s e i r e S tr u o C ss e n l l e W ot gn i l a e H la b i r T 

Main Office: 8235 Santa Monica Blvd., Suite 211 - West Hollywood, CA 90046 

P: 323.650.5467 - F: 323.650.8149 

Tribal Healing to Wellness Courts: www.WellnessCourts.org 

Tribal Law and Policy Institute: www.Home.TLPI.org 

Tribal Court Clearinghouse: www.TLPI.org 

May 2018

Tribal Healing to Wellness Courts:

Case Management

Case Management 

Tribal Healing to Wellness Courts:

Case Management

May 2018

A product of the

Tribal Law and Policy Institute

8235 Santa Monica Blvd., Suite 211

West Hollywood, CA 90046

Tribal Law and Policy Institute: www.Home.TLPI.org

Tribal Court Clearinghouse: www.TLPI.org

Tribal Healing to Wellness Courts: www.WellnessCourts.org

Walking on Common Ground: www.WalkingOnCommonGround.org

This project was supported by Grant No. 2016-DC-BX-K006, awarded by the Bureau of Justice 

Assistance. The Bureau of Justice Assistance is a component of Office of Justice Programs, which 

also includes Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile 

Justice and Delinquency Prevention, the SMART Office, and the Office for Victims of Crime. 

Points of view or opinions in this document are those of the authors and do not necessarily 

reflect the views of the U.S. Department of Justice.

Primary Authors

Carrie Garrow (Akwesasne Mohawk)

Chief Judge, Saint Regis Mohawk Tribal Court

Kori Cordero (White Mountain Apache)

Tribal Justice Specialist, Tribal Law and Policy Institute

Lauren van Schilfgaarde (Cochiti Pueblo)

Tribal Law Specialist, Tribal Law and Policy Institute

Special Thanks To

Heather Torres (San Ildefonso Pueblo, Navajo)

UC President’s Public Service Law Fellow, UCLA School of Law

Donna Humetewa Kaye (Hopi)

Program Director, Nakwatsvewat Institute

Editorial Assistance

Christine Dunn

Copyeditor
Free Training and Technical Assistance

The Tribal Law and Policy Institute, through support from the Bureau of Justice 

Assistance, offers free training and technical assistance for Healing to Wellness 

Courts. 

If you would like to request free training or technical assistance, please contact:

The Tribal Law and Policy Institute 

8235 Santa Monica Blvd., Ste. 211

West Hollywood, CA 90046

www.Home.TLPI.org

www.WellnessCourts.org

Phone: (323) 650-5467

E-mail: wellness@tlpi.org
Tribal Healing to Wellness Court Publication Series

With support from the Bureau of Justice Assistance, the Tribal Law and Policy Institute (TLPI) has 

developed the following additional Tribal Healing to Wellness Court–specific resource 

publications to assist tribal governments and tribal justice systems in developing, enhancing, 

and sustaining Tribal Healing to Wellness Courts. These resources are available for free 

download at www.Home.TLPI.org, the Tribal Court Clearinghouse website (www.TLPI.org), and 

TLPI’s website devoted solely to Healing to Wellness Courts: www.WellnessCourts.org. 

Tribal Healing to Wellness Courts: The Key Components, 2nd ed. (2014)

This publication (initially published in 2003; updated in 2014) provides key components and 

recommended practices for tribal justice systems to consider as they design, develop, and 

implement a Tribal Healing to Wellness Court that meets the needs of their community. 

Organized around the 10 Key Components adapted for tribes, this publication describes the 

basic elements of a Healing to Wellness Court. The purpose of each component is explained, 

followed by lessons learned, and examples of real-world applications.

Overview of Tribal Healing to Wellness Courts, 3rd ed. (2014)

This publication (initially published in 1999; second edition in 2002; third edition in 2014)

provides an overview of Tribal Healing to Wellness Courts. This overview discusses the history 

of the drug court movement and the adaptation of the drug court model for tribal justice 

systems. It provides an overview of some of the critical issues and challenges faced by Tribal 

Healing to Wellness Courts, including incorporating tribal custom and tradition, addressing the 

high volume of alcohol abuse cases, and addressing jurisdictional and resource limitations. 

Tribal Healing to Wellness Courts: Treatment Guidelines, 2nd ed. (2017)

This guideline has been developed to provide tribal communities with an overview of Western 

substance abuse treatment strategies that have been developed by drug court programs over 

the past several years and that tribal programs might consider adapting, along with traditional 

healing practices. This guideline draws upon drug court standards and best practices, and the 

experiences of hundreds of tribal and state adult and juvenile drug court programs, operating in 

various environments and serving a wide range of individuals addicted to alcohol and/or other 

drugs.

Tribal Healing to Wellness Courts: The Judicial Bench Book (2016)

The role of the Healing to Wellness Court differs dramatically from the adversarial trial court 

judge, both in mechanics and in philosophy. In Wellness Court, the judge serves as the captain 

or the coach of the team, focused on healing and collaboration. This publication orients and 

serves the Wellness Court judge while on the bench. The first section provides examples of key 

component performance in relation to component principles. The second section overviews key 

Wellness Court processes and procedures. Both sections include Bench Cards intended to serve 

as tools that package relevant information in an abbreviated format. 
Tribal Healing to Wellness Court: The Policies and Procedures Guide (2015)

The policies and procedures manual is the quintessential tool for the Healing to Wellness Court, 

documenting the structure and spirit of the court. This publication provides an overview of the 

key considerations for what should be included in the manual, including team roles and 

responsibilities, phase systems, alcohol and drug testing, and statutory provisions. Rather than 

detailing one “model” manual, this publication provides excerpts from more than fifteen 

operational manuals to preview the level of legal and cultural diversity that is possible within a 

Healing to Wellness Court. 

Tribal Healing to Wellness Courts: Program Development Guide (2002)

This publication provides step-by-step recommendations for the design, development, and 

implementation of Tribal Healing to Wellness Court programs from a practical standpoint. It is 

designed to assist steering committees and planning groups as they (1) use team-based 

approaches; (2) gain knowledge of Healing to Wellness Court concepts; (3) incorporate the 10

Key Components; (4) help establish policies and procedures suitable to the needs of the tribal 

community; (5) guide the court to integrate available resources; (6) develop interagency 

agreements; (7) incorporate management information systems to track participants and 

services; and (8) identify possible problem areas.

Perceptions of Methamphetamine Use in Three Western Tribal Communities: Implications for 

Child Abuse in Indian Country (2007)

This publication explores the increasing concerns raised by the emerging methamphetamine 

epidemic in Indian country. Professionals from three tribal communities detail their perceptions 

of meth use and implications for child abuse in the communities in which they work.
Case Management Table of Contents

TABLE OF CONTENTS

About This Resource ....................................................................................................................... 1

General Overview: Healing to Wellness Courts.............................................................................. 2

The Drug Court Movement......................................................................................................... 2

Tribal Healing to Wellness Courts............................................................................................... 2

The Tribal 10 Key Components................................................................................................... 1

The Wellness Court Process........................................................................................................ 3

The Tribal Healing to Wellness Court Team ............................................................................... 3

What Is Case Management? ........................................................................................................... 5

Functions of Case Management in Wellness Courts ...................................................................... 8

Information Flow ........................................................................................................................ 8

Screening and Assessment ....................................................................................................... 10

Planning..................................................................................................................................... 12

Linkage ...................................................................................................................................... 14

Monitoring ................................................................................................................................ 16

Advocacy ................................................................................................................................... 18

Cultural Competence ................................................................................................................ 19

Models of Case Management....................................................................................................... 20

Ethics of Case Management ......................................................................................................... 23

Confidentiality........................................................................................................................... 24

Shared Core Competencies....................................................................................................... 24

Drug Court Community Supervision Core Competencies......................................................... 25

Balancing Roles: Case Manager and Coordinator......................................................................... 27

Case Manager ........................................................................................................................... 27

Coordinator............................................................................................................................... 27

Balance...................................................................................................................................... 27

Data Collection and Evaluation..................................................................................................... 30

Participant Progress.................................................................................................................. 31

Program Progress...................................................................................................................... 31

Report Considerations.............................................................................................................. 32

Data Dictionary ......................................................................................................................... 32

Benchmarks............................................................................................................................... 32
Case Management Table of Contents

Additional Resources.................................................................................................................... 34

Appendix A: Models of Case Management .................................................................................. 37

Appendix B: Vicarious Trauma...................................................................................................... 40

Appendix C: Sample Job Descriptions........................................................................................... 42

Appendix D: Sample Participant Progress Reports....................................................................... 46

Appendix E: Sample Wellness Court Data Values......................................................................... 50
Case Management About This Resource

1

About This Resource

The Tribal Healing to Wellness Courts: Case Management resource (Case Management) is

designed to provide Tribal Healing to Wellness Courts (Wellness Courts) and their staff a guide 

to effective case management and the case manager role. This resource will discuss the ins and 

outs of case management as guided by the widely accepted standards set forth by the National 

Association of Drug Court Professionals Professional Services Branch and the National Drug 

Court Institute (NDCI), before moving into a more practical discussion of the role case 

management plays in Wellness Courts.

Because the resources and staff available to Wellness Courts are often limited, this publication 

will also address how several members of a Wellness Court team can effectively and ethically 

assist with case management. Additionally, this publication will provide strategies for how a 

Wellness Court case manager can balance their role with other duties.

While this short resource provides an overview of the subject, exploring the breadth of 

common issues impacting case management in Wellness Courts, this is not intended to be the 

sole resource for developing or revising the role of a Wellness Courts case manager. Instead, 

this resource is a first stop, with references to additional resources that will provide a more indepth discussion of the topic at hand. 
Case Management General Overview

2

General Overview: Healing to Wellness Courts

To understand case management within the context of a multidisciplinary Wellness Court team, 

it is important to have a general understanding of drug courts, Wellness Courts, and tribal court 

systems. The section will provide a brief general overview of tribal Wellness Courts; we strongly 

encourage those without Wellness Court experience to see the “Additional Resources” section 

to further develop their understanding.

1

The Drug Court Movement

The modern movement of Wellness Courts can be traced back to the formation of drug courts 

in state systems. The U.S. “War on Drugs” resulted in a large increase of drug-related cases in 

state criminal justice systems, increased drug-related convictions, and overcrowded jails and 

prisons.2In addition, the individuals impacted by this policy were not only subject to 

traumatization by the prison system, including the many barriers and stigma that follow 

previously incarcerated people in reentry, but also usually were not afforded meaningful 

opportunities to address their substance abuse and its underlying causes.3 Criminal justice 

systems quickly became overburdened by the process and were not achieving the desired 

deterrent or rehabilitative effect. Consequently, the drug court approach was developed to 

process substance abuse cases in a way that systematically prioritizes treatment, tethering 

treatment to judicial authority, multidisciplinary input, and personal accountability. What 

began as a grassroots initiative has become a nationwide trend.

Tribal Healing to Wellness Courts 

Word of the drug court movement spread to Indian country,4 where many tribal communities 

were encountering individuals and families with intergenerational substance abuse issues. 

Many indigenous forms of justice already embraced a restorative, holistic approach that 

prioritizes healing over punishment. Tribal communities and their leaders were thus particularly 

interested in how drug courts could help address severe alcoholism and alcohol-related crimes 

 

1

See Additional Resources at page 34. For those truly new to the topic, we recommend Joseph Flies-Away, Carrie 

Garrow, and Pat Sekaquaptewa, Tribal Healing to Wellness Courts: The Key Components, 2nd ed. (Tribal Law and 

Policy Institute, 2014).

2

Joseph Thomas Flies-Away, Jerry Gardner, and Carrie Garrow, Overview of Tribal Healing to Wellness Courts

(Tribal Law and Policy Institute, 2014), 1.

3

Ingrid A. Binswanger et al., “Return to Drug Use and Overdose after Release from Prison: A Qualitative Study of 

Risk and Protective Factors." Addiction Science and Clinical Practice 7, no. 1 (2012): 3; C. J. Mumola, and Jennifer C. 

Karberg, Drug Use and Dependence, State and Federal Prisoners, 2004 (Department of Justice, Office of Justice 

Programs, Bureau of Justice Statistics, 2006).

4 We use Indian country to refer to tribes, tribal governments, and nongovernment programs serving Native 

peoples living on tribal land. We do not mean to exclude Alaska tribal governments or other tribes lacking a land 

base. 
Case Management General Overview

3

prevalent in their communities in a more meaningful way. As interest and research grew, both 

tribal and federal advocates realized the drug court concept could have a positive impact within 

Native Nations and was already more in line with many tribal values related to restorative 

justice.5

In August 1997, tribal-specific drug court curriculums were drafted and adapted from state and 

national efforts and were used for the first formal tribal drug court training sessions. The tribalspecific drug court curriculums were quickly adapted further based on the communities 

receiving the training and their nations’ available systems and cultural values. Early on in this 

process, tribal teams preferred to avoid the term drug court for their new approach and 

searched for a new term that would both incorporate 

alcohol abuse cases and culturally connect to the tribal 

community.

Tribal names for this approach include Wellness Court, 

Healing Court, Treatment Court, Substance Abuse Court, 

Alternative Court, and other terms in their respective 

indigenous languages. We prefer the term Healing to 

Wellness Court, a nod to both the healing and wellness 

aspects of the approach and the idea that wellness is an 

ongoing journey. Healing to Wellness Court and Wellness 

Court are used in this publication interchangeably. 

Healing to Wellness Courts are not simply tribal courts that 

handle alcohol and drug abuse cases. A Wellness Court is a 

special court docket for cases involving alcohol- or drugusing offenders through an extensive supervision and 

treatment program. Wellness Court programs bring the full 

weight of all interveners—judge, prosecutor, defense 

counsel, treatment specialists, probation officers, law 

enforcement and correctional personnel, social services, 

community leaders, traditional healers, and others—

causing the offender to confront their substance use 

disorder. The structure of the court supports a higher level 

of accountability for program participants by leveraging the coercive power of the criminal 

justice system to achieve abstinence and alter criminalized behavior through the combination 

of judicial supervision, treatment, drug testing, incentives, sanctions, appropriate cultural 

components, and, importantly, case management.

A Tribal Healing to Wellness Court epitomizes a justice system that strives to meet the needs of 

the community, particularly the need to address the devastation caused by alcohol, drug abuse, 

 

5

Flies-Away et al., Overview of Tribal Healing to Wellness Courts, 1.
Case Management General Overview

4

and crime. The design of a Wellness Court program is developed at the local level, to reflect the 

unique strengths, circumstances, and capacities of each Native Nation.6

The first Wellness Courts were designed to 

serve either adult or juvenile participants in 

a criminal context. Later, Family Wellness 

Courts were developed to target parents 

with substance use disorders with a civil 

child welfare case. In a 2010 Wellness Court 

Needs Assessment,7 which included twentyeight operational Wellness Courts, 

respondents stated a need to work with 

whole families and household residents.

 

6

Ibid., 2–3.

7 Tribal Law and Policy Institute, Tribal Wellness Courts Needs Assessment (U.S. Department of Justice, Bureau of 

Justice Assistance, 2010).

Lummi Nation Tribal Court, 2017
Case Management General Overview

1

The Tribal 10 Key Components

Whether an adult, juvenile, family, or any other variation of a Healing to Wellness Court, all are 

guided by the 10 Key Components, the basic operational characteristics that all Healing to 

Wellness Courts should share as benchmarks for performance.8 Fashioned after the state drug 

court key components,

9

the Healing to Wellness Court 10 Key Components were crafted to 

reflect tribal notions of healing and wellness, particularly the concept of a healing-to-wellness 

journey, and the collaborative effort involved with supporting such a journey.10 They are also 

used by federal grant providers in consideration of drug court grant awards.

Key Component #1: Individual and Community Healing Focus

Tribal Healing to Wellness Court brings together alcohol and drug treatment, community 

healing resources, and the tribal justice process by using a team approach to achieve the 

physical and spiritual healing of the individual participant, and to promote Native nationbuilding and the well-being of the community.

Key Component #2: Referral Points and Legal Process

Participants enter Tribal Healing to Wellness Court through various referral points and legal 

processes that promote tribal sovereignty and the participant’s due (fair) process rights.

Key Component #3: Screening and Eligibility

Eligible court-involved substance-abusing parents, guardians, juveniles, and adults are 

identified early through legal and clinical screening for eligibility and are promptly placed into 

the Tribal Healing to Wellness Court.

Key Component #4: Treatment and Rehabilitation

Tribal Healing to Wellness Court provides access to holistic, structured, and phased alcohol and 

drug abuse treatment and rehabilitation services that incorporate culture and tradition. 

Key Component #5: Intensive Supervision

Tribal Healing to Wellness Court participants are monitored through intensive supervision that 

includes frequent and random testing for alcohol and drug use, while participants and their 

families benefit from effective team-based case management.

Key Component #6: Incentives and Sanctions

Progressive rewards (or incentives) and consequences (or sanctions) are used to encourage 

participant compliance with the Tribal Healing to Wellness Court requirements.

 

8 We encourage readers new to the topic to read Tribal Law and Policy Institute’s Tribal Healing to Wellness Courts: 

The Key Components (2014) before continuing with this Case Management publication. 

9 National Association of Drug Court Professionals Drug Court Standards Committee, Defining Drug Courts: The Key 

Components (U.S. Department of Justice, Bureau of Justice Assistance, reprinted Oct. 2004).

10 Flies-Away et al., The Key Components.
Case Management General Overview

2

Key Component #7: Judicial Interaction

Ongoing involvement of a Tribal Healing to Wellness Court judge with the Tribal Wellness Court 

team and staffing, and ongoing Tribal Wellness Court judge interaction with each participant 

are essential. 

Key Component #8: Monitoring and Evaluation

Process measurement, performance measurement, and evaluation are tools used to monitor 

and evaluate the achievement of program goals; identify needed improvements to the Tribal 

Healing to Wellness Court and to the tribal court process; determine participant progress; and 

provide information to governing bodies, interested community groups, and funding sources.

Key Component #9: Continuing Interdisciplinary and Community Education

Continuing interdisciplinary and community education promotes effective Tribal Healing to 

Wellness Court planning, implementation, and operation.

Key Component #10: Team Interaction

The development and maintenance of ongoing commitments, communication, coordination,

and cooperation among Tribal Healing to Wellness Court team members, service providers and 

payers, and the community and relevant organizations, including the use of formal written 

procedures and agreements, are critical for Tribal Wellness Court success.
Case Management General Overview

3

The Wellness Court Process

The Wellness Court process can vary and is designed by the team or steering committee to 

meet the needs of the community. Generally, a Wellness Court typically last twelve to eighteen 

months and is divided into four phases. Participants progress through phases by meeting 

weekly goals of treatment attendance (as recommended by the treatment provider, but may 

include group and possibly individual counseling), peer-support meeting attendance, 

community service, and drug testing. Participants then review their progress at weekly or 

biweekly hearings with the Wellness Court team. Through frequent hearings, the Wellness 

Court can quickly respond to progress and slipups through incentives and sanctions, as well as 

needs for services or support. 

The Tribal Healing to Wellness Court Team 

Unlike the adversarial process in which the attorneys, probation officers, treatment providers, 

and so forth, work independently and from their own agency perspective, the Wellness Court 

process relies on these professionals to come together as a “team.” Their shared goal is the 

recovery of each participant and the long-term wellness of the participants, their families, the 

community, and the tribe. Wellness Court team members should meet on a regular basis 

(generally weekly or biweekly) to review participant progress. The team, or preferably a 

steering committee, should also regularly meet (monthly or quarterly) to review program 

processes and develop and/or fine-tune policies and procedures.

At a minimum, the Wellness Court team should include:11

• Tribal Judge (or panel of judges)

• Prosecutor (or presenting officer)

• Defense Counselor (or lay legal advocate)

• Alcohol/Substance Abuse Counselor

• Coordinator

• Case Manager

• Probation Officer

• Law Enforcement Representative

• Child Welfare Representative (when applicable)

In addition, the team may also include:

• Traditional Healers

 

11 See Drug Court Best Practice Standards, Volume II (National Association of Drug Court Professionals, 2014), 38 

(recommending that the drug court team include at least a “judge or judicial officer, program coordinator, 

prosecutor, defense counsel representative, treatment representative, community supervision officer, and law 

enforcement officer”). In addition, a coordinator and case manager are recommended. 
Case Management General Overview

4

• Community Leaders (tribal council member, elders, etc.)

• Housing

• Mental Health Provider

• School/Vocational Training Representative

The Wellness Court team and their roles will be discussed later in this resource. However, it is 

important to note and distinguish between the roles of the coordinator and case manager. As 

with all team member roles of a Wellness Court, there may be some overlap. However, the 

difference between a coordinator and case manager is often further blurred. Many times, one 

person fills both roles, or tasks are delegated across the team. 

Coordinator

The coordinator looks to the “big picture,” coordinating the efforts of the court. The 

coordinator serves as a liaison between the Wellness Court and other agencies and community 

organizations, facilitating communication and collaboration, seeking further agencies for 

collaboration, and ensuring the lines of communication remain open. They are the “face” of the 

court. Further, the coordinator serves as the liaison for the Wellness Court outside the tribe, 

including grant managers and other funders. Frequently, the coordinator is responsible for 

documenting program activities and accomplishments, supervising data collection for program 

evaluation, managing budgetary concerns, and submitting grant applications for program 

funding. 

Case Manager

Where the coordinator is big picture, the case manager is detail-focused, directly assisting

participants on a day-to-day basis.

12 The case manager ensures that a participant successfully 

negotiates the entry process and obtains all the services necessary for their recovery. In 

addition to substance abuse treatment, these may include educational, vocational, housing, 

parenting, medical, mental health, and other services. The case manager monitors the 

participant’s progress in treatment. They notify the team of any issues that may warrant a 

change in the treatment plan and discuss issues such as the coordination of other services. 

When there is no funding available for a case manager, the functions of the case manager are 

shared among team members.13

 

12 See, e.g., Randy Monchick, Anna Scheyett, and Jane Pfeifer, Drug Court Case Management: Role, Function, and 

Utility (National Drug Court Institute, 2006).

13 Caroline S. Cooper et al., Tribal Healing to Wellness Courts: Treatment Guidelines, 2nd ed. (Tribal Law and Policy 

Institute, 2017).
Case Management What Is Case Management?

5

What Is Case Management? 

Case management can be difficult to define because it tends to vary by setting. Because this 

publication is focused on Wellness Courts, the best comparison will be case management in the 

drug court setting. The NDCI has defined case management as:

A series of inter-related functions that provides needed coordination and 

seamless collaboration, and is the force that holds the varied and many drug 

court elements together, ensuring that:

1. Clients are linked to relevant and effective services;

2. All service efforts are monitored, connected, and in synchrony; and

3. Pertinent information gathered during assessment and monitoring is 

provided to the entire drug team in real time.

Essentially, case management forms the framework around which the drug court 

process can credibly and effectively operate.14

While many Native Nations may have more nuances and resource challenges, case 

management in Wellness Courts should be guided by the same definition. Case management 

plays an integral part in 

• Linking participants to necessary services;

• A collaborative monitoring of the participants’ services and progress; and

• Gathering and sharing information for and within the Wellness Court team.

One of the many distinguishing features of Wellness Court is the significant number of activities 

required of a participant, particularly in the early phases. From individual therapy, to group 

sessions, to community service, to drug testing, participants are busy! By design, participants 

are occupied as a means for both engagement in treatment as well as accountability to 

 

14 Monchick et al., Drug Court Case Management, ix.

Key Component #5:

Tribal Healing to Wellness Court participants are monitored through 

intensive supervision that includes frequent and random testing for 

alcohol and drug use, while participants and their families benefit from 

effective team-based case management.
Case Management What Is Case Management?

6

discourage substance use. But as Key Component #5 notes, intensive supervision must be 

coupled with equally intensive case management.

Many participants, especially in the early phases, are not accustomed to successfully navigating 

numerous appointments or complex bureaucracies. Few have ever used a personal calendar. 

Frequently, treatment “fails” for individuals not because a curriculum or provider was 

inappropriate, but because the individual was tardy too frequently, or neglected to reschedule 

conflicting appointments. Mixed with the stresses of unstable housing, parenting, finances, and 

addiction, many participants feel set up to fail. Case management is intended to ease this 

burden, both actual and perceived. 

Whether case management is performed by an individual or by a team, the focus should be to 

assist the Wellness Court team in implementing a successful strategy that will allow participants 

to achieve a healthy lifestyle. This means a case manager’s duties will shift as a participant 

progresses through the program.

Ideally, Wellness Court teams should have a designated case manager with clear duties that are 

separate from those of other team members. The case manager is an important part of the 

team, one who tracks the larger picture of each participant for the benefit of the team;

whereas other team members may only be focused on a small aspect of the participant’s path 

to wellness. 

Case management is a series of interrelated functions that provides this needed 

coordination and seamless coordination, and is essential for sustaining 

integrated and effective drug court systems.

15

The case managers’ coordinated approach should include the delivery of the following services:

• General healthcare services

• Substance abuse services

• Mental health services

• Social services

Case management is an effective tool in companionship with substance abuse treatment.

Treatment is always more effective with retention, which is a principal goal of case 

management.16 Treatment is more likely to succeed when a participant’s other issues are 

addressed in tandem with substance abuse. Case management focuses on the whole individual, 

not just addiction.17 Participants come to Wellness Courts with numerous issues in addition to 

substance abuse, such as physical health, mental health, homelessness, and lack of education, 

 

15 Ibid., 1.

16 Department of Health and Human Services, Substance Abuse and Mental Health Services Administration 

(hereinafter referred to as SAMHSA), Comprehensive Case Management for Substance Abuse Treatment, 

Treatment Improvement Protocol Series, No. 27. HHS Publication No. (SMA) 12-4215 (2012), xiii.

17 Ibid., xiii.
Case Management What Is Case Management?

7

parenting, and job skills. A case manager serves to help identify those issues, connect the 

participant to the needed services, coordinate when in the phases a participant should access 

certain services, and work with the participant to follow up on the use of the services.

A case manager is a person that is not limited to the boundaries of their agency, but whose 

purpose is to look outside their agency to find the needed services for a participant. In a tribal 

setting, that often means assisting with creating and adjusting a transportation plan, so each 

participant has a fair chance to access services and make required appointments. 
Case Management Functions of Case Management

8

Functions of Case Management in Wellness Courts

A case manager must be able to perform several important 

functions to successfully serve participants, the Wellness 

Court team, and the tribal community. The case manager 

functions provided in this section of the resource are 

adapted from the NDCI benchmarks. NDCI created these 

benchmarks to help case managers, and their supervisors, 

more effectively track and evaluate their work. The case 

management functions include:

• Screening and assessment,

• Planning,

• Linkage,

• Monitoring, and 

• Advocacy. 

Each function will be discussed in the following sections of 

this resource. 

Information Flow

Before diving into the functions of case management, it is 

important to consider information flow. Adversarial courts 

and related systems are often criticized for operating in 

silos with limited information flows. The Wellness Court 

model, and multidisciplinary teams generally, are designed 

to counter this frequent challenge by prioritizing 

information flow between multiple agencies frequently. 

Information flow is critical to successful case management. 

The case manager must communicate effectively with both 

the participant(s) and the Wellness Court team. From the 

outset, the Wellness Court team should determine what 

information needs to be shared, how that information is 

relayed (i.e., secure e-mail, a data management system), 

and how quickly certain information should be relayed, and 

should clearly identify the kind of information that can wait 

until the Wellness Court staffing. Information flow will 

impact every aspect of case management.

Staffing

The “staffing,” “staffing meeting,” 

or “prehearing staffing” is the team 

meeting that takes place 

immediately prior to the status 

hearing. Depending on the 

frequency of status hearings, this 

generally occurs weekly or 

biweekly. 

Team members submit their 

progress reports for each 

participant, typically to the 

coordinator, who produces a

comprehensive staffing report. At 

the staffing, each participant’s 

progress is reviewed. Team 

members brief the judge on any 

special issues. 

Compliance with program 

requirements, even minimal 

compliance for participants in the 

early phases, is acknowledged with 

an incentive. If an individual has not 

complied with a Wellness Court 

program requirement, the team 

will make a recommendation to the 

judge regarding a proposed 

sanction or other response. The 

judge, however, makes the ultimate 

decision regarding the action to be 

taken. 
Case Management Functions of Case Management

9

Because participants may access an array of different services, including from service providers 

who do not serve on the core team, such as housing, vocational training, medical, parenting, 

and so forth, the case managers will typically need to track these different services and manage 

information flow between providers both on and off the team. Additionally, the case manager 

will be the designated liaison for the Wellness Court team, providing necessary updates during 

staffing. 

When there is not a designated case manager, a Wellness Court may employ a team-based 

approach to case management. When case management is handled by the team it is important 

to have one person designated as the lead case manager, otherwise confusion may arise. This 

coordinator typically serves this role, designating what information is collected, by whom, and 

how that information will be shared with the team.

If information flow breaks down, the impact on the participant is detrimental. A participant may 

not receive needed services or receive inappropriate services. Developments necessitating an 

incentive or sanction may go unnoticed, negating an opportunity for a quick and effective 

response. Ultimately, a participant’s progress is delayed. 

Tips for Case Managers

• Be clear when communicating with the court team.

• Standardize all methods of communication. Consider a standardized progress report 

that each team member completes. 

• Meet and communicate regularly with the court team.

• Maintain separate and distinct avenues for sharing information between the judge and 

participant, case manager and participant, and case manager and judge.
Case Management Functions of Case Management

10

Screening and Assessment

Once information flow has been discussed and systems are in place for successful 

communication, the case manager can focus on the day-to-day tasks. An initial task is the early 

identification and entry of a potential candidate into the Wellness Court. The entry process, 

often referred to as screening and assessment, varies widely between Wellness Courts, and 

depends upon the internal structure of the Wellness Court, attorneys, and treatment providers. 

Eligible candidates are identified based on their (1) legal eligibility (e.g., nature of the current 

charge or dependency case, prior criminal history of the defendant) and (2) clinical eligibility 

(e.g., nature of alcohol and substance abuse treatment needed).

Once a candidate has been identified, typically through the legal process, the case manager will 

refer the candidate for a clinical assessment to be conducted by a qualified professional, 

generally a licensed counselor. Wellness Courts frequently struggle with ensuring that 

participants complete their clinical assessments. Case managers play a critical role in 

connecting candidates to treatment providers, and thereby ensuring early engagement.

Once the assessment is complete and processed, the treatment provider will share that 

information with the Wellness Court team. Depending on the information flow protocols of the 

team, the case manager may be tasked with sharing the assessment. The Wellness Court should 

have policies and procedures in place that dictate requirements for entering the program.18

Further, depending on the type of assessment tool used by the counselor, a case manager may 

conduct their own assessment to gauge for other needs beyond substance use, such as mental 

health or housing. 

 

18 For more on key considerations in developing policies and procedures, read Tribal Law and Policy Institute’s 

Tribal Healing to Wellness Courts: The Policy and Procedures Guide (2015).

Key Component #2:

Participants enter Tribal Healing to Wellness Court through various referral 

points and legal processes that promote tribal sovereignty and the 

participant’s due (fair) process rights.

Key Component #3:

Eligible court-involved substance-abusing parents, guardians, juveniles, 

and adults are identified early through legal and clinical screening for 

eligibility and are promptly placed into the Tribal Healing to Wellness 

Court.
Case Management Functions of Case Management

11

Once the participant is accepted into the Wellness Court, the case manager must maintain an

ongoing assessment to determine what services the participant will need. In addition to 

substance abuse treatment services, participants may require services related to housing, 

physical health, mental health, child care, education, life skills class, parenting classes, financial 

literacy services, and/or employment services. It is likely that needs will change over time. 

Tips for Case Managers

• Only screen participants as appropriate; behavioral health professionals should always

conduct clinical assessments. 

• If necessary, the case manager may look to Cut down, Annoyed, Guilty, and Eye-opener 

(CAGE) screening19 and Texas Christian University screening resources for assistance.20

• Balance administrative responsibilities with ongoing participant needs assessments.

 

19 John A. Ewing, “Detecting Alcoholism: The CAGE Questionnaire.” Jama 252, no. 14 (1984) 1905–7.

20 Kristina Pacheco et al., “Pueblo of Laguna Community Wellness Court: Looking 10 Years Back, Looking 10 Years 

Ahead” (presentation, Annual Tribal Healing to Wellness Court Enhancement Training, Albuquerque, NM, 

September 13, 2017); Resources available at https://ibr.tcu.edu/forms/tcu-drug-screen/ and 

http://www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/CAGE Substance Screening Tool.pdf. 
Case Management Functions of Case Management

12

Planning

Once a comprehensive assessment is complete, the case manager should work with individual 

participants, focusing their attention on planning, setting, and implementing goals. Once 

service needs are identified, the case manager will work with the Wellness Court team to 

develop a case plan that includes all the needed services. The case manager then works with 

the participant directly, linking him or her to services in the case plan and monitoring their 

progress within those services. When needed, the case manager should be prepared to 

advocate on behalf of participants to ensure that they receive needed services in a timely 

manner. 

Consider that the substance abuse treatment provider will likely also have a treatment plan 

that specifies the level of care necessary for the participant, based on the ASAM Criteria for 

Determining Level of Care.21 The treatment plan should be coordinated with the case 

manager’s plan. The case manager’s plan will likely include services beyond treatment, such as 

housing, vocational training, and so forth. The case manager must be cognizant of the demands 

on the participant and the overarching goal to keep the participant engaged in treatment, 

particularly in the early phases. Finally, both plans should be integrated with the overall 

requirements of the Wellness Court.

Note that the sequence and timing of services should align with a participant’s immediate 

needs and capacity to receive. The National Association of Drug Court Professionals

recommends that when a participant first enters the program, their ability to remain in and 

comply with treatment should be the priority. Services to enable this retention (responsivity 

needs) should be prioritized, such as housing, mental health, and substance-related craving or 

withdrawal. As the participant progresses, focus should then expand to address the 

participant’s likelihood of relapsing and/or reoffending (criminogenic needs). Services should be 

geared toward initiating sustained abstinence, addressing antisocial thought patterns, and 

addressing antisocial peers and family conflict. In the latter phases, focus should expand further 

to assist the participant with maintaining their success (maintenance needs), including 

vocational and educational assistance, parent training, and other life skills.22

Performance Benchmarks

NDCI has developed the following benchmarks:23

• A written plan that encompasses broad-based life skills.

• The plan includes goals, objectives, and task-based strategies developed with the 

participant.

 

21 Tribal Law and Policy Institute, Treatment Guidelines, 48.

22 See Drug Court Best Practice Standards, Volume II, 9.

23 Monchick et al., Drug Court Case Management, 15.
Case Management Functions of Case Management

13

• The goals, objectives, and strategies are in a positive context.

• Objectives should be reasonable, obtainable, and prioritized with input from the 

participant. It may be necessary to use short-term goals that help create more 

reasonable objectives.

• Goals and objectives need to be behaviorally specific and measurable, have time frames, 

and define responsibility for actions.

• The written plan must be reassessed regularly with the team and participants.

• Sanctions and incentives are tied to completion or lack of completion for each objective.

Tips for Case Managers

• Empower the participant by including him or her in case planning.

• Facilitate goal setting that fits the phase the participant is in.24

 

24 For more information on case plan phases, see Flies-Away et al., The Key Components, 29–31.
Case Management Functions of Case Management

14

Linkage

With the case plan in place, the case manager works with the participant to link him or her to 

necessary services. This requires the case manager to be aware of community resources. The 

team also plays a role in identifying services in their area of expertise and then bringing them to 

the attention of the team. The case manager facilitates communication regarding the 

participant’s progress with the plan and assists the participant in obtaining the identified 

services.

Remember, the participant should always be linked with treatment at the outset, even if a case 

plan is not yet in place. Do not wait for assessment results before addressing the more obvious 

substance abuse issues that exist. For example, link participants to a local Narcotics 

Anonymous/Alcoholics Anonymous meeting at the outset and adjust frequency or meeting type 

based on the assessment and case planning. Similarly, housing should be addressed as soon as 

possible. 

Finally, adjustments to case plans are expected. The case manager should keep an eye out for 

ongoing linkage opportunities. As a participant’s needs and path to wellness shifts, so should 

services. 

Performance Benchmarks

The NDCI lists several performance important benchmarks to assess the case manager’s 

linkage.25

• The manager has knowledge of specific program philosophies, practices, costs, 

locations, and admissions requirements so he or she can link participants to the right 

services. This should be combined with a comprehensive assessment.

• The case manager does more than a single phone call or written referral to a service 

provider. The case manager needs to assess the participant’s ability to navigate the 

services and then assist while helping the participant learn the needed skill.

• The case manager identifies challenges and other issues in delivery of services, which 

goes beyond simply reviewing attendance reports.

 

25 Monchick et al., Drug Court Case Management, 19.
Case Management Functions of Case Management

15

Tips for Case Managers

• Remember some participants may need the basics (i.e., transportation); cast a wide net 

to catch necessary resources. 26

• Case managers should constantly engage in community resource mapping; stay updated 

with the local resources that can aid participants.

• Case managers should strive to maintain positive relationships with service providers.

• Because tribal resources are notoriously underfunded and tribal programming can be 

short-lived, a case manager should keep an eye on sustainability and have a backup plan 

in mind if current service programs are on their way out.

 

26 Some of the tips listed were acquired from “Healing to Wellness Court Case Managers and Case Coordinators:

Role Break-outs” (presentation, Annual Tribal Healing to Wellness Court Enhancement Training, Albuquerque, NM, 

September 13, 2017).
Case Management Functions of Case Management

16

Monitoring

As Key Component #5 notes, participants are marshalled through the Wellness Court through 

both supportive case management and supervision or monitoring. The case manager and team 

are part of the monitoring process. Through accountability, the case manager can help the 

participant achieve the objectives and goals in their case plan. 

Monitoring extends beyond the participant to the program. Firstly, the case manager must 

track data concerning each participant and their interaction with services. Case managers 

should track what services have been referred, how long before a participant received those 

services, and whether those services were completed. 

Secondly, the case manager monitors the quality of the service provided, with appropriate due 

deference to professional service providers. 

[I]t is imperative that he or she monitor each provider’s service delivery, reassess 

participants’ needs over time, and maintain a communication loop that involves the case 

manager, the service provider, and the participant. As part of this monitoring process, 

the case manager must maintain an appropriate record of the provider’s service delivery 

and the participant’s utilization of those services. Systematic collection of timely and 

reliable data is crucial for sustaining the trust of the drug court team, community 

leaders, service providers, and the drug court program’s funding sources.27

 

27 Monchick et al., Drug Court Case Management, 21.

Key Component #5:

Tribal Healing to Wellness Court participants are monitored through 

intensive supervision that includes frequent and random testing for 

alcohol and drug use, while participants and their families benefit from 

effective team-based case management.

Key Component #8:

Process measurement, performance measurement, and evaluation are 

tools used to monitor and evaluate the achievement of program goals; 

identify needed improvements to the Tribal Healing to Wellness Court and 

the tribal court process; determine participant progress; and provide 

information to governing bodies, interested community groups, and 

funding sources.
Case Management Functions of Case Management

17

Performance Benchmarks

NDCI’s benchmarks for monitoring are as follows:

• The case manager continues to have face-to-face meetings with the participant to 

review the case plan. The meetings are strengths-based and designed to encourage 

compliance, build self-esteem, and reward progress.

• Drug testing begins with acceptance into the Wellness Court and continues throughout 

the phases with appropriate frequency.

• The scope of testing should be broad.

• The case manager conducts announced and unannounced home visits along with other 

contacts to ensure compliance.

• The case manager communicates the gathered information to all team members and 

participants in the discussion of sanctions and incentives.

• The case manager communicates with treatment and service providers about the 

participant’s progress and achievement of goals and objectives.

Tips for Case Managers

• Remember, case management is primarily an advocacy role, while case coordination is 

largely a compliance role; the case manager should strive to balance compliance with 

compassion.28

• Utilize probation and detention officers, if available, to assist as an enforcement 

mechanism to allow the case manager or combined case manager/coordinator to focus 

on participant advocacy.

 

28 Some of the tips listed were acquired from “Healing to Wellness Court Case Managers and Case Coordinators: 

Role Break-outs.”
Case Management Functions of Case Management

18

Advocacy

The key to advocacy for a case manager is to act in the best interest of the participant and the 

community. Community safety must always be on the mind of the case manager. Advocacy in 

the Wellness Court setting is employed in the context of a team focused on achieving a 

common, comprehensive goal. Recognizing that the journey to sobriety may sometimes involve 

coerced decisions for the participant, the case manager may have to lobby for punitive 

sanctions in response to noncompliant behavior as well as for rewards following positive 

progress.29 But still, the role of the case manager is to advocate for and with the participant,

helping to ensure their voice is heard and their access to help is meaningful. The case 

manager’s advocacy is typically focused on working and educating service providers to help the 

participant.

Performance Benchmarks

NDCI’s benchmarks include:

• The case manager evaluates all observed and reported behavior and assesses whether 

the participant is achieving their case plan and goals.

• The case manager develops a response to noncompliant behavior or positive behavior 

based on the circumstances surrounding the behavior, and the participant’s progress.

• The case manager ensures that the case plan is based on and meets the participant’s 

needs and utilizes and enhances the participant’s strengths.

• The case manager strives to advocate for expansion of services when the current 

services do not meet the participant’s needs.

• The case manager provides prompt and ongoing feedback to the participant.

Tips for Case Managers

• Set realistic goals and reevaluate those goals as necessary.

• Celebrate the wins; no matter how small. 30

• Assist the judge and/or coordinator in securing a forum to communicate with Tribal 

Council to ensure that Tribal Council is aware of your Wellness Court participant 

successes, challenges, and needs.

 

29 Monchick et al., Drug Court Case Management, 22.

30 Some of the tips listed were acquired from “Healing to Wellness Court Case Managers and Case Coordinators: 

Role Break-outs.”
Case Management Functions of Case Management

19

Cultural Competence

Like the entire Healing to Wellness Court team, the case manager is sensitive to a participant’s 

cultural perspective and aware of culturally proficient services that can benefit the participant. 

Practice-based evidence has found this to be doubly true for Native participants in Wellness 

Court. 

“Being an Indian” often involves validations beyond a racial/ethnic identity. There are political, 

social, and cultural statuses to being Native. Helping a participant navigate their political 

identity can implicate complex social, family, and legal hurdles. 

For those who are new to working with Native participants, the Substance Abuse and Mental 

Health Services Administration (SAMHSA) Culture Card for American Indians and Alaska Natives

is a useful starting place.31 The short brochure covers regional difference, cultural customs, 

spirituality, communication styles, and the roles of veterans and elders in many Native 

communities. For those new to working with tribal governments, the White House Office of 

Personnel Management has developed a free online learning portal, “Working Effectively with 

Tribal Governments,” intended to familiarize federal employees with tribal issues and 

concerns.32 While intended for federal employees, it offers a useful and concise history of 

federal Indian law policy and the unique legal relationship the federal government has with 

federally recognized tribes. It can be useful for team members new to Indian country.33

Standards for Cultural Proficiency

The Association for Multi-Cultural Counseling and Development has developed and adopted 

standards of cultural proficiency applicable to treatment services,34 focusing on the following 

competencies:

• Be aware of counselors’ own assumptions, values, and biases and their ability not to 

impose these on their clients;

• Understand the worldview of the client whose cultural background maybe different 

from the counselor’s; and

• Develop appropriate strategies and techniques for dealing with clients from a wide 

range of cultural backgrounds.

 

31 Substance Abuse and Mental Health Services Administration, “American Indian and Alaska Native Culture Card: 

A Guide to Build Cultural Awareness,” SMA08-4354 (2009). 

32 “Working Effectively with Tribal Governments,” Emerging Solutions, Office of Personnel Management (2013), 

available at tribalgov.golearnportal.org. 

33 Mark E. Panasiewicz, Rebecca S. Panasiewicz, and Lauren van Schilfgaarde, Tribal Healing to Wellness Courts: 

Treatment Guidelines, 2nd ed. (Tribal Law and Policy Institute, 2017). 

34 D. Sue, R. Arredondo, and J. R. McDavis, “Multicultural Counseling: A Call to the Profession.” Journal of Counseling

and Development 70 (1992): 477–86.
Case Management Models of Case Management

20

Models of Case Management

There has been very little research on the use of case management in drug courts. But, lessons 

learned from other settings can assist with implementing case management in Healing to 

Wellness Courts. There are four main models of case management. Each court will need to 

determine which model, or combination of models, best suits their needs. The most commonly

used model in the drug court setting is the strengths-based perspective.

Strengths-Based Perspective

This model focuses on the participant’s strengths. The case manager works with the participant 

to identify their strengths, assists with setting goals, and enable using their strengths to achieve 

these goals. The role of the case manager is to provide support, so the participant asserts 

control over their life and obtains housing, employment, education, and a healthy lifestyle. The 

emphasis on identifying strengths and assets supplements the treatment’s focus on addiction 

as a disease.35

Broker/Generalist

The “broker” focuses on quickly connecting the participant to services needed and on making 

the necessary referrals.36 The case manager typically does not provide direct services, except 

for an initial intake screening, but refers the participant out for the needed services and 

monitors the participant’s progress. This type of case management does not include a 

significant monitoring component. 

Assertive Community Treatment

This is an intensive form of case management with low caseloads and frequent interaction with 

the participant and team. This model is based more on a team approach in which all team 

members share the case load. All team members work together and “provide proactive 

services, assertive outreach, and strong advocacy to clients.”37 If the participant accesses

services not provided by the team, the team monitors its provision.

Clinical/Rehabilitation

This model of case management is an integrated model, meaning the clinical treatment and 

case management services are not treated as separate processes.38 Five principles of the clinical 

case management model include continuity of care, use of the case management relationship, 

support and structure in response to client need, flexibility of intervention strategies, and 

facilitating client resourcefulness or strengths.39

 

35 SAMHSA, Comprehensive Case Management, 10.

36 Monchick et al., Drug Court Case Management, 7.

37 Ibid., 8.

38 Ibid.

39 Jerrold R. Brandell, “Clinical Case Management,” in Theory and Practice in Clinical Social Work (Sage, 2010), 562.
Case Management Models of Case Management

21

The case manager in this model has the primary responsibility for providing 

therapeutic intervention, including therapy, counseling, skills teaching, and other 

rehabilitative interventions along with case management services.40

Though research on the effectiveness of this model (and the other case management 

models) is limited, there are some promising studies on this model’s ability to assist 

substance abusers.41

For a breakdown of how particular models of case management would handle typical case 

management activities, see “Appendix A: Models of Case Management,” which has been 

adapted from a resource produced by SAMHSA.42

 

40 Monchick et al., Drug Court Case Management, 8; citing W. Anthony, M. Cohen, and M. Farkas, Psychiatric 

Rehabilitation (Boston: Boston University, Center for Psychiatric Rehabilitation, 1990).

41 Wouter Vanderplasschen et al., “Effectiveness of Different Models of Case Management for Substance-Abusing 

Populations.” Journal of Psychoactive Drugs 39, no. 1 (2007): 81–95.

42 SAMHSA, Comprehensive Case Management, 7–8. 
Case Management Models of Case Management

22

Treatment Improvement Protocol’s Case Management Principles:

• A single point of contact with health and social service systems—wraparound as 

opposed to requiring participant to navigate separate silos.

• Client driven—the case manager does not use a one-size-fits-all approach, while 

providing space for the participant to the initiative and lead in identifying needed 

resources.

• Use of advocacy—the case manager advocates on behalf of the participant to 

many agencies.

• Community based—all community services, including formalized services and 

informal care, are integrated.

• Pragmatic—case management is focused on where the participant is in need, 

which might be food, child care, or transportation. 

• Anticipatory—a case manager understands addiction and recovery and can 

anticipate potential barriers.

• Flexible—case management accounts for a wide range of factors, including 

mental health, agency structures, and lack of resources. 

• Culturally sensitive—case managers (1) value diversity, (2) make a cultural selfassessment, (3) understand the dynamics of cultural interactions, (4) incorporate 

cultural knowledge, and (5) adapt practices to the diversity present in a given 

setting.

“Treatment Improvement Protocol (TIP) Series 27: Comprehensive Case Management for Substance 

Abuse Treatment,” Substance Abuse and Mental Health Services Administration, HHS Pub. No. (SMA) 

15-4215 (2000). 
Case Management Ethics

23

Ethics of Case Management

Every member of the Healing to Wellness Court team holds a position of authority and trust. 

Following ethical standards, both individually and as a group, will allow the team to protect this 

trust and set an example for the participant, modeling integrity and healthy relationships.

The Wellness Court is the coming together of professionals from varied disciplines. There is 

therefore no single governing body that dictates the ethical standards for each team member. 

Rather, each member is responsible for abiding by their respective disciplinary ethical and 

professional standards, such as the American Bar Association Model Rules of Professional 

Conduct for attorneys and judges.43

Ethical considerations for case managers should first be determined by the case manager’s 

licensing or certification body, if any. For example, if the case manager is certified by the 

National Certification Commission for Addiction Professionals (NCCAP), the case manager’s 

conduct would be governed by the NCCAP Code of Ethics.44 Examples from the NCCAP Code of 

Ethics include:

• Principle I: The Counseling Relationship; I – 4 Limits of Confidentiality

o Addiction Professionals clarify the nature of relationships with each party and 

the limits of confidentiality at the outset of services when agreeing to provide 

services to a person at the request or direction of a third party.

• Principle II: Confidentiality and Privileged Communication; II – 4 Sharing

o Addiction Professionals shall encourage ongoing discussions with clients 

regarding how, when, and with whom information is to be shared.

• Principle III: Professional Responsibilities and Workplace Standards; III – 18 SelfMonitoring

o Addiction Professionals are continuously self-monitoring to meet their 

professional obligations. Providers shall engage in self-care activities that 

promote and maintain their physical, psychological, emotional, and spiritual 

well-being.

 

43 American Bar Association, Center for Professional Responsibility, Model Rules of Professional Conduct, 

Americanbar.org (accessed September 21, 2017). 

44 NAADAC, the Association for Addiction Professionals, NAADAC/NCC AP Code of Ethics (NAADAC, 2016).
Case Management Ethics

24

Confidentiality

Even if a case manager is not specifically licensed or certified, federal laws surrounding 

confidentiality should be followed by all Wellness Court team members. The Wellness Court, by 

design, has shed the formal rules of evidence and other communication protective measures 

present in the adversarial system. Nevertheless, the integrity of the Wellness Court, the 

willingness of the participant to honestly share their progress or slip with the team, and the 

trust of all team members upon each other and the Wellness Court rests upon the team’s 

ability to preserve each participant’s confidentiality. 

As a condition of entering the Wellness Court, whether in a criminal or civil context, the 

participant has waived their rights to confidentiality, but only pertaining to their substance 

abuse treatment and only to the Wellness Court team members.45 As a member of the team, 

the case manager is authorized to share necessary information about the participant’s 

substance abuse treatment with other members of the team. Similarly, the case manager is 

bound to protect that information from unauthorized persons, such as nonteam members. 

Additionally, the case manager is charged with ensuring that the information exchange 

between team members, such as during staffing, remains professional and relevant to progress 

monitoring, and does not devolve into gossip. 

For more on confidentiality, see TLPI’s Treatment Guidelines, chapter 5, section G: 

“Confidentiality and Communication.”46

Shared Core Competencies

Despite team members’ varied professional disciplines, there are some shared core 

competencies that all team members are expected to uphold, including the case manager. The 

NDCI has developed core competencies deemed necessary for each team member.47 The 

following are some examples of possible shared core competencies:

• Full participation as a team member—participation defined by policies and procedures.

• Operate in a nonadversarial manner and present unified front to participants.

• Advocate for effective incentives and sanctions in appropriate noncourt settings.

• Monitor progress within boundaries of confidentiality.

• Possess knowledge about addiction. 

• Facilitate community education about program and its efficacy.

 

45 For more information about the confidentiality laws governing Wellness Court, including the Health Insurance 

Portability and Accountability Act (HIPAA) and 42 C.F.R. Part 2, as well as participant waivers of confidentiality to 

enter Wellness Court, see Caroline S. Cooper et al., Tribal Healing to Wellness Courts: Treatment Guidelines, 2nd 

ed. (Tribal Law and Policy Institute, 2017), 67.

46 Panasiewicz et al., Tribal Healing to Wellness Courts.

47 National Drug Court Institute, The Core Competencies Guide: Adult DCPI Trainings.
Case Management Ethics

25

Ultimately, each team determines its own core competencies for each of its team members. 

Developing shared core competencies can help ensure compliance with the case manager’s 

ethical responsibilities to their licensing body and/or the Wellness Court team. For example, 

requiring case managers to possess knowledge about addiction will allow a case manager to 

understand and be able to identify relapse behaviors. With their knowledge of addiction, the 

case manager will understand that relapse is part of addiction and advocate for appropriate 

treatment rather than jail time or other sanction, which furthers the goals of the Wellness 

Court.

NDCI has further identified core competencies for particular roles within a drug court.48 The 

drug court community supervision core competencies are most relevant to the position of case 

manager. Observe the crossover between community supervision core competencies and the 

example shared core competencies mentioned in the preceding text.

Drug Court Community Supervision Core Competencies

• Participates fully as a Drug Court team member, committing him- or herself to the 

program mission and goals, and works as a full partner to ensure their success.

• Provides coordinated and comprehensive supervision to minimize participant 

manipulation and splitting of program staff.

• Develops effective measures for drug testing and supervision compliance reporting that 

provide the team with sufficient and timely information to implement incentives and 

sanctions systems.

• Coordinates the utilization of community-based services.

• Is knowledgeable about addiction.

• Is knowledgeable of gender, age, and cultural issues that may impact the participant’s 

success.

• Contributes to the team’s efforts in the community education and local resource 

acquisition.

• Contributes to the education of peers, colleagues, and judiciary around court efficiency.

These community supervision core competencies can aid case managers in being reliable 

advocates for participants and ethical members of the Wellness Court team. These 

competencies are especially valuable when a case manager is also the case coordinator. For 

example, coordinating the utilization of community-based services is an essential part of case 

management that may suffer due to administrative responsibilities of coordination. 

 

48 Ibid.
Case Management Ethics

26

Tips for Case Managers

• No excuses. Establish policies that respect client confidentiality and allow case managers 

to share information as the sharing of information is critical to the success of the 

Wellness Court.
Case Management Balancing Roles: Case Manager and Coordinator

27

Balancing Roles: Case Manager and Coordinator

The lines between the roles of case manager and coordinator can often be blurred. This is 

particularly true when a Wellness Court has limited resources and one staff person is tasked 

with the responsibilities of both case manager and coordinator. In the following text we discuss 

the differences between the positions and offer tips for balancing both roles. However, when 

feasible, a Wellness Court team should strive for an independent case manager and 

coordinator.49

Case Manager

A case manager’s role is to be in the trenches and can be summed up in one word: advocate. 

The case manager’s responsibilities require hands-on work and frequent contact with individual 

Wellness Court participants. The case manager links the participant to resources, monitors 

services, ensures those services are appropriate, and communicates activities to the larger 

team.50 In many ways, the case manager is the force that holds the Wellness Court together.51

The case manager facilitates the participant’s access and utilization of services to help the 

person heal, and does so in a manner that is responsive to the participant’s legal, familial, 

physical, emotional, mental health, and medical needs.

Coordinator

A coordinator’s role is to implement the big picture and can be summed up in one word: 

administrator. Though not devoid of participant contact, the coordinator’s responsibilities 

require focus on overall management of the Wellness Court. This includes supervising the case 

managers and evaluating their handling of their caseloads. The coordinator reports to the team 

on participant case plan compliance, while collecting data on overall completion rates and 

other performance measure information needed for grant reporting. While case managers 

dedicate a majority of their time to building relationships with participants, coordinators focus 

on establishing relationships that are beneficial for the overall Wellness Court, including with 

treatment service providers, future donors and grant administrators, and community members.

Balance

With or without a coordinator, Wellness Courts are frequently guilty of neglecting the big 

picture for the week-to-week tasks of monitoring and supporting the participants. Wellness 

 

49 Monchick et al., Drug Court Case Management, 9; “Healing to Wellness Court Case Managers and Case 

Coordinators: Role Break-outs.”

50 Monchick et al., Drug Court Case Management, ix.

51 Ibid.
Case Management Balancing Roles: Case Manager and Coordinator

28

Courts are encouraged to hold regular steering committee meetings, at least quarterly, to 

update memorandums of understanding to incorporate new partners, update the policies and 

procedures to reflect new practices, and regularly meet to problem solve barriers such as in 

referrals, access to treatment, or engagement. All too often, however, after responding to 

emergency meetings or tracking down service providers for progress reports, these metapicture meetings and tasks are postponed indefinitely. Similarly, the team member who is 

tasked with the responsibilities of both the case manager and the coordinator is likely to be 

engulfed by the day-to-day tasks of case management. Don’t be tempted!

Knowing this likelihood, consider carving out time dedicated exclusively to coordinator duties. 

For example, Fridays are dedicated to coordinator tasks during which the coordinator, for 

example, schedules calls with grant managers, holds steering committee meetings, plans for 

grants, and conducts performance measure analysis. No participant meetings are held on these 

days, nor is it the same day as staffing meetings or the status hearing. Alternatively, consider 

delegating some case management tasks to other team members. For example, the probation 

officer assumes all drug-testing duties, or the vocational trainer agrees to meet with each 

participant at least every other week. 

When a team member is required to handle both the case manager and coordinator 

responsibilities, the need for that team member to practice self-care is heightened. The 

immense toll of fieldwork is compounded by a heavy administrative burden. Case managers, as 

service providers to participants who have often experienced trauma, are at risk of undergoing 

vicarious trauma. Vicarious trauma is defined as “the cumulative transformative effect on the 

helper working with survivors of traumatic life events, both positive and negative.”52 The effect 

is a natural result of working closely with participants, hearing about their personal histories 

and backgrounds, and connecting with them.53 Thus, an integral piece of successful court 

coordination and case management is self-evaluating the needs of the helper: the case 

manager.

Visit “Appendix B: Vicarious Trauma” to review a resource developed by Donna Humetewa 

Kaye that expands on the signs and symptoms of vicarious trauma and contains useful 

suggestions on how to practice self-care.

 

52 Karen W. Saakvitne et al., Risking Connection: A Training Curriculum for Working with Survivors of Childhood 

Abuse (Sidran, 2000).

53 Karen W. Saakvitne, “Shared Trauma: The Therapist’s Increased Vulnerability.” Psychoanalytic Dialogues 12, no. 

3 (2002): 443–49. 
Case Management Balancing Roles: Case Manager and Coordinator

29

Tips for Case Managers

• Manage your time effectively by logging your time in the field compared to your time 

spent on administrative tasks. This will help prevent burnout and assist in balancing 

administrative responsibilities and participant advocacy.

• Stay in regular and consistent contact with the Wellness Court team.

• Practice self-care and self-reflection, which can allow you to assess your performance as 

a case manager.54

 

54 Some of the tips listed were acquired from “Healing to Wellness Court Case Managers and Case Coordinators: 

Role Break-outs.” For more resources on practicing self-care, review National Association of Case Management, 

www.yournacm.com/annual-conference/ for past presentations on self-care. See Amelia Doty and Genevieve 

Durkin, “Care for the Self and the Team” (presentation, 21st Annual Case Management Conference, Case 

Management Innovation, New Orleans, LA, September 2015).
Case Management Data Collection and Evaluation

30

Data Collection and Evaluation

In addition to shepherding the participant through the various Wellness Court requirements, 

available services, and incentives and sanctions, the case manager is also the hub of participant 

information. While all team members are tasked with tracking and sharing data from their 

relevant disciplines, the nature of the case manager’s intimate interaction with the participant 

means the case manager often has access to the greatest amount of information. It is critical, 

therefore, that the case manager systematically collect, document, and share this information 

with the Wellness Court team.

The relevance of information is determined by its reliability. A data collection system must work 

personally for the case manager, as well as be comprehensive, timely, and understandable by 

others. The consequences of inaccurate, incomplete, or untimely information can further a 

participant’s distrust in the system and derail the successes of the Wellness Court in the eyes of 

the team members, service providers, outside funders, and the community. 

The coordinator should ensure that each team member agency has an information-sharing 

agreement with the Wellness Court. The case manager often ensures these information-sharing 

agreements are practiced, coordinating data input from multiple team members. 

Given the large breadth of requirements and services to which Wellness Court participants are 

exposed, case managers and Wellness Courts are highly encouraged to utilize an electronic 

management information system. There is no single system that is considered a model for all 

courts. Rather, an effective management information system that is accessible and utilized by 

the team is the best. This can range from a commercially designed stand-alone system, a 

module as part of an existing court data management system, or an Excel spreadsheet designed 

by the case manager. Regardless, a computerized system is highly encouraged. 

When developing your data management system (whether contracting out to a commercial 

vendor or designing in-house), consider the purposes for which you intend to use your data. 

The primary uses are to track participants and the systems that serve the participants. There 

are both short- and long-term perspectives. Data collection and program evaluation can be 

Key Component #8:

Process measurement, performance measurement, and evaluation are 

tools used to monitor and evaluate the achievement of program goals; 

identify needed improvements to the Tribal Healing to Wellness Court and 

the tribal court process; determine participant progress; and provide 

information to governing bodies, interested community groups, and 

funding sources.
Case Management Data Collection and Evaluation

31

complex endeavors. Ideally, Wellness Courts should utilize an external evaluator. Consulting 

with the tribal evaluator or local college or university can be great options when designing the 

data management system. In the interim, however, the following are some key considerations 

for collecting Wellness Court data. See sample data values in the “Appendix E: Sample Wellness 

Court Data Values.” 

Participant Progress

In the short term, the Wellness Court needs to track the participant’s progress as he or she 

advances through the Wellness Court program. When tracking the participants’ progress, 

consider what information the Wellness Court needs to be meaningfully informed at the 

hearing. Week-to-week program compliance should be tracked including attendance at 

required appointments, drug test results (including all drug testing conducted by any team 

member such as probation and treatment), incentive and sanction history, their current phase 

and number of days in each phase, and any relapses. This data should be compiled by the 

coordinator into weekly progress reports provided to each team member for the staffing, 

especially the judge.

Just as the participant benefits from a multidisciplinary team with access to a variety of services 

and resources, the team benefits from having a comprehensive picture of the participant, 

including their history with services. During the program orientation, the Wellness Court should 

collect information on the participant, including their criminal case history, child welfare case 

history and current placement of children, substance abuse treatment history, and family 

background. Consider their current treatment needs including their substance of choice, level 

of care, residential treatment history, and medication assisted treatment need. This 

information can help inform potential challenging areas in the Wellness Court program.

In the long term, the Wellness Court should track a participant’s progress beyond the Wellness 

Court, including any subsequent criminal arrests/charges/convictions, dependency cases, 

employment, truancy, and relapses. The Wellness Court should track this information not just 

for participants that successfully graduate from the Wellness Court, but also for participants 

who were terminated, for participants who were neutrally discharged (such as their case 

moved residences), and for individuals who were referred to the Wellness Court but never 

enrolled.

Program Progress

In tandem with tracking participant progress, the Wellness Court should monitor the 

effectiveness of the Wellness Court in serving participants. Monitoring the effectiveness of a 

program implicates two distinct perspectives: participant outcomes and system outcomes. A 

Wellness Court produces positive participant outcomes measured, for example, by the number 

of participants referred, enrolled, and graduated from the program, and the number of 

participants who reoffended within six months, one year, and five years after being discharged 
Case Management Data Collection and Evaluation

32

from the program. Alternatively, a Wellness Court produces positive system outcomes 

measured, for example, by the number of services offered and utilized, the time between 

referral and assessment, and the time between assessment and enrollment.

Program evaluation has an immense qualitative component. Consider participant surveys to 

measure the effectiveness of a particular evidence-based program or the entire Wellness Court. 

Use surveys to gauge community interest and knowledge of the Wellness Court, or to gauge the 

concerns and interests of Tribal Council.

Report Considerations

Measuring participant progress and participant outcomes uses many of the same data inputs. 

But consider the need for your system to use these data inputs for different purposes. Ideally, a 

case manager can use their data management system to input an individual participant’s 

attendance and drug-testing results for that week. The coordinator can then print out a 

progress report that is individualized for each participant for the weekly staffing. The 

coordinator can additionally produce a report that captures the Wellness Court’s current case 

load, including, for example, how the number of positive drug tests that week for all 

participants.

Data Dictionary

Particularly critical for complex, multimodule systems, but relevant for any data management 

system, the data dictionary is a glossary of definitions. For example, consider how the team will 

define “participant.” Is an individual considered a “participant” when their case is referred by 

the prosecutor; when their clinical assessment is conducted; when they sign their participant 

contract? How does the court distinguish between graduation, termination, and a neutral 

discharge? 

Benchmarks

To measure the effectiveness of a process or program, data must be compared against set goals 

to gauge whether that data reflects a well-functioning program. At the outset, or at the 

beginning of a fiscal year, calendar year, or program year, develop benchmarks. Benchmarks 

are concrete, measurable markers of program success. For example, measure how much time a 

case manager spends with a participant each month, with a benchmark of one hour a week. 

Ensure there is a method to measure these benchmarks; for example, the case manager can log 

their time and differentiate between participants within the data management system. 

Data collection and evaluation are often overlooked and underestimated components of the 

Wellness Court. However, comprehensive data collection allows the court to quickly and 
Case Management Data Collection and Evaluation

33

effectively track participants, identify patterns and areas of the court, and celebrate the wins. It 

is critical for funder and community accountability, and for overall system integrity. 
Case Management Appendix

34

Additional Resources

Tribal Law and Policy Institute, Tribal Healing to Wellness Court Publication Series

This resource contains the TLPI’s publications on Tribal Healing to Wellness Courts. The 

series includes:

Tribal Healing to Wellness Courts: Treatment Guidelines, 2nd ed. (2017)

Tribal Healing to Wellness Courts: The Judicial Bench Book (2016)

Tribal Healing to Wellness Courts: The Policies and Procedures Guide (2015)

Overview of Tribal Healing to Wellness Courts, 3rd ed. (2014)

Tribal Healing to Wellness Courts: The Key Components, 2nd ed. (2014)

Binswanger, Ingrid A., et al. “Return to Drug Use and Overdose after Release from Prison: 

A Qualitative Study of Risk and Protective Factors.” Addiction Science and Clinical 

Practice 7, no. 1 (2012).

This resource is a qualitative study of former prison inmates who were recruited within two 

months after their release. It investigates those former inmates’ drug-use experiences, 

perceptions of overdose risk, and overdose experiences among former prisoners.

Brandell, Jerrold R., “Clinical Case Management,” in Theory and Practice in Clinical Social 

Work (Sage, 2010).

This resource outlines the clinical case management model and its components within the 

field of social work. 

Department of Health and Human Services, Substance Abuse and Mental Health Services 

Administration, Comprehensive Case Management for Substance Abuse Treatment, 

Treatment Improvement Protocol Series, No. 27. HHS Publication No. (SMA) 12-4215 

(2012).

This resource provides information on case management and its relationship to substance 

abuse treatment, expounding on best practices and models of case management.

Heck, Cary, Local Drug Court Research: Navigating Performance Measures and Process 

Evaluations, Monograph Series 6 (National Drug Court Institute, 2006).

This resource promotes the use of uniform data collection and evaluation strategy for local 

drug court programs.

Hardin, Carolyn, and Jeffrey N. Kushner, Quality Improvement for Drug Courts: EvidenceBased Practices (National Drug Court Institute, 2008).

This resource defines biopsychosocial assessment and discusses ways to improve drug court 

efficiency.
Case Management Appendix

35

Kushner, Jeffrey, Roger H. Peters, and Caroline S. Cooper, A Technical Assistance Guide for 

Drug Court Judges on Drug Court Treatment Services (Bureau of Justice Assistance Drug 

Court Technical Assistance Project, American University, April 2014).

This resource provides more information on medication-assisted treatment (MAT), an 

identified best practice in substance abuse treatment protocol, as well as other general 

information about addiction and treatment services.

Legal Action Center, Confidentiality and Communication: A Guide to the Federal Drug and 

Alcohol Confidentiality Law and HIPAA (2012)

This resource provides more information on the HIPAA and its consent forms relevant to 

maintaining participant confidentiality in a drug court setting.

Marlowe, Douglas B., and Hon. William G. Meyer, The Drug Court Judicial Bench Book

(National Drug Court Institute, 2011).

This resource provides a review of evidence-based practices in the field of drug courts and is 

meant to assist judges, old and new, in their roles. Chapter 9, “Confidentiality,” provides a 

review of Health Insurance Portability and Accountability Act (HIPAA) and other best 

practices that could be helpful for case managers.

Monchick, Randy, Anna Scheyett, and Jane Pfeifer, Drug Court Case Management: Role, 

Function, and Utility (National Drug Court Institute, 2006).

This resource provides an overview of drug court case management, reviewing case 

management functions, models, and best practices.

NAADAC, the Association for Addiction Professionals. NAADAC/NCCAP Code of Ethics

(NAADAC, 2016).

This resource is the Code of Ethics produced by the NCCAP. The Code of Ethics should be 

followed by members of the Association for Addiction Professionals and those certified by 

the Certification Commission.

National Drug Court Institute, The Core Competencies Guide: Adult DCPI Trainings.

This resource from the NDCI identifies core competencies for drug court team members and 

illustrates potential tasks handled by the team during the drug court planning process and 

in an operational drug court.

Office of Justice Programs, Drug Court Monitoring, Evaluation, and Management 

Information Systems: National Scope Needs Assessment (Department of Justice, 1998).

This resource discusses the findings of focus group participants surrounding the needs for 

drug court information systems.

Saakvitne, Karen W., et al. Risking Connection: A Training Curriculum for Working with 

Survivors of Childhood Abuse (Sidran, 2000).

This resource serves as a training curriculum for personnel working with survivors of 

childhood abuse particularly in the fields of community health and substance abuse.
Case Management Appendix

36

Saakvitne, Karen W., “Shared Trauma: The Therapist’s Increased Vulnerability.” 

Psychoanalytic Dialogues 12, no 3. (2002): 443–49.

This resource summarizes steps to anticipate, address, and transform the experience of 

vicarious traumatization.

Substance Abuse and Mental Health Services Administration, “American Indian and 

Alaska Native Culture Card: A Guide to Build Cultural Awareness,” SMA08-4354 (2009).

This handout provides useful tips for working with Natives, including cultural protocols, 

communication styles, and a brief historical background.

Treatment Improvement Protocol (TIP) Series 27: Comprehensive Case Management for 

Substance Abuse Treatment,” Substance Abuse and Mental Health Services 

Administration, HHS Pub. No. (SMA) 15-4215 (2000). 

This resource overviews the effectiveness of case management for substance-abusing 

populations and the models of case management.

Vanderplasschen, Wouter et al., “Effectiveness of Different Models of Case Management 

for Substance-Abusing Populations.” Journal of Psychoactive Drugs 39, no. 1 (2007): 81–

95.

This resource is a review of research on the effectiveness of case management in assisting 

substance-abuse populations and the various models of case management models. The 

authors note the limited availability of research.
Case Management Appendix

37

Appendix A: Models of Case Management

Models of Case Management55

(Reproduced from Treatment Improvement Protocol 27: Comprehensive Case Management)

Primary Case 

Management 

Activities

Broker/

Generalists 

Strengths 

Perspective

Assertive 

Community 

Treatment

Clinical/

Rehabilitation

Conducts 

outreach and 

case finding

Not usually Depends on 

agency mission 

and structure

Depends on 

agency mission 

and structure

Depends on agency 

mission and 

structure

Provides 

assessment and 

ongoing 

reassessment

Specific to 

immediate 

resource 

acquisition needs

Strengths-based, 

applicable to any 

of client life areas

Broad-based, 

part of a 

comprehensive 

(biopsychosocial) 

assessment

Broad-based, part of 

a comprehensive 

(biopsychosocial) 

assessment

Assists in goal 

planning

Generally brief, 

related to 

acquiring 

resources, 

possibly informal

Client-driven, 

teaches specific 

process on how 

to set goals and 

objectives, goals 

may include any 

of client life areas

Comprehensive, 

goals may include 

any of client life 

areas

Comprehensive, 

goals may include 

any of client life 

areas

Makes referral to 

needed 

resources

Case manager 

may initiate 

contact or have 

client make 

contact on own

As negotiated 

with client, may 

contact resource, 

accompany 

client, or client 

may contact on 

own

As needed, many 

resources 

integrated into 

broad package of 

case 

management 

services

As negotiated with 

client, may contact 

resource, 

accompany client, 

or client may 

contact on own

Monitors 

referrals

Follow-up checks 

made

Close 

involvement in 

ongoing 

relationship 

between client 

and resource

Close 

involvement in 

ongoing 

relationship 

between client 

and resource

Close involvement 

in ongoing 

relationship 

between client and 

resource

Provides 

therapeutic 

services beyond 

resource 

acquisition, for 

example, 

Referral to other 

sources for these 

services if 

requested

Usually limited to 

client questions 

about treatment,

identifying 

strengths and 

self-help 

resources

Provides many 

services within 

unified package 

of 

treatment/case 

management 

services

Provision of 

therapeutic 

activities central to 

the model

 

55 SAMHSA, Comprehensive Case Management, 7–8.
Case Management Appendix

38

therapy, skills, 

teaching

Models of Case Management - Continued56

(Reproduced from Treatment Improvement Protocol 27: Comprehensive Case Management)

Primary Case 

Management 

Activities

Broker/

Generalists

Strengths 

Perspective

Assertive 

Community 

Treatment

Clinical/

Rehabilitation

Helps develop 

informal support 

systems

No Development of 

informal 

resources—

neighbors, 

church, family—a 

key principle of 

the model

Through 

implementation 

of drop-in centers 

and shelters

Emphasis on family 

and self-help 

support through 

therapeutic 

activities

Responds to 

crisis

Responds to 

crises related to 

resource needs 

such as housing

Responds to 

crises related to 

both resource 

needs and mental 

health concerns; 

active in 

stabilization and 

then referral

Responds to 

crises related to 

both resource 

needs and mental 

health concerns; 

active in 

stabilization and 

then referral

Responds to crises 

related to both 

resource needs and 

mental health 

concerns; will 

stabilize crisis 

situation and 

provide further 

therapeutic 

intervention

Engages in 

advocacy on 

behalf of 

individual client 

Usually only at 

level of line staff 

Assertive 

advocacy, will 

pursue multiple 

administrative 

levels within 

agency 

Assertive 

advocacy, will 

pursue multiple 

administrative 

levels within 

agency 

Assertive advocacy, 

will pursue multiple 

administrative levels 

within agency

Engages 

advocacy in 

support of 

resource 

development

Not usually Usually in context 

of specific client 

needs

Either advocates 

for needed 

resources or may 

create resources 

as part of case 

management 

services

Usually in context of 

specific client needs

 

56 Ibid.
Case Management Appendix

39

Provides direct 

services related 

to resource 

acquisition as 

part of case 

management, for 

example, drop-in 

center, 

employment 

counseling

Referral to 

resources that 

provide direct 

services

Provides services 

crucial to 

preparing client 

for resource 

acquisition 

activities, for 

example, role 

playing, 

accompanying 

client to 

interviews

Provides many 

direct services 

within unified 

package of 

treatment/case 

management

Provides services 

that are part of 

rehabilitation 

services plan; skillteaching
Case Management Appendix

40

Appendix B: Vicarious Trauma

VICARIOUS TRAUMA57

Donna Humetewa Kaye (Hopi)

Program Director, Nakwatsvewat Institute

DEFINITION

The term vicarious trauma is also called “compassion fatigue.” Other terms used for compassion 

fatigue are: 

• Secondary traumatic stress 

• Secondary victimization 

It is believed that service providers working with trauma survivors experience vicarious trauma 

because of the work they do. Vicarious trauma is the emotional lingering of exposure that service 

providers have from working with people as they are hearing their trauma stories and become 

witnesses to the pain, fear, and terror that trauma survivors have endured. 

BURNOUT

Burnout is typically something that happens over time, and as it builds up a change, such as time off 

or a new and perhaps a different job, can take care of burnout or improve it. Vicarious trauma, 

however, is a state of tension and preoccupation of stories/traumatic experiences described by 

clients. This tension and preoccupation might be experienced by service providers in several ways. 

They might: 

• Avoid talking or thinking about what the trauma-effected client(s) have been talking about, 

almost being numb to it; and/or

• Be in a persistent state of emotional stress.

SIGNS AND SYMPTOMS

Service providers should be aware of the signs and symptoms of vicarious trauma and the potential 

emotional effects of working with trauma survivors.

• Difficulty talking about their feelings 

• Anger and/or irritation 

• Startle effect/being jumpy 

• Change in eating habits 

• Difficulty sleeping/losing sleep over patients 

• Worried that they are not doing enough for their clients 

• Dreaming about their clients’ trauma experiences 

• Diminished joy toward things they once enjoyed 

• Feeling trapped by work as a service provider (counselor) 

• Lacking a feeling of satisfaction and personal accomplishment 

• Dealing with intrusive thoughts of clients with especially severe trauma histories 

• Feelings of hopelessness associated with their work/clients 

 

57 [AU: this is not mentioned in the Additional Resources section] Donna Humetewa Kaye, “Vicarious Trauma” 

(presentation, Annual Tribal Healing to Wellness Court Enhancement Training, Albuquerque, NM, September 14, 

2017).
Case Management Appendix

41

BEHAVIOR

Frequent Job Changes, Tardiness, Anger, 

Irritability, Absenteeism, Irresponsibility, 

Overwork, Exhaustion, Talking to 

Oneself, Rejecting Closeness, Dropping 

Out of Community Affairs

INTERPERSONAL

Staff Conflict, Blaming Others, Conflictual 

Engagement, Poor Relationships, Poor 

Communication, Impatience, Lack of 

Interest in Collaboration, Avoiding Clients 

with Trauma History

VALUES/BELIEFS

Dissatisfaction, Negative Perception, 

Apathy, Blaming Others, Lack of 

Appreciation, Detachment, 

Hopelessness, Low Self-Image

WORK PERFORMANCE

Low Motivation, Increased Errors in 

Judgment, Decreased Work Quality, 

Avoidance of Job Responsibilities, 

Perfectionism, Lack of Flexibility 

EFFECTS OF 

VICARIOUS 

TRAUMA

• Blaming others

 

58 Ibid.

VICARIOUS TRAUMA OUTLINE - Continued58

Created by Donna Humetewa Kaye (Hopi)

Program Director, Nakwatsvewat Institute

HEALING THE HEALER

Healers need to be conscience about ways to incorporate self-care in daily efforts to help others.

Healers may not be aware of the impacts on behavior, interpersonal relationships, job, and 

values/beliefs unless we are self-aware. Some ways to heal the healer may include:

• Debriefing—Taking time out to discuss your experience with a colleague or other outside 

helping professional. This will allow for reflection on what impacted you the most.

• Cultural Cleansing—Some rituals are built in to a tribal ceremony to help heal the healer 

and strengthen bringing back perspective on the purpose healers serve (i.e., healing 

ceremony).

• Self-Awareness—Ask yourself: “Why do we choose to become healers?” For some it is a 

deep connection to a need to “save” or to “help” others out of their distress and misery. Ask 

yourself: “Is it truly healthy to ‘help’ and ‘save’ when we may be suffering from our own 

personal distress and misery?”
Case Management Appendix

42

Appendix C: Sample Job Descriptions

Sample Wellness Court Case Manager Job Description

Examples of Duties: 

Screening and Assessment

1. Complete program-appropriate screening and assessment.

2. Determine program eligibility.

3. Provide participant orientation.

4. Complete appropriate consent to release information and HIPAA forms.

5. Develop case management plan.

Participant Monitoring

1. Monitor overall compliance with case management plan.

2. Regularly review and update case management plan/referrals as needed.

3. Maintain accurate and complete documentation in the appropriate therapeutic database 

and/or case file.

4. Supervise urinalysis and other drug testing. 

5. Supervise an active caseload of up to thirty clients. 

Advocacy

1. Prepare timely information, both verbal and written, to the court concerning the participant. 

2. Consult with court personnel and other court-related parties as needed.

3. Communicate with outside community resources as needed.

4. Provide program information to outside entities. 

5. Represent and promote program concepts to outside entities.

6. Attend training and development.

7. Maintain appropriate individualized training on current trends.

Minimum Qualifications: 

KNOWLEDGE OF:

Wellness Court program functions and practices.

General organization, purpose, and functions of the judicial branch.

Services that address issues such as substance use disorders, mental illness, developmental disability, 

budgeting problems, housing, education, vocational needs, employment, medical problems, health 

issues, relapse issues, and histories of abuse. 

Case management best practices and protocols.
Case Management Appendix

43

ABILITY TO:

Establish and maintain cooperative working relationships with judicial officers, court staff at various 

levels, government officials, court users, and program participants.

Establish repertoire with clients, develop case management plans, and update plans as needed based 

on client needs.

Maintain confidentiality protocols.

Work independently; manage and/or coordinate resources for participants from other divisions or 

agencies.

Generate enthusiasm and support of a program's objectives.

Travel to locations within the county and/or to other jurisdictions as assigned.

EXPERIENCE/EDUCATION:

Possession of a bachelor’s degree from an accredited college or university in social work, sociology, 

criminal justice, or other related behavioral science AND three years of experience that would have 

developed the knowledge and abilities listed. 

OR 

A combination of recent education and/or experience that demonstrates the required knowledge and 

abilities. 
Case Management Appendix

44

Sample Wellness Court Coordinator Job Description

Examples of Duties: 

These duties are not inclusive but are clustered in broad categories. 

1. Facilitates group or team meetings and acts as liaison/representative for the Court with various 

service providers, community agencies, and/or other related parties.

2. Writes and disseminates correspondence including program bulletins, newsletters, and other 

court-related materials.

3. May assist judicial officers in composing correspondence, talking points, and/or presentations.

4. May make presentations to the community through outreach and education programs.

5. May participate in the development and documentation of standards and policies related to the 

Wellness Court Team; develops, communicates, and implements recommended improvements when 

necessary.

6. Maintains program data and prepares monthly reports; may assist with compiling budget status 

and statistical information for grant funding.

7. Reviews case eligibility following established criteria.

8. Monitors caseloads and program participant progress.

9. May attend hearings and prepare minute orders.

10. Coordinates graduation ceremonies; prepares invitations, guest speakers, and graduation 

certificates; arranges for photographic coverage of events.

11. Performs other duties as assigned. 

Minimum Qualifications: 

KNOWLEDGE OF:

Wellness Court program functions and practices.

General organization, purpose, and functions of the judicial branch.

Techniques for gathering, compiling, analyzing, and presenting information verbally and in writing.

Correct English usage for independent composition of reports and correspondence. 

Basic principles of mathematics including percentages, means, medians, and other elementary 
Case Management Appendix

45

statistical measures may be required of some positions.

ABILITY TO:

Establish and maintain cooperative working relationships with judicial officers, court staff at various 

levels, government officials, court users, and program participants.

Work independently; prioritize projects based on program objectives; manage and/or coordinate

projects involving participants from other divisions or agencies.

Generate enthusiasm and support of a program's objectives.

Use Court-specific computer applications to create reports, generate statistics, and prepare graphics.

Travel to locations within the county and/or to other jurisdictions as assigned.

EXPERIENCE/ EDUCATION:

Possession of a bachelor’s degree from an accredited college or university in social work, sociology, 

criminal justice, or other related behavioral science AND three years of experience that would have 

developed the knowledge and abilities listed. 

OR 

A combination of recent education and/or experience that demonstrates the required knowledge and 

abilities. An example of qualifying experience in lieu of education would include five years of 

progressively responsible experience in a trial court or public, private nonprofit, or criminal justice 

agency performing work such as a courtroom clerk, judicial assistant, program analyst, social worker, 

community outreach or other work that would have developed the knowledge and abilities required 

for this position. 

Successfully completed accredited college or university courses in a discipline used in the specific 

court program such as judicial, business or public administration, communications, psychology, 

behavioral science, and so forth may be substituted for up to two years’ experience based on three 

semester units or equivalent equaling three months of experience.
Case Management Appendix

46

Appendix D: Sample Participant Progress Reports

Name: Phase:

Start Date: Scheduled End Date: 

CASE INFORMATION

Cause Number

Convictions

Judge

Employer Shift [e.g., weekdays]

Driver’s License [Yes/No] Diploma or GED

Moved Phases [Phase/Date] Scheduled Phase Move [Date]

TREATMENT

[Treatment requirements and notes here]

DRUG TESTING

POSITIVE TESTS

Date

Substance

MISSED TESTS

Date

SANCTIONS

Date Sanction(s) Completed

[Description of sanction and notes] [yes/no; notes]

FEES

Drug Court: Other:

Court Review Information: [Notes]

Adapted from the Spencer County Drug Court Participant Progress Report, December 2016.

Participant picture 
Case Management Appendix

47

Adapted from the Gunnison County Recovery Court Report, September 2016.

Phase 1: [Date] # of days sober; Date Case No. Probation Dates

Drug testing (3× week):

• [Date]—[Result]

•

Community Service:

• [Date]—[Notes]

Treatment at Center for Mental Health:

• Type of Treatment: 

• Dates Attended: 

• Cancellations: 

• No-shows: 

• Progress/Changes in Treatment Goals: 

• Additional Comments:

Moral Reconation Therapy (MRT):

• [Notes]

Employment: 

• None

Risk/Needs

• [E.g., leisure/recreation; financial; companions]

Strengths

• [E.g., attitude/orientation; family/marital; education/employment]

Incentive History:

• [Incentive description]–[Date]

Sanction History:

• [Sanction description]–[Date]

Notes:

•

•

Phase 1: [Start Date]–[End Date]

Phase 2: [Start Date]
Case Management Appendix

48

John Doe: CR16-000 Wellness Court

1. Convictions

DOB:

00/00/00

Sex/Race

Entrance:

00/00/00

Employer: Payments: $

Owes: $

Jail Fees: $

Spouse/Partner: Jane Doe 

Children: Names, Ages

Medications: 

Sanctions and Reasons:

[Date] [Description of Sanction] [Reason]

[Date] [Description of Sanction] [Reason]

Phases: 

Phase #1: [[Start Date]

Initial Assessment:

Alcohol use disorder F10.20 303.90 Severe 

Amphetamine-type substance use disorder F15.20 304.40 Severe 

Opioid use disorder F11.20 304.00 Moderate 

Other problem related to employment Z56.

Current Treatment:

[Description of Treatment Plan]

Assessment: 

RANT: LSCMI: 

Additional Notes/Requirements:

DOC: 

Community Support Focus: Judge’s Instructions:

Officer Notes:

Sobriety: [Length of Time]

Staffing Notes: 
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Wellness Court Progress/Compliance Report59

Today’s Date: Case Number:

Participant Name: DOB:

Current Phase: Phase: Week:

Date Moved to Current Phase: 

Proximal Goal(s):

Coordinator Comments:

Treatment Provider #1 Comments [Insert Name of Treatment Agency]

Treatment Provider #2 Comments [Insert Name of Treatment Agency]

VRNA Comments

Social Worker Comments

Attendance: [ ] Excellent [ ] Good [ ] Fair [ ] Poor

Effort in Change/Recovery: [ ] Excellent [ ] Good [ ] Fair [ ] Poor

Days of Sobriety: Recovery Sponsor(s): [ ] Yes [ ] No

Number of Relapses Since Intake: ___ Family Involvement: [ ] Yes [ ] No

Supportive Family: [ ] Yes [ ] No

Supportive Group 

Attendance: 

Number of Meetings Since 

Last Update: 

Drug/Alcohol Screen Results:

Employment: [ ] Yes [ ] No Employer: Weeks Employed: 

Sanction: Sanction Received: 

 

59 Adapted from the Ho Chunk Nation Family Wellness Court Participant Evaluation of Progress/Compliance 

Report.
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Appendix E: Sample Wellness Court Data Values

1. Programmatic60

a. Program Name: (unique court ID) 

b. Program Type: (adult criminal, veteran’s, DUI, juvenile, family)

2. Assessment 

a. ASAM Level of Care Screening: (0.5, 1.0, 2.1, 2.5, 3.1, 3.3, 3.5, 3.7, 4.0, OTP) 

b. ASAM Level of Care Screening Date: (date) 

c. Risk Assessment Type: (LSI-R, NGA, START, JDAI, other) 

d. Risk Assessment Date: (date) 

e. Risk Assessment Results: (______________) 

f. Risk Level: (low, moderate, high) 

3. Intake 

a. Arrest Date: (date or approximate) 

b. Plea Date: (date or approximate) 

c. Referring Charge: (____________) 

d. Referral Date: (date or approximate) 

e. Referral Source: (prosecutor, defense attorney, law enforcement, probation, parole, 

family, treatment provider, court, self, family services, juvenile services, school, 

other) 

f. Review/Screening (legal) Date: (date or approximate) 

g. Review/Screening (program) Date: (date or approximate) 

h. Eligibility Determination Date: (date or approximate) 

i. Eligibility Denial Reason: (prosecutor or defense objection, judicial objection, out of 

jurisdiction, arrest/conviction/incarceration on other charge, transfer, doesn’t meet 

clinical criteria, medical issues, program at capacity, geographic/transportation 

issue, other) 

j. Decline/Denial Date: (date or approximate) 

k. Decline Reason: (requirements too strict, program length, competency issues, 

geographic/transportation issues, participant refused entry) 

l. Staffing Approval Date: (date or approximate) 

m. Acceptance Date: (date or approximate) 

n. Acceptance Type: (date or approximate) 

o. Orientation Date: (date or approximate) 

p. Treatment Start Date: (date or approximate) 

q. Exit Status: (graduated, completed, terminated-noncompliance, terminatedwithdrawal, discharged-administrative discharge, discharged-transferred, 

discharged-dismissal) 

r. Exit Status Date: (date or approximate) 

4. Phase 

a. Phase: (1, 2, 3, 4, 5/aftercare) 

 

60 Adapted from the Georgia Accountability Courts Data Collection Manual, 2015.
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51

b. Participant Status: (active, inactive, active-residential, active-co-occurring substance 

abuse disorder) 

5. Monitoring 

a. Primary Drug of Choice: (alcohol, crack/cocaine, ecstasy/MDMA, hallucinogens, 

heroin, inhalants, marijuana/cannabinoids, methamphetamines, prescription 

narcotics, other prescriptions, other, synthetic cannabinoids) 

b. Secondary Drug of Choice: (alcohol, crack/cocaine, ecstasy/MDMA, hallucinogens, 

heroin, inhalants, marijuana/cannabinoids, methamphetamines, prescription 

narcotics, other prescriptions, other, synthetic cannabinoids, none) 

c. Tertiary Drug of Choice: (alcohol, crack/cocaine, ecstasy/MDMA, hallucinogens, 

heroin, inhalants, marijuana/cannabinoids, methamphetamines, prescription 

narcotics, other prescriptions, other, synthetic cannabinoids, none) 

6. Treatment 

a. Diagnosis: (anxiety disorders, attention-deficit/hyper activity, autism spectrum, 

bipolar disorders, depressive disorders, dissociative disorders, intellectual disability 

and learning disorders; neurocognitive disorders, obsession-compulsive disorders, 

schizophrenia spectrum and other psychotic disorders, somatic symptom and 

related disorders, trauma/stress-related disorders, personality disorders) 

b. Treatment Type Is Evidence Based: (yes, no, unknown) 

c. Medication-Assisted Treatment Referral: (date or approximate) 

d. Medication-Assisted Treatment Prescribed: (methadone, suboxone, buprenorphine, 

naltrexone, extended-release injectable naltrexone, psychotropic medication, other) 

e. Medication-Assisted Treatment Denial: (declined to participate, medical 

disqualification, recent drug use, funding/availability) 

f. Medication-Assisted Treatment Completion: (completed, administrative discharge, 

terminated noncompliance removal, terminated-withdrawal) 

7. Mental Health Specific Data 

a. Hospital—Involuntary Hospitalizations: (date or approximate) 

b. Diagnosis (anxiety disorders, attention-deficit/hyper activity, autism spectrum, 

bipolar disorders, depressive disorders, dissociative disorders, intellectual disability 

and learning disorders; neurocognitive disorders, obsession-compulsive disorders, 

schizophrenia spectrum and other psychotic disorders, somatic symptom and 

related disorders, trauma/stress-related disorders, personality disorders) 

c. Medications (_________)

8. Demographics 

a. Participant Residence County: (________ County) 

b. Participant Gender: (male, female, transgender). 

c. Participant Race/Origin: (American Indian, Asian, Black/African American, 

Hispanic/Latino, Middle Eastern or North African, Pacific Islander or Native 

Hawaiian, white, other, two or more/mixed) 

d. Tribal Enrollment (_________)

e. Participant Age/DOB: (date or approximate) 

f. Participant Child DOB: (date or approximate) 

g. Participant Child Gender: (male, female) 
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52

h. Participant Child Unique ID: (number) 

i. Drug-Free Baby: (yes, no) 

j. Military Service: (army, navy, air force, marines, coast guard) 

k. Limited English Proficiency: (yes, no, unknown) 

l. Education Level: (elementary, middle, some high school, high school/GED, some 

college, associate’s degree, bachelor’s degree, professional or graduate degree) 

m. Education Level Date: (date or approximate) 

n. Employment Status: (unemployed, part-time less than 20 hours, part-time more 

than 20 hours, full time, student/training, disability, vocational rehab) 

o. Employment Status Date: (date or approximate) 

p. Chronic Unemployment or Unstable Employment: (yes, no, unknown) 

q. Income Level: (no income, Under $999, $1,000–$4,999, $5,000–$9,999, $10,000–

$14,999, $15,000–$19,999, $20,000–$24,999, $25,000–$34,999, $35,000–$44,999, 

$45,000–$54,999, $55,000–$64,999, $65,000–$74,999, $75,000 or higher) 

r. Income Level Date: (date or approximate) 

9. Family 

a. Child(ren) Parent: (last name, first name) 

b. Child(ren) Parent Type: (biological parent, adoptive parent, stepparent, foster 

parent, relative) 

c. Participant Child(ren) Status: (living with parent, living with spouse, living with 

family, no longer in home, alternative care placement) 

d. Participant Child(ren) Status Date: (date or approximate) 

e. Maltreatment Finding: (date or approximate) 

f. Custody Status: (full, partial, supervised, visitation, no contact) 

g. Custody Status Date: (date or approximate) 

h. Permanency Status: (temporary placement, foster care, reunification, guardianship, 

adoption, planned permanent living arrangement) 

i. Permanency Status Date: (date or approximate) 

j. Child Removed from Parent: (date or approximate) 

k. Alternative Care Placement Date: (date or approximate) 

l. Alternative Care Placement Type: (emergency, foster care, other parent, relatives, 

institution, supervised family) 

10. Juvenile 

a. GPA: (0.01–0.99, 1.00–1.99, 2.00–2.99, 3.00–3.99, 4.00+, NA) 

b. Not in School Reason: (already have GED/diploma, dropped out, expelled, home 

school, other) 

c. Education Status: (in school, enrolling, completed, suspended, expelled, home 

school) 

d. Education Status Date: (date or approximate) 

11. Community Service 

a. Community Service Completed: (hours) 

b. Community Service Completed Date: (date or approximate) 

Ongoing events and events subject to recurrence are tracked as the events occur and on a 

continuous basis. 
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53

1. Administrative Time 

a. Case Management Session Date: (date or approximate) 

b. Case Management Session Type: (treatment-based, programmatic, other) 

2. Demographics 

a. Employment Assistance Date: (date or approximate) 

b. Employment Assistance Type: (job skills, supported employment, vocational 

training) 

3. Monitoring 

a. Drug Test Date: (date or approximate) 

b. Drug Test Method: (cup, breathalyzer, internal lab, external lab, other) 

c. Drug Test Observed: (yes, no, unknown) 

d. Drug Test Type: (breath, hair, saliva, urine, sweat, blood) 

e. Drug Test Substances: (alcohol, crack/cocaine, ecstasy/MDMA, hallucinogens, 

heroin, inhalants, marijuana/cannabinoids, methamphetamine, prescription 

narcotics, other prescriptions, other, synthetic cannabinoids) 

f. Drug Test Results: (positive, negative, diluted, inconclusive, approved positive) 

g. Drug Test Comments: (admitted use, diluted, no show, refused, not producing 

sample in enough time) 

h. Electronic Monitoring Dates: (date or approximate) 

i. Electronic Monitoring Type: (RF, GPS, MEMS, SCRAM, voice verification, ignition 

interlock, kiosk, fingerprint/biometric, other) 

j. Hospital Emergency Room Visit: (date or approximate) 

k. Judicial Status Hearing Date: (date or approximate) 

l. Judicial Status Hearing Attendance: (yes, no-excused, no-unexcused) 

m. Medical Session Date: (date or approximate) 

n. Medical Session Type: (psychiatrist, psychologist, addictionologist, nursing, other 

medical, MAT) 

4. Treatment 

a. Treatment Session Date: (begin, end if applicable) 

b. Treatment Session Type: (group session, individual session, other) 

c. Treatment Session Duration: (minutes) 

d. Treatment Session Attendance: (yes, no-excused, no-unexcused) 

e. Medical Appointment: (medical/health screening, medication assisted treatment, 

psychotropic medication) 

f. Type of Treatment: (MRI, CBI, criminal thinking, matrix, seeking safety, DBT, living in 

balance, prime for life, prime solutions, EMDR, MI, RPT, TFAC, MET, other) 

5. Sanction/Incentive 

a. Incarceration Sanction: (yes, no, unknown) 

b. Sanction Date: (date or approximate) 

c. Incarceration Length: (number) 

d. Incentive Date: (date or approximate) 
For addiƟonal Healing to Wellness Court informaƟon,

visit the Wellness Court website:

www.WellnessCourt.org

“Providing resources and technical assistance for Tribal Healing to Wellness Courts”