one such opportunity

to examine both clinical effectiveness and delivery costs. Perinatal-20 refers to

a grant program comprising 20 treatment research demonstration projects, each

supported for up to 5 years by the National Institute on Drug Abuse. Most are

“comprehensive” by design; that is, they offer a broad array of therapeutic and

adjunct services on a long-term basis to women of childbearing age, their

children, and other members of the family.

As a result of many hours of collaboration among staff members from each

of the Perinatal-20 projects, a standardized program-descriptive checklist was

developed that each project can use to identify and adequately characterize

all of the clinically meaningful elements in its treatment program. In turn, this

checklist can be used to isolate, then evaluate, each of those clinical elements,

251
singly or in combination with other program components. Because most of

the Perinatal-20 projects include CM, with each system somewhat different,

various CM models or particular CM components can be examined in terms of

effectiveness and perhaps in terms of delivery costs. Ultimately, the degree of

cost-effectiveness and cost-efficiency for various forms of case management

can be critically evaluated in subsequent studies.

DEVELOPMENT AND STRUCTURE OF THE PERINATAL-20

Ten of the studies began in fall 1989 and 10 more by the end of September

1990 (appendix); thus, results are not yet available. At the outset, it was

apparent that each of these 20 research projects had a similar target

population; that is, their subjects were drug-abusing women who were

pregnant, postpartum, or qualified for inclusion because they were women

of childbearing age. Each project was designed to critically evaluate a

comprehensive therapeutic program or a particular aspect of treatment.

The primary emphasis was on determining the effectiveness of treatment

for women, but considerable attention also was given to identifying the

effects of that treatment on the women’s children. None of the projects had

the determination of cost as a major research objective, although many

evolved procedures for collecting cost-related data within their research

protocols.

Although each Perinatal-20 project has numerous unique features, the

similarity among the 20 projects in terms of their target populations, core

treatment/ancillary service elements, specific research questions, and clinical

research measures was striking. To derive the greatest benefit from that

degree of commonality, staff members from all 20 projects met to discuss

ways in which they could cooperate and collaborate. Their efforts resulted in

the creation of three descriptive tools: (1) a list of state-of-the-art measures

that each project could choose to collect the subject data; (2) a standardized

descriptive checklist, which all projects would use, that defined program and

service unit characteristics deemed to have clinical significance and properties

appropriate for assigning a cost to deliver; and (3) an operationally defined

method of reporting service utilization that all projects would use.

TYPES OF DATA COLLECTED BY THE PERINATAL-20

A distinction was made between data that describe the subjects (whether

measures of change or status), data that characterize the treatment program,

and data that summarize how much of the program was received (i.e., “utilized”)

by the subjects. Clarifying what is meant by each type of data allows constructs

such as “retention-in-treatment,” “incremental changes during treatment,” and

252
“treatment outcome predictors” to be identified and analyzed and findings to be

interpreted with less ambiguity than often occurs when evaluating complex

therapeutic programs. In addition, the extent to which two or more Perinatal-20

projects utilize the same (not just similar) measures provides the opportunity for

them to compare results. Projects also can combine their data to address

questions that no one project can address because of insufficient sample size

and limited diversity of subject pool.

Subject Data

Data will be collected on all women, children, and other family members

enrolled in the study. These include:

Data collected at pretreatment intake (e.g., age, gender [in regard to

offspring and relatives], race/ethnicity, marital status, parental status [i.e.,

maternal, paternal], employment status, educational level, physical and

mental health status, social functioning indicators, housing and other

environmental information)

Data collected at one or more times during treatment

Data collected at the time of treatment termination and/or at specified

points in time during posttreatment followup

Program and Service Unit Characteristics

This type of “data” will be collected when the study begins and can be revised

at any point thereafter if clinically significant changes are made. All information

will be organized under one of five major descriptive headings:

Facility/physical environment in which the treatment takes place,

differentiating among home-based, residential, hospital-based (inpatient

and outpatient), or community agency-based settings.

Therapeutic modalities/related services that constitute the project’s

comprehensive therapeutic “program.” For the Perinatal-20 projects,

modalities and services were categorized under services for the mother;

for the neonate/infant/developing child; or for the mother with someone

else such as her child, husband/male companion, relative, or other women.

Prescribed/optimal time-in-treatment such as a 28-day or a 3-, 6-, 12-, or

18-month program; open-ended/flexible.

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Staff characteristics that include staff caseload, staff:client ratio, staff contact

hours, and rate of staff turnover; professional staff qualifications related to

training and licensure; staff characteristics such as gender and racial/ethnic

composition.

Program management characteristics such as maximum program capacity,

policies related to admission and discharge, and all the functions that

characterize or are associated with a CM system. These include (1) case

finding and outreach activities, (2) screening and diagnostic assessment,

(3) service planning, (4) linking and coordinating services with referral

sources, (5) monitoring service delivery and utilization, and (6) advocating

for disadvantaged individuals and groups.

Program and Service Utilization Data

Each project will report the number of subjects who participated in or utilized

specific treatment-related services at specified points in time.

PERINATAL-20 SUBJECTS

The characteristics of women who are already enrolled in the Perinatal-20

projects, as of December 1991, are presented in the list below. Although this

information describes only a fraction of the women who will enter treatment at

these research sites, the data provide an indication of the type of populuation

that is and will be served by the 20 projects.

Average age: 27 to 28 years old for adult programs, 16 to 17 years old for

the three programs that admit teenagers

Maternal status: Pregnant, postpartum, or between pregnancies, depending

on the particular program

Marital status: 80 to 90 percent single, which includes never married,

divorced, and separated

Education: 75 percent with 11th grade education or less

Employment: 70 percent unemployed

Drug use: Polydrug use, including alcohol and tobacco, with cocaine the

primary drug of abuse

254
CASE MANAGEMENT REPRESENTED IN THE PERINATAL-20

Overview

The purpose of making some form of CM an integral part of the Perinatal-20

projects was twofold. First, clinical staff members thought that CM would

enable them to more efficiently coordinate all aspects of their complex,

comprehensive programs, thereby making treatment and related services

more accessible to the women. Second, the staff thought that, by having

easy access to a wide range of services, an adequate number of women

would enroll and remain in the study as “subjects.”

As these Perinatal-20 research projects continue to collect subject, program,

and service utilization data, they will be able to determine the degree of

effectiveness of treatment for specific groups of women, children, and other

family members. Some of the projects also will be able to calculate the related

costs as they pertain to their particular CM system. Then, to the extent two or

more projects collect data using the same, not just similar, collection measures,

comparisons across CM systems can be made. However, it is acknowledged

that most of the Perinatal-20 projects will encounter problems in conducting

their treatment and CM research. Even in the first year of operation, each

project has encountered difficulties not unlike those involved in conducting

evaluation research by many others in this particular health care field (Kilbey

and Asghar 1992).

The following are examples of functional components usually associated

with traditional CM systems that are incorporated into one of the Perinatal-20

projects. Each was selected because it appeared to offer an interesting feature

associated with a particular CM system. Each was included in the CM system

to reduce a barrier to providing adequate, appropriate, and sufficient treatment.

How successful the project will be toward meeting that goal remains to be seen.

Case Finding and Outreach Activities

The Howard/Beckwith UCLA medical school project predominantly serves

African-American women and their infants. CM includes a home visitor who

makes biweekly outreach visits. Vans, carrying an outreach worker and van

driver, pick up mothers and their children to transport them to the clinic-based

portion of the program. Clinical staff members periodically go to the home

to conduct home-based assessments. There is an emphasis on home visits

and provision of safe, convenient transportation to reduce the high number of

missed appointments. Unfortunately, the violence that pervades some of the

neighborhoods where the women live often prohibits entry, thereby making this

mode of outreach to some of the women difficult, if not impossible.

255
Stark’s King County MOM’s project serves African-American and white adult

and adolescent women and their children. Outreach teams go out as pairs,

each made up of a public health nurse from Seattle’s health department and a

social worker from the county’s public assistance office. Each team can then

respond to a wide array of problems, both medical and social-environmental,

when they contact the women in their homes. The team helps to locate women

when they move and ensures that these mothers have transportation to and

from their scheduled medical appointments.

Screening and Diagnostic Assessment

Hall’s San Diego Project PALS (serving Hispanics, African-American, and

white adolescents), Field’s Miami project (serving Hispanic, African-American,

and white adolescents), and Stark’s King County MOM’s project serve pregnant

and parenting teenage women. Each project is using the Problem-Oriented

Screening Instrument for Teenagers (English- and Spanish-language versions)

and selected diagnostic measures from the Comprehensive Assessment

Battery, both of which are part of the Adolescent Assessment/Referral System

(Rahdert 1991). Case managers from each project use the information

obtained from these assessment procedures to determine which services

the adolescents should receive in addition to medical and drug treatment.

Drucker’s Montefiore Medical Center project predominantly serves AfricanAmerican women and their children and families. This project conducts an

indepth assessment on the women and many members of their families.

To accomplish this, the data-gathering instruments include an elaborate

kinchart-sociogram that aids in the identification of kin, friends, neighbors,

drug-using associates, and service providers (Pivnick 1991); a questionnaire

that gathers detailed information on the children, child welfare and foster care

involvement, other household members, and sexual partners; and a lifetime

residence history. Case managers use this information to identify, then involve

in treatment, as many family members as possible.

Service Planning

Schnoll’s Richmond, VA, project and Kaltenbach’s Philadelphia project

include residential treatment and an outpatient clinic component. Both

projects predominantly serve African-American women and their children.

Both conduct a comprehensive assessment of all women and their children

who enter treatment. Based on results, treatment plans are tailored to meet

the individual needs of each woman and her child(ren). Services that are

considered include individual, peer group, and family counseling; social skills

training; parenting classes and household management; legal services;

256
education and literacy training; vocational and employment training; meals;

and transportation. In addition, women and their children can be referred for

appropriate medical care and drug abuse treatment.

Linking and Coordinating Services With Referral Sources

Strantz’s Los Angeles project predominantly serves African-American

women and their children. The treatment site is the Uhuru Family Center,

a community-based provider (in contrast to hospital-based), defined as any

noninstitutional provider located in the community or neighborhood where its

user population resides. CM staff members from the Uhuru Family Center

initiate, coordinate, and maintain functional linkages with appropriate health

care services in medical facilities and social service agencies.

Brown’s Boston City Hospital project primarily serves African-American

women and their children. The treatment site is a hospital-based pediatric

clinic (in contrast to a community-based service provider). Thus, CM staff

members from the hospital initiate, coordinate, and maintain the functional

linkages with social service agencies and a neighborhood community center

that houses some of the counseling services. In addition, the CM staff helps

coordinate medical services, such as psychiatric and obstetrical care, within

the hospital so that referrals can be made and appointment scheduling can run

smoothly.

Monitoring Service Delivery and Utilization

Mullen’s AMORE project at Amity in Tucson serves white, African-American,

Hispanic, and Native American women and their children. Because Amity is a

residential therapeutic community, all elements of the AMORE project are

defined, monitored, and evaluated in terms of the treatment process. This

includes monitoring attendance at all meetings, participation in educational

and vocational training, and appointments kept at needed health care services.

McCaul’s project at the Johns Hopkins Medical Center in Baltimore mostly

serves African-American women. As one part of the CM system, a behavioral

token economy system was established to encourage and monitor women’s

treatment participation and retention in the drug program. Daily attendance in

treatment activities is recorded, as are the results from the weekly, clinic-wide

random urinalysis drug screening.

Alemi’s Cleveland project is a telephone-assisted CM system (Alemi et al., this

volume). Among the many functions of this computerized, telephone-assisted

CM system is the automatic maintenance of complete service utilization

records.

257
Advocating for Disadvantaged lndividuals and Groups

Stark’s King County MOM’s project formed a “community committee” consisting

of health, social services, recreational, religious, educational, and neighborhood

representatives. Committee members work with outreach staff members,

assisting them with locating and/or providing safe housing and activities for

the women who have completed residential treatment and are returning to the

community. The CM team, in turn, makes numerous presentations to greater

Seattle community groups (e.g., Department of Youth Services, Washington

School Directors Association, Head Start Coordinating Council, Washington

State Adoption Council, Seattle Street Outreach Services) to facilitate

appropriate referrals into and out of the program.

Coletti’s Operation PAR project in St. Petersburg, FL, is, in part, the product

of extraordinary advocacy efforts at the Federal, State, county, city, and

neighborhood levels, where continued support has been received for obtaining

the resources to serve the multiple needs of the disadvantaged mothers and

their children and families.

CONCLUSION

The initial work of the Perinatal-20 projects appears to offer the opportunity

to address questions of effectiveness as they relate to implementing one or

more functional components of a CM system. By collecting a common set of

operationally defined subject, program and service, and service utilization data,

these projects may pool their data or make valid comparisons. Such options

will allow the Perinatal-20 to critically examine each CM functional component in

terms of its contribution to enlisting and retaining addicted women in treatment.

To the extent that delivery costs can be assigned, their cost-effectiveness and

cost-efficiency might also be determined.

REFERENCES

Finnegan, L.P.; Hagen, T.; and Kaltenbach, K.A. Scientific foundation of clinical

practice: Opiate use in pregnant women. Bull N Y Acad Med 67(3):223-239,

1991.

Kilbey, M.M., and Asghar, K., eds. Methodological Issues in Epidemiological,

Prevention, and Treatment Research on Drug-Exposed Women and Their

Children. National Institute on Drug Abuse Research Monograph 117. DHHS

Pub. No. (ADM)92-1881, Washington, DC: Supt. of Docs., U.S. Govt. Print.

off., 1992.

Lewis, B.E., and Phelan, A. Health maintenance organizations and the

treatment of substance abuse. J Ambul Care Manag 15(1):56-67, 1992.

258
Pivnick, A. “Kincharts-Sociograms: An Anthropological Method for Describing

the Personal Social Networks of Drug Using Persons.” Presentation at

Perinatal-20 Workgroup Meeting, Bethesda, MD, May 1991.

Rahdert, E.R., ed. The Adolescent Assessment/Referral System Manual. DHHS

Pub. No. (ADM)91-1735. Rockville, MD: National Institute on Drug Abuse,

1991.

Rice, D.P.; Kelman, S.; and Miller, L.S. Economic costs of drug abuse. In:

Cartwright, W.S., and Kaple, J.M., eds. Economic Costs, Cost-Effectiveness,

Financing, and Community-Based Drug Treatment. National Institute on

Drug Abuse Research Monograph 113. DHHS Pub. No. (ADM)91-1823.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 10-32.

ACKNOWLEDGMENT

Information in this chapter was drawn from the cumulative joint efforts of and

research progress reports from the Perinatal-20 treatment research

demonstration projects.

AUTHOR

Elizabeth R. Rahdert, Ph.D.

Program Officer

Treatment Research Branch

Division of Clinical Research

National Institute on Drug Abuse

Parklawn Building, Room 10A-30

5600 Fishers Lane

Rockville, MD 20857

259
APPENDIX. Perinatal-20 treatment research demonstration projects

Farrokh Alemi, Ph.D. (PI)

Richard Stephens, Ph.D. (Co-PI)

Cleveland State University

Cleveland, OH

Elizabeth Brown, M.D. (PI)

Boston University School of Medicine

Boston City Hospital

Boston, MA

Ira Chasnoff, M.D. (PI)

National Association for Perinatal

Addiction, Research, and Education

Chicago, IL

Shirley Coletti (PI)

Patrick Hughes, M.D. (Co-PI)

Operation PAR, Inc.

PAR Village Therapeutic Community

St. Petersburg, FL

Louis Cooper, M.D. (PI)

St Luke’s/Roosevelt Hospital Center

New York, NY

Ernest Drucker, Ph.D (PI)

Montefiore Medical Center

Bronx, NY

Tiffany Field, Ph.D. (PI)

Emmalee Bandstra, M.D. (Co-PI)

University of Miami School of Medicine

Miami. FL

James Fine, M.D (PI)

Elaine Blechman, Ph.D (Co-PI)

State University of New York at Brooklyn

Brooklyn, NY

James A. Hall, Ph.D. (PI)

University of California at San Diego

San Diego, CA

Judy Howard, M.D (PI)

Leila Beckwith, Ph.D. (Co-PI)

University of California at Los Angeles

School of Medicine

Los Angeles, CA

Karol Kaltenbach, Ph.D. (PI)

Thomas Jefferson University

Jefferson Medical College

Philadelphia, PA

Robert Lewis, Ph.D. (PI)

Purdue University

(Terros. Inc., Phoenix, AZ)

Lafayette, IN

Mary McCaul, Ph.D. (PI)

Johns Hopkins University School of

Medicine

Baltimore, MD

Paul Marques, Ph.D. (PI)

National Public Services Research Institute

Landover. MD

Rod Mullen (PI)

Amity, Inc.

Tucson, AZ

Sidney Schnoll, M.D., Ph.D. (PI)

Virginia Commonwealth University

Medical College of Virginia

Richmond, VA

Richard Schottenteld, M.D. (PI)

APT Foundation, Inc.

(Yale University School of Medicine)

New Haven, CT

Anne Seiden, M.D. (PI)

Cook County Hospital

Chicago, IL

Kenneth Stark (PI)

Washington State Division of Alcohol

and Substance Abuse

(King County Hospital, Seattle, WA)

Olympia, WA

Irma Strantz, Dr.P.H (PI)

Robert Nishomoto, D.S.W. (Co-PI)

University of Southern California School of

Social Work

(Watts Health Foundation Uhuru Family

Center)

Los Angeles, CA

KEY: PI=principal investigator; Co-PI=co-principal investigator; ( )=performance site when

other than applicant organization

260
Case Management: A

Telecommunication Practice Model

Farrokh Alemi, Richard C. Stephens, and John Buffs

INTRODUCTION

Numerous studies have shown that computers could reduce the cost of health

care, reduce variability in the quality of services, and increase access to care,

but because computers have not been widely available, their demonstrated

promise has not been fully realized. However, recently, computer technology

has changed. Because computers now can play recorded messages, these

machines can be accessed through any touch-tone telephone. This has

created vast opportunities for revolutionary changes in the delivery of health

care.

Most people are familiar with a telephone. Voice-interactive, or talking,

computers enable one to call a computer, listen to its questions, and answer

the questions by pressing numbers on the telephone pad. Sometimes the

computer questions are open ended, in which case, respondents’ answers

are recorded for later transcription.

Although talking computers can affect many aspects of the health delivery

system, this chapter focuses on their potential impact on case management.

Case management is a major component of the fragmented health delivery

system. It also has been proposed as a method of saving money and

improving the quality of and the accessibility to care. The authors believe

that telecommunications can radically improve the productivity of case

managers.

Recently, the authors designed a series of aids that increase the efficiency of

case management, and in February 1992, we started collecting data to evaluate

their effectiveness. This chapter reviews these aids and explains why we

expect them to make a difference in the productivity of case managers.

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EMPOWERING PATIENTS

The first thing one can do to improve the productivity of case managers is to

reduce the demand for their services. This could be done by empowering

patients to manage their own affairs. To this end, one needs not only to

educate the patients but also to reassure them when they decide on a course

of action. Two of our aids, described below, are designed to help patients

manage their own affairs.

Community Health Rap

Many patients need to have specific health- and service-related questions

answered before they can manage their own care. Many organizations have

started programs that answer patients’ questions. For example, Kaiser

Permanente operates a Nurse-Advice telephone system. Many hospitals

operate Ask-A-Nurse telephone programs. These programs have three

disadvantages. First, they require the health professional to wait for the

patients call, a waste of the health professional’s time. Second, they may

not provide access to the most appropriate health care professional but to a

usually less expensive and less qualified substitute. Third, these programs

do not reach patients who have no questions or believe that they are already

well informed. The Community Health Rap overcomes these difficulties. It

records both the patient’s questions and the health professional’s answers.

Thus, the health professionals do not need to wait for a call; they can answer

recorded questions at their convenience. Second, because it takes a short time

to answer recorded questions, physicians can answer the questions without

major time commitments. Third, anyone who calls the Community Health Rap

telephone line can hear answers to questions left by others, similar to listening

to a talk show. Thus, even individuals who have no questions can be exposed

to health education.

Telephone Support Groups

No matter how well informed patients are, most need the reassurance of talking

to others who have been in similar situations, who can demystify the health care

system, and who can provide emotional and social support when things are not

going well. In short, patients need social support groups. Studies show that

face-to-face group support (Bauman and James 1990) and computer networks

(Brennan et al. 1991a, 1991b) are effective not only in providing information

and support to patients but also in changing patients’ visits to clinicians.

However, face-to-face support groups are difficult to organize because many

patients find travel difficult and some patients prefer to remain anonymous.

Computer-networked support groups are difficult to organize because most

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patients do not have computers. In contrast, a telephone support group

enables patients to participate in group discussions from their homes without

revealing their identity. Patients obtain a time-dependent password from the

computer or their provider. At the specified time, patients call a telephone

switchboard, which then connects all patients calling with the same password

to a telephone conference.

CARE COORDINATION

Another step in reducing the demand on case managers is to ensure that

providers coordinate their care with each other without the help of a case

manager. Traditionally, providers have coordinated care through the medical

record. However, this option has become less and less useful because multiple

organizations, with various medical records, are now caring for the same

patient. Two of the authors’ systems are designed to help providers coordinate

their care without resorting to case management.

Care Mail

In complex organizations and when care is provided across organizations, a

provider of care seldom knows who else is caring for his or her patient. Thus,

providers are unable to transfer information to their partners in care. The

Care Mail system solves this problem by serving as a relational voice mailbox:

One can leave a message for someone who has a particular relationship to a

patient without knowing that person’s identity. For example, one can leave

mail for social workers treating a patient or for nurses in contact with a patient

without knowing who they are or to which organization they belong. The Care

Mail system can also be used by patients to reach their providers without

knowing the appropriate names or telephone numbers. The computer collects

messages and delivers them to the appropriate parties by calling them on

various schedules at preferred times.

Shared Progress Notes

As mentioned earlier, one reason patient care is not coordinated is that the

patient’s medical record often is not available. There are many reasons for this.

The record may be in use by another provider; it may be in transit from or to the

record room; or it may be kept at another institution. Some investigators have

suggested that computers can solve this problem; unfortunately, entering the

data into a computer often lags behind by several weeks, making such records

less useful. Shared Progress Notes is an alternative that avoids the pitfalls of

both paper and computerized medical records. Providers dictate their notes

about the patient into the telephone. These dictations are recorded by the
system and are available on a last-in/first-out basis to other providers. In

addition, when more than three notes are entered, a health professional listens

to the notes and updates a summary note about the patient. Notes are also

transcribed and sent back for inclusion in the patient’s paper record, so that

providers do not need to update records twice. Transcriptions can be searched

by key word to find specific notes. Providers from other institutions can obtain

access to the information through a telephone call, reducing the waiting time

for the transfer of records. The advantages are many: Voice entry is easier

than writing; transcribed notes are easier to read than handwritten notes;

information on the patient is immediately available without access to a paper

record; information entry into the computer is not lagged; transcription can be

searched by key words: and information can easily be transferred to people

outside the institution.

PRODUCTIVITY TOOLS

Finally, despite the informed and motivated patients who manage their own

affairs and despite the providers who on their own accord share information

with their care partners, there is always a group of patients and providers who

can be helped by case management. The question then is how to help case

managers become more productive, more capable of spending time with

patients, and less involved with the mundane tasks of reaching people and

keeping records. To this end, the authors have designed the aids described

below.

Voice Mailbox for Patients

One of the most important and easiest aids is a voice mailbox for every patient.

Such mailboxes enable providers and case managers to record messages for

their patients. A voice mailbox reduces the difficulty of reaching patients in the

community: The case manager leaves a message, and the computer takes

over the difficult and frustrating task of finding the individual and delivering the

message.

Obviously, some patients, such as drug addicts, may not have telephones.

Among pregnant drug-abusing women on Medicaid, an unpublished survey

showed that 50 percent do not have telephones; some of these patients were

homeless (R. Kleisman, personal communication, September 1991). The voice

mailbox does not require that patients have their own telephones. Homeless

patients and patients without a telephone can call a toll-free number from any

public telephone and pick up their messages. A voice mailbox is useful for

these patients in their everyday lives. Despite rapid changes in residence and

telephone access, the voice mailbox is a constant aspect of their lives and

helps them connect to their community.

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Friends, family members, and potential employers of homeless patients can

reach them through the system, and a voice mailbox is useful for maintaining

contact between the provider and the patient.

Assessment

A major portion of a case manager’s time is spent on filling out forms needed

for assessing patients. One way to improve the productivity of case managers

is to help them assess patients more efficiently. The authors have developed a

system for assessing patients over the telephone at regular intervals. The

system can be modified to assess various topics. We are in the process of

applying the assessment system to two topics: assessment for early detection

of labor and assessment of relapse into drug use.

Early Labor Detection. If onset of labor can be detected early, then labor

can be delayed and the probability of premature infants can be reduced. For

some time, nurse case managers have regularly called patients at high risk for

premature labor, asked them about their conditions, and advised them on a

proper course of action. Others have attempted to estimate the onset of labor

through devices that a pregnant woman can wear around her waist. Both

approaches are expensive. An alternative is needed that is as effective but

less costly. Early Labor Detection is a computer program that calls high-risk

patients on a periodic basis and asks them a series of questions posed by a

panel of four obstetric/gynecologic physicians, Based on the answers to these

questions, the system predicts whether the patient is in labor. If the patient is in

labor, the system pages the attending physician and reports its findings. The

advantage of the system is its rapid data collection and notification and low

operation cost.

Relapse Prevention Assessment. The majority of patients who go through

detoxification relapse into drug use within a 3-month period. If a case manager

is aware of the patient’s potential relapse, there are several steps that he or she

can take to prevent such relapse. After detoxification, the system periodically

contacts the patients and asks them a series of questions established by a

national panel on prevention of drug use. If a patient is at high risk of relapse,

the computer faxes a note to the case manager describing the situation, The

advantage of the system is that it automatically questions all patients and allows

the case manager to focus on the patients most in need. The advantage for the

patients is that the questions remind them about their vulnerability to relapse.

The assessment system is a shell that can be applied to other topics besides

detection of labor or prevention of relapse. The predictions of any diagnostic

system are occasionally wrong. If the system makes a prediction (e.g., patient

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is in labor or patient is likely to relapse) and the predictions are wrong, the

system has the capability to learn to avoid this error in the future. Thus, case

managers can use the system to tailor assessments to their own patient

populations.

Service Check

One of the main tasks of case management is to refer the patient to appropriate

services. The common practice today is for case managers to maintain a list

of available services. When patients need a particular service, they are

referred to one or more services on the list. The problem with this system is

that it is difficult to update the list, because the availability of services constantly

changes. Thus, most case managers leave it up to the patient to find out which

services are available, a task that is equally or more difficult for the patient than

for the case manager. An alternative is needed that does not take much time

and that enables providers to update service availability in real time and without

lag, like the airline reservation system.

In the system developed by the authors, the case manager records a patient’s

service needs and selects a list of agencies that offer those services. The

computer then calls the agencies on the list, delivers the patient’s description,

and asks whether the agency can accommodate the patient. If the agency

does not answer the call, the system manages a waiting list for the agency until

it calls the system. When an opening is found, the system informs the case

manager and removes the patient from the waiting lists of the other providers.

Followup

Case managers spend much time following patients to verify their compliance

with treatment or to understand the outcome of care. Providers sometimes

hospitalize a patient because they fear that they cannot otherwise monitor the

patient. Some providers schedule a clinic visit to check on the patient’s

progress. Other providers do not follow patients and, therefore, are unaware

of the outcomes of their care. Alternatively, providers may ask a case manager

to call the patient when other work commitments allow. These methods of

followup are disorganized and often fail. Even when they succeed, the data

still need to be transferred to computers for analysis, a time-consuming task.

The followup system calls the patient, asks one or more questions, collects

responses in a database, and sends a recorded message to the case manager

if the question is answered contrary to expectations. The intervention differs

from the usual practice in that it automatically asks followup questions, collects

the data in an organized fashion, and informs the provider in the case of

unexpected findings.

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Telephone Reminders

Many patients who are referred by the case manager do not show up for their

referral visits; as a consequence, they are lost to the system until they develop

more serious problems later. As health care becomes more fragmented, more

patients are lost in referrals. Telephone Reminders is a system that keeps

track of patients and reminds them to go to their appointments. Two days in

advance, the system calls to remind them of their scheduled appointment. If

the patient cancels the appointment or fails to keep the appointment, the

system calls back reminding them to reschedule. Data show that telephone

reminders substantially increase the number of patients who keep appointments

(Bone et al. 1989).

Most health care professionals rely on various tools to assist in providing care

to their patients. The authors are not aware of tools for case managers, except

rudimentary ones such as paper and pens. If case managers are expected to

make a difference and to be efficient, they must have the proper tools. The

tools presented so far are examples of how computers and telephone systems

can benefit case managers.

DISCUSSION

Talking computers are a new technology, and consequently, several questions

about their effect on the care of patients and the work of providers may be

posed. The following concerns are those most commonly raised.

Patient Reaction to Computer Assessment

For the most part, patients and case managers who use the aids described

herein do not feel that they are interacting with a computer. For example, the

Telephone Support Group does not involve any computer interaction after

signing in. The Community Health Rap may seem to callers like several

interrelated answering machines but not a computer. Most of the proposed

systems involve a short interaction with a computer followed by free-form

interaction with others through the computer. The system that is most likely to

remind people of computers is the assessment system, in which one interacts

for a long time with a menu-driven computer. Naturally, most concerns are

raised about the assessment system. Although computers are expected to

improve the interview process through standardization, clients may not accept

them. The argument is that computerized assessment may anger and frustrate

clients who have turned to the health care system in part because they needed

human care and attention.

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Although computerized telephone assessment is relatively new (Nicholls 1983;

Fink 1983; Shangraw 1986), cathode ray tube-based computerized assessment

has been around for some time and may indicate how patients may react to our

proposed methods. Data show that, contrary to expectations, patients prefer

assessment by computer to human clinical assessment, especially when they

have to report on such confidential matters as drug use, sexual preferences,

or suicidal thoughts (Erdman et al. 1985). Such preferences have been known

since the late 1960s and have been demonstrated in too many studies to be

considered just an artifact (Evan and Miller 1969; Johnson and Mihal 1973;

Kiesler and Sproull 1986; Lucas et al. 1977; Greist and Klein 1980; Carr et al.

1983). One explanation for such preferences is that computer interviews are

nonjudgmental, whereas clinicians by their status may be perceived as

judgmental. It seems that the computer’s mechanical reactions encourage

clients to trust it not only with more information but also with more confidential

and, surprisingly, more accurate information as well.

For example, Lucas and colleagues (1977) found that a computer that

interviewed subjects at an alcohol abuse unit identified significantly more

alcohol use than an experienced psychiatrist. Similarly, Angle and coworkers

(1978) found that a computer interview revealed twice as many mental health

problems as psychiatrists had indicated on patients’ records; in hindsight,

psychiatrists rated 76 percent of computer-identified problems as critical.

Sawyer and colleagues (1990, 1991) used computer-assisted interviews to

administer the Child Behavior Checklist in a child psychiatry service. Before

undergoing the interview, parents reported reservations about computer

interview, but after completing the interview, they showed more acceptance

of the procedure. The scores from the computer interview varied little from

scores obtained using a human interviewer.

As another example, Bungey and coworkers (1989) contrasted computer

assessment to face-to-face interview and paper-and-pencil questionnaire

assessments of drug abuse in a general practice unit. They found that the

levels of reported drug use were similar across the three assessment methods.

Patients’ preferences for the computer increased significantly after use, and

most important, those patients who reported illegal drug use-a potentially

threatening and sensitive issue-preferred the computer assessment.

The authors’ experience with employees and staff of Cleveland State University

showed that a computerized telephone appraisal/advice system, which included

a segment on drug use, was considered as favorably as clinical assessment

and education (Alemi et al. 1992).

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In summary, the literature suggests that our proposed strategy of computerized

telephone interviews for patients is not only possible but also reasonable.

Computer-Initiated Calls

There is a significant difference between a patient calling a computer and the

computer initiating a call to the patient. One concern is whether patients will

respond to computer-initiated calls. Most individuals are familiar with computer

calls through telephone marketing calls. Because these marketing calls are

frustrating, most people believe that, if a computer calls, the person being called

will hang up. But consider the circumstances under which people hang up on

the computers. These calls often arrive at unwanted times, interrupting other

activities; furthermore, they are about topics of little interest to the receiver.

Thus, it is not surprising that people hang up on these calls. Suppose it is not

a computer calling but a salesperson at your door. When a salesperson shows

up at your door in the middle of your dinner and tries to sell you something you

do not need, obviously you will tell him or her to go away. Now, consider if he

or she comes back every other day. Naturally, you would be frustrated. The

point is that the frustration is not with door-to-door salespersons in general but

with what is being sold and with the zeal and lack of judgment of this particular

salesperson. The same applies to computerized telephone calls.

We have taken several steps to ensure that computer calls are well received.

First, no one is called without explicit consent. Thus, our computer calls are

all invited and anticipated, whereas telephone marketing calls are made to

unsuspecting people. Second, patients specify the times they wish to be called,

and computer calls are restricted to these times. Third, patients interacting

with the systems can interrupt the call and return at a later time to complete the

computerized interview. The system allows the patient to call back at a more

convenient time. Fourth, the calls are discreet. If a call is made and the patient

has not been reached, there is no identification of the nature of the call; the

patient is simply asked to call the system back. Sixth, computer calls are

backed up with human operators. If at any time during the computer interview

the patient is frustrated, he or she can press the zero key, and the computer

will page an operator who within minutes will call the patient back to resolve

the problem. Because of these steps, there have been no problems with

acceptance. There are 40 individuals now receiving regular computerized

telephone calls, and by the end of 1992, there will be 350. There have been

no complaints, even though most individuals started to use this system with

much apprehension.

Besides the anecdotal evidence provided above, there have been systematic

studies of nonresponders to computerized telephone surveys. These studies

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show that the major reason for hanging up on these calls is lack of interest in

the survey topic rather than the computerized nature of the call. These studies

suggest that people are willing to answer computer calls if the calls are on

topics that they care about and if the calls are scheduled at convenient times

(Havice 1990).

Prevalence of Touch-Tone Telephones

The use of our computers requires access to telephones that make touch-tone

sounds; there is no need for an actual touch-tone line. Ohio Bell considers the

number of touch-tone telephones in their market area a business secret. We

randomly sampled 50 people in the Cleveland White Pages; 75 percent had

touch-tone telephones. These data suggest that touch-tone telephones are

widely available. Patients who do not have touch-tone calling can use our

communication aids through an operator, who listens to their requests and

keys them into the computer.

How Expensive Is It To Replicate the System?

The system, with the exception of telephone support groups, runs on a 386

personal computer, with a voice board. The total cost of the hardware is less

than $3,000, and the hardware can be easily used elsewhere.

SUMMARY AND PLANNED EVALUATIONS

Talking computers have made computers widely accessible to the health care

delivery system. As a consequence, much of the promise of these systems can

now be realized. An example is what talking computers can do to improve the

productivity of case managers. This chapter describes systems designed to (1)

allow patients to be better informed and more motivated to manage their own

affairs, (2) help providers coordinate treatment with their partners in care, and

(3) make case management easier. The literature reviewed in this chapter

suggests that our expectations that telecommunication aids will help are

reasonable.

There are, nevertheless, many lingering concerns about how these aids will

interact with and affect patients. The authors are in the process of determining

the impact of these aids on the delivery system and on patient outcomes.

We have designed a randomized trial to examine whether these aids can

correct deficiencies in existing case management of drug-abusing, poor,

pregnant women. The project randomly divides volunteer subjects into two

groups: the control group with traditional case management and the

experimental group with telephone-assisted case management. Table 1

shows the difference between the services available to each group.

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TABLE 1. Difference between services received by control and experimental

groups

Control Group Experimental Group

Telephone and telephone subsidy

Inpatient detoxification

Outpatient rehabilitation

Aftercare

Prenatal care

Labor and delivery

Well-child visits

Immunization

Existing case managers

Outreach home visits

Emergency child care

Telephone and telephone subsidy

Inpatient detoxification

Outpatient rehabilitation

Aftercare

Prenatal care

Labor and delivery

Well-child visits

Immunization

One computer-assisted coordinator

Outreach home visits

Emergency child care

Computer services

The computer services in the trial include the telecommunication aids described

in this chapter. It is anticipated that there will be 150 patients in the control

group and 150 patients in the experimental group. We are collecting data on

use of the services and the impact of services on patient outcomes (e.g., drug

use, weight of infant at birth, employment, and cost of care).

Despite the attempt to design a careful evaluation study of the impact of these

telecommunication aids on patient outcomes, there are two reasons to suspect

that the study may not be definitive. First, the case management practice

model is being tried on a limited patient population, thus requiring the case

managers to switch from using telecommunication aids to using no such aids.

This reduces the utility of the aids to the case managers. A more reasonable

test of the systems would have been to use the system on all patients, not just

the drug-abusing, pregnant patients,

Second, the telecommunication aids may have an impact on the system without

having a noticeable impact on patient outcomes. In part to overcome this

shortcoming of the evaluation study, the project is undertaking smaller scale

studies that focus on evaluating individual telecommunication aids. These

separate evaluations are being carried out for evaluating (1) response bias in

answering computerized telephone questions, (2) accuracy of predictions of the

Relapse Assessment and Early Labor Detection, (3) impact of the Telephone

Support Group on patients’ social support, (4) impact of the Community Health

Rap on encouraging patients to participate in prenatal care, and (5) utility of the

271
system in following patients over time, and (6) impact of voice mailboxes on

homeless patients.

The authors’ data collection will be complete in 2 years, at which time we will

report on our evaluation of the proposed telecommunication practice model.

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AUTHORS

Farrokh Alemi, Ph.D.

Associate Professor

Health Administration Program

Richard C. Stephens, Ph.D

Professor

Department of Sociology

John Butts, M.S.

Project Director

Health Administration Program

Cleveland State University

Cleveland, OH 44115

273
Aftercare for Formerly Homeless,

Recovering Women: Issues for Case

Management

Deborah McMillan and Rose Cheney

INTRODUCTION

The case management discussed in this chapter is one service component

of a National institute on Drug Abuse (NIDA) research demonstration project

titled Peer Support Groups for Recovering Women (the Aftercare project).

Designed to provide information on how aftercare services reduce the incidence

of readdiction among formerly homeless women, the research design for the

Aftercare project, which is being conducted in Philadelphia, includes peer

support groups and case management intervention. The primary objective of

this 5-year study is to measure the effect of peer support on abstinence from

drug use, establishment of drug-free social networks, improved mental health

and social functioning, and enhanced social and economic stability in the study

population.

DESCRIPTION OF THE TARGET POPULATION

The target population for this project is recovering women with children

leaving homeless shelters for independent housing. Recruitment is through

the Philadelphia Housing Authority, the Office of Services to Homeless Adults,

and homeless shelters and related agencies throughout the city.

The women in the program have many of the problems related to family

homelessness, such as a history of poverty and domestic violence as well as

little access to sources of social and economic support. Earlier studies in

Philadelphia found that families were particularly vulnerable after leaving the

shelter for permanent housing (Philadelphia Health Management Corporation

1992). Because they are often housed in new neighborhoods, women have

even fewer social supports to which they can turn. They often return to an

environment with a significant drug presence. The pressures of maintaining a

home, being a single parent, and maintaining sobriety can be overwhelming.

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The characteristics of the women participating in the Aftercare project reflect

the sociodemographic characteristics of substance-abusing homeless families

in the shelter system in Philadelphia. Preliminary baseline data reveal that the

women in the program are primarily unmarried black women in their twenties.

Only women with children are eligible for the project, and the majority have

two or more children. Most of the children are young (54 percent are age 5 or

younger), and many of the children were living with relatives (16 percent) or

foster parents (16 percent) at the time of their mothers’ recruitment into the

study.

Many young, minority, urban mothers face the struggle of intergenerational

cycles of substance abuse, child abuse, and physical violence with few

social and environmental resources (Comfort et al. 1990). In the Aftercare

project, almost all the women are unemployed and receiving public assistance.

Slightly more than half the women have not completed high school. The

women have a history of extreme residential instability, averaging nine

episodes of homelessness in the 2 previous years. The majority report

physical abuse both as a child and as an adult. More than half were raised

by at least one substance-abusing parent or caretaker, and a third had been

sexually abused as children. Approximately one in five report having attempted

suicide.

The primary drug of addiction for these women is cocaine, with many dually

addicted to alcohol or marijuana. Sixty percent have been treated at least

once previously for drug addiction, and half of those had been treated more

than once. More than 15 percent overdosed on drugs at some time in their

lives.

THE CASE MANAGEMENT MODEL

The National Association of Social Workers standards for case management,

developed in 1984, define case management within the framework of generic

social work practice with functionally impaired individuals and their families

(National Association of Social Workers 1984). This view of case management

recognizes that a trusting and enabling relationship is needed to expedite the

utilization of services along a continuum of care and to restore or maintain

independent functioning to the extent possible. Case managers are viewed as

being engaged in a process of continual assessment, planning, evaluating, and

monitoring as clients’ needs change and resource demands fluctuate.

Miller (1983) stated that case management is viewed as a means of overcoming

the complexity and fragmentation of service systems and of reaching the

inadequately served, chronically and severely disabled population. It is a

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shared function, requiring accountability, program evaluation, development

of resources, social action, and a supportive agency environment (National

Association of Social Workers 1984).

With some modification, the case management model used by the Aftercare

staff is defined within a framework found in standard social work practice. In the

Aftercare project, however, this model is adapted to incorporate a philosophy

of empowerment. Empowerment is defined as a process whereby the social

worker engages in a set of activities with the client or client system that aims to

reduce the powerlessness that has been created by negative valuations based

on membership in a stigmatized group (Solomon 1974).

In addition to their history of homelessness and drug abuse, the clients in this

project also have faced a history of barriers related to their gender, race, and

social status. The empowerment process is based on the development of an

effective support system for those who have been blocked from achieving

individual or collective goals because of the severity or complexity of the

personal, social, and economic barriers they have encountered. Therefore,

the case managers focus on helping the client to:

Perceive herself as a causal agent in achieving a solution to her problem

or problems

Perceive the case manager as having knowledge and skills that the client

can use

Perceive the case manager as peer-collaborator or partner in the

problemsolving effort

Perceive the “power structure” as multipolar, demonstrating varying degrees

of commitment to the status quo and, therefore, open to influence

In the Aftercare project, case management operates within a framework of

traditional social work practices. As such, the case management tasks include

multidisciplinary assessment, the development and implementation of a plan of

care, the coordination and monitoring of services, advocacy for the client, and

the planned, orderly termination of each case. The specific elements of these

tasks as they are implemented in the Aftercare project are described in greater

detail below.

The initial phase of case management begins with an assessment, the

purpose of which is to understand the client as a whole and to be aware of

the client’s strengths and needs in a particular situation. The case manager

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must understand the client in the context of the clients interactions with the

external world. The assessment includes an appraisal of the client’s needs

and the resources of the client’s informal supports, including family members,

friends, and organizational memberships; an understanding of the impact and

consequences of homelessness and substance abuse on the client and the

clients family; an understanding of the clients preexisting problems, specific

behaviors, family functioning, and values; and an estimation of the client’s ability

to become increasingly self-sufficient and independent.

On the basis of the assessment, the case manager develops a family service

plan that incorporates the client’s expectations and choices and delineates

clearly agreed-on short- and long-term goals. This plan is reviewed and

amended every 3 months. The bulk of the case management process is

devoted to implementing the plan by arranging for a continuum of informal

and formal services to be provided to the client and her family and for individual

and family counseling.

The case manager links the client to the complex service delivery system.

As the plan is being implemented, the coordination and monitoring of services

helps ensure that clients receive appropriate services in a timely fashion.

Because many families are involved with several agencies, regular efforts need

to be made to coordinate the services received to ensure continuity and reduce

duplication. Services are monitored through reports by the client and through

the observations of the service providers.

The case manager also serves as an advocate for the entire family so they

may receive their entitlement and obtain needed services. The case manager

often has to act as an advocate to ensure that services are delivered, gaps in

services are identified and filled, the individual’s needs are recognized, and the

client is not prematurely discharged by the service providers,

Based on this program design and the practical limitations of caseload size,

case management services can be delivered for up to 12 months. It is the

case manager’s responsibility to prepare the family for the termination of

aftercare. Earlier termination may be initiated by families who repeatedly fail

to keep scheduled appointments with the case manager or adhere to the

service plan. A 1 in 3 rate of early termination had been anticipated, but the

dropout rate was closer to 1 in 10.

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BARRIERS

Barriers to Implementing a Model for Women

The majority of the work done in the alcohol and other drug field has related to

men. Perhaps because men traditionally have been more involved than women

with illicit drugs, the specific needs and problems of women addicts were largely

ignored until the mid-1970s (Beschner and Thompson 1981; Sutker 1982; Reed

1987; Marsh and Miller 1985). However, given the rapid rise in crack/cocaine

addiction among economically disadvantaged urban women, it is increasingly

important that the effects of gender are addressed.

Traditional models of drug treatment and aftercare remain primarily male

oriented and are not appropriate to the needs and problems of female

addicts (Cuskey et al. 1977). These models are usually confrontational in

their approach. Although confrontation can be useful in working with women

as well, it is not uniformly effective. In particular, evidence on battered women

with patterns of learned helplessness suggests that such approaches are not

only ineffective but also destructive (Reed 1987). Many addicted women have

been battered and sexually abused, and their adaptive responses to dealing

with males or to confrontation may reflect an important survival mechanism.

Unfortunately, these responses may be maladaptive in a traditional treatment

or case management setting.

In this client population, almost three-quarters of the women self-report a

history of physical abuse, and one-third report sexual abuse as a child. It

is likely that many of the remainder have also experienced sexual intimidation

or the threat of physical violence by males. The women’s relationships

with men have revolved around viewing themselves as sexual objects.

Unfortunately for these women, the staff members at most of the traditional,

male-oriented treatment programs are male, although there is a trend at newly

created treatment programs for women and children toward hiring female staff

members. Based on the belief that the women are more comfortable working

with women, the case management staff members for this project are female.

There is a gender difference in the stigmas attached to drug use (Cuskey

et al. 1977; Reed 1987; Marsh and Miller 1985). It has been important to

help women explore their feelings about women who have used drugs. Often,

a woman has internalized the prejudices and misconceptions she hears about

substance-abusing women. The particular circumstances of a woman’s life

must be explored to help her identify the sources of the guilt and shame. This

helps women to validate their feelings of being stigmatized.

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Barriers to Working With the Target Population

There are internal and external factors that make it difficult to work with this

population. The internal factors include addictive behaviors and adjustment

and personality issues. The external factors include environmental and

structural barriers imposed by society and particular institutions on this

population. Some specific barriers are itemized below.

Addictive Coping Behaviors. As a result of their addictive lifestyle, many

substance abusers can be manipulative. The women have used manipulation

to adapt to various life experiences, Although the women in this project have

been abstinent from drugs for an average of 8 months, the addictive behaviors

continue long after the chemical leaves the body. Case managers must be

aware of the range of addictive behaviors and of how to bring these behaviors

to the attention of the client.

Keeping Scheduled Appointments. Because of their chaotic lifestyles, many

of the women are not accustomed to adhering to a schedule. With a relatively

intensive caseload of 15 families, it is difficult for case managers to visit families

twice a month, in large part because of frequent broken appointments. In

addition, because all the women in this project are recovering from substance

abuse, they need to attend Narcotics Anonymous meetings on a frequent basis

and often are enrolled in outpatient counseling. This means that a great deal of

their time is taken up with these other meetings, which often makes it difficult for

them to schedule time to meet the case managers.

Limited Resources and Independent Living. The material and concrete

needs of the clients are great, but there are shrinking resources in the

community to meet these needs. Most of the women have never lived on

their own before. The case manager must spend a great deal of time helping

the parent develop household and money management skills. The women

have learned to save a percentage of their public assistance benefits, but they

frequently do not have enough money to adequately furnish their new homes

because the startup costs of acquiring basic appliances and furniture can be

high. Often, these women have not learned to comparison shop or “bargain

hunt” and, as a result, spend too much of their limited resources on overly

expensive household items.

Children and Parenting. All the women in this project are mothers, and they

face many barriers that relate to their children. Many need to work with the

case manager to develop life and parenting skills. In the shelter, there usually

were other parents and staff who assisted the mother. With independent living,

the stress on the single parent can increase. A lack of available formal or

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informal child care interferes with scheduling and opportunities for training. The

immediate needs of their children often take precedence over the women being

able to meet with their case managers.

Transportation. It can be difficult for women with more than one preschoolage child to travel and make appointments. Even something as simple

as a stroller can make a difference in the daily mobility of a mother with

preschoolers. Public transportation can be costly, and the women need

help in budgeting their limited resources to cover transportation costs.

Potential for Relapse. Compounding the effects of all the above barriers is

the high relapse rate for cocaine. The stress of establishing and maintaining a

household (often for the first time), assuming total child-care responsibilities,

and maintaining recovery is very taxing and sometimes triggers a relapse.

Role of the Case Manager. In light of these barriers, the role of the case

manager working with addicted women can change repeatedly. These different

roles require a range of skills. As an individual who establishes limits, the case

manager needs to assess and respond to the inappropriate behavior of clients

by challenging manipulative behavior and communicating limits. This helps a

woman feel safe and begin to deal constructively with her problem(s). As an

advocate, the case manager must help the client access often limited services.

A client may lack assertiveness and basic skills needed to negotiate for services

from community resources. She may not feel deserving and may need active

intervention on her behalf. As a treatment coordinator, the case manager can

ensure that services are coordinated and that there is continuity of care. Often,

the client may need a treatment plan that involves a variety of activities and

services. As an educator, the case manager helps the clients acquire new

knowledge and specific skills, including parenting, household, budgeting, life,

negotiation, and vocational skills. The case manager can teach the client

directly, provide role model behavior (as in parenting), and identify and obtain

other psychosocial educational opportunities. Finally, as a therapist, the case

manager provides an ongoing relationship to initiate and guide a process to

improve a client’s functioning and well-being.

GAPS IN SERVICES

The major gaps in services for the target population include the lack of

affordable housing, lack of affordable child care, and lack of material goods

Advocacy on behalf of the clients, individually and collectively, is often the

only method available to the case manager to deal with these gaps in

accessing needed resources.

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Many of the families in this project have a difficult time receiving subsidized

or traditional public housing. Approximately 40 percent of the women have

Section 8 certificates or are assigned to conventional public housing. (Section

8 is a federally funded program that certifies private housing for rent and

subsidizes the rent payment.) Ten percent are in transitionally subsidized

housing, and half are in private or other types of housing. For women in

transitional subsidized housing, the subsidy lasts only 1 year; at the end of this

year, the family may become homeless again if they are not issued a Section 8

certificate, are not assigned to public housing, or do not gain employment that

enables them to afford the higher rent. There is a great deal of stress on the

parent in maintaining permanent housing, and this can contribute to relapse.

Parents who want to continue their education or gain employment have

difficulty in locating affordable child care due to the shortage in slots. Because

they have often moved into a new area to obtain available housing, informal

social supports also are unavailable for child care. One of the goals of the

peer support component of the Aftercare project is to allow women to develop

a helping, supportive network. Unfortunately, the dispersion of their housing

assignments has hindered the development of informal, shared child care. In

the absence of readily accessible child care, the transportation of preschool

children becomes another major barrier in reaching many services.

LINKAGES WITH OTHER COMMUNITY AGENCIES

As a new aftercare service, the staff of this project faced problems of visibility

and acceptance by other community agencies. Although a comprehensive

guide to services in the area is available and announcements about the

program were distributed throughout the service system, it was still necessary

to establish more concrete connections with appropriate providers. To this

end, the staff held a symposium that was attended by social service providers

throughout the city to develop awareness of the program. This event set the

Aftercare project apart as the only one providing services to this population in

the city. The project’s visibility increased, resulting in many more referrals.

In addition, the staff represents the project on various citywide committees that

are concerned with the needs of homeless children and recovering families.

Representatives from the Aftercare staff are included in advocacy groups

involved with housing issues and other issues related to the lives of the

project’s clients.

Because there are often several different agencies working with one family,

the case manager must not only make appropriate referrals but also monitor

the provision of services to the family. Information exchange among agencies

is facilitated by using release-of-information forms. Issues related to client

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confidentiality as it relates to human immunodeficiency virus (HIV) infection

and its legal implications are addressed. Referrals are made to city agencies

that can best meet the families’ needs. (Formal programmatic linkages have

been developed with a transitional housing program, which serves recovering

women, that has requested the program’s help in providing case management

to these families when they leave the transitional housing program.) Aftercare

staff members attend training sessions to keep abreast of the resources

available to this population. New information is constantly being filtered to

them through the network of agencies working with this population.

RESEARCH DESIGN

The research will focus on the effectiveness of peer support groups for

approximately 200 formerly homeless women who have moved from

emergency shelters or residential treatment programs to independent housing.

The long-term goal of the research demonstration is to provide information that

will lead to a reduction in the incidence of readdiction by providing improved

aftercare services for this population. The research will compare outcomes

over an 18-month period for women from the target population.

The basic structure of the research is a randomized experimental design with

longitudinal followup over 18 months. Volunteers are randomly assigned to

either an experimental group, which participates in peer support and case

management, or a control group, which receives case management alone.

The outcome of clients in the peer support group will be compared over time

with those receiving only case management. The longitudinal comparison of

control and experimental groups utilizes structured followup interviews every

3 months for the 18-month period. There is also a qualitative research

component that includes field observation of the initial peer support cohort,

client life histories, and a review of case management records. In addition

to a process evaluation of case management activities, the effectiveness

of case management also can be estimated through a comparison of the

outcomes for project clients with previously published data on homeless and

recovering women.

INSTRUMENTS

The intake and followup interviews provide a participant profile that includes

demographic baseline data, substance abuse histories, psychosocial histories,

and information on social networks. The interview includes the administration

of a modified version of the Addiction Severity Index (ASI), the Rosenberg

Self-Esteem Scale, a health and daily living assessment, a depression scale,

and a social support network inventory. Demographic data include living

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arrangements, residential history, and self-reported information on substance

abuse. Because the ASI was developed primarily for a specific population

of males, it was necessary to modify it somewhat to make it more appropriate

for women.

Because information on substance abuse is collected as part of the research

design, informed consent is obtained from each project volunteer. In addition

to understanding the interview, it is also important that the client understands

the obligations of the case manager with respect to reporting suspected child

abuse or neglect.

Case management activities are evaluated through process data such as

client and service contact rates. Outcome measures of success for case

management include the client’s progression along mutually identified goals

and the successful accessing of needed services. As part of the intake

process, a comprehensive social history is taken by the case manager, and

release-of-information forms are signed to expedite referrals. Family service

plans and family service plan summary forms provide documentation in a

consistent format that includes the case managers’ assessment, progress,

goals, objectives, services and activities, providers, monitoring, timeframes,

and outcomes. Quarterly summary forms require that the case managers

identify the degree to which specific service area goals are being met.

FINDINGS

Because it is still early in the data collection process, no final outcome data

are available. Findings at this point consist only of preliminary baseline data

and qualitative observations; there is insufficient followup data available for

even tentative conclusions on the effectiveness of aftercare services. However,

preliminary data analyses have been useful in indicating areas of concern

specific to this population. Data for this project are being collected from

successive cohorts of women as they leave homeless shelters. Followup

interviews are conducted at 3-month intervals over an 18-month observation

period. Final analysis of these data will begin in 1996 in year 5 of the project.

The results presented below are based on observation of the women during

the first year and a half of the project and on 46 baseline interviews.

Preliminary baseline data for this project indicate that most of these women

have long histories of the regular use of alcohol, marijuana, and cocaine (Roth

et al. 1991). In addition, the majority reported previous treatment for drug use.

An unusual result in the preliminary review of the baseline data was that the

women’s scores on a self-esteem scale were slightly higher than the general

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population, but this result was not statistically significant (Wylie 1974). It will

be interesting to see whether this result holds up with a larger sample and, if it

does, whether it changes over time. It is possible that the initial move from

shelter and treatment to independent living could be marked by a greater sense

of control in the women’s lives. For many women, successful recovery, leaving

the shelter, and obtaining housing for the first time represent the most positive

experience in their lives. However, it also is possible that during the course of

treatment the women learned the appropriate answers to the type of questions

found on this scale.

The women’s scores for social networks were on par with those of an urban

area. However, few of the supports named, often immediate family members,

did not live in the same neighborhood as the respondent. Although most

women had men in their lives, only a third reported their spouse or lover as

one of the five people most important to them.

Observation data from the peer group have made it evident that project

participants are at high risk for relapse as they leave the supportive, structured

recovery environment for the potentially overwhelming situation of living on

their own (Roth and Fox 1991). Often, the women are afraid that the freedom

and privacy of independent living will trigger their relapse into drug use.

Other factors placing women at risk for drug relapse are rooted in the reality

of poverty. These women stand little chance of becoming economically

independent and breaking a lifelong cycle of dependency. Observational

summaries also indicate that, although the women’s lives are unsettled, the

peer group members seem relatively committed to the peer support group.

A series of issues raised in peer support groups identified several gender issues

relevant to recovery and maintenance for these women. Currently, available

aftercare is primarily limited to 12-step programs and outpatient counseling. In

addition to needing nonconfrontational emotional support, these women need a

forum to discuss other issues directly affecting their recovery as women, such

as battering, parenting, and sexual relationships. The women report that the

peer support group is the only place where they have been able to raise many

of the issues that are troubling them.

COSTS

This aftercare model requires fairly intensive case management, which includes

frequent home visits and limits the caseloads to 15 families per case manager.

Cost-containment requires the termination of clients who do not participate or

do not keep appointments. However, despite these aftercare costs, the direct

and indirect cost of recurring cycles of substance abuse and homelessness are

certainly greater.

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Direct cost data for aftercare services were not a specific part of the research

design, but because complete budget information is available for the case

management services and process data are kept on the case management

services provided, relative cost comparisons can be made. At present, initial

startup costs interfere with this analysis.

One of the direct costs of relapse that can be estimated is the cost of

emergency shelter. The annual cost to the city of Philadelphia to provide

a family with emergency shelter is more than $11,000. Baseline data indicate

a history among clients of extreme residential instability with many repeated

episodes of homelessness. Of course, the indirect costs of drug abuse are

innumerable and often unmeasurable. These include the economic and

social impacts of drug use, the increased risk of HIV infection, and the

intergenerational effects on the children.

RESEARCH PROBLEMS WITH CASE MANAGEMENT

The proper framing of the research design within the contextual realities of

case management is a key concern. Case managers must operate within a

system of social and economic resources for their clients. The research design

must, at a minimum, document how these system effects influence case

management. In the face of serious fiscal crisis in local government and a

withdrawal of supports on a national level, case managers are facing a greater

range of needs among their clients, combined with steadily shrinking resources.

With this myriad of unmet needs, the activities of case managers can be

reduced to full-time crisis intervention.

The context of resource availability should be fully identified for any research

project operating in an environment of extreme competition for limited services.

Often, case managers can change the priority status of their clients on waiting

lists for limited services only at the expense of similarly needy persons who

do not have the advocacy power of a case manager. This can introduce

significant bias into a research model that assumes that case management

increases the universe of accessed services, rather than merely shifting who

successfully accesses those services. To avoid the potential for inappropriate

generalization, it is important to identify whether the case management effects,

when implemented on a larger scale, will be additive to or competitive with

existing access to and availability of services.

On a less global level, within the Aftercare project, design problems also arise

from the natural tension between research and service provision. This is

highlighted in an experimental design that includes a control group. The

nature of the case management advocacy process makes it difficult to maintain

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a control group with limited services. To balance this, research focused on

the effects of one element of aftercare, the peer support group, with case

management services remaining constant across both groups. Qualitative

observational data, process data, and comparisons with other published data

provide the only direct evaluation of the case management component.

The intrusiveness of collecting baseline and followup data also provides another

potential for bias. The data are collected by interviewers rather than the case

managers. This has resulted in a duplication of requested information from the

client. Given the nature of the interaction between client and case manager,

this process of interviewing may help pattern client interactions with the case

manager, trigger the supply of additional information, or fatigue the client. The

direction of this bias is not clear, and although it cannot be fully overcome, this

bias can be addressed in part by ensuring that case managers follow protocols,

take complete social histories at intake, and maintain methodical followup

contacts.

IMPLICATIONS FOR FURTHER RESEARCH

Although there are many areas for further research, several issues related to

gender need to be examined in greater detail. The effects of gender on case

management should include an examination of women’s roles and selfperceptions.

Many poor, inner-city mothers are single parents. In the target population, 90

percent of the mothers were single. Despite efforts at empowerment, most of

these women have little chance of becoming economically independent.

Children are a larger part of their life than many other case-managed

populations. The problems that arise range from the simple mechanics

of getting from one place to another to the interpersonal complexities of

parenting and the impact on these children. Any case management of this

population must address multiple factors linked to children and poverty.

Gender also affects levels of actual and perceived vulnerability. Many of these

women have a history of being abused. They may distrust men and often have

come to expect violence (Armstrong et al. 1991). Most women in this study

named other women or their children as their most significant social support,

rather than a male partner. Often, their new apartments and welfare payments

put them at risk for having former abusive and/or addicted partners return.

Role playing and skill building are important in building the client’s skills for

communication and negotiation. However, in cases where communication

is not enough, it is important that case management operates with an

understanding of the constraints that such vulnerability can place on clients.

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Finally, understanding gender differences may be useful in addressing the

issues related to preventing relapse to drug use and homelessness. These

may include differences between men and women in addiction, treatment,

self-esteem, and the development of social support networks. A better

understanding of gender effects can be an important building block in

understanding the client, and a complete and multidimensional understanding

of the client is vital to effective case management.

REFERENCES

Armstrong, K.; Kenen, R.; and Samost, L. Barriers to family planning services

among patients in drug treatment. Fam Plann Perspect 23(6):264-271, 1991.

Beschner, G., and Thompson, P. Women and Drug Abuse Treatment: Needs

and Services. National Institute on Drug Abuse Services Research

Monograph Series. DHHS Pub. No. (ADM)81-1057. Rockville, MD: US.

Department of Health and Human Services, U.S. Public Health Service,

Alcohol, Drug Abuse, and Mental Health Administration, 1981.

Comfort, M.; Shipley, T.E., Jr.; White, K.; Griffith, E.M.; and Shandler, I.W.

Family treatment for homeless alcohol/drug-addicted women and their

preschool children. Alcohol Treat Q 7(1):129-147, 1990.

Cuskey, W.; Berger, L.; and Densen-Gerber, J. Issues in the treatment of

female addiction: A review and critique of the literature. Contemp Drug Prob

6(3):307-355, 1977.

Flaherty, J.; Gavira, M.; and Pathak, D. The measurement of social support:

The social support network inventory. Compr Psychiatry 24:521-529, 1983.

Marsh, J., and Miller, N. Female clients in substance abuse treatment. lnt J

Addict 20(6 and 7):995-1019, 1985.

Miller, G. Case management: The essential service. In: Sanborn, C., ed. Case

Management in Mental Health Services. New York: Haworth Press, 1983.

pp. 3-16.

National Association of Social Workers. NASW Standards and Guidelines for

Social Work Case Management for the Functionally Impaired. No. 12. Silver

Spring, MD: National Association of Social Workers, 1984.

Philadelphia Health Management Corporation. The Homeless Families

Initiative. Philadelphia, PA: Philadelphia Health Management Corporation,

1992.

Reed, B. Developing women-sensitive drug dependence treatment services:

Why so difficult? J Psychoactive Drugs 19(2):151-164, 1987.

Roth, L., and Fox, E. “Homeless Recovering Women: Risk Factors for Relapse

and Homelessness.” Paper presented at the 1991 National Health Care for

the Homeless Conference, Washington, DC, October 28-29, 1991.

Roth, L.; Coughey, K.; McMillan, D.; and Klein, G. “Substance Abuse History of

Recovering Formerly Homeless Women: Implications for Effective Aftercare.”

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Paper presented at the annual meeting of the American Public Health

Association, Atlanta, GA, November 10-14, 1991.

Solomon, B. Black Empowerment: Social Work in Oppressed Communities.

New York: Columbia University Press, 1974.

Sutker, P. Drug dependent women: An overview of the literature. In: Beschner,

G.; Reed, B.; and Mondanaro, J., eds. Treatment Services for Drug

Dependent Women. Vol. 1. DHHS Pub. No. (ADM)81-1177. Rockville, MD:

National Institute on Drug Abuse, 1982. pp. 25-49.

Wylie, R.C. Measures of Self-Concept. Lincoln, NE: University of Nebraska

Press, 1974.

ACKNOWLEDGMENT

The research described in this chapter was supported by NIDA grant DA-06989

AUTHORS

Deborah McMillan, M.S.W.

Program Coordinator

National Institute on Drug Abuse Aftercare Project

Rose Cheney, M.A.

Principal Investigator

Philadelphia Health Management Corporation

20th Floor

260 South Broad Street

Philadelphia, PA 19102

288
Intensive Case Management for Youth

With Serious Emotional Disturbance

and Chemical Abuse

Mary E. Evans and Norin Dollard

INTRODUCTION

New York State has developed an intensive case management program for

children and youth that is client centered and linkage and advocacy focused.

The goal is to maintain children and youth with serious emotional disturbance

(SED) in natural home, school, and community environments. Intensive case

managers work with small caseloads and have access to flexible funds to meet

the needs of individual and target population children. There have been no

specific modifications in the program model to accommodate children and youth

who have both mental health and chemical abuse problems. This chapter

describes the Children and Youth Intensive Case Management (CYICM)

program, discusses barriers to model development and implementation, and

identifies impediments to interagency cooperation and gaps in services. The

authors also outline several research strategies, including descriptive studies,

program evaluation, and funded research, that are being used in assessing the

effectiveness of CYICM.

Adolescents with chemical abuse problems enrolled in CYICM (22 percent,

n=130) differ from nonabusing enrollees (n=451). Those in the abusing

cohort are more likely to be emancipated minors and not enrolled in school,

less likely to be members of a minority group, and more likely to have private

health care coverage. They also evidence a different constellation of symptoms

than the nonabusing cohort, with abusers tending to display suicidal symptoms

and behaviors and sexual acting out. Abusers are also more likely to have

been admitted to private psychiatric hospitals and to have crisis contacts in

emergency rooms. Similar to nonabusers, however, abusers spend significantly

fewer days as inpatients in State hospitals and have fewer admissions to these

hospitals following their enrollment in CYICM.

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Although case management has been deemed an essential service to address

the problems of fragmented service delivery systems in both medical and

human services (Rapp and Chamberlain 1985), there is no common agreement

about the definition of case management, the setting in which it should be

provided, or the most appropriate providers (Rapp and Chamberlain 1985;

Huz and Pulice 1988). However, there are goals, principles, and activities

that should, theoretically, characterize a case management program.

DEFINITION OF CASE MANAGEMENT

The essential goals of case management are to promote continuity of care

and to maintain people in the community. These goals are achieved via

“traditional” case management activities, including assessment, planning,

monitoring, linkage, and advocacy (Sullivan 1981). Regardless of who

provides case management and where these services are provided, the

values of empowerment and advocacy frame a crucial context for provision

of services (Rose and Black 1985).

In New York State, CYICM can be described as an intensive, client-focused,

advocacy-oriented program. The goal of this program is to provide intensive

services to a family with a child who has SED and to work with the family

(natural, adoptive, or foster) and child-serving systems to maintain the child

in natural school, family, and community environments.

NEW YORK STATE’S INTENSIVE CASE MANAGEMENT PROGRAM

The case management model developed in New York State by the Office

of Mental Health (OMH), Intensive Case Management (ICM), was informed

by the experiences of other case management programs for adults with

serious mental illness, including Stein and Test’s PACT (Program for

Assertive Community Treatment) model (Stein and Test 1980); Washington,

DC’s Community Connection program (Harris and Bergman 1988);

Philadelphia’s Intensive Case Management program (Philadelphia Three

Year Plan 1986); Witheridge and Dincin’s (1985) Thresholds model; and the

Kansas Developmental Acquisition model (Rapp and Chamberlain 1985).

As described by Surles and colleagues (1992), the philosophy and value

system underlying the ICM model combine principles of advocacy and

empowerment (Rose and Black 1985) with those of psychiatric rehabilitation

(Anthony et al. 1988).

Distinct from models reported elsewhere in which case managers may also

function as primary therapists, New York’s ICM is not “therapeutic.” It is

intended to deal with the problems experienced by persons with mental illness,

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not mental illness in and of itself (Rapp and Chamberlain 1985). It is client

centered, and services are delivered in the natural environments (i.e., they are

not office based). Unlike traditional “9 to 5” outpatient services, the hours of

operation are quite flexible, with a 24-hour-per-day, 7-day-per-week response

capability. To ensure high intensity of services, the child-to-worker ratio is quite

small: 10:1. Finally, intensive case managers have access to flexible service

dollars that can be used to facilitate the client’s access to needed services and

supports.

In addition to improving the quality of care for individuals, ICM is intended

to improve the service system in which clients receive care. Although case

management is sometimes seen as a method of facilitating cost-containment

(Henderson and Wallack 1987; Rodriguez and Maher 1986), ICM may increase

the number and types of services provided as the system becomes more

responsive to the needs of individuals. This shift from a provider-driven system

to a client-driven system is an important policy change.

LITERATURE REVIEW

Historically, attention and funding for children’s mental health services in

the public sector have been directed toward residential and inpatient settings.

Following civil rights and due process reforms (Willie M. v. Hunt 1984) and

stimulated by the book “Unclaimed Children” (Knitzer 1982), however, national

recognition was achieved for the treatment of children in the least restrictive

setting appropriate to their needs (1975 Education for All Handicapped

Children Act, 1975). Leadership was evidenced by the National Institute of

Mental Health (NIMH) in its development of the Child and Adolescent Service

System Program (CASSP) in 1984. CASSP developed technical assistance

packages and provided funding to States to assist with the development and

implementation of a community-based system of care for children and their

families. Consistent with the philosophy of treatment in the least restrictive

setting appropriate to their needs and to the goal of treatment in a family

context whenever possible, in 1987 OMH began to develop programs that

represent alternatives to inpatient and restrictive residential treatment. OMH is

committed to building an array of services, including inpatient hospitalization,

day treatment, residential treatment, therapeutic foster care, intensive case

management, family support services, home-based crisis intervention and other

emergency care programs, clinic treatment programs, and respite programs.

A review of literature in the area of case management for children and youth

with mental health problems indicated that no studies of the effectiveness of

this intervention have been published. The data contained in this chapter and

elsewhere (Evans et al. 1991) provide early indicators of the effectiveness of

case management in decreasing hospitalization of enrolled children.

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NEW YORK STATE’S CYICM PROGRAM

Children and youth with SED are one of four target populations for the ICM

program. The model described above was designed for adults but was

implemented, without modification, for children and youth. CYICM is intended

to reach a historically underserved, at-risk population. Children and youth are

designated as being at risk if they have one or more of the following (New York

State Office of Mental Health 1991 a):

History of psychiatric hospitalization within the preceding 2 years or are at

risk of rehospitalization

Long length of stay during a psychiatric hospitalization (in excess of 90 days)

History of crisis-related contacts

History of out-of-home placement due to psychiatric difficulties

History of ineffective mental health treatment (e.g., a history of unplanned

movement out of treatment)

No particular modifications are made in the CYICM model to accommodate

persons with substance abuse problems. This is equally true of adult ICM in

which 44 percent of the clients receiving services could be classified as having

both mental illness and chemical abuse (Donahue et al. 1989). The underlying

philosophy of ICM is client centered and client and system advocacy oriented;

therefore, changes are not made in the model per se, but in the specifics of the

activities undertaken on the clients behalf.

In 1988 the New York State OMH implemented CYICM to keep children

and adolescents with SED in as natural and nonrestrictive environments

as possible (New York State Office of Mental Health 1989). CYICM is an

intensive client-centered service provided to the identified child in his or her

natural environment, home, school, and community. As with the adult model,

services delivered by the intensive case manager are dictated by the needs of

the child in the context of his or her family. CYICM services are provided 24

hours per day, 7 days a week, 365 days a year. The intensity of services is

ensured by the low child-to-worker ratio.

DEMOGRAPHIC CHARACTERISTICS

To date, CYICM has been implemented in 35 counties in the state, including

the five counties of New York City. The demographic characteristics of

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adolescents, 13 years of age and older, who have been served in CYICM are

displayed in table 1. For comparison purposes, data on the general population

under the age of 18 from the 1990 census are included (New York State Data

Center 1990).

Statewide, adolescents (n=581) served by CYICM are typically white nonHispanic (66 percent), male (56 percent), 15 years of age on admission, and

in the custody of their biological parents (71 percent). They reside in singleparent households (46 percent), are covered by Medicaid (60 percent), and

are in a special education program (55 percent). They display five problem

behaviors or symptoms, such as fighting and sexual acting out; are functionally

impaired in 2.5 areas, such as self-direction and social relationships; and have

been hospitalized or placed out of home due to psychiatric impairment 2.5

times.

BARRIERS TO MODEL DEVELOPMENT AND IMPLEMENTATION

Several difficulties were experienced in developing and implementing the

model. First, it is important to realize that ICM is a statewide program that

has been implemented in counties with diverse service systems, geography,

economics, political structures, populations, and needs. Second, although

this is a statewide program and a set of guiding principles was developed,

the program was implemented locally by varying auspices. ICM is operated

directly by both the State mental health authority through its State psychiatric

hospitals and the local public mental health systems through local mental health

TABLE 1. Race and ethnicity of CYICM adolescents vs. general population

New York State

(n=581)

New York City

(n=104)

CYICM General CYICM General

Adolescents Population Adolescents Population

Race/Ethnicity* (Percent) (Percent) (Percent) (Percent)

White 66 74 30 52

Black 22 16 51 29

Other races 2 10 18 19

Hispanic 11 12 32 24

*These categories are not mutually exclusive (i.e., the Hispanic category

includes all ethnic backgrounds).

293
departments or through contracts with local voluntary agencies. This model of

program implementation trades control and strict accountability for flexibility and

sensitivity to the needs of the local community.

It is also important to note that the New York State program was developed

for adults and that CYICM program staff and evaluators are only beginning

to understand some of the ways in which it could, and perhaps should, be

modified for children and adolescents. An NIMH-funded research demonstration

project, Project FIRST (Family-focused Intensive Resources for Support and

Treatment) (Evans 1990), which is under way in three rural counties

in New York state, examines the outcomes of a modified ICM model, called

Family-Centered Intensive Case Management (FCICM) with the outcomes of

a therapeutic foster care program. This research has important implications

for future policy and program development in the area of CYICM, particularly

in the area of caseload size.

Project FIRST addresses several issues raised during the initial implementation

of CYICM. Primary among these is the need to recognize explicitly the family,

not the child, as the focus of the intervention. CYICM intensive case managers

have a de facto caseload of 10; in most cases, however, they routinely deal with

numerous family members, teachers, and human services providers. They must

also consider the needs of family members and the stress placed on parents and

siblings in living with and caring for a child with SED. Recognition of this stress

has led to the incorporation of peer support groups for parents/caregivers, the

use of a parent advocate (PA), and the planning of recreational events to reduce

the isolation experienced by families. Respite is frequently cited as a need by

parents of children with SED. Rather than expending flexible service dollars on

this service, money for planned and crisis respite services was included in the

model. Because of the complexity of the case manager’s job in focusing on

families rather than individual children, the caseload has been reduced to 1:8.

Consistent with the philosophy of empowerment, the Project FIRST staff

believes that parents should also be recognized as experts in the care of

their children (Friesen and Koroloff 1990). In Project FIRST, this belief is

implemented in three ways. (1) Parents are included as members of the

treatment team, and their needs, wishes, and suggestions are an integral

part of treatment and service planning. (2) To assist parents as members

of the treatment team, parenting and behavior modification skills are taught

in the context of support group meetings and practiced at home with the

assistance of the FCICM PA. (3) To further establish the importance and

expertise of parents, a PA, the parent of a child with SED, is included in the

project. The PA’s role is to support the parents, coordinate support group

meetings and recreational events, serve as a member of the treatment team,

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and assist parents in advocating on behalf of their child. PAS also serve as role

models for other parents enrolled in Project FIRST.

In many cases when CYICM was implemented, only one children and youth

intensive case manager was assigned to a county, requiring that person to

cover a large, rural area. This introduced logistic problems and resulted in

the social isolation of the case manager. Because this type of work is

demanding, these case managers wanted opportunities to discuss their

work with a supervisor or other intensive case managers. Coverage for the

24-hour-a-day, 7-day-a-week work period was also problematic in these

cases.

BARRIERS TO WORKING WITH THE TARGET POPULATION

The main barrier to working with the target population is the severe inadequacy

of community-based services to which children and families can be linked.

Historically, clinic-based treatment and residential care were the only options

available. Despite the changing orientation of mental health providers, the

number and type of community services available have not kept pace with the

needs of children and families. For example, to support parents in maintaining

their children at home, programs are needed that fill the gap between the end

of the schoolday and the end of the workday. Day-long summer activities are

also needed.

DEALING WITH GAPS IN SERVICES

Two mechanisms are used to deal with gaps in service. The first is the use

of the flexible service dollars to create or stimulate the creation of needed

services. Up to 75 percent of the flexible funds available can be used to

purchase services for the class of CYICM clients, and the other 25 percent

must be used to meet the needs of individual children. If such services as

crisis services, respite, or after-school programs are not available in a

community, the flexible funds can be used to initiate such programs.

Tangible needs must also be addressed if families are to remain in and derive

benefit from services (Rapp and Chamberlain 1985; Surles and Blanch 1989).

As discussed earlier, flexible service dollars are one method of meeting these

needs. Money for transportation to support group meetings, trained child care

workers who function as baby-sitters to allow parents to attend meetings, and

refreshments at meetings are ways of ensuring maximum participation from

parents. Provisions for transportation, particularly in rural areas, is essential.

Frequently, mass transportation is unavailable; personal transportation is

inaccessible; and the distance to services is prohibitive. Finding child care for

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children with SED is cited frequently as a barrier to active participation by

families. If such issues as transportation and child care can be addressed

adequately, it will be easier for parents to participate as partners in developing

and implementing a treatment plan for their child.

The second way of dealing with gaps in service is through advocacy. Intensive

case managers are engaged in advocacy at two levels-the client and the

service system. They not only aggressively seek services for a particular

client but also work to make the service system more responsive to the target

population.

ISSUES IN DEVELOPING LINKAGES WITH OTHER COMMUNITY

AGENCIES

A lack of coordination and “turf” issues among the various human services

agencies impede coordination of services (Friedman and Duchnowski 1990).

In New York State there are 13 child-serving agencies. There are often

conflicting requirements for receipt of services across agencies, contrasting

and uncoordinated philosophies about how best to serve children and families,

and inadequate information sharing among human service agencies.

OMH is committed to serving children who are clients in multiple agencies.

The program staff believes that there may be children in the custody of the

Department of Social Services who are in need of ICM services. When the

program model was released, OMH recommended that an interagency intake

committee be developed at the local level. The purpose of the committee would

be to review records of children referred to the committee and to put on a roster

those appropriate for CYICM. Although many counties established such an

interagency committee, some did not. In the future, interagency committees

may be mandated to ensure the referral of children from non-mental health

agencies.

Collaboration with local departments of social services and schools has been

difficult in some areas. In particular, access to schools has been problematic

for some intensive case managers, with school principals refusing to allow

intensive case managers to work with teachers. Continuous efforts are being

made to forge more collegial links with other child-serving agency staffs.

Another way in which OMH is seeking to develop linkages and foster

coordination is through an approach in which agencies at the State level

attempt to avoid duplicative regulations, develop memoranda of understanding

on funding, foster information sharing, and provide assistance across agencies

in meeting the total needs of children and their families.

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Initially, there was also difficulty associated with accessing and using the

flexible service dollars. In particular, the case managers were uncertain for

what purposes they could use the money; that is, could it be used to meet

family needs as well as those more clearly recognized as the child’s needs?

The model indicates that at least 25 percent of the service dollars must be

used for the needs of individual children; the remaining funds may be used to

develop services and programs, such as respite and after-school programs,

for all ICM clients. However, the guidelines were not specific regarding the

expenditure of funds for the family vs. the individual child.

In addition, at the State level, there were concerns about funding for CYICM,

but OMH was able to access funds through Medicaid’s Comprehensive Case

Management option. Billing under this option is appropriate because of the

limited target population and the rostering procedures used in CYICM. A

positive outcome of the ability to access this option is that case managers need

only to document four face-to-face contacts per month to access Medicaid

funds instead of the frequent paperwork required when each service contact

must be documented.

RESEARCH STRATEGIES AND INSTRUMENTATION

Three general research strategies are used in evaluating the outcomes of

CYICM. The first is to collect descriptive data on all children enrolled in the

program. The staff at OMH developed a Client Description Form for Children

and Adolescents (CDF) based on minimum data set recommendations

developed by the Mental Health Statistics Improvement Program at NIMH

(Leginski et al. 1989). This form is completed by the intensive case manager

within 30 days of a child’s enrollment and contains demographic, living situation,

custody status, educational placement, problem behaviors and symptoms,

treatment and placement history, and functional impairment variables. This

form also is used for collecting data on all children enrolled in seven other

community-based programs, thus allowing for cross-program comparisons.

The descriptive data permit program and policy staff to determine whether the

target population is being served in the CYICM program.

The Program Termination Form (PTF), a companion form to the CDF, is

completed on discharge. It provides information on the reason for termination,

service referrals, the living situation on discharge, and whether this living

situation has changed since admission. Based on the data collected by the

CDF and the PTF, the evaluation staff is able to describe the children enrolled

in the programs, compute average length of stay, identify and compare

subpopulations of children (e.g., long-stay vs. shorter stay children), and

determine proximal outcomes associated with the program. Such outcomes

include changes in restrictiveness of living environment.

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The second research strategy involves classic program evaluation and

addresses questions about program implementation, case manager behavior,

and client and system outcomes. A 3-year evaluation of CYICM is being

conducted in New York State (Huz et al. 1990). The logic model underlying

this evaluation appears in figure 1. The endogenous variables are

characteristics of the service system and the organizations providing

the service; the characteristics of intensive case managers; and the

characteristics, status, and functioning of the children and their families.

These variables affect intensive case manager behavior, which in turn

influences the service system and child and family outcomes. The expected

service system outcomes include decreased number of days spent in the

most restrictive levels of care by enrolled children and decreased use of crisis

services such as psychiatric emergency rooms. Expected child and family

outcomes include fewer unmet needs for a variety of services and improved

child functioning in home, school, and community environments. A 30-percent

random sample of children receiving CYICM services will be studied intensively

using a Baseline Supplemental Form (BSF) containing information on family

structure, unmet needs, and child and family functioning. These children

will be compared with a nonequivalent comparison group, probably children

on CYICM waiting lists, to more definitively assess the outcomes of this

intervention.

The third research strategy is to design and seek funding for research

demonstration projects that permit the use of rigorous research designs to

answer questions about the effectiveness of the intervention and to begin to

understand what types of services work best for which children and families.

For example, as mentioned previously, the authors currently have a 3-year

research demonstration project funded by NIMH to establish a new program

model, Family-Centered Intensive Case Management, in three rural counties

and to compare the program’s outcomes with those of Family-Based Treatment,

New York State’s model of therapeutic foster care. The research uses a

positive controlled randomized study design with multiple observations,

assigning children ages 6 to 12 years who are referred for therapeutic foster

care to one of these two treatment conditions. The evaluation focuses on

provider behavior and family, child, and system outcomes, including costeffectiveness of the two programs, Figure 2 presents the logic model for this

research, including the classes of variables identified for study in each of the

domains of interest.

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FIGURE 1. Logic model for the evaluation of CYlCM

SOURCE: Huz et al. 1990

INSTRUMENTATION

The instruments employed in the evaluation of CYICM using the second

strategy identified above include the CDF, PTF, and BSF developed jointly

by program and research staff at OMH. Additional data on children hospitalized

in State-operated psychiatric centers are available through the Department of

Mental Hygiene Information System. Also, the evaluation staff has requested

permission to access the State’s Medicaid Management Information System to

more fully explore the use of services by children who are Medicaid-eligible.

The strongest test of an intensive case management program is being

conducted through a funded research project on FCICM, and a battery of

instruments has been compiled to test the study’s hypotheses. A listing of the

instruments and their schedule for use appears as table 2. The service system

is being described and key informants’ opinions about it are being assessed

through use of an instrument developed by the research team, based on work

done by Morrissey and colleagues (1990). This instrument, Assessing the

System of Care for Children with Serious Emotional Disturbance (New York

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FIGURE 2. Logic model of the research

State Office of Mental Health 1991b), was pilot tested in a nonstudy county

before its use in the three study counties. A snowball sampling technique is

used to identify providers, parents, and other key informants who record their

perceptions of the nature and adequacy of the local service system. The form

is completed annually over the 3-year study period.

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TABLE 2. Timeline for administration of evaluation of tools

Date What Is Measured

10/90-11/90 Assessing of local Service system

(Time 1)

3/91

10/91-9/92

Human resource data collection

Provider behavior

3/91-7/91 Initial assessment of children and

families

10/91-11/91

10/92-9/93

Assessment of local service system

(Time 2)

Provider behavior

Measurement Tools

Assessing the System of Care for

Children with Serious Emotional

Disturbance

Human Resources Questionnaire

Daily Activity Log

Activity Time Log

Advocacy Log

Casework Contact Form

CDF

BSF

Parenting Skills Index

Child and Adolescent Functional

Assessment Scale

Child Behavior Checklist

Teacher Report Form

Piers-Harris Children’s Self-Concept

Scale

FACES Ill

Parent and Child

(Self-Efficacy) Form

Assessing the System of Care for

Children with Serious Emotional

Disturbance

Daily Activity Log FCICM/FS/PA

Activity Time Log

Advocacy Log

FCICM/FS/PA

FCICM/FS/PA

Casework Contact Form FCICM/FS/PA

Respondent

County MH directors

OMH regional office

Provider agency staff

Informed citizens

FCICM/FS/PA

FCICM/FS/PA

FCICM/FS/PA

FCICM/FS/PA

FCICM/FS/PA

FClCM/FS

FClCM/FS

FCICM/FS

FCICM/FS

Parent

Teacher

Proband child and siblings

Parents and siblings over 12

Parents

County MH directors

OMH regional office

Provider agency staff

Informed citizens
TABLE 2. (continued)

10/91-1/92 6-month followup assessment of

child/family

4/92-7/92 1 -year followup assessment of

child/family

10/92-11/92

10/92-7/93

10/92-1/93

4/93-6/93

Assessment of local service system

(Time 3)

Provider behavior

18-month followup assessment of

child/family

6-month postservice

assessment of child/family

KEY FS=family specialist. MH=mental health

Client Follow-Up Form

Parenting Skills Index

Client Follow-Up Form

Parenting Skills Index

Child and Adolescent Functional

Assessment Scale

Child Behavior Checklist

Teacher Report Form

Piers-Hams Children’s Self-Concept

Scale

FACES III

Parent and Child (Self-Efficacy)

Form

Job Description Index

Assessing the System of Care for

Children with Serious Emotional

Disturbance

Daily Activity Log FCICM/FS/PA

Activity Time Log FCICM/FS/PA

Advocacy Log FCICM/FS/PA

Casework Contact Form FClCM/FS/PA

Client Follow-Up Form

Parenting Skills Index

Child Behavior Checklist

Teacher Report Form

Piers-Harris Children’s

Self-Concept Scale

FACES III

Parent and Child (Self-Efficacy)

Form

Job Description Index

FCICM/FS

FCICM/FS

FCICM/FS

FCICM/FS

FCICM/FS

Parent

Teacher

Proband child and siblings

Parents and siblings over 12

Parents

FCICM/FS

County MH directors

OMH regional office

Provider jagency staff

Informed citizens

FCICM/FS

FClCM/FS

Parent

Teacher

Proband child and siblings

Parents and siblings over 12

Parents

FCICM/FS/PA
The CDF is used to collect a minimum data set on all children at the time

of enrollment in the two interventions. The BSF is completed after 6 months,

and the PTF is used on discharge. The Child Behavior Checklist for Ages

4-18 (Achenbach 1991 a), completed by a parent, and the Teacher Report

Form (Achenbach 1991 b) are completed shortly after enrollment and

approximately every 6 months thereafter. These instruments, along with

the Child and Adolescent Functional Assessment Scale (Hodges 1990),

provide information on the child’s functioning in the home, community, and

school. The Piers-Harris Children’s Self-Concept Scale (Piers and Harris

1984) is completed by the proband child and by his or her siblings, ages 8 to

18, at two or more points in time.

Two measures of parenting skills are used in this study. The first, the Parenting

Skills Index, comprises six scales selected from the Child Well-Being Scales

(Magura and Moses 1986) and uses the provider of care to rate parenting skills.

The second, Parent and Child (Self-Efficacy) Form (New York State Office

of Mental Health 1991 c), obtains information on parenting and parenting

self-efficacy directly from the parents. The Family Adaptability and Cohesion

Scale (FACES) III (Olson et al. 1985) is used to obtain information on family

adaptability and cohesion at several points in time. It is completed by the

parents and all siblings 12 years of age and older. The final parent and child

outcome being measured is satisfaction with services, and instruments are

being developed to measure this outcome. Because data are collected at

several points in time, the evaluators are able to determine the system, child,

and family outcomes associated with both the study’s interventions.

Data are collected on providers of care, including FCICMs, FSs, and PAS,

through use of a Human Resources Questionnaire for Community-Based

Programs for Children and Adolescents (HRQ) (New York State Office of

Mental Health 1990) and the Job Description Index (Smith et al. 1969). The

former was developed by the Bureau of Evaluation and Services Research

and is based on the minimum data set recommendations developed by Leginski

and colleagues (1989). whereas the latter is a well-known and frequently used

measure of job satisfaction. Providers of care are also keeping activity logs that

will assist the researchers in describing the interventions and in completing a

comparative cost study.

PRESENTATION OF DATA

Description of Adolescents Enrolled in CYICM

As of December 1, 1991, data were available for 581 adolescents enrolled

in CYICM, of whom 130 (22 percent) had one of the following: a history of

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treatment for alcohol or substance abuse, a DSM-III or DSM-III-R alcohol or

other drug diagnosis or symptoms of alcohol or other drug abuse on admission,

or a referral for alcohol or other substance abuse treatment on discharge.

Adolescents with alcohol or other drug problems are significantly (p<=0.001)

older (15.9 years) than those without such problems (15.1 years). This age

difference has implications in two areas: custody status and educational

placement. Adolescents with substance abuse problems are more likely to

be emancipated minors (6.9 percent) than their counterparts (2.2 percent),

who are likely to be in the custody of their parents or other family members

(79 vs. 86 percent, respectively).

Adolescent chemical abusers have problems educationally as well: 19.2

percent of youth with substance abuse problems are not enrolled in school,

and only 1.5 percent have a high school diploma or general equivalency degree

(GED), although 29 percent are legally required to attend school. Of those who

are not enrolled in school (n=25), only one has a diploma or GED. Significantly

(p<=0.01) more adolescents without substance abuse problems are enrolled in

school.

Demographically, the two groups are also dissimilar. There are significantly

(p<=0.05) fewer minorities among the abusers (78 percent white non-Hispanic)

than the nonabusers (62.3 percent white non-Hispanic). There are roughly

equal numbers of males and females among both group (52 percent male in

the chemical abuse group and 57 percent male in the nonabusing group).

Although both groups are predominantly of lower socioeconomic status as

indicated by the percentage who receive Medicaid benefits, the adolescents

with substance abuse problems are significantly (p<=0.01) more likely to be

covered by private third-party insurers (33.1 vs. 20.0 percent). This is one

possible explanation for why chemical-abusing adolescents are more likely to

be treated in private psychiatric facilities (21.9 vs. 13.6 percent) than are the

nonabusing adolescents.

The treatment and placement histories of chemical-abusing adolescents

are also quite different from those of the nonabusing group. Adolescents

who abuse substances are more likely to have a history of at least one

emergency room presentation due to psychiatric problems (67 percent) than

their nonabusing counterparts (55 percent). They are slightly more likely to

have spent time in a nonsecure or secure detention setting (5 vs. 2 percent),

but this difference is nonsignificant.

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Chemical-abusing adolescents seem to have greater contact with other childserving systems than do nonabusers, with 24 percent of the abusers referred

to CYICM from outside the mental health system (p<=0.01) and 14 percent in

the custody of other systems. For nonabusers, 13 percent were referred from

outside the mental health system and 13 percent were in the custody of other

systems.

The problem behaviors and symptoms displayed by the abusing group are

markedly different from those of the nonabusing group. Seventy percent of the

abusing group display suicidal symptoms (p<=0.01) and 31.5 percent are acting

out sexually (p<=0.001), but they display fewer developmental delays than the

nonabusing cohort (8.5 percent, p<=0.01). Overall, the average number of

symptoms and behaviors displayed is higher for abusers than for nonabusers

(6.2 vs. 4.7, p<=0.001). Although both groups are functionally impaired in 2.5

areas, the abusing group has a more difficult time with self-direction (87.7 vs.

72.1 percent, p<=0.001).

A major goal of CYICM is to prevent unnecessarily restrictive placements.

One measure of this is to look at the change in living situation between

admission and discharge. The authors have defined the least restrictive

environment as independent living and as living with natural or adoptive

parents or with extended family members. The next higher category of

restrictive placement is foster care, followed by group home placement and

institutional living. For both the abusing (n=46, p<=0.001, chi-square=48.4)

and the nonabusing (n=115, p<=0.001, chi-square=64.6) groups, the living

situation on discharge was significantly different from the living situation on

admission (figure 3).

For the abusing group (n=46), 76 percent had no change in living situation

between admission and discharge, 2 percent moved to a less restrictive

placement, and 22 percent moved to a more restrictive placement. For

comparison purposes, 68 percent of the nonabusing group (n=115) had no

change between admission and discharge, 8 percent moved to less restrictive

settings, and 24 percent moved to more restrictive placements. There was no

statistical difference between abusers and nonabusers in changes in living

situation.

Related to the goal of preventing unnecessarily restrictive placements is

reducing the number of days spent in inpatient settings. The analysis of these

data for the period ranging from 6 months prior to 6 months postenrollment in

CYICM shows that 74 percent of all State inpatient admissions among the

abusing cohort (n=35) were within the 6 months prior to their enrollment in

CYICM, whereas 26 percent were within the 6 months postenrollment. Sixty305
FIGURE 3. Change in restrictiveness of living situation

eight percent of all inpatient admissions among the nonabusing group (n=69)

were within the 6 months preceding their enrollment, and 32 percent within 6

months postenrollment (figure 4).

In terms of the number of days spent in State hospitals, the abusing group

spent 1,582 (89 percent) days in the hospital before enrollment and 192 (11

percent) following enrollment. The nonabusing group spent 5,666 (78 percent)

of total hospital days before CYICM and 1,575 (22 percent) after enrollment

(figure 5).

The data for both groups show that enrollment in CYICM is associated with

decreased hospitalization of high-risk children, but the authors are not able to

attribute causation to the intervention because the findings were observed in

the absence of a comparison group. Targeted statistical analyses are under

way to examine changes in the slope of the regression line over time.

306
FIGURE 4. Number of inpatient admissions to State-operated facilities

Description of Intensive Case Managers

This section presents a summary of the demographic characteristics of

intensive case managers serving children and adolescents. Data are being

collected from intensive case managers to obtain an aggregate profile of the

workforce. The HRQ developed by OMH’s Bureau of Evaluation and Services

Research (New York State Office of Mental Health 1990) collects demographic,

educational, and experiential information from all intensive case managers. As

of December 1, 1991, HRQs have been completed by 78 children and youth

intensive case managers, 4 CYICM coordinators, and 4 CYICM supervisors,

representing 33 counties. This represents 63 percent of filled positions.

Respondents were from all five OMH regions.

307
FIGURE 5. Number of inpatient days spent in State-operated facilities

Forty-two percent (n=35) of the intensive case managers report being

employed by a local nonprofit agency, 36 percent by a State-operated program,

21 percent by local government, and the remaining 1 percent by local for-profit

or other types of agencies.

Typically, intensive case managers and their supervisors tend to be white

non-Hispanic (58 percent) and female (74 percent). Approximately 21 percent

are black and 12 percent are of Hispanic origin, with higher percentages of

minority case managers in New York City (28 percent black non-Hispanic,

4 percent other non-Hispanic, and 28 percent Hispanic) than upstate. Their

average age when hired is 38, with a range of 23 to 61 years.

308
Most intensive case managers and their supervisors have attained master’s

degrees (64 percent), and 37 percent hold bachelor’s degrees as their highest

degree. Overall, 45 percent earned their degrees in clinical or nonclinical social

work, and 24 percent earned their degrees in mental health-related fields (e.g.,

clinical counseling). Intensive case managers have a great deal of work

experience. Table 3 presents years of experience in inpatient, outpatient,

and case management services.

Slightly more than 52 percent of intensive case managers have both inpatient

and outpatient mental health experience, 46 percent have outpatient mental

health experience only, and only 1.2 percent (1 intensive case manager) has

inpatient experience only.

ASSESSING COST-EFFECTIVENESS

The most comprehensive assessment of the costs associated with CYICM

is being conducted as part of Project FIRST. Several instruments have

been developed by the research team and consultants to describe the

interventions (i.e., Family-Based Treatment and Family-Centered Intensive

Case Management) and to provide information necessary for determining the

cost-effectiveness of both study interventions. The instruments include the

Daily Activity Log, completed each day during the survey period except on the

one day each week when the Activity Time Log, a more detailed reporting, is

completed. An Advocacy Log, which seeks descriptions of the advocacy

activities performed, is also used by service providers. Finally, a Casework

Contact Form is used by providers to record daily contacts with or on behalf of

the children and their families. This form provides information on the persons

contacted and the mode of contact.

TABLE 3. Mental health experience of intensive case managers (by years of

experience)

Area of Expertise* Average

Inpatient 3.3

Outpatient 5.3

Case management 2.8

Children’s inpatient 2.4

Children’s outpatient 5.7

Range

0-23

0-24

0-17

0-14

0-24

*These categories are not mutually exclusive.

309
The cost analysis focuses primarily on the direct labor costs associated

with caring for children with SED in each model. The analysis also makes

comparisons of other costs associated with delivery of care, including

transportation, child care costs for siblings, training materials, and supply

costs. The end result of the cost analysis will be the ability to estimate the

total cost of delivering care under each of the two models, identifying and

evaluating the cost components of each model, and identifying the costs of

specific services such as training and respite care.

PROBLEMS IN CONDUCTING RESEARCH

To date, the greatest difficulty in conducting research on case management

in New York State has been the identification of an equivalent comparison

group. To control nonprogram sources of variance, children should be

randomly assigned to treatment conditions. In practice, this is not always

feasible. It is most feasible when outside funding is used to establish new

programs or when several state-of-the-art treatment programs are available

for random assignment of children and no one is assigned to a no-treatment

condition.

The comprehensiveness of the study of CYICM introduces difficulties in

obtaining permission to study child and family outcomes. It is relatively easy

for the evaluation staff to obtain a minimum data set on all children enrolled

in ICM, but it is much more difficult to obtain supplementary materials on

children and, particularly, on families without an outside funding source. Case

managers find the additional time and paperwork burdensome and are often

unable to obtain data from teachers and other nonfamily members within their

working hours. The administration of study instruments creates additional time

and paperwork burdens for case managers. As presently designed, the CYICM

model focuses on the child rather than on the family unit. Additional personnel

resources are likely to be necessary in decreasing caseload size and in

facilitating additional data collection in families served.

The length of time required to implement complex interventions was

underestimated. There are numerous political, fiscal, and other systems

factors that slow implementation. These issues arise at all levels involved:

national, State, regional, and local. Based on the authors’ experience with

Project FIRST, it is preferable to conduct a process evaluation for at least

1 year during implementation. In addition, the window of observation should

be as long as possible to truly assess program attrition and longer term

outcomes of the intervention. Goering and coworkers’ (1988) study of case

management, for example, found that case management and control groups

did not differ on some outcomes until the 2-year followup period.

310
Two additional barriers to conducting research on case management are the

time and paperwork burdens associated with institutional review board (IRB)

examination of human subjects issues and obtaining relevant data sets from

other State agencies. Whenever research is undertaken, one or more IRBs

are involved in reviewing the procedures for protection of human subjects.

OMH’s central office IRB reviews these procedures, but sometimes one or

more agencies ask to have the procedures reviewed by their IRB or refuse

to release information on the grounds that it violates client confidentiality.

Because our CYICM program is statewide, dealing with issues related to

protection of human subjects can be very time consuming. In relation to

obtaining relevant data sets from other State agencies, OMH does not have

access to general hospital data or to Medicaid data except through petitions

to review committees in other State agencies. Again, this is time consuming

and not always productive in regard to the program staffs ability to access

data.

SUMMARY AND IMPLICATIONS

This chapter has presented an overview of New York State’s CYICM

program. This client-centered, linkage- and advocacy-focused model of

case management has been implemented in 35 counties in the State and has

provided service to 581 adolescents. The program uses a caseload ratio of

1:10 and targets children and adolescents with SED, some of whom also have

problems with chemical abuse. Case managers have flexible service dollars

available for use in meeting the needs of individual children and of the target

population of children.

The identified barriers to model development cluster around issues related to

the application of a model designed for adults to a population of children and

adolescents. The efficacy of modifications, such as lower caseload, use of a

PA, and parent support groups, is under study.

Gaps in services are primarily addressed through use of flexible service

dollars to stimulate the development of needed services and through advocacy

activities of the intensive case managers. Linkages with other community

agencies are accomplished through individual case manager contact,

interagency rostering committees at the county level, and coordination of

child-serving agencies at the State level.

The authors’ research strategies have involved descriptive studies, program

evaluation, and funded research. All these efforts are guided by a heuristic

model of mental health services research (Shern et al. 1992) and make use

of minimum data sets, often enhanced by concurrent use of other assessment

instruments.

311
In this chapter, the authors have presented a comparison of adolescents

enrolled in CYICM who abuse chemicals (n=130) with nonabuser enrollees

(n=451). The chemical abusers were more likely to be emancipated minors,

were not enrolled in school, were less likely to be members of minority groups,

and were more likely to be covered by private third-party insurers. Chemical

abusers were more likely to be admitted to private psychiatric facilities, were

more likely to use emergency rooms, and had greater contact with other childserving systems. Finally, chemical abusers displayed a greater number of and

a different constellation of problem behaviors and symptoms, primarily suicidal

behavior or ideation and sexual acting out, than did nonabusers. Similar to

nonabusers, following their enrollment in CYICM the abusing group spent

significantly fewer days in State inpatient hospitals and had fewer numbers

of admissions than they had experienced in the year prior to enrollment.

Because of the client-centered nature of CYICM and the generally positive

outcomes, the authors have not felt it necessary to make system-wide

changes in the program model to accommodate the subpopulation (22 percent)

of adolescents who are identified as chemical abusers. However, serving this

subgroup within CYICM does have some implications for program managers

and intensive case managers. These implications include the need for accurate

and ongoing assessment of clients accepted into CYICM and the necessity

of continuing to work toward greater interagency coordination so that the

needs of adolescents who abuse chemical substances will be met.

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ACKNOWLEDGMENTS

The authors acknowledge their colleagues Mary Armstrong, Caren Cavitch,

Steven Huz, and Donald Rahn at the Bureau of Children and Families and the

Bureau of Evaluation and Services Research for their assistance with the

conceptualization and conduct of this and other work related to the evaluation

of Intensive Case Management.

AUTHORS

Mary E. Evans, Ph.D.

Principal Research Scientist

Norin Dollard, M.P.A.

Research Scientist I

Bureau of Evaluation and Services Research

New York State Office of Mental Health

44 Holland Avenue

Albany, NY 12229

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Case Management as a Mechanism for

Linking Drug Abuse Treatment and

Primary Care: Preliminary Evidence

From the ADAMHA/HRSA Linkage

Demonstration

William E. Schlenger, Larry A. Kroutil, and E. Joyce Roland

INTRODUCTION

The continuing acquired immunodeficiency syndrome (AIDS) epidemic is

bringing about major changes in the delivery of both primary care and drug

abuse treatment. Because they engage in a variety of high-risk behaviors,

drug users put themselves, their sexual partners, and their children at risk for

exposure to human immunodeficiency virus (HIV) infection—and therefore,

ultimately, to the development of AIDS—and to a variety of other infectious

diseases (e.g., other sexually transmitted diseases, hepatitis B, tuberculosis).

Drug users are at higher risk of being infected with these diseases and passing

them on to other people through a variety of mechanisms, including needle

sharing, trading sex for drugs, having sex with multiple partners, and perinatal

transmission. Therefore, drug users as a group are in need of direct treatment

and are an important target for preventive public health efforts.

Consequently, increased attention is being paid to the relationship between

the substance abuse treatment and primary care systems. To foster the

development and testing of models for improved linkage between the two

systems, the Federal agencies with lead responsibilities for substance

abuse treatment and primary care—the Alcohol, Drug Abuse, and Mental

Health Administration (ADAMHA) and the Health Resources and Services

Administration (HRSA)—agreed to create a 3-year demonstration program.

The goals of the ADAMHA/HRSA Linkage Demonstration are as follows:

To recognize and treat the health care problems of drug abuse treatment

clients

316
To recognize and treat substance abuse in the context of the primary care

system

To identify feasible approaches to the provision of integrated health care in

the context of existing community-based services

In August 1989, 21 applications were selected to be funded under the

demonstration, for a total of about $9 million per year. The 21 grantees are

located in 19 cities and 15 States across the country. About one-third of the

grantees are community health centers; another third are city or county health

departments; and the remaining third are other agency types (usually hospitals

or State agencies). In only one instance is the primary grantee a drug treatment

program, but all projects include both community-based drug treatment and

primary care components. Grant awards for the first year varied from about

$170,000 to $600,000.

In addition, ADAMHA funded separately an independent evaluation of the

demonstration-the National Evaluation of Models for Linking Drug Abuse

Treatment and Primary Care (National Evaluation). The primary objective of

the National Evaluation is to identify and describe promising models for linking

drug abuse treatment and primary care. As a result, the National Evaluation

is focused on process questions: To what extent are the alternative linkage

models able to provide primary care and drug abuse treatment to people who

are in need of both kinds of services? This reflects a purposeful decision on

the part of ADAMHA: Given the relatively limited current knowledge concerning

"what works” in comprehensive service delivery and the fact that the Linkage

Demonstration did not include any requirements for experimental design, the

evaluation should be descriptive and focused on identifying and describing

promising models whose efficacy could be studied more rigorously in

subsequent demonstrations.

The National Evaluation represents an unusual opportunity to study case

management and drug treatment because all 21 projects proposed to use

case management as a mechanism for achieving linkage and, in some

projects, it was the primary or sole mechanism. Case management is a

strategy increasingly being employed in settings where the service needs

of the target population are complex, service systems are highly bureaucratized,

and resources are fragmented. Although the concept of case management

has received increasing attention as a means of improving the delivery of a

variety of health and social services, its application in drug abuse treatment

programs, and particularly in programs focusing on linking drug abuse and

primary care services, has not been systematically studied. The National

Evaluation provides the opportunity to study the role and function of case

317
management in a variety of promising service models in a variety of

organizational settings.

This chapter presents preliminary findings from the National Evaluation

that describe the delivery of drug abuse treatment, primary care, and other

services to demonstration clients. In addition, preliminary evidence is presented

concerning the relationship between services received and case management.

METHODS

Procedures

In the first phase of the National Evaluation, data describing clients’

sociodemographic characteristics, treatment needs, and services received

were abstracted from the clinical records of “identified clients” of each of the

21 demonstration projects who were enrolled in the demonstration during

1990. An “identified client” was defined as anyone who was served during

1990 by any of the providers participating in the demonstration project and

who was identified as having both drug treatment needs and health care needs.

It was recognized from the outset that there would be substantial variability

both in the record systems of the specific providers within a project and across

projects. To increase the likelihood that projects’ records would contain the

data of interest to the evaluation, the National Evaluation specified in advance

a “core data set” that identified basic information that all projects would be

required to maintain in their records.

A record abstraction form was developed that was used at all 21 sites to record

data. The abstraction form included sociodemographic characteristics, drug

use and health problems histories, identified service needs and treatment plans,

and treatment and services received.

Data were abstracted by local abstractors who were hired and trained by

the National Evaluation team. The two major qualifications for abstractors

were (1) some clinical background in drug abuse treatment or primary care

and (2) familiarity with the record systems of participating providers.

Abstractor candidates were identified by local project directors, and those

selected attended a 1-day training session conducted by the National

Evaluation team. Abstraction forms were sent to the National Evaluation

team by abstractors on a flow basis and were edited carefully as they came

in so that feedback could be provided quickly to abstractors concerning any

problems.

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The 2,409 forms received from the 21 projects were keyed and analyzed

centrally by the National Evaluation team.

The analyses presented in this chapter are multiway cross-tabulations.

Findings are presented separately for those who were identified through

primary care vs. those who were identified through drug abuse treatment.

These two groups were separated because preliminary analyses of their

characteristics suggested that those identified through primary care differed

from those identified through drug abuse treatment. The differences were

consistent with the “earlier intervention” hypothesis-those identified through

primary care were younger, less likely to have had prior drug abuse treatment,

more likely to identify marijuana or alcohol as their primary drug (vs. heroin and

cocaine for those identified through drug treatment), and more likely to receive

outpatient drug-free treatment (vs. methadone maintenance).

Findings are also provided separately for clients served by projects with

differing linkage models. Although there are many ways to conceptualize

the notion of “linkage” of drug abuse treatment and primary care, for the

analyses presented here the authors used a conceptualization based on

the perspective of the service user. That is, can clients receive many

primary care and drug abuse treatment services at a single location, or

must clients go to multiple locations to receive needed services? Findings

are presented separately for clients served by projects implementing

“centralized” vs. “decentralized” models. Centralized projects are those in

which most primary care and drug abuse treatment services are offered at a

single location (i.e.,“one-stop shopping”), whereas decentralized projects offer

most primary care and drug abuse treatment services at different locations

(e.g., clients may give a medical or drug abuse history at a single location but

must go to different locations for a more extensive workup and treatment

services).

We recognize that, in practice, it is probably not feasible to establish a “pure”

centralized system in which all services that a client might need are available at

a single location. For the purposes of this classification, we consider a project

to be implementing a centralized model if clients can be assessed and treated

for both primary care and substance abuse problems at a single location.

Five projects in the Linkage Demonstration are best described as centralized

and five as decentralized. An example of a centralized model is the Seattle/

King County project. In this project, the grantee has placed nurse practitioners

onsite at the drug treatment facilities to conduct assessments and “provide as

much health care as possible onsite before referring to the linked clinic for

followup and ongoing care.” Similarly, drug treatment counselors have been

319
established in the participating primary care clinics. Although it is intended that

these counselors refer patients to drug treatment when a problem is identified,

they begin the process of counseling within primary care. Furthermore, at one

of the project sites, a drug-free program and a medical clinic are located in the

same building.

An example of a decentralized model is provided by the project being

conducted by the Maricopa County Public Health Department in Phoenix,

AZ. In this project, primary care, outpatient drug-free, and methadone

maintenance services are offered at different locations, with case managers

designed to play a key role in intake and referral to the appropriate providers.

Limitations

The scope of this chapter and of the National Evaluation are limited in several

ways. First, the chapter is largely descriptive. It is intended to provide a broad

base of descriptive information about the Linkage Demonstration.

Second, the National Evaluation was designed to take account of an important

constraint that results from the fact that no experimental design was built

into the Linkage Demonstration. That is, grantees were not required to

have experimental or quasi-experimental comparison groups as part of the

demonstration; rather, the grantees were simply to focus on implementing

model approaches for providing linked services. This is an important reason

for the descriptive focus of the evaluation.

Third, as is typical of demonstration programs, the projects involved in

this study were not selected at random; rather, they were selected on the

basis of a competitive, peer-reviewed process. Consequentiy, they are

neither representative of the universe of drug abuse treatment and primary

care programs, nor do they necessarily represent the full range of possible

approaches to linkage. The demonstration projects that are studied in this

chapter are best understood as examples of potential approaches to linkage

and the findings as preliminary information about their implementation. This

is consistent with the National Evaluation’s overall goal of identifying feasible

and promising models of linkage.

Fourth, it is important to remember that the projects involved in the

demonstration are not implementing a common intervention. Instead,

each is implementing its own intervention in an attempt to identify promising

approaches. Consequently, pooling across projects may obscure some

true differences and exaggerate some spurious differences.

320
Finally, because the findings presented in this chapter are derived primarily

from information abstracted from client records, they are subject to all the

limitations inherent in record-based studies. Foremost among these is the

failure to document in the records everything that is known or done, rendering

the records an incomplete subset of the “true” characteristics and services

received. Therefore, the tabulations presented here are probably best

understood as lower bound estimates. That is, positive indications in the

record suggest that an event happened, but negative indications do not

necessarily mean that it did not.

RESULTS

Services Received

The first question addressed in this chapter is: What kinds of services are

Linkage Demonstration clients receiving? Table 1 shows the distribution of

the type of drug treatment that clients received. Findings indicate that those

who are identified through drug abuse treatment are more likely than those

who are identified through primary care to receive drug abuse treatment; more

than 90 percent of those identified through drug treatment received some type

of treatment vs. 30 to 60 percent of those identified through primary care.

The findings also suggest a substantial advantage to a centralized model for

identification through primary care, because clients identified in centralized

model projects were nearly twice as likely to receive treatment as those

identified in decentralized models (65 vs. 31 percent for any treatment, 59

vs. 30 percent for any formal rehabilitation).

Table 2 shows the distribution of amount of formal drug treatment received,

operationalized as the number of months during which a client actively

participated in formal treatment. Findings indicate that 41 to 70 percent of

Linkage Demonstration clients enrolled through primary care received no formal

drug abuse treatment. In addition, another 16 to 18 percent of those enrolled

through primary care stayed in formal treatment 1 month or less. These

findings contrast sharply with those for clients enrolled through drug abuse

treatment, where, typically, fewer than 1 in 10 received no formal treatment and

the majority remained in treatment for at least 4 months.

The findings also suggest a substantial advantage for centralized over

decentralized models in providing drug abuse treatment to those identified

through primary care. Seventy percent of those identified through primary care

in decentralized programs received no formal drug abuse treatment, and less

than 10 percent remained in formal treatment for 4 months or longer. By

contrast, 41 percent of those identified in centralized programs received no

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TABLE 1. Drug abuse treatment received by linkage Demonstration clients, by point of enrollment and linkage

model

Group

Enrolled through primary care

Centralized

Decentralized

Enrolled through drug abuse treatment

Centralized

Decentralized

Group

Enrolled through primary care

Centralized

Decentralized

Enrolled through drug abuse treatment

Centralized

Decentralized

Any Drug

Unweighted Treatment

N (%)

110 64.5 6.4 21.8 0.0

266 30.8 1.1 4.9 0.0

566 92.0

228 97.4

Any Formal Outpatient

Rehabilitation Drug-Free

(%) (%)

59.1 27.3 10.9

30.1 27.8 1.5

86.6 52.5 15.2

95.6 57.5 39.5

Detoxification Self-Help Acupuncture

(%) (%) (%)

13.4 46.5 1.4

7.9 21.5 0.0

Formal Rehabilitation

Methadone Residential Other

(%) (%) (%I

4.5

1.1

17.7

1 .a

29.1

1.1

15.5

1.8
TABLE 2. Time in formal drug abuse treatment (months) for Linkage Demonstration clients, by point of enrollment

and linkage model

Group

Enrolled through primary care

Centralized

Decentralized

No Formal 1 Month

Unweighted Treatment or Less 2-3 Months 4-6 Months 7 2 Months - 1

N (%) (%) (%) (%) (%)

110 40.9 18.2 12.7 10.9 17.3

266 69.9 15.8 6.8 4.9 2.6

Enrolled through drug abuse treatment

Centralized 566 13.4 19.1 26.0 18.4 23.1

Decentralized 228 4.4 30.7 25.0 19.3 20.6
formal treatment, and nearly 30 percent remained in treatment 4 months or

longer.

Table 3 shows the distribution of the kinds of primary care services received by

Linkage Demonstration clients. Findings indicate that most clients enrolled in

the Linkage Demonstration received some kind of primary care services

regardless of where they were enrolled and that the services most frequently

received included HIV prophylaxis (e.g., a primary prevention intervention,

such as a condom-use or needle-cleaning intervention, or a secondary

prevention intervention, such as aerosolized pentamidine), health education,

treatment for chronic conditions, and nutritional services.

Table 4 shows the distribution of the kinds of social and support services

received by Linkage Demonstration clients. Among those enrolled through

primary care, 25 to 32 percent received at least one such service. Among the

specific services, family counseling, transportation assistance, and “other”

were among those most freqently received. Those enrolled through drug

treatment, however, seem more likely to have received social and support

services: Thirty-one to seventy percent received at least one such service.

In addition, there appears to be a substantial advantage to decentralized

models in the provision of social and support services to drug treatment

clients, because they were more than twice as likely to receive at least one

such service than those treated through centralized projects.

Relationship to Case Management

The second question addressed in this chapter is: Given that clients are

receiving services, is there any relationship between the services they

receive and case management? To examine this question, we added

another dimension, representing the amount of case management received,

to our tables. “Amount” of case management is operationalized as the number

of months during which the client had at least one contact with his or her case

manager.

Table 5 summarizes the relationship between case management received

and the receipt of other services: drug abuse treatment (any treatment and

any formal treatment), primary care, and “other” services. As might be

expected, those who come seeking (i.e., are identified through) drug abuse

treatment are more likely to receive at least some treatment than are those

who come seeking primary care, regardless of linkage model or amount of

case management received. More than 90 percent of those who are enrolled

through drug abuse treatment receive some form of treatment, compared with

as few as 16 percent of those enrolled through primary care.

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TABLE 3. Primary care services received by Linkage Demonstration clients, by point of enrollment and linkage model

Any Unweighted Service

Group N

Enrolled through primary care

Centralized 110 77.3

Decentralized 266 97.7

Enrolled through drug abuse treatment

Centralized 566 83.0

Decentralized 228 72.4

‘Female dients only

Group

Enrolled through primary care

Centralized

Decentralized

Enrolled through drug abuse treatment

Centralized

Decentralized

HIV

Unweighted Prophylaxis

N (%)

110 29.1

266 26.7

566 51.4

226 36.3

Group

Health

Unweighted Education

N (%)

Enrolled through primary care

Centralized

Decentralized

Enrolled through drug abuse treatment

Centralized

Decentralized

110 19.1

266 82.0

566 30.0

228 44.0

Treatment Family

of Chronic Planning/

Condition Birth Control

(%) (%)

30.0

15.4

12.1 66/24.2 4.5 10.0

56.5 115/8.7 4.1 6.0

20.7

14.9

22.4 268114.9

22.0 100/17.0

Nutritional

Services

(%)

Hospitalization

(%)

15.7

13.2

8.2 8.2 0.9 2.7

1.5 13.5 0.0 1 .9

3.5 21.9 1.9 3.7

7.0 10.1 0.4 2.2

Other

(%)

22.7

71.4

33.9

29.4

Prenatal/

Postpartum

Care

N/Percent*

(%)

Dental

Care

(%)

Immunization

(%)

Acute Care Treatment of

for Non-HIV Opportunistic ER

Conditions Infections Utilization

(%) (%) (%)

6.0 7.6

5.3 5.3

20.9

4.1
TABLE 4. Other services received by linkage Demonstration clients, by point of enrollment and linkage model

Any family

Unweighted Service Counseling

Group N (%) (%)

Enrolled through primary care

Centralized 110 24.5 4.5

Decentralized 266 32.3 10.2

Enrolled through drug abuse treatment

Centralized

Decentralized

566 30.7 15.2 6.2 5.8

228 70.2 13.6 49.6 39.0

Group

Enrolled through primary care

Centralized

Decentralized

Financial Child

Unweighted Assistance Care

N (%) (%)

110 1.8 1.8

266 9.8 1.1

Enrolled through drug treatment

Centralized

Decentralized

566 2.7 1.2

228 33.8 3.1

Transportation

Assistance

(%)

Entitlement

Assistance

(%)

1.8 4.5

16.5 5.3

Employment Housing

Assistance Assistance

(%) (%)

Other

(%)

2.7 6.4 10.0

10.9 6.4 13.9

3.9 3.9 9.4

32.0 26.8 37.7
TABLE 5. Services received by Linkage Demonstration clients by linkage model, point of enrollment, and case

management received (percent)

Any Formal Any Any

Group

Enrolled through primary care

Centralized

CM for 1 month or less

CM for 2-6 months

CM for 7-12 months

Any Drug

Treatment

61.7

68.2

Drug Primary “Other”

Treatment Care Services

56.8 72.8 18.5

59.1 86.4 31.8

Decentralized

CM for 1 month or less

CM for 2-6 months

CM for 7-12 months

16.2 16.2 96.2 12.3

36.4 34.7 99.2 46.6

100.0 100.0 100.0 83.3

Enrolled through drug abuse treatment

Centralized

CM for 1 month or less

CM for 2-6 months

CM 7-12 months

90.7 84.2 82.6 22.6

92.1 87.1 77.7 34.5

100.0 100.0 98.3 71.7

Decentralized

CM for 1 month or less

CM for 2-6 months

CM for 7-12 months

94.0 89.2 57.8 44.6

99.1 99.1 76.1 83.2

100.0 100.0 96.9 90.6

*Insufficient sample size

KEY: CM=case management
Table 5 also suggests a strong relationship between case management

and drug abuse services received for those enrolled through primary care,

particularly in decentralized projects, but not for those enrolled through drug

abuse treatment. For those enrolled through primary care at decentralized

projects, 16 percent who were case managed for 1 month or less received any

drug treatment, compared with 36 percent of those who were case managed

for 2 to 6 months. For those enrolled through drug abuse treatment, 90 percent

or more received drug treatment regardless of the amount of case management

received or the linkage model implemented.

In addition, table 5 shows the relationship between case management

received and primary care services received. The findings indicate that those

who receive more case management also receive more primary care, although

the differences tend to be relatively small. In all conditions, virtually all those

with the highest levels of case management received some kind of primary care

service. The strongest relationship was for those enrolled through drug abuse

treatment at decentralized linkage projects: 58 percent of those who were case

managed for 1 month or less received some primary care service vs. 97 percent

of those case managed for 7 or more months.

Table 5 also shows the relationship between case management received and

social or support services received. The relationship with case management

seems stronger for these services than for either drug abuse treatment or

primary care. In all instances, substantially higher proportions of those with

more case management received one or more social or support services.

Typically, about one in five of those who were case managed for 1 month or

less received one or more such services, compared with 70 to 90 percent of

those who were case managed for 7 or more months.

DISCUSSION

Preliminary findings from the National Evaluation indicate that projects funded

through the ADAMHA/HRSA Linkage Demonstration are delivering drug abuse

treatment, primary care, and other services to people whom they identify as

having both drug treatment and health care needs. These findings demonstrate

the feasibility of identifying substance abuse problems in primary care settings

and highlight the potential benefits of doing so. They also demonstrate the

feasibility of providing primary care to drug abuse treatment clients and the

range of health care needs that those clients have.

However, the findings identify a problem that remains to be addressed: how

to engage and retain in drug treatment substance abusers who are identified

via screening in the primary care context. Findings suggest that although the

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demonstration projects recommended and offered treatment (through direct

service or referral) to substance abusers whom they identified in primary care,

many substance abusers never entered drug treatment, and those who did

enter typically did not stay very long. Although findings from other analyses of

National Evaluation data suggest the possibility that screening in primary care

may result in earlier identification, it is clear that the engagement and retention

in drug abuse treatment of substance abusers identified in primary care (earlier

intervention) are important challenges that have not yet been adequately

addressed. This suggests the possibility that substance abuse interventions

different from those currently offered by drug treatment programs may be

required to reach this group of clients.

Findings concerning the delivery of health care services to drug abuse

treatment clients demonstrate the variety of health care needs that these

clients have. Our findings are consistent with a growing literature that

documents the physical health comorbidities of drug treatment clients.

Findings of the National Evaluation concerning the delivery of health care

to drug treatment clients suggest a potential advantage of centralized

approaches to the delivery of such care.

Findings concerning the delivery of social and support services to Linkage

Demonstration clients demonstrate that substance abusers typically have

a variety of other social and life adjustment problems in addition to their

substance abuse and health care needs. Services that have been provided

to Linkage Demonstration clients include family counseling, employment

assistance, transportation assistance, entitlement assistance, housing

assistance, and child care. These findings are also consistent with the

general notion of multiple comorbidities, that is, that a variety of personal

and interpersonal problems frequently accompany drug abuse.

National Evaluation findings concerning case management, although

preliminary, are encouraging. Findings suggest that, in general, those who

receive more case management receive more services of all kinds-health

care, drug abuse treatment, and other services. The relationship is particularly

strong in decentralized models, where one would expect case management to

play a more critical role in tracking patients, locating needed services, and

facilitating patient compliance.

Because of the lack of experimental design in the Linkage Demonstration, it

is not possible to attribute causality to the observed relationship between case

management and other services received. That is, we cannot tell from the

National Evaluation findings whether clients stay longer in treatment because

of the case management services they received, or whether they received

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more case management services because they stayed in treatment longer.

Nevertheless, the findings are consistent with the hypothesis that case

management leads to more effective service delivery and suggest that case

management may play an important role in comprehensive service delivery.

In addition, the findings suggest that case management is more important in

decentralized models and may be most important in the delivery of services

to meet clients’ social and support service needs.

The findings presented in this chapter address only the most basic descriptive

question about linkage and case management. We recognize that case

management is sometimes in the eye of the beholder and that many different

models of case management may have been applied by the different sites.

In fact, little is known about the nature of the case management applied by

the projects, about the characteristics of the case managers, or about many

other details of how the services were delivered. However, these aspects

are among the topics to be addressed in the second phase of the National

Evaluation, in which we will conduct detailed case studies of a subset of the

Linkage Demonstration projects. These case studies will permit us to attach

“meat” to the service skeleton that has been outlined through descriptive

analysis of the client record abstraction data in this first phase of the

evaluation.

AUTHORS

William E. Schlenger, Ph.D.

Program Director

Mental and Behavioral Health Research

Larry A. Kroutil, M.P.H

Health Analyst

E. Joyce Roland, Ph.D.

Research Psychologist

Center for Social Research and Policy Analysis

Research Triangle Institute

P.O. Box 12194

Research Triangle Park, NC 27709-2194

330
Development and Implementation of an

Interorganizational Case Management

Model for Substance Users

Ellen P. McCarthy, Zoila Torres Feldman, and Benjamin F. Lewis

ORGANIZATIONAL ENVIRONMENT

The Linkage Program is an interorganizational effort to develop and evaluate a

model for the provision of primary health care services to substance abusers

and for the referral to appropriate substance abuse services of individuals

identified as in need of treatment. In general terms, the target population

comprises persons in Worcester, MA, who are injection drug users, their

sexual contacts, and their children; pregnant addicts; and other drug users

who are at risk of or already infected with the human immunodeficiency virus

(HIV). Worcester is the second largest city in Massachusetts and New England,

with a population of 175,000.

The central organizing and coordinating entity for the Linkage Program is the

Great Brook Valley Health Center (GBVHC), a federally funded community

health center whose mission includes serving populations who historically

have not had access to health care. GBVHC serves a predominantly Hispanic

population in and around a low-income housing project but also provides

services citywide. Through these efforts, GBVHC has had considerable impact

on the planning and development of general health, perinatal, prevention, and

HIV-related services citywide and has had a history of working in and with the

community to develop linkages necessary to maximize appropriate service

delivery in an environment of limited resources.

The Linkage Program was developed and is carried out in an environment of

preexisting interorganizational networking focused on HIV among intravenous

drug users (IVDUs). Since 1986, and building on a citywide effort to combat a

hepatitis B epidemic, the Worcester Health Department laid the groundwork for

the Worcester AIDS Consortium (WAC), which is a loosely coupled network of

agencies and institutions where members of the target population are likely to

surface. The initial WAC organizations are listed below:

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Worcester Department of Public Health and Code Enforcement

GBVHC—a community health center

Spectrum Addiction Services (including inpatient detoxification, residential

and outpatient methadone, and drug-free services)

Worcester County House of Correction and Jail

University of Massachusetts at Amherst, School of Public Health,

Epidemiology Division

AIDS Project Worcester-an advocacy and support agency

The primary goal of WAC has been to conduct an epidemiological surveillance

of HIV and related drug use and sexual risk behaviors in the target population.

Although not a service delivery system per se, various WAC agencies have

provided HIV counseling, testing, priority access to drug abuse treatment,

advocacy, and support for the target population of injection drug users and

members of their social network. Some WAC agencies participate principally

as part of their mission, such as the Worcester Health Department and

community health centers, others in exchange for resources to provide services,

such as drug abuse treatment programs and the County House of Correction.

This context has been both a benefit and a barrier in achieving Linkage

Program goals in terms of differences in mission, objectives, commitment of

collaborating members, and experience with minority and culturally diverse

populations.

LINKAGE GOALS

Notwithstanding these potential barriers, GBVHC saw the infrastructure

created by WAC as a critical component of what could become an effective

system for integrating primary health and substance abuse treatment services.

Accordingly, the GBVHC’s proposal sought to (1) increase the effectiveness of

interaction between established primary care and substance abuse treatment

providers and (2) recruit the participation of agencies that, although delivering

neither service, were in a position to identify clients in need of both services.

At the same time, GBVHC sought to (3) accelerate the readiness of community

organizations to respond to the HIV epidemic. The Linkage Program is 1 of a

total of 21 service demonstration projects and a subset of 8 community health

centers funded nationally through this National Institute on Drug Abuse (NIDA)/

Health Resources and Services Administration (HRSA) collaboration.

332
The underlying assumption guiding the development of both WAC and the

Linkage Program was the acknowledgment that HIV is a preventable disease

and that comprehensive, coordinated intervention efforts should be directed to

infected individuals as well as to individuals at risk of infection. It was expected

that the community health centers and other organizations were already caring

for populations at risk or already infected, but had not yet had the opportunity

or the resources to refine or more fully develop their system of care and to

become responsive to the unique demands created by people affected by

HIV disease. The Linkage Program sought to establish mechanisms to identify

these individuals, link them with appropriate services while providing access

to a comprehensive array of services, and increase communication among

agencies to preclude the duplication of services. Through the implementation

of the Linkage Program, the HIV surveillance structure created by WAC has

been solidified and expanded into a solid delivery care system.

The primary objectives of the Linkage Program are as follows:

Refer and admit clients from primary care into substance abuse treatment

programs

Refer and admit clients from substance abuse programs into primary care

Refer and admit clients affected by HIV and receiving neither service into

both services

A system of interorganizational case management or case coordination

activities was designed and implemented to accomplish these objectives.

This intervention model, implemented in a community context, was chosen

as opposed to a centralized model, because it was conducive to addressing

systemic issues of access and appropriateness of service. The centralized

model, which locates primary health care in substance abuse treatment

agencies or substance abuse services in community health centers, would

not serve the community as a whole, but only those individuals who already

had access to either service delivery system.

METHODOLOGY

The Linkage Program created a communitywide bilingual/bicultural case

management system in the city of Worcester to operationalize the objectives

necessary to integrate the services of these two traditionally separate systems.

Thirteen key agencies providing services to the target population were

approached and agreed to participate in the implementation of a model

system of care:

333
AIDS Project Worchester

FAITH, Inc.

Family Health and Social Service Center

GBVHC

Homeless Outreach and Advocacy Project (HOAP)

Pakachoag Church

The Medical Center of Central Massachusetts, Memorial: Prenatal Clinic

Social Justice for Women/MCI Framingham

Spectrum Addiction Services

University of Massachusetts Medical Center, Clinic 7

University of Massachusetts Medical Center, HIV Screening Clinic

Worcester County House of Correction and Jail

Y.O.U., Inc.

Among these were the WAC-affiliated health centers, drug treatment programs,

and advocacy organizations. The structure of the Linkage Program also has

an outreach component specifically targeted to access homeless, black, and

gay populations. This particular component of the Linkage Program system

complements the outreach efforts to the Hispanic community, which are

primarily provided through the State-funded Latino AIDS Network, under the

auspices of GBVHC.

A major goal of the Linkage Program is to institutionalize the model’s service

delivery system into the daily operations of each organization. Consistent

with this goal, a pivotal component of the Linkage Program was to nurture and

structure institutional commitment and ownership by participating agencies by

entering into a contract with GBVHC for the provision of certain services,

This method of contractual engagement, rather than placement of GBVHC

employees at hosting sites, proved to be perhaps the most significant factor

in gaining cooperation from network agencies. The contract enabled the

participating agency to hire a Linkage Program case coordinator as an

employee of the agency. This approach not only increased each agency’s

staff but also increased the level of supervision provided to the Linkage

Program case coordinator by the collaborating agency.

Furthermore, a standard risk assessment the Addiction Severity Index

(ASI), and a referral procedure were institutionalized in each of the contracting

institutions. Through the referral network of the Linkage Program, the agency is

able to provide its clients benefits beyond the level possible by the actual dollar

amount available to those individual organizations. The contractual agreements

specify that each contracting organization must assess all its clients for their

need for primary care and substance abuse treatment services and refer

accordingly. The assumption supporting this mode of implementation was that

334
if integration of services is to be truly successful, it needs to happen regardless

of grant-specific resources, and it needs to target a whole community.

In the Linkage Program, case management is defined as a professional

service that includes assessment, development of an individualized service

plan, service arrangement and continuing coordination, monitoring, periodic

reassessment, advocacy, and quality assurance. This system of case

management is considered both a process and an outcome. It is further

defined as successful coordination of services by a cadre of uniformly trained

bilingual case coordinators so that individuals at risk of or infected with HIV

have the ability to access an integrated system of primary health care and

substance abuse treatment. The case coordinator is the point of entry into

the Linkage Program and acts as an intermediary to link the services of

agencies in the community together so that the client has access to a

comprehensive range of care.

In addition to the above activities, resources have been allocated by the

Linkage Program for substance abuse services to increase the capacity

of the drug treatment facility and create a priority system for individuals

who otherwise would not access treatment. The referral from a Linkage

Program case coordinator serves as an approval for the service as well as

a mechanism for reimbursement. Functionally, the Linkage Program is a

system of interorganizational communication, with all case coordinators

marketing the services available through their organizations to clients

serviced by colleagues and vice versa.

The job description and caseload of Linkage Program workers vary depending

on each organization’s specific population and needs. Although all workers

coordinate the level of services provided to clients, some carry responsibility

for greater comprehensiveness and intensity of services. For example, at

the County House of Correction, the case manager-a registered nurse-has

coordinating responsibilities for the education, counseling, and testing; medical

care delivery; and emotional support of the inmates in the system.

The case management model of the Linkage Program differs from the

standard definition of case management to the extent that each case manager

is not responsible for the delivery of a package of services in a longitudinal

fashion and is not limited to a discrete number of individuals. A team of case

coordinators is available to serve a client based on the client’s location, the

client’s perceived need, the intensity and the immediacy of the need, and the

level of sophistication needed to respond. In the Linkage Program model, a

substantially larger number of individuals can be managed by providers with

the right level of expertise and at the community level, because the level of

service is responding to the stage of need of the client.

335
The fundamental assumption influencing the design of this model is that the

needs of clients identified by providers through outreach efforts differ from

those who have self-identified their need and/or have already sought care.

Clients encountered through outreach and assessed as in need of care often

do not have the ability to negotiate their way into a health care system.

However, clients already in a system have minimal or no barriers to care

because they are familiar enough with the health care system to negotiate

their wants. This assumption is based on the authors’ collective experience

that underserved persons, particularly IVDUs, were not experienced in seeking

care.

COORDINATION OF SERVICES AMONG AGENCIES

Coordination takes place at multiple levels. At the case coordinator level,

a beeper system facilitates the coordinators’ immediate access and response to

the needs of clients identified by a colleague seeking assistance. Furthermore,

all case coordinators meet with the program director on a weekly basis to

address issues of access and discuss client cases. These weekly team

meetings ensure that agencies in the community are working in conjunction

with each other to provide an unduplicated array of services to clients. The

program director meets regularly with agency supervisors, and she or the

executive director of GBVHC addresses issues of a more systemic or corporate

nature. The program’s data manager and evaluation team meet regularly with

the program director, executive director, and other relevant staff members to

review findings and refine or redirect program activities based on process and

preliminary outcome evaluation.

Client Confidentiality

In the Linkage Program, all efforts are made to protect client confidentiality.

The evaluation team, program director, and executive director meet on a

regular basis to review and evaluate confidentiality procedures to ensure that

the program operates in complete compliance with the standards set by WAC.

furthermore, the program director and the case coordinators meet individually

and as a team to ensure that the proper channels are followed. The Linkage

Program case coordinators must obtain written informed consent from their

clients to release and exchange any client information, including HIV status.

Informed consent is critical in the Linkage Program because it is the mechanism

that enables the caseworkers to effectively coordinate care. Clearly, the

coordinators do not have the right to discuss client cases and case conference

with providers and/or other Linkage Program colleagues without the clients’

written consent. Clients have the right to choose which of the 13 Linkage

Program agencies can receive their personal information.

336
The communitywide level of activity of this demonstration program exceeds

the direct impact of the case coordinators. The following are some areas

developed and enhanced by the Linkage Program:

1.

2.

3.

4.

5.

6.

7.

Expansion of a model of care demonstrated at the men’s County House

of Correction to the statewide women’s prison.

Acceleration of HIV-related medical services at the community level. A

system of continual training and support available to physicians and other

medical providers has resulted in the identification and enrollment in

ongoing coordinated medical care of a substantial number (592) of HIVinfected individuals.

Expansion of sites where HIV counseling and testing are available and

consequent early identification of clients in need of care.

Expansion of data-gathering sites with standardized instruments (ASI, WAC

Encounter Form, Linkage Monthly Referral Summary). The information

gathered by these tools is critical in the planning and delivery of services.

Through coordination and uniform reporting, the delivery model has

maintained the benefits of a superimposed public health model, rich in

epidemiological analysis and a tool for community planning.

Expansion of collaborating agencies’ capacity to care for minorities. At

times, this exposure has been a catalyst in broadening an agency’s

understanding of minority issues.

Inclusion of community health centers in the system. This expansion has

created the availability of a family practice model of care to individuals who

heretofore have been cared for in an insular manner and have been

marginalized historically.

UNIQUENESS OF DELIVERING CASE MANAGEMENT SERVICES TO THE

HISPANIC POPULATION

Delivery of case management to the Hispanic population requires

understanding the unique requirements specific to the Hispanic community.

Therefore, the case management system must be structured to address these

requirements. Bilingualism of the case coordinators is only one critical aspect.

A successful client-centered linkage between primary care and substance

abuse is one in which the client is successfully case managed into as well as

through the system. The agency’s acceptance of the client is not sufficient if

337
the agency has not built adequate clinical capacity (i.e., professional and

support staff) to serve that client or if its policies and procedures are not

user friendly to a population unfamiliar with roles historically developed for a

different population. Acceptance by the substance abuse treatment facility of

Hispanic clients, specifically monolingual clients, is further complicated by

illness or unique conditions (e.g., HIV-related or not-HIV-related conditions

or pregnancy).

Cultural definitions of illness as well can further polarize the reluctant

Hispanic client from the provider. For example, the substance abuse treatment

provider’s assumption of readiness for treatment may not be compatible with

the client’s, Whereas the client may want a specific service, the provider may

“decide,” under a set of assumptions not shared by the client, that the client

does not need the service or is in need of a different service. The Linkage

Program case management system promotes the opportunity for organizational

accountability and an organic review of systems and assumptions.

SYSTEMS RESPONSE-DEVELOPING LINKAGES WITH OTHER

COMMUNITY AGENCIES

Implementation of Linkage Program case management activities and

engagement in the contemplated interorganizational referral relationships in

each participating organization has developed at different rates. Below are

some of the factors affecting the time for and effectiveness of integration:

Level of complexity of individual organizations

Prior history of collaboration with GBVHC or other collaborating

organizations

Presence or absence of HIV-related services

Presence or absence of data management systems and consequent

experience with meeting reporting requirements

Experience in and commitment to serving minorities

Presence or absence of bilingual/bicultural staff

Difference in financial and human resources

Peer pressure (participating in a collaborative arrangement presented new

challenges for institutions that previously had been accountable only

Internally to their board members)

338
GAPS AND BARRIERS TO CARE

The implementation of the Linkage Program has led to an identification

of critical organizational, interorganizational, structural, and cultural

differences among the participating organizations. Perhaps next to

inadequate reimbursement for services, inadequate bilingual capacity has

been the most significant barrier to care. However, each organization,

although acknowledging the linguistic barrier, still attempted to obtain a

waiver from the bilingual requirement when hiring the case coordinator.

All Linkage Program case coordinators are bilingual with the exception of a

nurse case manager already located at the County House of Correction prior

to implementation of the program.

Another barrier to care is that access to substance abuse services has been

severely limited by cuts in reimbursement in Massachusetts. Although the

Linkage Program has targeted a substantial portion of its resources to direct

reimbursement, the level of demand created by access to counseling, testing,

and case management exceeds the supply of treatment slots in community

programs. Furthermore, changes in the existence or the extent of entitlement

programs, such as Medicaid and publicly financed services for the uninsured,

have created long waiting lists and continue to play a role in limiting the number

of services available to minorities. GBVHC and others are trying to restructure

the reimbursement system so that the entitlement is client based rather than

organization based.

The Linkage Program identified a major gap in engaging individuals who

are not receiving services in health centers, drug treatment programs, or

correctional facilities. Historically, the drug abuse treatment system has not

viewed outreach as a treatment modality. In the face of the HIV epidemic,

outreach efforts have gained increasing legitimacy but are often HIV specific

rather than treatment general. Although WAC and the Linkage Program each

has developed an outreach component, this activity is not as well developed

as more traditional approaches to engaging the drug-abusing population.

HOAP, a component of the local community mental health center and a

participant in both WAC and the Linkage Program, reaches a portion of the

not-in-treatment population. However, an estimated three-quarters of the

target population still is not being reached.

The Linkage Program has created a collaborative arrangement rather than a

collection of agencies working independently but with shared objectives, such

as WAC. Collaboration through a network has required reaching agreement

on protocols of care and delivery systems. It also has required mutual

accountability and responsibility toward each other and to the lead agency—

339
GBVHC. Significantly, the greatest outliers in this regard are some

substance abuse treatment providers and the AIDS advocacy organization.

Institutionalized rigidity or overriding concerns about confidentiality make

it difficult for these organizations to reach a level of readiness for collaboration.

Because of the nature of HIV and substance abuse, issues regarding

confidentiality have forced the Linkage Program to address what sometimes

appear to be the opposing needs of providing confidential services while

ensuring accountability to the U.S. Department of Health and Human Services

through appropriate reporting mechanisms.

Each individual agency’s experience in collaborative relationships has played

a role in its level of comfort and success in participating in the Linkage Program.

For example, the Worcester Department of Public Health and the community

health centers were at higher levels of readiness because they had collaborated

previously in the hepatitis B epidemic program. The County House of

Correction was eager to enter into this collaborative effort because it had

historical referral relationships with the drug treatment system. The HIV

epidemic among incarcerated IVDUs further increased the County House

of Correction’s readiness to collaborate with the medical care system.

Historically, the drug abuse treatment system has been insulated and has

operated outside the mainstream of community health, mental health, and

other human service organizations. This self-imposed isolation, particularly in

an environment of intense competition for human service dollars, has left the

substance abuse treatment system at a distinct disadvantage and lower level

of readiness for community networking and collaborative relationships.

Furthermore, the drug treatment program has been more reluctant to

(1) collaborate on community-based initiatives, such as outreach, and

(2) substantially explore interorganizational collaboratives, including changing

the methodology of service delivery, to increase the capacity to care and be

accountable for increases in units of services.

The fact that the Linkage Program provides financial incentives to the drug

treatment provider in the form of reimbursed care has allowed the “community”

to cross the threshold of the drug treatment system and “fund” a case

coordinator to enable desirable cross-referral. The Linkage Program model

has a better chance of being institutionalized over time if client outcomes

derived from the program’s goals are cost-effective, increase appropriate

referrals, and/or give the drug treatment program a marketing edge. It is

then that true ownership will be realized and operationalized.

The HIV epidemic among drug abusers has forced a self-contained, isolated

system to develop community ties to provide appropriate medical services to its

340
clients. Reimbursement rates and mechanisms have made it infeasible to

provide onsite treatment for HIV disease or other medical problems.

Contemporary emphasis on managed care and case management models

have both forced and supported the drug abuse treatment system to adopt a

linkage-type model to survive. The need for approval from primary care

physicians will serve to solidify this relationship.

DEMOGRAPHIC DESCRIPTION OF THE TARGET POPULATION

The target population is an estimated 4,000 to 5,000 injection drug users and

their sexual contacts and HIV-infected children in any of 13 community and

public health, criminal justice, HIV/AIDS support, or substance abuse treatment

environments. Based on data from the WAC surveillance, the cumulative

prevalence of HIV among recent (previous 3 months of free-living time) IVDUs

is 21 percent (table 1).

The following information is based on data obtained from the WAC surveillance

effort from February 1987 to December 1990:

Sixty-six percent of the participants were male

Twenty-two percent were Hispanic, 8 percent non-Hispanic black, and 66

percent non-Hispanic white.

Twenty-five percent were under age 25.

Thirty-nine percent had a history of previous drug abuse treatment.

TABLE 1. Seroprevalence of HIV by reported risk behavior

Risk Behavior Number Tested Percent Positive

Gay men/no IVDU 197 7

Gay men/lVDU 87 22

IVDU in risk period 1,533 21

IVDU before risk period 522 11

Sexual contact of needle user 464 3

Multiple partners in risk period 353 1.5

None of above 1,371 1

SOURCE: Unpublished data from the Worcester AIDS Consortium data project

research grant DA-05615-02. Published by permission of Dr. Jane

McCusker, Director of AIDS Research Unit, School of Public Health,

University of Massachusetts. Amherst data collected February 1987

to December 1990.

341
Twenty-five percent had a history of previous incarceration.

Sixty-seven percent of those interviewed were tested for HIV.

Eight percent of the sample tested positive for HIV antibodies.

Thirty-four percent had used needles in the most recent 3-month free-living

period.

Percentages of those who reported needle use are as follows:

Sixty-three percent reported sharing their works; among those who shared,

64 percent used bleach “some of the time.”

Nineteen percent reported multiple sexual partners; of those, 66 percent

never used a condom.

There was a slight decrease in seroprevalence among recent needle users

from 20 to 18 percent from the first to the second quarter of 1991. Over time,

risky needle behavior has continued to decline: Forty-seven percent of needle

users reporting currently state that they did not share works; of those reporting

sharing, 74 percent used bleach at least “some of the time.” Recently there

have been more modest declines in risky sexual behaviors: Of those with

multiple sexual partners, 59 percent had “never used a condom” compared

with 62 percent in the previous quarter.

Between June 1990 and December 31, 1991, 2,909 individuals have been

encountered through the Linkage Program. Males account for 48 percent of

participants. Hispanics constitute 42 percent of Linkage Program clients,

9 percent are non-Hispanic black, and 44 percent are non-Hispanic white.

The majority of clients are 20 to 29 years of age (42 percent). Thirty-eight

percent are 30 to 44 years, and 13 percent are younger than 15 years. HIV

seropositivity for Linkage Program clients is 22 percent, although 7 percent

have never been tested and 10 percent are waiting for results of tests.

The Linkage Program provides case management services to 858 IVDUs, 30

percent of the clients receiving services. This figure represents 20 percent

of the estimated number of injection drug users in the city of Worcester and

one-half of those encountered in WAC. Based on surveillance data ascertained

through WAC, the authors estimate that there are approximately 945 IVDUs

infected with HIV in the city of Worcester. The Linkage Program serves 474

seropositive IVDUs who represent one-half of the estimated number infected

in the city (see table 2).

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CLIENT TRACKING

Client tracking is accomplished through both active and passive methods.

Clients are actively tracked by case coordinators through case conferences

with other Linkage Program staff as well as outreach efforts to locate clients.

Passive tracking of clients occurs through the use of the Linkage Program

database. When a client enters the Linkage Program, she or he is assigned

a unique identification code, called the “WAC ID,” composed of letters from

the clients’ first and last names and birthdate. The WAC ID is constructed

by the case coordinator according to the standardized methods developed by

WAC. Therefore, the code serves as a device that links all clients across all

participating agencies without using clients’ names. In the event that a client is

lost to followup and cannot be located through conventional methods of active

tracking, the identification code enables the data manager to report to the case

coordinator the last Linkage Program site that provided services to the client.

This method of locating clients is especially valuable for case coordinators at

agencies where clients may be unexpectedly discharged without a completed

discharge plan (e.g., correctional facilities and substance abuse treatment

facilities) and at agencies that deal with highly transient, noncompliant

populations, such as the HOAP.

The unique identifier is the code used to monitor the HIV surveillance program

implemented by WAC. Using this code enables the authors to evaluate

the interaction of the Linkage Program and the HIV surveillance program to

determine what proportion of people tested through the efforts of WAC are

receiving integrated services through the Linkage Program. To link the two

databases, written Informed consent is obtained from the client at the time of

enrollment in the Linkage Program.

EVALUATION ACTIVITIES

As mentioned previously, the Linkage Program is being evaluated locally in

terms of process and outcome dimensions, with specific information being

collected as part of a larger evaluation of all of these NIDA/HRSA-funded model

programs. Because the purpose of the Linkage Program is to provide improved

access to primary health care and substance abuse treatment, the evaluation

component focuses on the extent to which linkages have been accomplished

between these two systems. The evaluation systematically monitors provision

of services by each case coordinator as well as the number of referrals made

to substance abuse treatment, primary health care, and other AIDS-related

services.

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TABLE 2. The demographic profile of all substance users and IVDUs

encountered in the Linkage Program from July 1, 1990, to

December 31, 1991

Cumulative Total

Client category

IVDU

Former IVDU

Substance user non-IVDU

IVDU/risk

Age

15-19 years

20-29 years

30-44 years

45-64 years

Data missing

Sex

Male

Female

Data missing

Race

White

Hispanic

Black

Asian/Pacific Islander

Other

Data missing

HIV status

Positive

Negative

Tested, results unknown

Never tested

Data missing

HIV positivity among

those tested

Percent N Percent N

66 687

16 171

16 169

2 19

80 687

20 171

2 23 1 12

41 433 39 334

50 525 54 465

4 40 4 35

2 25 1 12

73 761 74 635

25 265 25 216

2 20 1 7

41

44

10

0

0.4

4

431

459

107

1

4

44

46 482

39 404

6 69

7 7 1

2 20

37

49

10

0

0.2

4

55

35

5

4

0.7

322

419

86

0

2

29

474

300

42

35

7

51

344

58

Substance Users IVDUs

(n=1,046) (n=858)
Data are collected on each client served by the Linkage Program. At the

end of each month, case coordinators submit to the data manager a completed

Linkage Monthly Referral Summary for each client provided services by the

coordinator during the month. This tool was developed by the evaluation

team and has been continually refined and improved to meet Federal reporting

requirements and to capture additional data of specific interest to the Linkage

Program administrators. The instrument serves as a referral summary and

documents the case management services provided directly by each case

coordinator. It also is a tracking device to document the number of contacts

the client had with the program as well as the number of referrals made to

substance abuse treatment, health care, and AIDS-related services.

When a referral is made for a service, the case coordinator follows up with both

the agency and the client to determine whether the referral was successfully

completed and services were provided. The following information is based on

data compiled through December 31, 1991.

Referrals to Primary Health Care Services

Three hundred and sixty referrals were made to primary health care

services, and 73 percent were completed.

Sixty-four percent of referrals to primary care were for males.

Seventy-seven percent of referrals among males were completed, compared

with 65 percent of referrals for females.

Sixty-three percent of referrals to primary care were made for Hispanics, of

which 73 percent were completed.

Twenty-three percent of primary care referrals were made for whites, of

which 74 percent were completed.

Fourteen percent of referrals were made for blacks, of which 70 percent

were completed.

Among substance abusers, 301 referrals were made to primary health care

and onsite medical services, and 77 percent were completed.

Referrals to Substance Abuse Treatment Services

A total of 411 referrals were made to six substance abuse treatment

modalities, and 55 percent were completed.

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The majority (29 percent) of substance abuse referrals were made to

inpatient detoxification services, and 55 percent were completed

successfully.

Twenty-five percent of referrals to substance abuse treatment were made to

methadone services, and 63 percent of these referrals were completed.

Sixty-two percent of substance abuse referrals were made for Hispanics, of

which 56 percent were completed.

Twenty-seven percent of referrals were made for whites, of which 55 percent

were completed.

Ten percent of referrals were made for black substance abusers, of which 50

percent were completed.

The percentages of completed referrals to substance abuse treatment were

similar among males and females. However, the number of substance abuse

referrals made for males is two and a half times greater than for females. This

difference can be explained partially by the lower prevalence (25 percent) of

substance abuse among women encountered in the Linkage Program.

Nevertheless, the authors are concerned that the following conditions might

preclude a case manager from making referrals: (1) The case coordinator has

a perceived barrier based on a substance abuse agency’s lack of capacity to

provide treatment services to women, and (2) a systematic assessment of

women for substance abuse has not been institutionalized in all agencies

participating in the Linkage Program.

It is necessary to further assess and evaluate both perceived and real barriers

that may prevent a case coordinator from initiating a referral. To address these

issues, a mechanism was recently instituted in the data collection system to

enable tracking individuals who refuse referrals to services, have been placed

on waiting lists for services, or are actively engaged in services.

Some measures of success to date are as follows:

Thirty percent (n=858) of Linkage Program clients are IVDUs.

This figure represents 20 percent of the estimated number of injection drug

users in the city of Worcester and one-half of those in the WAC surveillance.

Based on WAC data, there are an estimated 954 IVDUs infected with HIV.

346
The Linkage Program provides services to 474 seropositive IVDUs, who are

one-half of the estimated number infected in the city.

COST-EFFECTIVENESS

Although the cost-effectiveness of this intervention has not been measured

directly, the Linkage Program model was structured to integrate primary

health care and substance abuse services and provide coordinated care,

thus preventing the duplication of services by community organizations. The

case manager is conceived as a coordinator who acts as an intermediary

to facilitate access to providers while ensuring nonduplication of services.

Furthermore, institutionalizing risk assessments in participating agencies and

providing onsite HIV counseling and testing permit early identification of clients

at risk for HIV or infected with HIV. Once identified, clients are linked with a

case manager who further assesses client needs and connects clients with a

primary care provider. Prior to the implementation of the Linkage Program,

many of these clients would receive medical services only at the tertiary level

as their health began to fail.

IMPLICATIONS FOR FUTURE RESEARCH ON CASE MANAGEMENT

Although not a research project per se, in many ways the Linkage Program

has set the stage for possible future research by virtue of the data-gathering

instruments utilized, the ability to link with the WAC database, and the use

of informed consent to permit fuller exploration of processes, barriers, and

outcomes, both on an individual and a systemic level. The Linkage/WAC

Programs created a structure that enabled the authors to compare the

effectiveness of the Linkage Program intervention with a cohort in the WAC

surveillance that was not exposed to the intervention. The natural extension

to the current demonstration is to apply rigorous research methodologies to

evaluate the effectiveness of the existing linkage models. Specifically, research

might be conducted to evaluate the effectiveness of linkage models in the

following areas:

Reduce alcohol and other drug consumption and prevent relapses among

clients

Enhance clients’ physical and mental health status

Link clients effectively with other needed services

347
Enhance clients’ compliance with prescribed treatment and case

management plans

Reduce rates of HIV seroconversion

Prevent or reduce clients’ HIV risk-related behaviors

Enhance residential, economic, and employment status

Clearly, this type of information would help guide the development of effective

linkage programs in the future. Detailed and specific treatment protocols,

training manuals, and suggested evaluation instruments should be developed

to be used by service providers seeking to implement identical or similar

program models.

ACKNOWLEDGMENTS

This work was supported in part by the Great Brook Valley Health Center, a

federally funded (Sec. 330) community health center (93.224), and by grants

from the National Institute on Drug Abuse (DA-0516) and the Health Resources

and Services Administration (CHS000117).

AUTHORS

Ellen P. McCarthy, M.P.H.

Research Data Analyst

Health Care Research Unit

Section of General Internal Medicine

Boston University School of Medicine

Suite 1108

720 Harrison Avenue

Boston, MA 02118

Zoila Torres Feldman, M.S.

Executive Director

Great Brook Valley Health Center

32 Great Brook Valley Avenue

Worcester. MA 01605

Benjamin F. Lewis, Ed.D

Senior Research Fellow

AIDS Research Unit

348
University of Massachusetts School of Public Health

Amherst. MA 01003

349
Assertive Community Treatment With a

Parolee Population: An Extension of

Case Management

James A. Inciardi, Howard Isenberg, Dorothy Lockwood, Steven

S. Martin, and Frank R. Scarpitti

INTRODUCTION

Prison inmates with histories of infection drug use or trading sex for drugs

face diverse potential problems on release from the institution. In addition

to the adversities associated with community reintegration and recidivism,

there is the likelihood of relapse to drug abuse. Also, for those whose drug

involvement includes the sharing of injection equipment and/or the high-risk

sexual behaviors associated with the bartering of sex for drugs or money to

purchase drugs, there is also the real potential for human immunodeficiency

virus (HIV) infection. Considering the greater numbers of drug-involved

offenders being incarcerated each year and the economic burden of providing

health care to the expanding pool of HIV-positive inmates, the need to

intervene in the cycle of relapse and recidivism with thus population is obvious.

Case management services combined with an intensive outpatient treatment

regimen for prison releases is an attractive option. The University of Delaware’s

Assertive Community Treatment (ACT) program is a National Institute on Drug

Abuse (NIDA)-funded treatment research demonstratron initiative funded during

the closing months of 1989 to address these phenomena. ACT is an extension

of the case management framework in its approach and in the clients served.

CASE MANAGEMENT AND ASSERTIVE COMMUNITY TREATMENT

Case management has been described in a variety of ways. In the mental

health field where case management originated, a widely accepted definition

comes from the Joint Commission on Accreditation of Hospitals (1976):

Case management services are activities armed at linking the

service system to a consumer and coordinating the various

system components in order to achieve a successful outcome

350
The objective of case management is continuity of services. .

Case management is essentially a problem-solving function

designed to ensure continuity of services and to overcome

systems rigidity, fragmented service, misutilization of certain

facilities and inaccessibility.

Within this context, case management is a problemsolving activity designed

to address inadequacies in the human service delivery network that become

barriers to a client’s need for an integrated system of benefits, support, and

care. In more conceptual terms, case management is a mechanism through

which the client’s goals, rather than the system’s goals, can be realized

(Anthony et al. 1988). A second and more recent perspective regards case

management as an integrative, individualized, proactive process that is more

community based. Under this system, the manager accomplishes a variety of

tasks on behalf of the client, from advocating benefits to monitoring outpatient

treatment visits (Harris and Bergman 1987).

A third perspective, advocated in this chapter, follows an even more intensive

and proactive response to client needs. Assertive community treatment, often

referred to in the literature as “assertive case management” (Bond et al. 1988),

is a developmental step in the traditional approach to case management in that

counselors make contacts with clients in their homes and on their turf, rather

than in treatment centers; attention is paid to the practical problems of daily

living; caseload sizes are manageable, permitting workers to have frequent

client contact; and there is a team approach in which caseloads are shared.

THE FOUNDATIONS OF ASSERTIVE COMMUNITY TREATMENT

Assertive community treatment is based on a continuity of care model for the

community treatment of the chronically mentally ill that originated in Madison,

WI, during the early 1970s (Test et al. 1985). The focus of the model is helping

the client reenter the community by providing “in vivo treatment” in small clientto-staff ratios, and it is characterized by material, interpersonal, and moral

support in the areas of education, vocational training, use of leisure time, and

self-care in dealing with the stresses and pressures of interpersonal living.

The most important components are (Anthony and Margules 1974; Cutler

et al. 1984; Thompson et al. 1990):

Counselors actively keeping track of their clients with numerous face-to-face

contacts, rather than waiting for problems to arise

Staff being available to clients at all times

351
Counselors having access to instrumental support for clients (e.g., job

training, rent and food money, tools for work, transportation, child care)

The more traditional forms of treatment, rehabilitation, and support group

services

Although evaluations of the assertive community treatment approach with the

mentally ill are limited, the results are generally positive. Studies demonstrate

that, when compared with matched control patients who are discharged from

inpatient psychiatric and other mental health settings without some form of case

management program, those in the assertive treatment models tend to (1) have

better occupational functioning, (2) live in residential situations requiring some

level of independence, (3) be less socially isolated, and (4) be rehospitalized

less often and remain in the community longer before rehospitalization (Stein

and Test 1980; Test 1981; Rapp and Chamberlain 1985; Bond et al. 1988;

Goering et al. 1988; Olfson 1990).

APPLICATIONS WITH A DRUG-INVOLVED PAROLEE POPULATION

There are similarities between the chronically mentally ill and drug users

that suggest that assertive community treatment would be appropriate in the

drug abuse field. Both populations require treatment and a comprehensive

network of continuing support to interrupt the relapse cycle and allow the client

to remain stabilized in the community. Moreover, such factors as prior criminal

involvement, prison experience, injection drug use, and HIV risk factors further

suggest the need for assertive case management intervention.

Research has suggested that treatment outcome is more likely to be

successful when drug use is treated as a complex of symptom patterns

involving various dimensions of the individual’s life (McLellan et al. 1981;

Lipton 1989). This perspective lends itself to the biopsychosocial assertive

community treatment model of rehabilitation used with the chronically

mentally ill, an approach that stresses multimodal and holistic methods of

assessment and treatment. Although relapse prevention can be presented

as a psychoeducational, skill development approach (Daley 1986), other

problem dimensions also can be treated effectively when properly integrated

in a comprehensive rehabilitation program that provides reinforcement and

support in the community.

By contrast, there are some major differences in the assertive community

treatment model in the mental health field when applied to drug-involved

parolees. First, there is the expectation that the drug abuse and related

problems of the parolee population can improve, and eventually, the need

352
for treatment may cease. Because of this expectation, the ACT program

for parolees has time limits and success goals, rather than the continuous

availability of help envisioned for the mentally ill. Second, there is the matter

of overcoming resistance to the traditionally passive role of clinicians waiting

for clients to come to them. For example, Bond and colleagues (1991) noted:

In the early 1970s the tenets of ACT must have seemed

quite radical, even preposterous, to the traditionally trained

clinician, Imagine a treatment approach in which the

professional staff were not only permitted but actually

required to leave the comfortable surroundings of their

hospitals and clinics, doing most of their work in the clients’

own homes and neighborhoods! Imagine an approach in

which the “treatment” often entailed not the exploration of

transference phenomena but rather the exploration of YMCA

sleeping rooms, public welfare offices, and coin-operated

laundries!

Since the advent of assertive community treatment, there has been resistance

to being more proactive with clients by delivering treatment and support to

clients in the community. This was a difficult barrier to overcome in the mental

health field. It is even more difficult when dealing with criminal justice clients;

clinicians and case managers may have the perception of serious physical risk

and the underlying feeling that the clients are more responsible for the situation

they are in.

SPECIFICS OF THE DELAWARE ACT INTERVENTION

On classification to parole status, each ACT client receives an indepth,

comprehensive, biopsychosocial evaluation, after which a primary case

manager is assigned and an individualized Master Treatment or Service

Plan is prepared. It is developed with the client and addresses his or her

involvement with all aspects of treatment as well as necessary adjunctive

services available in the community. The treatment or service plan contains

specific, measurable goals and objectives that include expected achievement

timeframes.

An intensive outpatient drug treatment program is provided, which includes

individual, group, and family therapy; drug education; relapse prevention

skill training; acquired immunodeficiency syndrome (AIDS) education; and

onsite Alcoholics Anonymous and Narcotics Anonymous meetings. Relapse

prevention skill training and support is based on a synthesis of available

psychoeducational models. Skills development emphasizes the efficacy of

353
lifestyle changes that produce increased self-esteem, including, but not limited

to, developing healthy, supportive friendships, coping with cravings and

situations that are risks to relapse, effective use of leisure time, and stress

management.

In general outline, the course of drug treatment occurs in five phases:

1.

2.

3.

4.

Intensive Treatment Phase (6 weeks). During the first 2 weeks, clients

are involved in group counseling (7.5 hours/week), drug and AIDS

education and discussion groups (4 hours/week), and individual

counseling (minimum of one 50-minute session/week). Family

assessment therapy is scheduled based on the needs of each family.

The next 4 weeks of intensive treatment comprise three group sessions

each week, 5 days of drug and AIDS education and discussion, and

special issue groups. Individual counseling is provided a minimum of

one session per week. Family therapy is scheduled reflecting the needs

of the family.

Moderately Intensive Treatment Phase (6 weeks). For the first 3 weeks of

this phase, clients participate in group counseling twice a week. Education

and discussion sessions become more frequent (three times a week) and

begin to focus on relapse prevention while continuing with AIDS-related

issues. Individual sessions continue as previously scheduled and vary

according to individual needs. Family sessions occur as needed, at the

discretion of the therapist. For the next 3 weeks, treatment takes on a

more supportive posture. Group counseling is scheduled once a week;

relapse prevention (psychoeducational model) is provided twice a week.

Individual counseling and family therapy are on an as-needed basis.

Relapse Prevention Phase (6 weeks). During this period, group sessions

meet once per week for support of relapse prevention. In addition, relapse

prevention education is provided twice a week, and individual counseling

and family therapy are scheduled as needed.

Case Management Phase (12 weeks). After clients have successfully

completed their active involvement in the ACT program, they transfer into

a case management phase designed to support their transition into less

intensive treatment involvement. This transition may include placement in

a vocational training program or direct job placement. Case management

can include continued active participation in the supportive elements of the

treatment program, if the client is motivated and the treatment team agrees

Case management contacts are initiated to determine whether clients have

remained alcohol- and drug-free, have complied with vocational training or

354
job placement plans, are in stable family and employment situations, and/or

are in need of further service or referral.

5. Followup Phase (1 year). Followup contacts or assessments are initiated

by case managers for each client at 1 month after discharge, as well as at

3-, 6-, 9-, and 12-months postdischarge intervals. These contacts are face

to face if possible, or by letter or telephone, for determining whether the

client has remained alcohol- and drug-free, compliance with the aftercare

plan, education and training and employment status, status of family and

social relationships, legal status, psychological and psychiatric status,

medical status, and appropriateness of any further service or referrals.

CASE MANAGEMENT AND ADVOCACY

The implementation of the relatively lengthy case management phase is

crucial to the effectiveness of assertive community treatment and needs to

be described in more detail. The case management component comprises

a multidisciplinary staff, which takes a team approach to the overall case

management of the clients.1 In addition, ACT staff members provide client

advocacy with other programs, treatment, and service providers in Delaware’s

human service network as well as with the criminal justice system. These

ancillary service agencies provide additional resources to clients and include

mental health treatment, medical and dental services, financial support, social

services, child care, and transportation.

Case managers provide direct counseling services and work with clients

to develop the skills necessary to function successfully in the community.

Case managers also function as group facilitators to provide direct skill

training and support in the area of their specialty, such as AIDS education,

relapse prevention, remedial education, and employability skills training.

Scheduled activities rotate to provide staff with available time to work closely

with the clients on their caseloads. Regularly scheduled team meetings are

held during which the staff members adjust client and program goals and

objectives in a realistic manner. This process keeps the program responsive

to the immediate needs of the clients, and case managers benefit from the

input and support of other staff members involved with their clients. The

assigned case manager reviews the team staffing outcome with each client

(and his or her family, if appropriate). Client services are monitored at all

stages to ensure the stability and quality of the client/provider relationship.

The progress of clients in the planned services is evaluated on an ongoing

basis to adjust services in response to the client’s ability to benefit from them.

In addition, staff members teach adaptive behavior through instruction,

modeling, encouragement, and realistic limit setting. There are family

355
consultation and crisis intervention services whenever necessary that are

geared toward maintaining the client in the community and preventing relapse.

Finally, the ACT intervention includes, when necessary, an “employability”

program of education and/or reeducation, job readiness, and job-seeking

skills training, all designed to increase the client’s marketable employment

skills. This is accomplished through remedial education in the areas of reading,

mathematics, and language arts. Also, when appropriate, there is general

equivalency diploma (GED) preparation utilizing video instruction materials

and accompanying workbooks. Teacher assistance is available to facilitate

the learning process. The employability skills training component uses the

PACE Learning Systems Employability Skills Training program (McKee 1987).

This program focuses on employability, job-retention skills, and valuable life

or ‘survival” skills (e.g., how to live within a budget, buy a reliable used car).

Support and assistance in job seeking or placement are provided, with

consideration given to both immediate, short-term employment and long-term

vocational needs.

STUDY POPULATION AND RESEARCH DESIGN

The target population for the assertive community treatment initiative is

parolees with histories of injection drug use and other drug users whose

sexual behaviors have placed them at high risk for HIV/AIDS. As potential

inmates or subjects approach their parole eligibility dates, they are identified

by the research staff, and their participation in the project is elicited. Those

who agree to be study subjects are randomized into treatment and control

groups. The treatment subjects are placed into the ACT program as described.

The control subjects receive traditional parole supervision, in which the only

treatment services are those deemed needed and appropriate at the discretion

of the client’s parole officer. During the course of the study, 200 study subjects

will be randomized into each of the treatment and control groups. A third

comparison group includes parolees who have graduated from the KEY, a

prison-based therapeutic community (TC) located in Delaware’s Multi-Purpose

Criminal Justice Facility-a maximum security institution in Wilmington. The

inclusion of this third group provides the opportunity to assess the relative

effectiveness of three levels of treatment intervention with essentially the

same population—ranging from high intensity (prison-based TC treatment)

to moderate intensity (ACT) to low intensity (parole as usual).

There are two primary research strategies employed to assess the efficacy

of the ACT intervention. First, data are being collected using a series of

research questionnaires administered at baseline, 6-month followup, and 18-

month followup.2 All drug treatment research subjects are interviewed. The

356
baseline questionnaire solicits information about drug use and sexual and

criminal history, childhood experiences, education, employment, and basic

demographics. The 6-month followup coincides with completion of treatment

for those entering the ACT intervention. This questionnaire focuses on activities

and experiences during the previous 6 months, with a particular focus on drug

treatment involvement. It also includes questions pertaining to drug use and

criminal activities during the past 6 months. The final questionnaire focuses

on activities and experiences during the previous year. All three questionnaires

will provide impact and outcome data. The data for the control group and the

treatment group will be compared to see what factors influence relapse and

recidivism, including the effect of treatment. HIV and urine testing are also

done at the three contact points.

Second, a process evaluation is being conducted. This research component

focuses on the nature and quality of program components and their effects

on individual case outcomes. The process evaluation targets the day-to-day

operations of the treatment and helps to assess what occurs in that “black box”

of intervention. Data for this process analysis include observations in the

treatment setting as well as structured interviews with staff and clients. In

addition, client records are used to assess client participation in the program

and case management activities and techniques.

Selected baseline characteristics of the first 208 subjects recruited into the

project appear in table 1. Overall, with a higher proportion of women than

expected, the sample characteristics generally reflect those of the correctional

population as a whole. Although women account for only 5 percent of the

Delaware prison population, their overrepresentation in the control and ACT

groups is a reflection of their greater tendency to be paroled. The absence of

women in the KEY results from the lack of a TC for women in the Delaware

prison system.

BARRIERS TO WORKING WITH A PAROLEE POPULATION

It has been argued that drug-involved offenders have limited experience with

health care services, often lack skills related to setting and keeping

appointments, and typically distrust substance abuse treatment providers

because the providers are perceived as representatives of “the system.” As

Peters and May (1992) state:

The belief that community treatment programs are affiliated

with the criminal justice system can act as an impediment to

the building of the appropriate patient/client relationship.

Involvement with substance abuse or mental health treatment

357
TABLE 1. Selected characteristics of the first 208 control, ACT, and KEY

subjects in the Delaware parole project

Characteristics

Control

(n=79)

Gender

Male

Female

67%

33%

Race/ethnicity

African-American

White

Hispanic

Other

50%

38%

4%

-

Age (mean) 29.3

Education

Eighth grade or less

9th through 11th grade

High school or GED

More than high school

9 %

42%

39%

10%

Marital status

Married

Widowed, divorced, separated

Never married

4%

28%

68%

Number (mean) of

criminal charges

1 1%

27%

62%

7.1 9.6

Violent crime on record

Yes

No

56%

44%

Number of times in prison

1

2

3

4 or more

Number (mean) of different

drugs used

Used marijuana

Used cocaine

24%

24%

24%

28%

5.3

98%

80%

ACT

(n=78)

358

64%

36%

70%

26%

1%

3%

29.8

12%

37%

45%

6%

1 0%

22%

68%

7.8

60%

40%

23%

26%

22%

29%

5.1

99%

81%

KEY

(n=51)

100%

82%

18%

-

-

31.3

4%

12%

72%

12%

74%

26%

18%

24%

20%

38%

5.4

98%

77%
TABLE 1. (continued)

Characteristics

Used crack

Used heroin

Used speed

Used intravenous drugs

Used alcohol or other

drugs inside prison

Consider self addict

Yes

No

Health status

Excellent

Good

Fair or poor

How well informed on HIV/AIDS

Very well

Somewhat

Little or not

How likely to develop AIDS

No chance

Some chance

High chance

HIV status

Negative

Positive

Not tested

HIV status (for those tested)

Negative

Positive

Control

(n=79)

70%

24%

63%

67%

37%

77%

23%

39%

38%

23%

62%

23%

15%

27%

57%

16%

63%

13%

24%

83%

17%

ACT

(n=78)

67%

26%

52%

73%

28%

74%

26%

36%

44%

20%

58% 94%

35% 6%

8% 0%

31%

50%

19%

67%

14%

19%

82%

18%

KEY

(n=51)

61%

43%

5 1%

65%

57%

92%

8%

51%

39%

10%

24%

55%

21%

67%

8%

25%

90%

10%

NOTE: Due to rounding, percentages may not add exactly to 100.

359
is seen by the members of some groups as a sign of

weakness, reflecting an inability to cope with stress. Many

offenders report feeling overwhelmed by the transition from a

highly structured correctional environment that does not permit

self-sufficiency, to the very same community in which they

failed to adapt in the first place. Return to home environments

with the possibility of lingering anger and fear from past

relationship problems related to drug use presents a major

intervention point for treatment. However, significant others

are often reluctant to become involved in the necessary

treatment to resolve the problems, Thus, there is a multitude

of problems related to “returning home” that become

impediments to establishing the necessary support for

recovery. The expectations of the criminal justice system also

produce stresses that impinge on a parolee’s ability to cope

with a drug-free lifestyle.

In addition to these expected barriers to working with the target population,

there are more subtle issues. Case management functions that require

tracking and making contacts with clients as they pass through the correctional

system have been challenging. ACT staff members have been faced with the

fact that criminal justice personnel are not always advised as to clients’ release

dates. In addition, access to clients prior to their release can be restricted by

sudden lockdowns, work-release agreements that were not communicated to

the case manager, or even the basic inability of the correctional system to

physically locate many of its inmates. Also, after clients have been released

to the community, their levels of compliance and motivation often deteriorate.

Finally, perhaps the major barrier is attempting to structure a case management

treatment initiative in conjunction with a correctional system characterized

by fragmented leadership, limited services, and problematic communication.

For example, the Delaware Department of Corrections has no mechanism

for transferring inmates from the prison to release status that ensures that

the parolee is involved with the appropriate authorities in the community—

including parole officers and treatment providers. Occasionally, parolees

are released from prison and community authorities are notified. Frequently,

potential respondents are identified through the Parole Board, screened and

interviewed for the research project, but never released from prison. For

example, when the Parole Board makes a release decision, it is often unaware

of an inmate’s “open charges” (if any). On the day of release, the parolee is

returned to court and additional charges can be pressed; thus, the parolee is

returned to prison without having been released to the community.

360
PROBLEMS IN CONDUCTING RESEARCH ON CASE MANAGEMENT

The objective of research on case management is to determine how and why

therapeutic program components are linked to individual case outcomes. This

process includes examining the nature of the case management model utilized,

the manner of implementing the model, the social context within which it is

based, and the quality of the case managers delivering the service. Once the

theoretical basis for specific treatment strategies is known and understood,

case management research must determine precisely how those strategies

are applied, how they are received by clients, what their impact is on behavior

modification or change, and what changes in program strategies grow out of

day-to-day experience. Case management research is capable of revealing

what happens to a client from the time of entry into a program until the client’s

discharge or failure. It also helps to determine whether and how programs are

responsive to changing client needs and shifting social and political dynamics

in the community.

Three different ways of evaluating the outcome of the intervention—

dichotomies, degree indicators, and time at risk-will provide a more rigorous

evaluation of the effectiveness of the treatment alternatives than simple

success or failure comparisons alone. For example, a “yes” or “no” measure

for drug use in the past year may show no differences between treatment and

controls at the 12-month followup, but those emerging from the ACT program

may use fewer drugs, use less frequently, or may have stayed clean for a

longer period. Success may be judged not only on the numbers who remain

drug-free but also in terms of how long they remain so and whether they

reduce use.

Although the mechanics of outcome evaluation may be complex and

statistically intensive, the basic premise is rather straightforward, based on

operational definitions of success and failure. Assessing case management

may be methodologically simpler, but it is far more complex in its premises.

Relevant variables are more difficult to determine and hard to measure. How

important is the atmosphere that exists in a program? Are values pertaining

to treatment principles and goals shared by the staff, by the staff and clients,

by the staff and supervisors? Because the overall ethos of a program will

influence the morale and spirits of all participants, whether staff or clients, it

is a justifiable area of inquiry for assessing case management.

To a large extent, research on case management is research on case

managers, since it is often difficult to separate the two. Although there are

different philosophies and techniques of case management, most agencies

appear to expect a fair amount of conformity among managers. Therefore,

361
the role of the case manager may be crucial in understanding the varied

impact of treatment programs on clients. How do staff members facilitate the

therapeutic process? Does staff effectiveness vary by training, philosophy,

personality, caseload, or charisma? Although impact or outcome analysis will

answer some of these questions, it is also necessary to probe their qualitative

aspects as well.

Once variables are identified, measurements become extremely important in

case management research. It is essential to use both quantitative and

qualitative data in attempting to determine program effectiveness. Ideally,

each type of data will be used to supplement and reinforce the other, adding

greater certainty to conclusions drawn about issues that are intrinsically

difficult to measure.

Assessing the role and quality of case management also demands that

relevant data be collected from different sources. Case managers, supervisors,

and clients are obvious sources of information, as are other professionals

with knowledge of a therapeutic program as well as families and employers

of clients. Comprehending data from such diverse sources may be tricky

and necessitate keen insight and interpretive skills. Nevertheless, the case

management researcher can learn a great deal about a program and its effects

by talking to an array of persons involved, directly and indirectly, in a program.

In addition to interview data and information from records of various sorts,

observations may also be used to understand and evaluate the case

management taking place in a program. A trained social scientist can

learn a great deal from observing a case manager at work, in group and

individual counseling sessions, at staff meetings, and in homes. However,

case managers are often reluctant to participate in this type of observation,

citing the potential breach of confidentiality and the discomfort such

observations may cause troubled clients.

Case managers are service providers whose primary concern is the welfare of

their clients. Often, they have an incomplete understanding and appreciation

of research and its demands for random assignment, uniformity, and objectivity.

Hence, the researcher is often seen as an intruder whose requirements are

obtrusive, invasive, and even detrimental to clients’ welfare. In addition, it is

sometimes believed that those not trained in the delivery of services cannot

comprehend its many nuances and, thus, cannot render a fair evaluation. A

researcher overcomes issues of this sort only by patient discussion, the

expression of empathy, and the manifestation of a great deal of humility.

362
POSTSCRIPT

Future research is certainly a worthy topic. However, there are some basic

issues associated with conducting treatment research in correctional and other

criminal justice settings that need to be resolved.

1. A major difficulty involves the use of random assignment in drug treatment

research, particularly in environments where releasing high-risk people

from prison is unpopular. Moreover, there are a variety of ethical and

practical considerations. For example, some inmates wishing to be in

the ACT program were assigned to the control group; some inmates

assigned to the ACT intervention were not those that clinical personnel

would normally classify as ready for treatment; some of those assigned

to the control group sought treatment on their own or were referred to

separate programs by correctional officials and parole officers.

Taking this one step further, it can be argued that random assignment

can compromise the treatment evaluation initiative. In the real world

of drug abuse treatment, program staff members choose the clients

they feel are ready for treatment and are appropriate for their particular

modality. Random assignment does not allow for client selection.

As a result, inappropriate clients are assigned to treatment groups,

often undermining the effects of treatment and contaminating the

treatment environment. Consequently, conclusions made about

treatment conducted within the context of research may not

necessarily apply to treatment conducted apart from any research

design.

One could also argue that the problems associated with random

assignment could be eliminated by drawing from a pool of subjects

who are eligible for treatment, ready for treatment, and willing to enter

treatment. However, that situation may pose practical dilemmas in

terms of the size of the sample pool and the resources necessary to

conduct preassignment screening and assessment.

Moreover, what does a research team do with those recruits who are

eligible, ready, and willing to enter treatment but who end up in a

no-treatment control group?

2. Another practical dilemma involves human subjects’ research. Drug

treatment for criminal justice clients seems to work best when it is

coerced. This has been documented at length in the literature (Leukefeld

and Tims 1988). The criminal justice system can provide both the stick

363
and the carrot. Compulsory treatment requires clients to remain in

treatment for a given length of stay, and length of stay seems to be the

major factor associated with success in treatment. This, too, has been

documented at length in the literature (Hubbard et al. 1989; Platt et al.

1990). When the treatment of criminal justice clients is voluntary, attrition

rates tend to be higher. Yet protocols for research on prisoners require

voluntary participation and also require that sentences and correctional

status not be affected by participation in the research project. Thus, a

treatment demonstration project may not offer the possibility of early

parole or a reduction in sentence length as part of participation, which in

effect eliminates much of the carrot and the stick essential to treatment

success.

3. On the positive side, it would appear that combining ACT with parole

supervision could have some significant effects. Perhaps the most

appropriate way to accomplish this combination would be a linkage to

existing treatment resources in the community through the Treatment

Alternatives to Street Crime (TASC) initiative. TASC has been described

at length elsewhere (Inciardi and McBride 1991). In conjunction with

parole, work release, supervised custody, or any other form of conditional

release, TASC seems logical and cost-effective.

NOTES

1. Currently, the case management staff includes a senior clinician (M.A.

in counseling and 5 years experience in outpatient counseling), a senior

case manager (M.S.W., 3 years experience in child protective service in

a drug unit, and a certified HIV trainer), a second senior case manager

(M.A. in human services and 7 years experience in residential substance

abuse treatment), a case manager (B.A. in public policy and 3 years

experience with inpatient mental health and substance abuse treatment

with adolescents), and an intake coordinator (A.A. in criminal justice and

3 years experience as a detoxification counselor and assessment

specialist).

2. Because the subjects at baseline are about to be released from prison,

the questionnaire has been developed to reflect prison life, rather than

street life, in the immediate past. Because of this orientation, instruments

like the Addiction Severity Index and NIDA’s Risk Behavior Assessment

would be inappropriate.

384
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MD: National Institute on Drug Abuse, 1991.

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evidence. Hosp Community Psychiatry 41:634-641, 1990.

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AUTHORS

James A. Inciardi, Ph.D

Director

Dorothy Lockwood, M.A.

Associate Scientist

Steven S. Martin, M.A.

Associate Scientist

Center for Drug and Alcohol Studies

University of Delaware

Newark, DE 19716-2582

Howard Isenberg, M.A.

Project Director

NorthEast Treatment Centers

2055 Limestone Road

Wilmington, DE 19808

366
Frank R. Scarpitti, Ph.D.

Chair

Department of Sociology and Criminal Justice

University of Delaware

Newark, DE 19716-2580

367
TASC: Case Management Models

Linking Criminal Justice and Treatment

Foster Cook

INTRODUCTION

Treatment Alternatives to Street Crime (TASC) programs in the United States

developed in response to a growing understanding of the relationship between

drugs and crime and a need to do something about it. lnciardi and McBride

(1991) noted that TASC began in response to three fundamental assumptions:

(1) Significant portions of the populations of major metropolitan areas had

serious problems of drug abuse and addiction; (2) drug addiction is often

coupled with a cycle of crime, arrest, incarceration, release, and continued

addiction; and (3) the frequency of contact between the addict and the criminal

justice system provides viable opportunities to intervene.

The TASC concept evolved to provide a structured linkage between the justice

system and the treatment system. The concept met the justice system’s need

for access to treatment coupled with accountability and the treatment system’s

need for predictable and supportive interaction with the justice system. The

TASC model was first described in 1972 by the Special Action Office of Drug

Abuse Prevention. Through funding from the National lnstltute on Drug Abuse

(NIDA) and the Law Enforcement Assistance Administration (LEAA), six

programs were created in 1972. TASC had expanded to 130 sites by 1982

when LEAA and Federal funding were terminated. In 1984, as a testament

to their perceived value, 100 programs were locally funded in 18 jurisdictions.

Renewed Federal interest and the 1980s “war on drugs” saw TASC expand

to the current 185 programs in 24 States and 2 territories. TASC programs

surveyed by the National Consortium of TASC Programs in 1987 reported that

30,000 clients were served in 60 reporting TASC programs in 14 States during

1986. The majority of these TASC clients were adults between the ages of

25 and 40, 82 percent were male, and 53 percent were minorities. Seventyeight percent were charged with a felony arrest, and 75 percent had prior

arrests. Sixty-six percent were polydrug abusers; drug users would not receive

treatment without TASC outreach. TASC is critical in reaching previously

unserved drug users, because 67 percent of TASC clients had received no

368
alcohol and other drug treatment. The need for ancillary services beyond

primary substance abuse treatment was illustrated by 50 percent being

unemployed and 52 percent lacking high school diplomas (Tyon 1988).

Recent interest in TASC has expanded from the basic assumptions noted

above to interest based on a new understanding of the efficacy of compulsory

treatment (Leukefeld and Tims 1988; Hubbard et al. 1989). These studies

document the success of coerced treatment for drug-involved offenders. The

most important identified variable in these studies appears to be extended

retention in treatment for offenders who participate under court order. This

interest in TASC requires a renewed look at how TASC works to lengthen stay

and ultimately enhance treatment outcomes.

THE DRUG-CRIME CONNECTION

Criminal justice system studies reveal that drug abusers can be found

throughout the justice process and that a significant amount of crime is related

to alcohol and other drugs. “The link between drug use and crime has been

firmly established, making it difficult to discuss one to the exclusion of the other”

(Bureau of Justice Assistance 1989). Research by Ball and colleagues (1980)

has revealed that offenders commit six times the number of crimes when

addicted to drugs than when not addicted.

The influence of drugs on pretrial criminality is borne out in findings from a

Washington, DC, study (Toborg et al. 1986), which showed that the pretrial

rearrest rates were 50 percent higher for released drug users than nonusers.

The Washington, DC, study also found that the rearrest rate is directly related to

the severity of drug abuse. For example, offenders who tested positive for one

drug had a 22-percent rearrest rate, those who used two drugs had a 28-

percent rearrest rate, and those who used three or more drugs had a 40-

percent rearrest rate.

State prison inmates are disproportionately involved in serious drug use

(Chaiken and Chaiken 1982; lnnes 1988). The lnnes analysis, based on

data collected in 1986 during interviews with more than 13,700 inmates in

State correctional facilities, indicates that 35 percent were under the influence

of a drug at the time of their offense and 43 percent said they were using drugs

daily in the month before the offense.

Drug use among offenders is extremely high. According to reports from the

Drug Use Forecasting System (DUF) of the National Institute of Justice (1989),

as many as 75 percent of the men arrested in 10 major U.S. cities tested

positive for recent use of illicit drugs. The data indicate that in many cities

369
FIGURE 1. Percent drug-positive urinalysis. by DUF site, 1990

SOURCE: National Institute of Justice 1990

370
the extent of drug use by female offenders may even be higher than that of

male offenders (figure 1). This study noted that women arrestees are more

likely than men to test positive for any drug and more likely to test positive for

heroin or cocaine.

Offenders interviewed through the DUF program indicate that many desire

and need treatment (figure 2). However, most offenders have never received

treatment (Tyon 1988). To obtain treatment, offenders need structured

methods to access treatment programs. The evidence that successful drug

abuse treatment reduces crime (Simpson et al. 1978; McGlothlin et al. 1977;

Nash 1976), along with criticisms of traditional criminal justice approaches to

dealing with drug-abusing offenders (Lipton et al. 1975; Carter and Klein 1976).

has reinforced the need for programs-such as TASC-that link offenders to

treatment and provide a broad continuum of care. When treatment is offered,

it seems to work best when the offender is released into the community through

a structured case management approach (Collins and Allison 1983).

DOES TASC WORK?

TASC programs are effective in linking the criminal justice system with the

treatment system and bringing treatment to offenders who otherwise will not

FIGURE 2. Need for treatment among arrestees testing positive for drugs*

*Data based on self-reports of booked arrestees, 1989

SOURCE: National Institute of Justice 1991

371
receive it (System Sciences, Inc. 1979). TASC programs seem to work

because they gain the broad-based support of the justice and treatment

systems. Their legally sanctioned referral mechanism has been found to be

more effective than informal referrals to treatment. Their monitoring function

has been found to improve the client’s treatment performance, and TASC’s

involvement seems to reduce rearrest rates (Lazar Institute 1976). TASC

offers programs as a cost-effective alternative to the criminal justice system

for handling drug-abusing offenders; its functions and procedures work; it is

capable of intervening prior to trials; its legal sanctions improve the treatment

process; and it can achieve “remarkably progressive” success rates with clients

(System Sciences, Inc. 1978).

Another reason TASC seems to work is that it imposes treatment in the context

of program rules and graduated sanctions. When applied in a timely and

consistent manner, these rules and sanctions prolong treatment stays and

improve outcomes (Collins and Allison 1983). The length of time in treatment

(retention) has been associated with positive outcomes (Simpson 1981;

Hubbard et al. 1988). TASC clients have been found to remain in treatment,

both residential and outpatient, 6 to 7 weeks longer than other criminal justicereferred or voluntary clients and to improve as much in relation to drug use,

employment, and criminal behavior as “voluntary” clients during their first 6

months of treatment (Hubbard et al. 1988; Collins and Allison 1983).

HOW DOES TASC WORK?

How does TASC function as a case management model to retain clients in

treatment? Are the procedures employed criminal justice functions or treatment

functions? Does it matter?

In 1986, because of renewed interest in TASC by the Department of Justice,

personnel from TASC programs were brought together to define common

program structures and attributes that contribute to successful TASC

programing. The result was the identifying of critical program elements

(listed below) and accompanying performance standards. These were then

published by the Department of Justice as a program brief (Bureau of Justice

Assistance 1988) and by NIDA in a research monograph (Cook and Weinman

1988). More recently, the National Consortium of TASC Programs has

developed program assessment protocols based on these critical elements

and performance standards. These have been “field tested” in selected

programs at multiple sites around the Nation.

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• Organizational elements

—Element 1: a broad base of support within the justice system with a

protocol for continued and effective communication

—Element 2: a broad base of support within the treatment system with a

protocol for continued and effective communication

—Element 3: an independent TASC unit with a designated administrator

—Element 4: policies and procedures for required staff training

—Element 5: a data collection system to be used in program management

and evaluation

• Operational elements

—Element 6: several agreed-on offender eligibility criteria

—Element 7: procedures for the identification of eligible offenders that

stress early justice and treatment intervention

—Element 8: documented procedures for assessment and referral

—Element 9: documented policies and procedures for random urinalysis

and other physical tests

—Element 10: procedures for offender monitoring that include criteria for

success/failure, required frequency of contact, schedule of reporting, and

notification of termination to the justice system

TASC programs seem to either adopt a criminal justice orientation or place

greater emphasis on treatment depending on the program’s parent organization

or a general philosophy that has evolved in the program. There are clear

variations in the management of TASC clients. Some TASC programs are

more “system centered” as an extension of criminal justice system control.

Other TASC programs are more “client centered,” focusing on the rehabilitation

needs of the offender (R. Hendrix, personal communication, March 1992).

A mix of both seems to produce the healthy symbiosis of criminal justice

system leverage, access to treatment, and therapeutic tension. When TASC

works best, this mix is maintained by active case management and ongoing

TASC contact with the offender, the treatment system, and the criminal justice

system.

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TASC CASE MANAGEMENT

Case management in substance abuse treatment is usually defined as the

process that links individuals in treatment with ancillary community services.

It is usually seen as an adjunct to primary treatment and as an enhancement

to treatment. It builds on services already offered by primary substance abuse

treatment programs. Enhancements often include eliminating barriers to

treatment participation, expanding access to complementary social services,

making referrals and coordinating the services obtained, monitoring progress,

adjusting plans as required, and serving as patient advocates. TASC programs

generally provide all these elements of case management.

TASC case management provides, in addition to traditional case management

functions, structured linkages between the criminal justice system and the

treatment system. This structure, defined in the TASC critical elements as

outlined in the TASC program brief and listed above, is programmatically

measured by performance standards that accompany each element. It is

notable that the operational elements build on and help maintain the first two

organizational elements-broad-based support of the criminal justice system

and broad-based support of the treatment system.

TASC criminal-justice-related case management objectives include (1)

increasing control and supervision through urinalysis, (2) reducing drug use

and criminal behavior through supervision and treatment, (3) broadening the

range of criminal justice sanctions, (4) providing systems of graduated and

intermediate sanctions, (5) offering treatment in lieu of punishment, (6)

reporting to the criminal justice system, (7) providing a basis for judicial

decisionmaking, and (8) extending the power of the court to influence

behavior in an area most critical to community safety.

Treatment-related TASC objectives include (1) screening offenders for

treatment eligibility; (2) assessing the level of treatment need; (3) referring

offenders to appropriate treatment programs and thereby providing better

utilization of resources; (4) orienting clients to the treatment system through

treatment readiness groups and individual counseling; (5) retaining clients

in treatment using criminal justice leverage; (6) supporting treatment

compliance with urinalysis and case management; (7) accessing ancillary

social, educational, vocational, and medical services for clients; and (8)

providing treatment within a structure where failure to comply has consistent

and predictable results yet is flexible enough to accommodate the reality of

addiction and the “process” of treatment.

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TASC Operational Elements

The activities of case managers operating within TASC model programs

support these goals. These activities are organized within the TASC

operational elements 6 through 10 and their accompanying performance

standards. These activities bring life to a TASC program.

Element 6. This element requires clearly defined client eligibility criteria. TASC

programs require that participants be involved with the justice system and that

they use alcohol or other drugs. Beyond these basic requirements, each

program builds eligibility criteria based on the resources available, the justice

system’s or funding entities’ expectations of the program, and the role TASC is

expected to play vis-a-vis probation or pretrial services. These criteria are

usually defined by designating “linkage points” in the criminal justice process

or by accepting or excluding offenders by, for example, charge, age, mental

status, or previous TASC involvement. TASC is capable of intervening from

the time of arrest through parole, with juveniles or adults, and with all types

of offenses. TASC programs routinely serve offenders as they move forward

through the justice system, coordinating services throughout the process.

Case managers are responsible for measuring offenders against these

eligibility criteria and admitting or denying access to TASC services. This is

accomplished through case manager interaction with jail officials, judges,

probation officers, or other referral sources; by reviewing jail, court, and TASC

records; or through direct interaction with the offender. Clearly communicating

eligibility criteria to referring agencies or persons in the justice system aids the

identification process and reduces inappropriate referrals.

Element 7. The formalized process of qualifying offenders for TASC is

outlined through element 7, screening procedures for early identification of

TASC candidates within the criminal justice system. Screening of offenders

involves selecting appropriate candidates for treatment from the pool of eligible

offenders. Early criminal justice and treatment intervention is stressed, and

most TASC programs develop eligibility criteria stressing early involvement.

Case managers, sometimes referred to as “screeners,” interview offenders in

the jail, at court, or in the TASC facility. The case manager verifies eligibility

criteria, explains TASC program requirements to the offender, and reviews

the possible positive and negative aspects of participating in the program.

The case manager may use a urine test as a screening tool in making this

initial determination of eligibility. The case manager plays a critical role in

representing the opportunity for change or help that is available to the offender

through treatment. This intervention often occurs at a critical point in the

offender’s life when the ultimate consequences of his or her drug-using and

criminal behavior have finally been realized. The ability of the TASC case

375
manager to motivate the client to turn this crisis into an opportunity for life

change is exercised at this point. The case manager also plays a critical role

by defining rules, structure, and expectations of the offender if he or she

chooses to participate in the program. This includes objectively reporting

progress or lack of progress to the criminal justice system.

Element 8. The process of assessment and referral is outlined through

element 8, documented procedures for assessment and referral. Performance

standards require documentation of a face-to-face assessment with each TASC

client within a specified time from initial contact. The TASC case manager or a

TASC assessment specialist conducts the assessment utilizing a standardized

assessment tool. The TASC assessment combines basic clinical evaluation

with criminal justice risk assessment. Drug use history, criminal history, family

history, community ties, employment, education, and previous treatment are

explored. Assessment instruments such as the Offender Profile Index or

the Addiction Severity Index are often used to sort offenders to various

interventions and treatment modalities. The end product of the assessment

is a case management plan that outlines service needs over time. The client

is then referred to the most appropriate treatment program. Documentation

is forwarded by the case manager to the chosen treatment facility. Case

managers follow up with treatment facilities and the offender or his family to

ensure that the offender keeps the scheduled intake appointment. When there

are waiting lists, the case manager monitors the offender’s stability until a bed

or slot becomes available. it is essential that TASC support offender treatment

that provides thorough clinical assessment of the client’s needs, which are

often multidimensional. The treatment response should be substantial enough

that the offender “feels” it. it should be protracted and “phased” to extend

involvement. There should be family involvement, and positive recovering role

models should be available in the treatment setting and through support groups.

The treatment program and TASC should mutually support rules, structures,

and sanctions. TASC case managers and treatment staff should maintain

access to as full a continuum of care as possible, and there should be

formalized linkages to other needed services in the community.

Element 9. Element 9 requires program policies, procedures, and technology

for monitoring TASC clients’ drug use/abuse status through urinalysis or other

physical evidence. For criminal justice officials to choose treatment as an

alternative to incarceration, they require offenders to be monitored frequently

for continued drug use. Urinalysis provides objective documentation of drug

use. It is the case manager’s role to determine the frequency of drug testing

and the drugs to be tested for. The case manager reviews test results, reports

compliance to the court or other criminal justice officials, and periodically

adjusts the frequency of testing as indicated by the offenders’ success in

376
“staying clean.” Breathalyzer tests and alcohol-sensitive saliva sticks are

used as adjuncts to the drug test.

Element 10. TASC element 10 requires monitoring procedures for ascertaining

clients’ compliance with established TASC treatment criteria and regularly

reporting their progress to referring justice system components. TASC cannot

function effectively without maintaining a high level of credibility with the

criminal justice system through careful monitoring of compliance with the

case management plan. Case managers review progress reports from

treatment agencies, react as needed, and disseminate these reports to the

justice system. Case managers also document each client contact or any

collateral contact regarding the client in the clients file. They are responsible

for measuring client performance against standardized success/failure criteria.

Case managers terminate clients based on success in (1) completing their case

management plan, (2) treatment, and (3) compliance with court mandates. On

the other hand, they terminate clients for absences, positive urinalysis tests,

new offenses, and other failure criteria. Many TASC programs incorporate

systems of “graduated sanctions” or progressive responses when clients do not

comply with the requirements of the case management plan. These strategies

intensify treatment and monitoring. They may also incorporate criminal justice

sanctions. Case managers actively manage the rehabilitation of clients through

the assessment and reassessment of client needs; through planning the flow or

order in which services occur; through linking to primary treatment and ancillary

educational, vocational, and social services; and by serving as advocates for

offenders in both the criminal justice and treatment systems.

The “active” case manager uses criminal justice leverage and his or her neutral

position to communicate clearly and effectively to the client the program’s

expectations and the consequences of failure. Case managers must be well

trained in the workings of the criminal justice and treatment systems. They

must be respected in both systems to effectively accomplish the TASC mission,

which is as follows:

Reduce the criminality of drug-dependent offenders by maximizing the

rehabilitative aspects of the treatment and criminal justice systems

Work within the justice system to identify, assess, and refer to treatment

those offenders who are dependent on alcohol or other drugs

Work within the treatment system to support offender participation with

criminal justice leverage

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TASC’s philosophy is to act as a bridge between the justice system (with legal

sanctions that reflect community concerns for public safety) and the treatment

community (with emphasis on changing individual behavior and reducing the

personal suffering associated with substance abuse). Through TASC,

community-based treatment is made available to drug-dependent offenders

who would otherwise burden the justice system with their persistent criminal

behavior.

TASC CASE MANAGEMENT: WOMEN OFFENDERS

It should be noted that trends indicate that increasing numbers of TASC

clients will be women. The number of women entering the criminal justice

system is reflected in a 41-percent increase in the number of women

incarcerated between 1985 and 1988 (O’Connor 1989). Between 1984

and 1988 the number of women arrested for violent crimes rose nearly

29 percent. Women offenders in TASC may require special attention as a

unique group with distinct needs (National Consortium of TASC Programs

1991). Substance abuse represents a more significant risk of acquired

immunodeficiency syndrome (AIDS) for female offenders than for males.

Intravenous (IV) drug use has been associated with the majority of AIDS

cases among women (Koonin et al. 1989), and women are more likely than

men to live with an addicted partner and to share drug paraphernalia (Anglin

et al. 1987). Rosenbaum (1981) found that only one-third of the women

sampled had ever shot heroin alone, whereas three-fourths of the men had

used alone. Addicted women have a greater tendency to have multiple sex

partners (many of whom are IV drug users) as a means of obtaining drugs

(Drug Abuse Report 1987). The National Consortium of TASC Programs

(1991) report on female offenders suggested these implications for the

treatment of female TASC clients: (1) Although fewer women than men are

arrested, their need for treatment is the same or greater. (2) Cocaine use is

the most widespread problem among women (as with men), but the potential

for heroin addiction may be higher with women. (3) Many women addicts

begin their drug use as a result of a relationship with a man; dealing with this

relationship may be critical during treatment. (4) Women develop addiction later

than men, but a larger proportion move quickly to an active addiction following

first use. Thus, early intervention should be stressed.

TASC staff members surveyed as a part of the Consortium study uniformly

pointed out that child care must be included in a treatment regime for it to

be successful and that women addicts suffer a much greater degree of

stigmatization than do male addicts. It is critical that TASC programs and

case managers be prepared to advocate for treatment that is sensitive to the

needs of female clients. Ancillary services, including primary medical care,

must be obtained to support a woman’s successful participation in treatment.

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IMPLICATIONS FOR RESEARCH

More than 40 local program evaluations took place between 1972 and 1982.

Most found TASC effective in linking the criminal justice and treatment systems.

Most studies of TASC have shown that lack of data collection and evaluation as

critical program elements has hindered TASC programing (Bureau of Justice

Assistance 1988). It should be noted that there has never been a national

evaluation of the entire TASC effort, but three representative studies are under

way. NIDA is currently funding a six-site TASC evaluation that will evaluate

TASC clients against a set of controls not receiving TASC services. An

extensive process evaluation of the six sites will be incorporated in the study,

and AIDS risk reduction effects will be monitored. Also, the General Accounting

Office is currently conducting a multisite review of TASC programs for the U.S.

Congress. The third study, a three-site Focused Offender Disposition Project

funded by the Bureau of Justice Assistance, is nearing completion. Conducted

in three TASC sites (Birmingham, AL, Phoenix, AZ, and Chicago, IL), the

project randomly assigned presentence offenders either to urinalysis monitoring

only or to treatment in order to study treatment effect. Within the study a new

assessment tool was employed to sort offenders assigned to treatment to

different treatment modalities. Accurate client/treatment matching will be

studied through examining retention in the assigned treatment.

Certainly, TASC could profit from additional evaluation. Areas of potential

research include treatment outcomes of TASC clients, cost-benefit analysis,

relative effect of linkage to treatment at different criminal justice system points,

and criminal justice and treatment histories of TASC clients as a predictor of

outcome. The data necessary to pursue such research efforts have not been

readily available in many TASC programs. In response to this problem, a Model

Management Information System has been developed by Search Group Inc.

under contract with the Bureau of Justice Assistance. It is hoped that this

system coupled with an active National Consortium of TASC Programs will

promote data acquisition and evaluation efforts.

CONCLUSION

The majority of offenders use alcohol or other drugs and most offenders

normally would not receive treatment through conventional mechanisms.

TASC provides a formalized program structure to offer treatment and case

management services to this population. This program structure is incorporated

in 10 critical elements that provide the framework for case management.

TASC case management activities and TASC program structure support both

criminal justice system and treatment system goals as well as the welfare of

the client and the community. Treatment is enhanced by the leverage afforded

379
by the continuous support of TASC case management. TASC clients stay in

treatment longer, and this enhances ultimate outcomes. Through TASC, the

power and accountability of the criminal justice system can be used to push

offenders into the treatment system and keep them there. The treatment

system uses this control and support for treatment to promote sobriety as the

client works to gain control over his or her own life.

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AUTHOR

Foster Cook, M.A.

Assistant Professor

Department of Psychiatry

Director

UAB Substance Abuse Programs

Birmingham TASC Program

University of Alabama at Birmingham

718 30th Street South

Birmingham, AL 35233

382
Case Management Community

Advocacy for Substance Abuse Clients

Rebecca Sager Ashery

INTRODUCTION

The purpose of this chapter is to discuss case management community

advocacy, its importance as an integral part of the case management

process, and its specific relevance to substance abuse clients. In addition,

cost-containment issues and research evaluation are addressed in relation

to advocacy as a part of case management.

BACKGROUND

Case management has long been associated with social work, and social

workers have been and continue to be leaders in this domain (Roberts 1987;

Lamb 1980; Rothman 1991; Austin 1983). The impetus, however, for the

growth of case management models that continue to evolve today was events

such as the categorization (which resulted in fragmentation) of social service

in the late 1960s and the release of patients from State mental hospitals in the

early 1970s (Turner and TenHoor 1978; Schulberg and Bromet 1981; lntagliata

1982; Rapp and Chamberlain 1985).

The Joint Commission on Accreditation of Hospitals (1979) has identified

five functions for case management that have been accepted by various

authors in the literature with some slight variations: (1) assessment,

(2) planning, (3) linkage, (4) monitoring, and (5) advocacy, including

resource development (Sullivan 1981; lntagliata 1982; Johnson and Rubin

1983; Kaplan 1991). The board of directors of the National Association of

Social Workers (1992) has addressed standards for social work case

management, which include elements such as assessing, arranging,

coordinating, monitoring, evaluating, and advocacy. Social work case

management addresses the client’s biopsychosocial status as well as the

social systems in which case management operates. The standards state

that social work case management is both micro and macro in nature with

intervention occurring at both the client and systems levels. The board

383
recognized that there is no one definitive model of social work case

management.

Although several models exist (Lamb 1980; Kisthardt and Rapp 1989; lnciardi

et al. 1991; Rothman 1991; Willenbring et al. 1991; Cook, this volume; Levy,

this volume; Ridgely and Willenbring, this volume), there has been no overall

agreement on the operational definitions of the various functional components

and activities of case management. To complicate matters, case management

is mainly regarded as a process utilized to reach a goal rather than as a goal

itself (Kaplan 1991; Ridgely and Willenbring, this volume; Franklin et al. 1987).

CASE MANAGEMENT AND SUBSTANCE ABUSE

Case management functions have been operative in the field of mental

health for the past 20 years, stimulated by the Federal Government and the

impetus to access services for chronically mentally ill persons released from

State mental hospitals. Case management for substance abusers initially

gained attention through the Treatment Alternatives to Street Crime (TASC)

program, which began in 1972 and has grown to 185 programs that link

the criminal justice system with the drug abuse treatment system (Cook,

this volume). Notwithstanding the TASC program, case management for

substance abusers in drug treatment programs has gained attention only

within the past 6 years. This is reflected in the few descriptive articles on

case management and substance abuse in the literature and the lack of

randomized clinical trials or evaluation protocols for case management with

substance abusers. This volume contains papers presented at the National

Institute on Drug Abuse (NIDA) technical review, “Progress and Issues in

Case Management,” that represent the cutting edge for these studies.

Why has case management not been an integral part of drug treatment in

the past, and why has it become important to the field of substance abuse

today? The answers can be found in the history of substance abuse treatment

and the current nature of the drug epidemic. In the mid-1960s drug treatment

programs were developed as separate entities from health programs and were

not considered a part of the health care delivery system. The two systems

(drug treatment and health care) largely grew separately with infrequent

communication and coordination between the two. There have also been few

linkages between drug treatment programs and the child welfare system. This

may have been because treatment programs in the past have not been geared

toward the needs of women.

Two events within the past 10 years are forcing linkages among the

substance abuse treatment system, the health care delivery system, and

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the child protective service system: the acquired immunodeficiency syndrome

(AIDS) epidemic and the crack/cocaine epidemic. The advent of the human

immunodeficiency virus (HIV) and AIDS has catapulted the importance of case

management to center stage. One can no longer speak of substance abuse

without speaking of HIV and AIDS. Currently, and in the future, drug treatment

programs will be serving clients along the spectrum of HIV disease and may

well be the primary program with which clients who are HIV positive will be

associated. This necessitates the development of community linkages. It

is now imperative that treatment programs develop close ties with health

departments, hospitals, housing programs, entitlement programs, home

health care agencies, and other service resources.

In recognition of the urgency to develop linkages and collaborative efforts, a

national conference on HIV and substance abuse (U.S. Department of Health

and Human Services 1990) was jointly sponsored by four Federal Government

agencies and two private professional associations specifically to encourage

(1) development of joint policies and collaborative activities between State

health departments and State substance abuse agencies and (2) collaborative

efforts between the States and the Federal Government.

To encourage the development of linkages between the primary health care

system and substance abuse treatment services, a special demonstration

program has been jointly funded by the Alcohol, Drug Abuse, and Mental

Health Administration and the Health Resources and Services Administration

(Schlenger et al., this volume). These programs use various models of case

management to link primary care and substance abuse treatment programs.

The crack/cocaine epidemic has been blamed for the burgeoning case

overload in the child protective service system. Crack is highly appealing to

women, which translates into abandoned infants who are fetally exposed to

crack and born with varying degrees of physical consequences and children

who are abused and/or neglected as these women pursue their addiction. A

survey by the American Public Welfare Association (Besharov 1990) of all 50

States found that child welfare agencies showed an unprecedented increase

of 29 percent in the number of children entering foster care from June 1987 to

June 1990. This increase was associated with the crack epidemic. Newspaper

articles (Taylor 1992; Lewis 1992) directly link the increase of children in child

protective services to the crack/cocaine epidemic. A study comparing children

in foster care whose families had parental drug abuse with children in foster

care whose families did not have a drug abuse background indicated that

many of the parental service needs of drug-abusing parents, such as drug

treatment, housing, parenting education, employment, and financial services,

remained as barriers to reunification at the end of the study period (Walker et al.

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1991). Moreover, the link between child welfare services and substance

abuse treatment services was weak. In one study, referrals for drug

rehabilitation were offered to parents before child placement in foster care in

only 16 percent of the cases (National Black Child Development Institute, Inc.

1989). Particularly, services for pregnant addicts and female addicts with

infants and young children were not being addressed comprehensively or

systematically (Rahdert, this volume).

COMMUNITY SERVICE SYSTEMS OVERLOAD

Although there is an urgent need to develop the case management

process, workers find themselves overwhelmed by both case overload

and community service systems overload. Waiting lists for drug treatment

programs predominate, and in many instances, programs for women and

pregnant addicts either do not exist or cannot meet the need. Child protective

service agencies have been forced to prioritize their services because of an

increase in reports of child abuse and neglect and lack of resources (National

Black Child Development Institute, Inc. 1989). Substance abuse HIV/AIDS

cases have overburdened the health care system in some cities because of

the multiplicity of needs and complexity of health complications.

The question is: Can case management be successful in a service system

that is overloaded? Can services be brought to clients when no service

resources exist? Austin (1988) has stated as a myth of case management:

“Case Managers can effectively manage scarce resources and have enough

authority to perform their jobs well.” She emphasizes that the responsibility

of managing scarce resources assumes that there are service resources to

manage. She advocates that case managers have sufficient fiscal authority

to effectively perform their jobs and enable them to purchase services--again

assuming that services exist. Rothman (1991) expresses concern that case

management can become a panacea to take pressure off politicians and

government leaders to respond to needs. In discussions at NIDA’s technical

review on “Progress and Issues in Case Management,” concerns were

expressed that case managers are becoming “professional beggars” within

the community. Many projects reported that they were able to obtain services

for clients, not because of a formalized, structured referral mechanism within

the community, but because of personal relationships with workers in other

agencies and quid pro quo agreements. Some projects had available dollars

to purchase services, yet expressed concerns that while they were able to

obtain services for their own clients, they were literally pushing other clients

farther down on the waiting list. Essentially, they were using additional service

dollars to skillfully jockey for scarce resources. There are growing concerns

that case management may promise more than it can deliver and that it does

386
not adequately address or account for gaps in resources and system failure.

In other words, case management cannot and should not be expected to

ameliorate a faulty service system.

CASE MANAGEMENT AND ADVOCACY

Because of the above issues, it is essential that case management models

include advocacy. According to Kaplan (1991) advocacy can have a

client-specific focus ensuring coordination activities and agency responsiveness

by the worker on behalf of the client or a systems-level approach to identify

and fill gaps in scarce resources. In terms of social work vocabulary, one

might refer to the micro and macro elements of case management (National

Association of Social Workers 1992). Micro refers to the agency, staff, and

client level, that is, the interactions between the worker and the client. Macro

(Rothman 1979) refers to the community systems level, that is, identifying gaps

in services, addressing gaps in resources, developing appropriate liaisons and

referral mechanisms with community agencies, forming community coalitions,

breaking barriers to access, and presenting issues to the mayor, city council,

or State legislature. Graham and Timney (1990) have used the terms “client

advocacy” and “class advocacy.” Intagliata (1982) identifies three models of

case management based on a continuum that ranges from client-focused

activities to community-focused activities, including advocacy for resource

development. In the late 1970s the National Institute of Mental Health

recognized the need for a community support program that would focus

on a comprehensive systems approach and continuity of care for severely

mentally disabled adults (Turner and TenHoor 1978; Levine and Fleming

1985). Specific systems-level activities engaged in by social workers include,

but are not limited to, resource development, financial accountability, social

action, agency policy formation, data collection, information management,

program evaluation, and quality assurance (National Association of Social

Workers 1992). The National Association of Social Workers recognizes that

systems intervention occurs along a continuum and comprises an ongoing,

uninterrupted cycle of tasks that are performed by the social work case

manager.

Of the functions of case management, systems- or community-level advocacy

is probably the least understood and is seldom discussed in the literature.

Birchmore-Timney and Graham (1989) found that most liaison or advocacy

types of case management functions were provided infrequently and that

most programs defined their case management role narrowly. Kurtz and

colleagues (1984) found that more than 75 percent of the workers in their

study seldom engaged in advocacy activities or linking activities; only 12

percent of the workers in the study actively engaged in activities to encourage

387
resource development. The majority of activities were client oriented, including

assessment, planning, and monitoring. For the most part, monitoring did

not include followup services after discharge or consultation with other

agencies regarding the client’s progress. In three illustrative examples

of case management in addictions treatment presented by Graham and

Timney (1990), community-level actions as opposed to case-level actions

were not addressed, although there was some emphasis on interagency

coordination. Fisher and colleagues (1988) found that advocacy accounted

for only 10 percent of the services provided by case managers and linkage

referral for only 13 percent.

It is unclear how community-level advocacy should be implemented. lntagliata

(1982) and Levine and Fleming (1985) suggest a core community agency to

ensure systems integration. The role of the core agency would be the

development of a formal set of contracts among agencies to provide specific

services, therefore eliminating the professional beggar role of case managers

and the dependence on personal relationships to access services for clients.

Additional roles would be the development of new service components. In

other cases, an agency worker(s) may be designated as a community systems

advocate whose specific responsibility may be to function on a systems level

(Piette et al. 1992). Another model may involve case coordination with

participating community agencies (McCarthy et al., this volume).

In any case, advocacy can represent a threat to the status quo of the system.

Anthony and colleagues (1988) suggest that case managers plan an advocacy

campaign when needs for service improvement are documented and actively

persuade decisionmakers to be more responsive to clients’ service needs.

lntagliata (1982) suggests that case managers should act as catalysts in

stimulating others to act. Piette and colleagues (1992) concede that community

advocacy may be more likely to occur within agencies on the periphery of the

established bureaucracy (i.e., community-based organizations) because they

may not be politically tied to supporting traditional agency activities. There is

even a question of how professionals can be true advocates (as opposed to

special interest groups) when they are working for the establishment (Lamb

1980).

Using community advocacy to open some service doors to drug abusers may

prove difficult. The substance abuse population served by public programs has

the reputation of being the least desirable group with which to work, the most

unstable, the most uncooperative, and the least understood by others. Some

programs have specifically eliminated substance abusers by their eligibility

criteria (National Center for Social Policy and Practice 1989).

388
It is this author’s contention that case management cannot be successful for

underserved populations, such as substance abusers, without an active

community advocacy/systems intervention component that is integrated into

the case management model. Most desirable is a citywide coalition of agencies

engaging in several functions to ease the job of case managers on the clientworker level and to work together on a community level to increase scarce

resources. Activities of this coalition should include (1) documentation of

gaps in services, (2) documentation of service duplication, (3) examination

of eligibility criteria, (4) formation of a comprehensive referral network with

formalized mechanisms of referral, (5) development of communication channels

between agencies, (6) ability to merge some services where needed, (7) ability

to address gaps in services, (8) political advocacy for more resources and/or

making changes in the service system, (9) data collection and evaluation, and

(10) quality assurance of programs. Without a community advocacy approach,

there is concern that case managers will spend an inordinate amount of time

“spinning wheels” for individual clients in an effort to obtain services in a

nonviable service system.

ANOTHER MYTH: COST-CONTAINMENT

Case management should not be considered as a method of cost-containment

and should not be confused with managed care (Woodward, this volume; Mittler

1988). The overall purpose of case management is to link clients with services.

Because clients need multiple services and the paucity of resources must be

addressed, case management intervention most likely will not contain costs.

Studies attempting to examine cost-containment issues have mixed outcomes

in terms of dollars spent, dollars saved, and client outcomes (Borland et al.

1989; Goering et al. 1988; Bond et al. 1988; Franklin et al. 1987; Bigelow and

Young 1991).

Increased costs are immediately evident because of lower client-to-worker

ratios. In many methadone clinics, it is not unusual for a worker to have

100 cases with little opportunity for intensive intervention. The suggested

ideal caseload for a case manager is 15 to 20 clients (National Center for

Social Policy and Practice 1989; Goering et al. 1988; Harris and Bergman

1988). Borland and colleagues (1989) had a ratio of one worker to nine

clients in their study. Levy and colleagues (this volume) has a ratio of two

staff members (an outreach worker paired with a case manager) serving 50

clients. At a Health Resources and Services Administration meeting (Health

Resources and Services Administration 1992) a caseload of 30 was

suggested, which would include cases of diverse intensity of need with a

maximum of 7 high-intensity cases. In addition to lower caseloads, clientworker contact is more frequent and intense. In three case studies on the

389
use of case management with substance abusers, the number of in-person

client contacts ranged from 9 to 60 (Graham and Timney 1990). It should be

noted that this number represents client contacts only and does not represent

the case manager’s contacts with referral agencies. Harris and Bergman

(1988) found that, although the type of service did change over time, it is a

myth that clients can be maintained with less intensive case management

services after initial stabilization in the program. Lower caseloads coupled

with frequent and intense contacts, along with community advocacy to bridge

the gaps and create more resources, will not initially be cost-effective, nor will

costs be contained. Case management is not a short-term investment. The

investment in dollars for services and personnel may “pay off” only in terms of

long-range prevention of further client deterioration and a gradual change in the

client’s life situation. Case management is but one component in a scheme to

improve and enhance the lives of clients.

CASE MANAGEMENT RESEARCH

How does one measure “success” with case management, and where does

community advocacy fit into the research? Chamberlain and Rapp (1991)

found a paucity of outcome research on case management. A major question

in case management studies is: What is being measured-the process of

case management itself or a test of the effectiveness of other services? When

conducting outcome studies on case management, the researcher is first

confronted with all the problems inherent in conducting randomized clinical

trials with difficult populations, that is, obtaining clients to participate in the

study, dealing with problems of no-shows and dropouts, finding clients for

followup, and addressing conflicts that may arise between the clinical and

research staffs (Ashery and McAuliffe 1992; McAuliffe and Ashery, in

press). Willenbring (this volume; Willenbring et al. 1991) emphasizes that

qualitative study and documentation are as important as the quantitative

measurements. Qualitative components include descriptive information

regarding the community context in which the case management was located,

the agency environment in which case management functions, linkages,

resource availability, length of wait for services, participation in or receipt of

referred services, activities of the case manager, and the case management

process. Fisher and colleagues (1988) suggest that future research delineate

a measurement of resource availability that could be considered as a variable

affecting service provision. In addition, there should be documentation of the

community advocacy process. Without an understanding and documentation

of the qualitative information, quantitative information may be difficult to interpret

or lead to an erroneous conclusion.

390
CONCLUSION

Case management community advocacy must be integrated into case

management models for substance abusers. Case management without

advocacy will perpetuate the role of the “professional beggar.” Advocacy

will compel agencies and communities to address barriers to access and

gaps in services. It is important to have a coalition of agencies or community

persons on a macro level to address these issues to facilitate the activities of

case managers on the micro level or client-worker level. By its nature, case

management for substance abusers and other underserved populations will

increase costs rather than contain them. However, it is hoped that case

management activities will reduce further client deterioration. Finally, all

research studies should include qualitative data, such as the documentation

of community advocacy activities and the gaps in resources.

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Contract No. 89mf00933901D, Rockville, MD: U.S. Department of Health

and Human Services, U.S. Public Health Service, Alcohol, Drug Abuse, and

Mental Health Administration, February 1991.

AUTHOR

Rebecca Sager Ashery, D.S.W.

Senior Social Work Specialty Consultant

Community Research Branch

Division of Applied Research

National Institute on Drug Abuse

Parklawn Building, Room 9A-30

5600 Fishers Lane

Rockville, MD 20857

394
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free of charge from the Office for Substance Abuse Prevention’s National

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71 OPIATE RECEPTOR SUBTYPES AND BRAIN FUNCTION. Roger M.

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105 PROBLEMS OF DRUG DEPENDENCE, 1990: PROCEEDINGS OF THE

52ND ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS

OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-01435-4 $22

106 IMPROVING DRUG ABUSE TREATMENT. Roy W. Pickens, Ph.D.; Carl

G. Leukefeld, D.S.W.; and Charles R. Schuster, Ph.D., eds.

GPO Stock #017-024-01439-7 $12 NTIS PB #92-105873

Paperback $50 Microfiche $19

107 DRUG ABUSE PREVENTION INTERVENTION RESEARCH:

METHODOLOGICAL ISSUES. Carl G. Leukefeld, D.S.W., and William J.

Bukoski, Ph.D., eds.

GPO Stock #017-024-01446-0 $9 NTIS PB #92-160985

Paperback $35 Microfiche $17

108 CARDIOVASCULAR TOXICITY OF COCAINE: UNDERLYING

MECHANISMS. Pushpa V. Thadani, Ph.D., ed.

GPO Stock #017-024-01446-0 $7 NTIS PB #92-106608

Paperback $35 Microfiche $17

399
109 LONGITUDINAL STUDIES OF HIV INFECTION IN INTRAVENOUS DRUG

USERS: METHODOLOGICAL ISSUES IN NATURAL HISTORY RESEARCH.

Peter Hartsock, Dr.P.H., and Sander G. Genser, M.D., M.P.H., eds.

GPO Stock #017-024-01445-1 $4.50 NTIS PB #92-106616

Paperback $26 Microfiche $12.50

110 THE EPIDEMIOLOGY OF COCAINE USE AND ABUSE. Susan Schober,

Ph.D., and Charles Schade, M.D., M.P.H., eds.

GPO Stock #017-024-01456-7 $11 NTIS PB #92-14624-0

Paperback $43 Microfiche $17

111 MOLECULAR APPROACHES TO DRUG ABUSE RESEARCH VOLUME I:

RECEPTOR CLONING, NEUROTRANSMITTER EXPRESSION, AND

MOLECULAR GENETICS. Theresa N.H. Lee, Ph.D., ed.

Not for sale at GPO NTIS PB #92-135743

Paperback $35 Microfiche $17

112 EMERGING TECHNOLOGIES AND NEW DIRECTIONS IN DRUG

ABUSE RESEARCH. Rao S. Rapaka, Ph.D.; Alexandros Makriyannis, Ph.D.;

and Michael J. Kuhar, Ph.D., eds.

GPO Stock #017-024-01455-9 $11

113 ECONOMIC COSTS, COST-EFFECTIVENESS, FINANCING, AND

COMMUNITY-BASED DRUG TREATMENT. William S. Cartwright, Ph.D.,

and James M. Kaple, Ph.D., eds.

Not for sale at GPO NTIS PB #92-155795

Paperback $35 Microfiche $17

114 METHODOLOGICAL ISSUES IN CONTROLLED STUDIES ON EFFECTS

OF PRENATAL EXPOSURE TO DRUG ABUSE. M. Marlyne Kilbey, Ph.D., and

Khursheed Asghar, Ph.D., eds.

GPO Stock #017-024-01459-1 $12 NTIS PB #92-146216

Paperback $43 Microfiche $17

115 METHAMPHETAMINE ABUSE: EPIDEMIOLOGIC ISSUES AND

IMPLICATIONS. Marissa A. Miller, D.V.M., M.P.H., and Nicholas J. Kozel, M.S.,

eds.

GPO Stock #017-024-01460-5 $4

116 DRUG DISCRIMINATION: APPLICATIONS TO DRUG ABUSE

RESEARCH. Richard A. Glennon, Ph.D.; Torbjõrn U.C. Järbe, Ph.D.; and

Jerry Frankenheim, Ph.D., eds.

GPO Stock #017-024-01470-2 $13

400
117 METHODOLOGICAL ISSUES IN EPIDEMIOLOGICAL, PREVENTION,

AND TREATMENT RESEARCH ON DRUG-EXPOSED WOMEN AND THEIR

CHILDREN. M. Marlyne Kilbey, Ph.D., and Khursheed Asghar, Ph.D., eds.

GPO Stock #017-024-01472-9 $12

118 DRUG ABUSE TREATMENT IN PRISONS AND JAILS. Carl G.

Leukefeld, D.S.W., and Frank M. Tims, Ph.D., eds.

GPO Stock #017-024-01473-7 $16

119 PROBLEMS OF DRUG DEPENDENCE 1991: 53RD ANNUAL

SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-01474-5 $22

120 BIOAVAILABILITY OF DRUGS TO THE BRAIN AND THE BLOODBRAIN BARRIER. Jerry Frankenheim, Ph.D., and Roger M. Brown, Ph.D., eds.

121 BUPRENORPHINE: AN ALTERNATIVE TREATMENT FOR OPIOID

DEPENDENCE. Jack D. Blaine, Ph.D., ed.

122 RESEARCH METHODS IN WORKPLACE SETTINGS. Helen Axel, M.A.,

and Dennis J. Crouch, M.B.A., eds.

123 ACUTE COCAINE INTOXICATION: CURRENT METHODS OF

TREATMENT. Heinz Sorer, Ph.D., ed.

124 NEUROBIOLOGICAL APPROACHES TO BRAIN-BEHAVIOR

INTERACTION. Roger M. Brown, Ph.D., and Joseph Frascella, Ph.D., eds.

125 ACTIVATION OF IMMEDIATE EARLY GENES OF ABUSE. Reinhard

Grzanna, Ph.D., and Roger M. Brown, Ph.D., eds.

126 MOLECULAR APPROACHES TO DRUG ABUSE RESEARCH VOLUME

II: STRUCTURE, FUNCTION, AND EXPRESSION. Theresa N.H. Lee, Ph.D.,

ed.

401
DHHS Publication No (ADM) 92-1946

Alcohol, Drug Abuse, and Mental Health Administration

Printed 1992