Comprehensive

Case Management

for Substance Abuse

Treatment

27

Treatment Improvement Protocol (TIP) Series

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration
Blue Lines FPO

(for spine positioning)

Comprehensive Case Management for Substance Abuse Treatment CSAT (TIP)

27
Comprehensive 

Case 

Management for 

Substance Abuse 

Treatment 

Treatment Improvement Protocol (TIP) Series 

27 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

1 Choke Cherry Road 

Rockville, MD 20857 
Acknowledgments 

This publication was prepared under 

contract number 270-95-0013 by the 

Knowledge Application Program (KAP), a 

Joint Venture of The CDM Group, Inc., and 

JBS International, Inc., for the Substance 

Abuse and Mental Health Services 

Administration (SAMHSA), U.S. 

Department of Health and Human Services 

(HHS). Christina Currier served as the 

Government Project Officer. 

Disclaimer

The views, opinions, and content of this 

publication are those of the author and do 

not necessarily reflect the views, opinions, 

or policies of SAMHSA or HHS. 

Public Domain Notice

All material appearing in this report is in the 

public domain and may be reproduced or 

copied without permission from SAMHSA. 

Citation of the source is appreciated. 

However, this publication may not be 

reproduced or distributed for a fee without 

the specific, written authorization of the 

Office of Communications, SAMHSA, 

HHS. 

Electronic Access and Printed Copies 

This publication may be ordered for free 

from SAMHSA’s Publications Ordering 

Web page at http://store.samhsa.gov. Or, 

please call SAMHSA at 1-877-SAMHSA-7 

(1-877-726-4727) (English and Español). 

The document can be downloaded from the 

KAP Web site at http://kap.samhsa.gov. 

Recommended Citation

Substance Abuse and Mental Health 

Services Administration. Comprehensive 

Case Management for Substance Abuse 

Treatment. Treatment Improvement Protocol 

(TIP) Series, No. . HHS Publication No. 

(SMA) 12-4215. Rockville, MD: Author, 

2012. 

Originating Office 

Quality Improvement and Workforce 

Development Branch, Division of Services 

Improvement, Center for Substance Abuse 

Treatment, Substance Abuse and Mental 

Health Services Administration, 1 Choke 

Cherry Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 12-4215 

Printed 2012 

First printed 2000 

Revised 2002, 2003, 2006, 2008, 2010, DQG2012
iii

Contents 

What Is a TIP?............................................................................................................................................................ v 

Editorial Advisory Board....................................................................................................................................... vii 

Consensus Panel ...................................................................................................................................................... ix 

Foreword.................................................................................................................................................................... xi 

Executive Summary............................................................................................................................................... xiii 

Case Management and Substance Abuse Treatment................................................................................... xiii 

Interagency Case Management....................................................................................................................... xiv 

Evaluation and Quality Assurance of Case Management Services ............................................................ xv 

Case Management for Clients With Special Needs .....................................................................................xvii 

Funding Under Managed Care .....................................................................................................................xviii 

Chapter 1—Substance Abuse and Case Management: An Introduction.........................................................1 

Why Case Management .......................................................................................................................................2 

Case Management—A Brief History..................................................................................................................4 

Definitions and Functions....................................................................................................................................5 

Models of Case Management with Substance Abusers...................................................................................6 

Chapter 2—Applying Case Management to Substance Abuse Treatment ...................................................13 

Case Management Principles ............................................................................................................................13 

Case Management Practice—Knowledge, Skills, and Attitudes ..................................................................15 

The Substance Abuse Treatment Continuum and Functions of Case Management .................................17 

Chapter 3—Case Management in the Community Context: An Interagency Perspective .........................29 

Characteristics of the Three Models .................................................................................................................30 

Forging the Linkages ..........................................................................................................................................33 

Identifying Potential Partners ...........................................................................................................................35 

The Agency Environment..................................................................................................................................36 

Potential Conflicts...............................................................................................................................................39 

Chapter 4—Evaluation and Quality Assurance of Case Management Services ..........................................41 

A Brief Overview of the Research Literature ..................................................................................................41 
Contents 

iv

Evaluating Case Management Programs.........................................................................................................43 

Future Research...................................................................................................................................................49 

Chapter 5—Case Management for Clients With Special Needs .....................................................................51 

Minority Clients ..................................................................................................................................................51 

Clients With HIV Infection and AIDS..............................................................................................................52 

Clients With Mental Illness................................................................................................................................53 

Homeless Clients.................................................................................................................................................54 

Women With Substance Abuse Problems .......................................................................................................55 

Adolescent Substance Abusers .........................................................................................................................57 

Clients in Criminal Justice Settings ..................................................................................................................57 

Clients With Physical Disabilities.....................................................................................................................62 

Gay, Lesbian, Transgendered, and Bisexual Clients ......................................................................................63 

Case Management in Rural Areas ....................................................................................................................64 

Chapter 6—Funding Case Management in a Managed Care Environment..................................................65 

Funding Case Management in a Managed Care World ................................................................................65 

Preparing a Program for Managed Care..........................................................................................................68 

Future Directions ................................................................................................................................................71 

Appendix A—Bibliography...................................................................................................................................73 

Appendix B—Practice Dimensions ......................................................................................................................87 

Referral .................................................................................................................................................................87 

Service Coordination ..........................................................................................................................................90 

Appendix C—Managed Healthcare Organizational Readiness Guide and Checklist: Special Report...99 

Introduction .........................................................................................................................................................99 

Goals and Objectives ........................................................................................................................................100 

Background........................................................................................................................................................100 

Ways To Use the Guide and Checklist...........................................................................................................100 

Managed Healthcare Organizational Readiness Checklist .........................................................................104 

Summary of Answers.......................................................................................................................................111 

Common Questions and Answers..................................................................................................................112 

How Can We Design an Action Program for Change? ...............................................................................113 

Summary and Conclusion ...............................................................................................................................113 

References ..........................................................................................................................................................114 

Appendix D—Resource Panel.............................................................................................................................115 

Appendix E—Field Reviewers ............................................................................................................................117
v

What Is a TIP? 

Treatment Improvement Protocols (TIPs) are 

developed by the Substance Abuse and Mental 

Health Services Administration (SAMHSA) 

within the U.S. Department of Health and 

Human Services (HHS). Each TIP involves the 

development of topic-specific best-practice 

guidelines for the prevention and treatment of 

substance use and mental disorders. TIPs draw 

on the experience and knowledge of clinical, 

research, and administrative experts of various 

forms of treatment and prevention. TIPs are 

distributed to facilities and individuals across 

the country. Published TIPs can be accessed via 

the Internet at http://kap.samhsa.gov. 

Although each consensus-based TIP 

strives to include an evidence base for the 

practices it recommends, SAMHSA recognizes 

that behavioral health is continually evolving, 

and research frequently lags behind the 

innovations pioneered in the field. A major goal 

of each TIP is to convey "front-line" information 

quickly but responsibly. If research supports a 

particular approach, citations are provided. 
vi
vii

Editorial Advisory Board 

Karen Allen, Ph.D., R.N., C.A.R.N. 

President 

National Nurses Society on Addictions 

Associate Professor 

Department of Psychiatry, Community 

Health, and Adult Primary Care 

University of Maryland, Baltimore 

Baltimore, Maryland 

Richard L. Brown, M.D., M.P.H. 

Associate Professor 

Department of Family Medicine 

University of Wisconsin School of Medicine 

Madison, Wisconsin 

Dorynne Czechowicz, M.D. 

Associate Director 

Medical/Professional Affairs 

Treatment Research Branch 

Division of Clinical and Services Research 

National Institute on Drug Abuse 

Rockville, Maryland 

Linda S. Foley, M.A. 

Former Director 

Project for Addiction Counselor Training 

National Association of State Alcohol and 

Drug Counselors 

Director 

Treatment Improvement Exchange 

Health Systems Research, Inc. 

Washington, D.C. 

Wayde A. Glover, MIS, NCAC II 

Director 

Commonwealth Addictions Consultants and 

Trainers 

Richmond, Virginia 

Pedro J. Greer, M.D. 

Assistant Dean for Homeless Education 

University of Miami School of Medicine 

Miami, Florida 

Thomas W. Hester, M.D. 

Former State Director 

Substance Abuse Services 

Division of Mental Health, Mental 

Retardation and Substance Abuse 

Georgia Department of Human Resources 

Atlanta, Georgia 

Gil Hill 

Director 

Office of Substance Abuse 

American Psychological Association 

Washington, D.C. 

Douglas B. Kamerow, M.D., M.P.H. 

Director 

Center for Practice and Technology 

Assessment 

Agency for Health Care Policy and Research 

Rockville, Maryland 
Editorial Advisory Board 

viii

Stephen W. Long 

Director 

Office of Policy Analysis 

National Institute on Alcohol Abuse and 

Alcoholism 

Rockville, Maryland 

Richard A. Rawson, Ph.D. 

Executive Director 

Matrix Center 

Los Angeles, California 

Ellen A. Renz, Ph.D. 

Former Vice President of Clinical Systems 

MEDCO Behavioral Care Corporation 

Kamuela, Hawaii 

Richard K. Ries, M.D. 

Director and Associate Professor 

Outpatient Mental Health Services and Dual 

Disorder Programs 

Harborview Medical Center 

Seattle, Washington 

Sidney H. Schnoll, M.D., Ph.D. 

Chairman 

Division of Substance Abuse Medicine 

Medical College of Virginia 

Richmond, Virginia 
ix

Consensus Panel 

Chair 

Harvey A. Siegal, Ph.D. 

Professor and Director 

Substance Abuse Intervention Programs 

School of Medicine 

Wright State University 

Dayton, Ohio 

Workgroup Leaders 

James A. Hall, Ph.D. 

Associate Professor 

School of Social Work 

University of Iowa 

Iowa City, Iowa 

Howard Isenberg, M.A. 

Division Director 

Outpatient Treatment Services 

Northeast Treatment Centers 

Wilmington, Delaware 

Mary Nakashian 

Vice President and Director of Program 

Demonstration 

National Center on Addiction and Substance 

Abuse at Columbia University (CASA) 

New York, New York 

Richard C. Rapp, M.S.W. 

Co-Investigator, Assistant Professor 

Substance Abuse Intervention Programs 

School of Medicine 

Wright State University 

Dayton, Ohio 

M. Susan Ridgely, M.S.W., J.D. 

Associate Professor 

Department of Mental Health Law and 

Policy 

Florida Mental Health Institute 

University of South Florida 

Tampa, Florida 

Patrick Sullivan, Ph.D. 

Division Director 

Division of Mental Health 

Family and Social Services Administration 

Indianapolis, Indiana 

Panelists 

Kathleen Andolina, R.N., M.S., C.S. 

Consultant 

Center for Case Management 

Natick, Massachusetts 

Barbara A. Blakeney, M.S., R.N., C.S., A.N.P. 

Principal Public Health Nurse 

Long Island Shelter 

Homeless Services and Addiction Services 

Public Health Commission 

Boston, Massachusetts 

Elizabeth Garcia, M.S.W. 

Director 

Managed Care 

Pinal Gila Behavioral Health Association 

Apache Junction, Arizona 
Consensus Panel 

x

Margaret E. Hanna, M.Ed. 

Executive Director 

Bucks County Drug and Alcohol 

Commission 

New Britain, Pennsylvania 

Albert Hasson, M.S.W. 

Administrative Director 

Matrix Institute on Addictions 

Pizarro Treatment Center 

Los Angeles, California 

Judith Levy, Ph.D. 

Associate Professor 

School of Public Health 

University of Illinois 

Chicago, Illinois 

Duane C. McBride, Ph.D. 

Director of Research 

Behavioral Science Department 

Andrews University 

Berin Springs, Michigan 

Sylvia M. Ryan, M.A., B.A. 

Program Director 

Rocky Boy Health Board 

Rocky Boy Chemical Dependency Program 

Box Elder, Montana 

Anne C. Sowell, A.C.S.W., L.I.S.W. 

Coordinator of Community Projects 

Miracle Village 

MetroHealth Medical Center 

Cleveland, Ohio 
xi 

Foreword 

he Treatment Improvement Protocol (TIP) 

series fulfills the Substance Abuse and 

Mental Health Services Administration’s 

(SAMHSA’s) mission to improve prevention and 

treatment of substance use and mental disorders 

by providing best practices guidance to clinicians, 

program administrators, and payers. TIPs are the 

result of careful consideration of all relevant 

clinical and health services research findings, 

demonstration experience, and implementation 

requirements. A panel of non-Federal clinical 

researchers, clinicians, program administrators, 

and patient advocates debates and discusses their 

particular area of expertise until they reach a 

consensus on best practices. This panel’s work is 

then reviewed and critiqued by field reviewers. 

The talent, dedication, and hard work that TIPs 

panelists and reviewers bring to this highly 

participatory process have helped bridge the gap 

between the promise of research and the needs of 

practicing clinicians and administrators to serve, 

in the most scientifically sound and effective ways, 

people in need of behavioral health services. We 

are grateful to all who have joined with us to 

contribute to advances in the behavioral health 

field. 

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

Peter J. Delany, Ph.D., LCSW‐C RADM, USPHS

Director

Center for Substance Abuse Treatment  

Substance Abuse and Mental Health Services

Administration  

   

T 

xiii

Executive Summary 

ase management has been variously 

classified as a skill group, a core 

function, service coordination, or a 

network of “friendly neighbors.” Although it 

defies precise definition, case management 

generally can be described as a coordinated 

approach to the delivery of health, substance 

abuse, mental health, and social services, linking 

clients with appropriate services to address 

specific needs and achieve stated goals. The 

Consensus Panel that developed this TIP 

believes that case management lends itself to the 

treatment of substance abuse, particularly for 

clients with other disorders and conditions who 

require multiple services over extended periods 

of time and who face difficulty in gaining access 

to those services. This document details the 

factors that programs should consider as they 

decide to implement case management or 

modify their current case management activities. 

This summary is excerpted from the main text, 

in which references to the research appear. 

Research suggests two reasons why case 

management is effective as an adjunct to 

substance abuse treatment. First, retention in 

treatment is associated with better outcomes, 

and a principal goal of case management is to 

keep clients engaged in treatment and moving 

toward recovery. Second, treatment may be 

more likely to succeed when a client’s other 

problems are addressed concurrently with 

substance abuse. Case management focuses on 

the whole individual and stresses 

comprehensive assessment, service planning, 

and service coordination to address multiple 

aspects of a client’s life. Comprehensive 

substance abuse treatment often requires that 

clients move to different levels of care or 

systems; case management facilitates such 

movement. 

Any definition of case management will be 

contextual, depending on who is implementing 

the program. Perhaps a more helpful way to 

understand it is to examine the functions that 

generally comprise case management: (1) 

assessment, (2) planning, (3) linkage, (4) 

monitoring, and (5) advocacy. 

Case Management and 

Substance Abuse 

Treatment 

When implemented to its fullest, case 

management will enhance the scope of 

addictions treatment and the recovery 

continuum. A treatment professional utilizing 

case management will 

 Provide the client a single point of contact for 

multiple health and social services systems 

 Advocate for the client 

 Be flexible, community-based, and clientoriented 

 Assist the client with needs generally 

thought to be outside the realm of substance 

abuse treatment 

C 
Executive Summary 

xiv

To provide optimal services for clients, a 

treatment professional should possess particular 

knowledge, skills, and attitudes including 

 Understanding various models and theories 

of addiction and other problems related to 

substance abuse 

 Ability to describe the philosophies, 

practices, policies, and outcomes of the most 

generally accepted and scientifically 

supported models of treatment, recovery, 

relapse prevention, and continuing care for 

addiction and other substance-related 

problems 

 Ability to recognize the importance of family, 

social networks, community systems, and 

self-help groups in the treatment and 

recovery process 

 Understanding the variety of insurance and 

health maintenance options available and the 

importance of helping clients access those 

benefits 

 Understanding diverse cultures and 

incorporating the relevant needs of culturally 

diverse groups, as well as people with 

disabilities, into clinical practice 

 Understanding the value of an 

interdisciplinary approach to addiction 

treatment 

In addition to the above competencies, 

treatment professionals must have skills relating 

to interagency functioning, negotiating, and 

advocacy. CSAT’s Addiction Technology 

Transfer Centers classify referral and service 

coordination—basic case management 

functions—as core competencies for substance 

abuse treatment providers. 

The Substance Abuse Treatment 

Continuum and Functions of Case 

Management 

The continuum of substance abuse treatment 

ranges from case finding and pretreatment to 

primary treatment to aftercare. Although there 

are distinct goals and treatment activities at each 

point on the continuum, rarely do clients’ needs 

fit neatly into any one area at a given time; case 

management serves to span client needs and 

program structure. Substance abuse treatment 

and case management functions differ in that 

treatment involves activities that help substance 

abusers recognize their problems, acquire the 

motivation and tools to stay abstinent, and use 

the acquired tools; case management focuses on 

helping the substance abuser acquire needed 

resources. Case management supports a client 

as he moves through the recovery continuum 

and reinforces treatment goals. 

Interagency Case 

Management 

The goal of interagency case management is to 

expand the network of services available to 

clients. All organizations have boundaries to 

what they can do, and case managers or 

“boundary spanners” transcend them to 

facilitate interactions among agencies. In the 

field of substance abuse, three interagency 

models have been identified. In the single agency

model, the case manager personally establishes 

a series of distinct relationships on an as-needed 

basis with counterparts in other agencies. In the 

informal partnership model, staff members from 

several agencies work as a collaborative team, 

often constituted case by case; the formal 

consortium binds case managers and service 

providers through formal written agreements. 

Clearly defined roles are essential to all three 

models to ensure that services are coordinated 

and relevant gaps addressed. 

Although informal exchange or “social 

service bartering” among different agencies is 

intrinsic to case management, a more formalized 

connection among agencies sometimes may be 

required. Examples include memoranda of 

understanding and interagency agreements and 

contracts; each of these methods for formalizing 
Executive Summary 

xv

expectations can be used in single agency 

models, informal partnerships, and formal 

consortia. 

To be successful, a case management plan 

must thoroughly and critically examine 

community resources to determine what forms 

of assistance are available and how case 

management efforts can help clients attain 

necessary assistance. Many communities have 

published directories of social, health, welfare, 

housing, vocational, and other service 

organizations to help case management 

programs identify resources, possible provider 

linkages, and potential gaps in services for their 

clients. Although such directories are a good 

starting point, it is important to follow up on the 

listings to ensure they are still accurate and will 

be of use to the client. 

The Environmental Assessment 

Exploring the environment in which an agency 

operates is crucial to determining the feasibility 

of an interagency effort. Analysis of the 

community environment will enhance 

understanding of the changes that occur among 

clients, within the program, and in the 

community. Case management takes place 

within a dynamic social service environment in 

which agencies are in constant flux. Programs 

considering interagency efforts must devise 

strategies to respond to change while providing 

continuity for the client. Regular reevaluation 

helps ensure continued relevance; community 

service provider networks or consortia are 

particularly effective in sharing information 

about changes and developments. 

Potential Conflicts 

Whenever agencies or service providers work 

together, the potential for conflict exists. Areas 

of tension may be present from the very onset of 

the collaboration. For example, a new project 

may be viewed by established social service 

agencies as competition for scarce resources. 

Sometimes social pressures or the need to 

maximize resources can force public agencies 

into joint ventures even if they do not mesh well 

or have a history of being service competitors. 

Tensions can also develop in the course of 

delivering services; for example, interagency 

collaboration may result in a client having two 

case managers. Recognizing potential triggers 

for conflict is a necessary first step in developing 

a system to handle them. When problems do 

arise, case managers and other agency personnel 

can use both informal and formal 

communication to clarify issues, regain 

perspective, and refocus the interagency case 

management process. 

Evaluation and Quality 

Assurance of Case 

Management Services 

Substance abuse treatment programs, including 

those that receive public funding, are 

increasingly operating in a managed care 

environment. In such an environment, policy 

and clinical decisionmaking rely on outcome 

data that traditionally describe the impact of 

case management and substance abuse 

treatment interventions in the context of services 

used and money spent. An additional demand 

for data comes from public and private payers 

who want services linked to specific outcomes. 

To gauge the effectiveness of case 

management, indicators of “success” must be 

defined by the substance abuse program and its 

stakeholders (including funding and regulatory 

agencies). In documenting a case management 

effort, it is necessary to establish benchmarks to 

measure the case management process, for 

example, recording how often a client shows up 

at treatment. Once the benchmarks are defined 

in measurable terms, the next step is to develop 

and implement a method for measuring 

practice; that is, to answer the questions, “What 

are case managers doing, and how does their 
Executive Summary 

xvi

practice conform to the benchmarks?” Methods 

of such documentation include 

 Maintenance of a simple staff log procedure 

that measures case managers’ activities by 

contact 

 Reviews of case manager client records to 

evaluate how service planning and referrals 

adhere to benchmarks 

 Interviews or surveys of case managers or 

clients and their family members to collect 

information on activities in which case 

managers engage, to identify how clients’ 

and case managers’ views of case 

management activities differ 

 Analysis of data from the agency’s 

management information system (to examine 

patterns on type, number, and duration of 

case manager contacts with different target 

populations). 

Measuring System Outcomes 

System outcomes are particularly important in a 

managed care environment, where overall use 

of expensive services such as hospitalization and 

residential treatment is strictly monitored. 

System outcomes can measure cost savings and 

quality of care: For example, continuity of care is 

an appropriate measure for a client at risk for 

relapse after detoxification and before entry into 

outpatient treatment. Tracking clients within a 

comprehensive service agency or analyzing data 

on costs and encounters within a network of 

agencies are two methods for measuring system 

outcomes. For such analyses, a computerized 

management information system (MIS) is 

essential. 

Measuring Client Outcomes 

Although “evaluation” is generally considered 

worthwhile, there is little agreement about the 

measurement and documentation of specific 

outcomes for individual clients. Some view a 

single measure such as sobriety to be the only 

meaningful indicator of success; others believe 

success should be gauged against a range of 

factors, including reduced substance use, 

improved family functioning, and fewer 

encounters with the criminal justice system. 

Until the debate is resolved, programs should 

identify treatment objectives and extrapolate 

from them the outcome variables they want to 

measure. 

Anticipating Quality Assurance 

Data Needs 

The types of data required for an evaluation of 

case management, how the data are collected, 

and the manner in which data are put to use 

vary among different stakeholders. It is 

important to understand the types of data that 

various stakeholders need to evaluate the 

program. Structured feedback loops should be 

established to ensure that the gathered data are 

returned to various stakeholders in some 

meaningful way so that they have an impact on 

shaping future program development (and 

future data needs). One of the benefits of the 

case management approach is that it can be 

adapted to meet the sometimes contradictory 

needs of the various stakeholders. 

Management Information Systems 

A management information system contains all 

of the case management services information 

and allows stakeholders to access it. In 

evaluating a MIS, local programs should 

 Determine how to use data already routinely 

collected by a statewide MIS or a managed 

care company-based MIS, saving the 

program from duplicating primary data 

collection 

 Develop or enhance a program-level MIS 

that tracks data the program needs locally 

 Integrate with other computer-based or 

paper-based systems 

 Supply data required by third party payer 

and governmental bodies 
Executive Summary 

xvii

All staff members of a specific program 

should be stakeholders in the MIS, which 

increases both system accuracy and the 

likelihood that a broad array of staff members 

will use it. If an agency does not have the 

resources to develop a sophisticated system, it 

should be able to automate at least a minimum 

amount of client information through 

commercially available software. When 

designing today’s MIS, the data requirements of 

managed care organizations must be addressed. 

Future Research 

Research centered on case management and the 

substance abuse field is limited, thus offering 

local substance abuse programs the opportunity 

to make significant contributions to the field. 

Suggested directions for future research include 

the following: 

 Key ingredients of successful programs, 

especially for hard-to-reach populations 

 Relative cost-effectiveness of particular case 

management models, including cost outcome 

results within systems incorporating full 

parity of substance abuse with other health 

care; outcome results when a full continuum 

of care is available to patients; and outcome 

results associated with use of standardized 

guidelines for placement, continued stay, 

and discharge for substance abuse patients 

 Improved methodology to investigate 

research questions in “real world” settings 

 Development of brief versions of valid and 

reliable research outcome instrumentation 

 The effect of particular forms of case 

management on societal costs of substance 

abuse and its treatment 

 Cost shifting among health, behavioral 

health, criminal justice, and other systems 

that can be accessed by the target population 

 Creative ways to use secondary data sets 

(such as Medicaid and Medicare) to 

determine trends and patterns of care 

 Research questions from broader sociological 

or multidisciplinary perspectives 

Case Management for 

Clients With Special 

Needs 

Case management is especially appropriate for 

substance abusers with special treatment needs, 

related to such issues as HIV infection or AIDS, 

mental illness, chronic and acute health 

problems, poverty, homelessness, responsibility 

for parenting young children, social and 

developmental problems associated with 

adolescence and advanced age, involvement 

with illegal activities, physical disabilities, and 

sexual orientation. Ideally, a case manager will 

possess all the expertise and skills needed to 

treat the many special needs she confronts, but 

this is unlikely—understanding the 

ramifications of even one special need can be a 

staggering task. In the absence of such 

comprehensive knowledge, a case manager 

should have a basic foundation of attitudes and 

skills for delivering services to “special needs 

clients.” The case manager should 

 Make every effort to be competent in the 

special circumstances that affect clients 

typically referred to a particular substance 

abuse treatment program 

 Understand the range of clients’ reactions to 

the challenges associated with particular 

special circumstances 

 Remain aware of the limits of his own 

knowledge and expertise 

 Evaluate personal beliefs and biases about 

clients who have special problems or needs 

 Maintain an open attitude toward seeking 

and accepting assistance on behalf of a client 

 Know where additional information on 

special problems can be accessed
Executive Summary 

xviii

Funding Under Managed 

Care 

Whatever treatment providers’ attitudes toward 

managed care, they will have to accept that it is 

the new paradigm for health care. Well over 

one-half of the States are currently in the process 

of adopting some form of managed care for 

providing public-sector behavioral health care 

services. Many have already received Federal 

waivers to implement Medicaid managed 

behavioral health programs, and other waivers 

are planned or pending. Managed care has 

changed the context in which substance abuse 

treatment services are delivered, and substance 

abuse programs must prepare to function within 

this new environment if case management is to 

survive. 

Treatment providers using case management 

may not only survive but actually thrive under 

managed care. Many managed care 

organizations (MCOs) reimburse for case 

management, so it behooves providers to prove 

that their brand of case management should be 

covered. The program should develop a 

comprehensive case management system with 

the flexibility and resources necessary to 

eventually show tangible savings.

To adapt to this new way of doing business, 

treatment programs must assess how they use 

case management and appraise their readiness 

to operate in a managed care environment. One 

way providers can thrive under managed care is 

to position themselves and their case 

management services in a competitive market 

by identifying market niches, such as clients 

with HIV/AIDS, criminal justice clients, or older 

clients. 

As MCOs increasingly reimburse for case 

management, licensing requirements are 

becoming stricter. The trend is toward case 

managers who have advanced degrees. 

Accreditation standards will also tighten under 

managed care. 

In short, there are many reasons for 

substance abuse treatment providers to adopt 

case management or to formalize their existing 

case management activities. This will not 

necessarily mean an upheaval, as many 

programs are already helping clients navigate 

their other, non-substance abuse problems. This 

TIP equips providers with the knowledge they 

need to fully serve their clients at the same time 

they conform to the changing health care 

system. 
1

1 Substance Abuse and Case 

Management: An Introduction 

he term case management has appeared in 

social services literature more than 600 

times in the last 30 years, referring to 

everything from the routing of court dockets 

through the judicial system to the medical 

management of a hospitalized patient’s care. 

This TIP uses the term to refer to interventions 

designed to help substance abusers access 

needed social services. 

Support for the use of case management in 

this setting developed from both clinical practice 

and empirical observation suggesting that 

substance abusers who seek treatment have 

significant problems in addition to using 

psychoactive substances. Alcohol or other drug 

use often damages many aspects of an 

individual’s life, including housing, 

employment, and relationships (Oppenheimer et 

al., 1988; Westermeyer, 1989). Clients in 

substance abuse treatment programs, 

particularly publicly funded treatment 

programs, present a variety of associated 

problems. Many use multiple substances and 

may be poly-addicted. Many suffer from related 

health disorders, either caused by their 

substance abuse—such as liver disease and 

organic brain disorders—or exacerbated by 

neglect of health and lack of preventive health 

care. In addition, some diseases—including 

HIV/AIDS, tuberculosis, and some strains of 

hepatitis—are transmitted by substance abuse, 

either directly or indirectly. 

Substance abusers also have a higher 

incidence of mental health disorders than the 

general population. Up to 70 percent of 

individuals treated for substance abuse have a 

lifetime history of depression (Mirin et al., 1988). 

Between 23 and 56 percent of individuals with 

diagnosable Axis I mental disorders also have a 

substance abuse or dependence disorder (Regier 

et al., 1990). 

Substance abuse clients often arrive in 

treatment programs with numerous social 

problems as well. Many are unemployed or 

under-employed, lacking job skills or work 

experience. Many in publicly funded treatment 

programs do not have a high school diploma. 

Some are homeless, and those who have been 

incarcerated may face significant barriers in 

accessing safe and affordable housing. Many 

substance abuse clients have alienated their 

families and friends or have peer affiliations 

only with other substance abusers. Women in 

treatment have often been victims of domestic 

violence, including sexual abuse; some women 

in treatment may be living with an abuser. 

Achieving and maintaining abstinence and 

recovery nearly always requires forming new, 

healthy peer associations. 

T 
Chapter 1 

2

A significant number of clients in treatment 

are also under some form of control by the 

criminal justice system. Criminal justice 

substance abuse clients represent more than half 

of all clients in treatment in many state and local 

jurisdictions. Although those afflicted by 

chemical addiction are found among all 

socioeconomic groups, persons already plagued 

by poverty, disease, and unemployment are 

over-represented (CSAT, 1994). Particularly in 

publicly funded treatment programs, substance 

abuse clients have limited resources and may 

lack health insurance. Many are eligible for 

publicly supported health and social benefits, 

including Medicare, food stamps, or welfare. 

Data suggest that substance abusers who 

receive professional attention for these 

additional problems will see improvements in 

occupational and family functioning and a 

lessening of psychiatric symptoms (McLellan et 

al., 1993; McLellan et al., 1982; Moos et al., 1990; 

Siegal et al., 1995). Clinicians who develop a 

"helping alliance" with substance abusers have 

been shown to produce better treatment 

outcomes than those who do not (Luborsky et 

al., 1985). 

Why Case Management 

Because addiction affects so many facets of the 

addicted person’s life, a comprehensive 

continuum of services promotes recovery and 

enables the substance abuse client to fully 

integrate into society as a healthy, substance-free 

individual. The continuum must be designed to 

provide engagement and motivation, primary 

treatment services at the appropriate intensity 

and level, and support services that will enable 

the individual to maintain long-term sobriety 

while managing life in the community. 

Treatment must be structured to ensure smooth 

transitions to the next level of care, avoid gaps 

in service, and respond rapidly to the threat of 

relapse. Case management can help accomplish 

all of the above. 

Case management is needed because, in most 

jurisdictions, services are fragmented and 

inadequate to meet the needs of the substanceabusing population. This lack of coordinated 

services results from a variety of factors, 

including 

 Different funding streams. Substance abuse 

treatment is funded from a variety of 

sources—block grants, competitive grants, 

state and local funding, criminal justice 

funding, and others. The different 

requirements or goals of these sources can 

result in a piecemeal approach to 

programming 

 A focus on program funding rather than 

system funding 

 Funding focused on single modalities rather 

than a continuum of care 

 Inadequate funding created by missing 

pieces in the continuum 

 Waiting lists caused by inadequate funding 

 Barriers between systems (e.g., mental health 

vs. substance abuse, criminal justice vs. 

mental health and substance abuse) 

 Lack of incentives geared to client outcome; 

programs rewarded for process measures, 

not outcome measures 

 Eligibility/admission criteria that exclude 

certain clients 

 Lack of agreement on priority for 

admission/treatment 

 Lack of incentives for programs to work 

together

Due to the fragmentation of services, the 

accompanying inefficiency, and a growing 

scarcity of resources, some form of case 

management is used with virtually every 

population that routinely seeks social services. 

The variability in social services system 

configurations has led to many different 

implementations of case management, resulting 
Introduction 

3

in conceptual disagreements about case 

management and difficulty in assessing its 

value. Inevitably, many of the same issues will 

arise in the substance abuse setting. This TIP is 

designed to establish a common starting point 

for case management work with substance 

abusers. To address at least some of those 

conceptual disagreements, the TIP makes 

several assumptions, including 

1. Case management is a set of social service 

functions that helps clients access the 

resources they need to recover from a 

substance abuse problem. The functions that 

comprise case management—assessment, 

planning, linkage, monitoring, and 

advocacy—must always be adapted to fit the 

particular needs of a treatment or agency 

setting. The resources an individual seeks 

may be external in nature (e.g., housing and 

education) or internal (e.g., identifying and 

developing skills). 

2. Advocacy is one of case management’s 

hallmarks. While a professional conducting 

therapy may speak out on behalf of a client, 

case management is dedicated to making 

services fit clients, rather than making clients 

fit services. 

3. Case management may be implemented by 

an individual dedicated solely to helping the 

client access needed resources⎯a case 

manager⎯or by a professional who has this 

responsibility along with therapeutic or 

counseling functions. This TIP stresses the 

intervention rather than the intervener’s 

profession. 

4. The primary difference between case 

management and therapy is that the former 

stresses resource acquisition, while the latter 

focuses on facilitating intra- and 

interpersonal change. However, case 

management and therapy are not 

incompatible. Indeed, both are generally 

called for in addressing the needs of a 

majority of substance abuse clients. 

5. When implemented to its fullest, case 

management challenges the addiction 

treatment continuum of pretreatment, 

primary treatment, and aftercare (discussed 

further in Chapter 2). This occurs because of 

the advocacy function of case management; 

the need for case managers to be flexible, 

community-based, and community-oriented; 

and the need for case managers to be the 

primary figures in planning work with the 

client.

These assumptions are all affected by the 

setting in which case management is practiced. 

Practitioners who work with substance abusers 

do so in methadone maintenance clinics, 

hospital- and community-based addiction 

programs, local social service departments, 

family preservation programs, and storefront 

community outreach programs. These physical 

settings are in turn influenced by numerous 

other factors, including the source(s) of an 

agency’s funding; the agency’s mission; staff 

orientation, education, and training; the 

agency’s treatment philosophy; and the makeup 

of other social services in a particular 

geographical area. 

Complicating the implementation of case 

management with substance abusers are three 

trends that will alter the current manner in 

which substance abuse treatment and case 

management are implemented: Managed care, 

treatment provided in the criminal justice 

system, and diminishing social services and 

resources. Managed care uses case management 

to restrict access to services as well as to facilitate

access to services. In addition to the issue of 

cost containment, the movement of a great deal 

of substance abuse treatment (and thereby case 

management) into criminal justice venues is 

significant. The potential conflicts between 

coerced involvement in treatment and case 

management will test the limits of advocacy and 

client-driven aspects of the intervention. 

Finally, unlike the early period of case 
Chapter 1 

4

management, clients and professionals 

practicing case management now negotiate a 

drastically constricted menu of services. Each of 

these contemporary conditions makes 

implementation and evaluation an increasingly 

difficult task. 

Case Management – A 

Brief History 

More than 70 years ago when Mary Richmond 

envisioned a cadre of “friendly neighbors” 

helping others in their struggles with real world 

needs (Richmond, 1922), she created not only 

the field of social work, but case management as 

well. While she applied the term social casework

to the activities that affected the adjustment 

between an individual and the social 

environment, she could well have been 

describing the key functions that now comprise 

case management. 

One of the first legislative embodiments of 

case management occurred in the 1963 Federal 

Community Mental Health Center Act 

(Intagliata, 1982) in anticipation of 

deinstitutionalization, in which persons in longterm psychiatric care were moved into 

community settings. The expectation that these 

individuals would need services previously 

provided in the institution led to the rapid 

expansion of community-based social services. 

Unfortunately, these services were often created 

independently of one another and, coupled with 

the categorical nature of the eligibility for 

services, led to difficulties for persons used to 

having these services provided in institutions. 

The Community Support System developed by 

the National Institutes of Mental Health in 1977 

envisioned case management as a mechanism 

for helping clients navigate this fragmented 

social service system. Accessing these resources 

would thus enable them to live and function 

adequately in their communities (Intagliata, 

1982; Stein and Test, 1980; Test, 1981; Turner and 

TenHoor, 1978). 

Substance abusers historically were never 

institutionalized as often as were persons with 

chronic mental illness and so were not directly 

impacted by deinstitutionalization legislation. 

Substance abusers were not generally targeted 

for the development of categorical systems of 

service delivery and were not generally 

recipients of case management services. 

However, case management-like services were 

provided to substance abusers under other titles, 

such as “mission work,” and frequently 

delivered by the clergy or others in skid row 

missions, detoxification centers, and ad hoc 

halfway houses. Jails and county work farms 

were generally the institutions of choice in 

dealing with this population. Only after 

substance abuse began to be decriminalized and 

defined as a disease were substance abusers 

referred to various social services. 

Policymakers in Canada were among the first 

to translate many generic case management 

functions into the field of substance abuse 

treatment, outlining the essential elements of a 

union of case management and substance abuse 

treatment (Graham and Birchmore-Timney, 

1990; Ogborne and Rush, 1983; Rush and 

Ekdahl, 1990). Case management for substance 

abusers initially gained attention in the United 

States through the Treatment Alternatives for 

Safe Communities (TASC) program (formerly 

known as Treatment Alternatives to Street 

Crime), which began linking the criminal justice 

system with the drug abuse treatment system in 

1972 and has grown to over 185 programs 

(Cook, 1992) today. 

A 1987 National Institute of Mental Health 

initiative funded 13 demonstration projects 

targeted at young adults with coexisting mental 

health and substance use problems. Of these 13 

projects, 10 identified some form of case 

management as a primary service and provided 

a general description of the case management 
Introduction 

5

intervention (Teague et al., 1990). Initiatives 

undertaken by both the National Institute on 

Drug Abuse (NIDA) and National Institute on 

Alcohol Abuse and Alcoholism (NIAAA) 

resulted in numerous projects that used case 

management to enhance treatment (Bonham et 

al., 1990; Conrad et al., 1993; Cox et al., 1993; 

Inciardi et al., 1993; Fletcher et al., 1994; Mejta et 

al., 1994). Case management in these projects 

was designed to increase retention in the 

treatment continuum and to improve treatment 

outcomes. 

Definitions and Functions 

Any definition of case management today is 

inevitably contextual, based on the needs of a 

particular organizational structure, 

environmental reality, and prior training of the 

individuals who are implementing it, whether 

they are social workers, nurses, or case 

management specialists. Nonetheless, there is 

relatively widespread agreement on the basic 

definition, as illustrated in Figure1-1. 

While definitions are useful in guiding 

general discussions, functions are a more helpful 

way to approach case management as it is 

actually practiced. As with definitions, there is a 

high degree of consensus about a core group of 

functions. One widely accepted set of functions 

comprises (1) assessment, (2) planning, (3) 

linkage, (4) monitoring, and (5) advocacy (Joint 

Commission on Accreditation of Healthcare 

Organizations, 1979). The National Association 

of Social Workers’ standards for social work 

case management include assessing, arranging, 

coordinating, monitoring, evaluating, and 

advocacy (National Association of Social 

Workers, 1992). 

Figure 1-1 

Definitions of Case Management 

Case management is 

 “planning and coordinating a package of health and social services that is individualized to meet a 

particular client’s needs” (Moore, 1990, p. 444) 

 “[a] process or method for ensuring that consumers are provided with whatever services they need in 

a coordinated, effective, and efficient manner” (Intagliata, 1981) 

 “helping people whose lives are unsatisfying or unproductive due to the presence of many problems 

which require assistance from several helpers at once” (Ballew and Mink, 1996, p. 3) 

 “monitoring, tracking and providing support to a client, throughout the course of his/her treatment 

and after” (Ogborne and Rush, 1983, p. 136) 

 “assisting the patient in re-establishing an awareness of internal resources such as intelligence, 

competence, and problem solving abilities; establishing and negotiating lines of operation and 

communication between the patient and external resources; and advocating with those external 

resources in order to enhance the continuity, accessibility, accountability, and efficiency of those 

resources” (Rapp et al., 1992, p. 83) 

 “assess[ing] the needs of the client and the client’s family, when appropriate, and arranges, 

coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific 

client’s complex needs.” (National Association of Social Workers, 1992, p. 5) 
Chapter 1 

6

There is also general agreement about case 

management functions in the specific context of 

substance abuse treatment. Case management is 

one of eight counseling skills identified by the 

National Association of Alcoholism and Drug 

Abuse Counselors (National Association of 

Alcoholism and Drug Abuse Counselors, 1986) 

and one of five performance domains developed 

in the Role Delineation Study (International 

Certification and Reciprocity Consortium, 1993). 

Another framework is supplied by the 

Addiction Technology Transfer Centers 

(ATTCs), established by CSAT to transmit 

current information on treatment to providers in 

the field. The essential elements of case 

management are laid out in their publication 

Addiction Counseling Competencies: The Knowledge, 

Skills, and Attitudes of Professional Practice (CSAT, 

1998). That document has been endorsed by 

many leading addiction organizations. 

Referral and service coordination are two of 

eight practice dimensions the ATTCs deem 

essential to the effective practice of addiction 

counseling. Activities considered part of those 

two dimensions include engagement; 

assessment; planning, goal-setting, and 

implementation; linking, monitoring, and 

advocacy; and disengagement. The document 

defines service coordination as: 

“The administrative, clinical, and evaluative 

activities that bring the client, treatment 

services, community agencies, and other 

resources together to focus on issues and needs 

identified in the treatment plan. Service 

coordination, which includes case management 

and client advocacy, establishes a framework of 

action for the client to achieve specified goals. It 

involves collaboration with the client and 

significant others, coordination of treatment and 

referral services, liaison activities with 

community resources and managed care 

systems, client advocacy, and ongoing 

evaluation of treatment progress and client 

needs” (CSAT, 1998, p. 53). 

Addiction Counseling Competencies describes 

the knowledge, skills, and attitudes required for 

all eight practice dimensions. Those supporting 

referral and service coordination are reproduced 

in full in Appendix B. 

Models of Case 

Management With 

Substance Abusers 

Case management models, like the definitions of 

case management, vary with the context. Some 

models focus on delivering social services, 

others on coordinating the delivery of services 

by other providers. Some provide both. The 

models result as much from the needs of specific 

client populations and service settings as they 

do from distinct theoretical differences about 

what case management should be. Four models 

from the mental illness field have been adapted 

for the field of substance abuse treatment. Each 

of these models—broker/generalist, strengthsbased, assertive community treatment, and 

clinical/rehabilitation—has proved valuable in 

treating substance abusers in a particular 

setting. 

For example, the strengths-based approach 

was adapted to work with crack cocaine users. 

This approach was chosen not only for its focus 

on resource acquisition but also because it helps 

clients see their own assets as a valuable part of 

recovery (Siegal and Rapp, 1996). Assertive 

community treatment was implemented to 

provide parolees a wide range of integrated 

services, including drug treatment, skills 

building, and resource acquisition. 

Figure 1-2 compares the four models across 

11 activities of case management and specifies 

which models are appropriate for particular 

substance abuse populations. Implementation of 

these models may vary with other populations 

and from setting to setting. 
Introduction 

7

Figure 1-2 

Models of Case Management 

Primary Case 

Management 

Activities 

Broker/Generalist Strengths 

Perspective 

Assertive 

Community 

Treatment 

Clinical/ 

Rehabilitation 

Conducts outreach 

and case finding 

Not usually Depends on 

agency mission & 

structure 

Depends on 

agency mission & 

structure 

Depends on 

agency mission & 

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, 

e.g., therapy, skillsteaching 

Referral to other 

sources for these 

services if 

requested 

Usually limited to 

responding to 

client questions 

about treatment 

issues, education 

about how to 

identify strengths 

and about selfhelp resources 

Provides many 

services within 

unified package of 

treatment/case 

management 

services 

Provision of 

therapeutic 

activities central to 

the model 

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 selfhelp support 

through 

therapeutic 

activities 
Chapter 1 

8

Figure 1-2 Continued 

Primary Case 

Management 

Activities 

Broker/Generalist Strengths 

Perspective 

Assertive 

Community 

Treatment 

Clinical/ 

Rehabilitation 

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 

Provides direct 

services related to 

resource acquisition 

as part of case 

management, e.g., 

drop-in center, 

employment 

counseling 

Referral to 

resources that 

provide direct 

services 

Provides services 

crucial to 

preparing client 

for resource 

acquisition 

activities, e.g., 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; 

skill-teaching 

Appropriate for the following substance abuse populations 

 Injectable drug 

users; HIV positive 

and at-risk 

substance abusers 

Male crack 

cocaine users; 

female 

polysubstance 

abusers 

Chronic public 

inebriates; 

parolees with 

substance abuse 

problems; dually 

diagnosed clients 

Dually diagnosed 

clients; female 

polysubstance 

abusers 
Introduction 

9

Brokerage/Generalist 

Brokerage/generalist models seek to identify 

clients’ needs and help clients access identified 

resources. Planning may be limited to the 

client’s early contacts with the case manager 

rather than an intensive long-term relationship. 

Ongoing monitoring, if provided at all, is 

relatively brief and does not include active 

advocacy. 

Brokerage/generalist models are sometimes 

disparaged in discussions of case management 

because of the limited nature of the client–case 

manager relationship and the absence of 

advocacy. Nonetheless, this approach shares the 

basic foundations of case management and has 

proved useful in selected situations. The 

relatively limited nature of the relationship in 

this model allows the case manager to provide 

services to more clients. This approach is also 

appropriate in instances where treatment and 

social services in a particular area are relatively 

integrated and the need for monitoring and 

advocacy is minimal. The model works best 

with clients who are not economically deprived, 

who have significant intent and sufficient 

resources, or who are not in late-stage addiction. 

Small agencies or agencies that offer narrowly 

defined services may be in an ideal position to 

offer brokerage-only services. 

Two creative uses of a brokerage model 

involved clients who were infected with the 

human immunodeficiency virus (HIV) or who 

were at significant risk of acquiring HIV. In one 

program, case managers also served as 

educators, delivering cognitive, behaviorally 

oriented, educational sessions focusing on 

substance abuse and high-risk behaviors (Falck 

et al., 1992). The mixing of the educator and 

case manager roles was intended to increase 

clients’ receptivity to HIV prevention messages 

by reducing barriers to services that would 

address problems that might divert attention 

from those messages. In another variation of the 

brokerage model, case managers in a large 

metropolitan area conducted extensive 

assessments with HIV-infected clients, generally 

making at least two referrals during the initial 

session. This “quick response” approach was 

intended to provide immediate results to clients 

and to link them with agencies or services that 

would provide ongoing services (Lidz et al., 

1992). 

 Generalist approaches to working with 

substance-abusing clients have taken several 

forms. Case managers in the central intake 

facility of a large metropolitan area performed 

the core functions of case management, linking 

clients with area substance abuse treatment and 

other human service providers. These case 

managers had access to funds for purchasing 

treatment services, thereby drastically reducing 

waiting periods for these services (Bokos et al., 

1993). Another example of a generalist model is 

Providence, Rhode Island’s Project Connect, a 

family-centered, community-based intervention 

program designed to address the problems of 

substance abuse among high-risk families in the 

child welfare system. Staff members provide 

intensive home-based counseling services and 

work with families to obtain other services they 

may need, including safe and affordable 

housing and adequate health care. 

 Assertive Community Treatment 

The Program of Assertive Community 

Treatment (PACT) model, originally developed 

in Wisconsin (Stein and Test, 1980), emphasizes 

the following components 

 Making contact with clients in their homes 

and natural settings 

 Focusing on the practical problems of daily 

living 

 Assertive advocacy 

 Manageable caseload sizes 

 Frequent contact between a case manager 

and client 

 Team approach with shared caseloads 

 Long-term commitment to clients 
Chapter 1 

10

Willenbring and his colleagues were among 

the first to adapt a mental health model for 

persons with substance abuse problems, 

specifically chronic public inebriates 

(Willenbring et al., 1990). Following the tenets 

of PACT, an individual case manager was 

closely supported by a core services team that 

together carried the responsibility for providing 

services. The model deviated from the usual 

approach to dealing with substance abuse 

clients in two ways. First, instead of expecting 

clients to come to services when they “hit 

bottom,” case managers sought out clients 

through a process known as “enforced contact.” 

Second, case managers and the services team 

acknowledged the chronic nature of the client’s 

condition and sought to modify the course of the 

condition and to alleviate suffering. The clients 

were not required to pledge a goal of abstinence. 

A derivation of PACT, the Assertive 

Community Treatment (ACT) model, was used 

with parolees who had histories of injecting 

drugs (Martin and Scarpitti, 1993). In this 

implementation, case managers provided direct 

counseling services and worked with clients to 

develop the skills necessary to function 

successfully in the community. Case 

management staff also provided family 

consultations and crisis intervention services 

and functioned as group facilitators to provide 

skills training in areas such as work skills, 

relapse prevention, and education about 

HIV/AIDS. Departing from the mental health 

tenets of the PACT model, ACT had time limits 

and success goals rather than the continuous 

care envisioned for the mentally ill. 

Achievement of protracted periods of abstinence 

and graduation from treatment continuum 

components were expected of clients (Martin 

and Scarpitti, 1993). Assertive Community 

Treatment has been implemented alone and in 

conjunction with a therapeutic community 

(Martin et al., 1993).

Strengths-Based Perspective 

The strengths-based perspective of case 

management was originally developed at the 

University of Kansas School of Social Welfare to 

help a population of persons with persistent 

mental illness make the transition from 

institutionalized care to independent living 

(Rapp and Chamberlain, 1985). The foremost 

two principles on which the model rests are (1) 

providing clients support for asserting direct 

control over their search for resources, such as 

housing and employment, and (2) examining 

clients’ own strengths and assets as the vehicle 

for resource acquisition. To help clients take 

control and find their strengths, this model of 

case management encourages use of informal 

helping networks (as opposed to institutional 

networks); promotes the primacy of the 

client−case manager relationship; and provides 

an active, aggressive form of outreach to clients. 

A strengths perspective of case management 

has been selected for work with substance 

abusers for three reasons. First is case 

management’s usefulness in helping them 

access the resources they need to support 

recovery. Second, the strong advocacy 

component that characterizes the strengths 

approach counters the widespread belief that 

substance abusers are in denial or morally 

deficient—perhaps unworthy of needed services 

(Bander et al., 1987; Ross and Darke, 1992). Last, 

the emphasis on helping clients identify their 

strengths, assets, and abilities supplements 

treatment models that focus on pathology and 

disease. Strengths-based case management has 

been implemented with both female (Brindis 

and Theidon, 1997) and male substance abusers 

(Rapp, 1997; Siegal et al., 1995). 

 Because of the advocacy component and 

client-driven goal planning, a strengths-based 

approach can at times cause stress between a 

case manager and other members of the 

treatment team (Rapp et al., 1994). Despite this, 

there is evidence that the approach can be 
Introduction 

11

integrated with the disease model of treatment 

and that its presence leads to improved 

outcomes for clients. The improved outcomes 

include employability, retention in treatment, 

and (through retention in treatment) reduced 

drug use (Rapp et al., in press; Siegal et al., 1996; 

Siegal et al., 1997).

Clinical/Rehabilitation 

Clinical/rehabilitation approaches to case 

management are those in which clinical 

(therapy) and resource acquisition (case 

management) activities are joined together and 

addressed by the case manager. It has been 

suggested that the separation of these two 

activities is not feasible over an extended period 

of time and that the case manager must be 

trained to respond to client-focused, as opposed 

to solely environmental issues (Kanter, 1996). 

Client-focused services could include providing 

psychotherapy to clients, teaching specific skills, 

and family therapy. Beyond the usual repertoire 

of case management functions (e.g., monitoring), 

the case manager should be aware of numerous 

issues including transference, 

countertransference, how clients internalize 

what they observe, and theories of ego 

functioning (Harris and Bergman, 1987; Kanter, 

1996). 

Many substance abuse treatment programs 

use a clinical model in which the same treatment 

professional provides, or at least coordinates, 

both therapy and case management activities. 

Such an approach is frequently driven by 

staffing considerations: It is more economical to 

have one treatment professional provide all 

services than to have separate clinical and case 

managers deliver them. 

One example of combining clinical and case 

management activities is found in a program for 

women who have substance abuse problems 

(Markoff and Cawley, 1996). In Project Second 

Beginning, an emphasis on relationships and 

empowerment is used both to secure needed 

resources and to guide implementation of 

therapy activities. This approach is based on the 

belief that women have special needs in the 

treatment setting—needs that can most 

appropriately be addressed through a 

therapeutic relationship with a single caregiver. 

The clinical/rehabilitation approach has been 

widely used in the treatment of persons with 

diagnoses of both substance abuse and 

psychiatric problems (Anthony and Farkas, 

1982; Drake et al., 1993; Drake and Noordsey, 

1994; Lehman et al., 1993; Shilony et al., 1993). 

13

2 Applying Case Management to 

Substance Abuse Treatment 

ase management is almost infinitely 

adaptable, but several broad principles 

are true of almost every application. 

This chapter will discuss those principles, the 

competencies necessary to implement case 

management functions, and the relationship 

between those functions and the substance 

abuse treatment continuum. For the purposes of 

discussion, case management and substance 

abuse treatment are presented as separate and 

distinct aspects of the treatment continuum, 

although in reality they are complementary and 

at times thoroughly blended. 

Case Management 

Principles 

Case management offers the client a single 

point of contact with the health and social 

services systems. The strongest rationale for 

case management may be that it consolidates to 

a single point responsibility for clients who 

receive services from multiple agencies. Case 

management replaces a haphazard process of 

referrals with a single, well-structured service. 

In doing so, it offers the client continuity. As the 

single point of contact, case managers have 

obligations not only to their clients but also to 

the members of the systems with whom they 

interact. Case managers must familiarize 

themselves with protocols and operating 

procedures observed by these other 

professionals. The case manager must mobilize 

needed resources, which requires the ability to 

negotiate formal systems, to barter informally 

among service providers, and to consistently 

pursue informal networks. These include selfhelp groups and their members, halfway and 

three-quarter-way houses, neighbors, and 

numerous other resources that are sometimes 

not identified in formal service directories. 

Case management is client-driven and 

driven by client need. Throughout models of 

case management, in the substance abuse field 

and elsewhere, there is an overriding belief that 

clients must take the lead in identifying needed 

resources. The case manager uses her expertise 

to identify options for the client, but the client’s 

right of self-determination is emphasized. Once 

the client chooses from the options identified, 

the case manager’s expertise comes into play 

again in helping the client access the chosen 

services. Case management is grounded in an 

understanding of clients’ experiences and the 

world they inhabit⎯the nature of addiction and 

the problems it causes, and other problems with 

which clients struggle (such as HIV infection, 

mental illness, or incarceration). This 

understanding forms the context for the case 

manager’s work, which focuses on identifying 

psychosocial issues and anticipating and 

helping the client obtain resources. The aim of 

case management is to provide the least 

C 
Chapter 2 

14

restrictive level of care necessary so that the 

client’s life is disrupted as little as possible. 

Case management involves advocacy. The 

paramount goal when dealing with substance 

abuse clients and diverse services with 

frequently contradictory requirements is the 

need to promote the client’s best interests. Case 

managers need to advocate with many systems, 

including agencies, families, legal systems, and 

legislative bodies. The case manager can 

advocate by educating non-treatment service 

providers about substance abuse problems in 

general and about the specific needs of a given 

client. At times the case manager must 

negotiate an agency’s rules in order to gain 

access or continued involvement on behalf of a 

client. Advocacy can be vigorous, such as when 

a case manager must force an agency to serve its 

clients as required by law or contract. For 

criminal justice clients, advocacy may entail the 

recommendation of sanctions to encourage 

client compliance and motivation. 

Case management is community-based. All 

case management approaches can be considered 

community-based because they help the client 

negotiate with community agencies and seek to 

integrate formalized services with informal care 

resources such as family, friends, self-help 

groups, and church. However, the degree of 

direct community involvement by the case 

manager varies with the agency. Some agencies 

mount aggressive community outreach efforts. 

In such programs, case managers accompany 

clients as they take buses or wait in lines to 

register for entitlements. This personal 

involvement validates clients’ experiences in a 

way that other approaches cannot. It suits the 

subculture of addiction because it enables the 

case manager to understand the client’s world 

better, to learn what streets are safe and where 

drug dealing takes place. This familiarity helps 

the professional appreciate the realities that 

clients face and set more appropriate treatment 

goals—and helps the client trust and respect the 

case manager. Because it often transcends 

facility boundaries, and because the case 

manager is more involved in the community 

and the client’s life, case management may be 

more successful in re-engaging the client in 

treatment and the community than agencybased efforts. For clients who are 

institutionalized, case management involves 

preparing the client for community-based 

treatment and living in the community. Case 

management can ensure that transitions are 

smooth and that obstacles to timely admissions 

into community-based programs are removed. 

Case management can also coordinate release 

dates to ensure that there are no gaps in service. 

The type of relationship described here is likely 

at times to stretch the more narrow boundaries 

of the traditional therapist-client relationship. 

Case management is pragmatic. Case 

management begins “where the client is,” by 

responding to such tangible needs as food, 

shelter, clothing, transportation, or child care. 

Entering treatment may not be a client priority; 

finding shelter, however, may be. Meeting these 

goals helps the case manager develop a 

relationship with and effectively engage the 

client. This client-centered perspective is 

maintained as the client moves through 

treatment. At the same time, however, the case 

manager must keep in mind the difficulty in 

achieving a balance between help that is positive 

and help that may impede treatment 

engagement. For example, the loss of housing 

may provide the impetus for residential 

treatment. Teaching clients the day-to-day skills 

necessary to live successfully and substance free 

in the community is an important part of case 

management. These pragmatic skills may be 

taught explicitly, or simply modeled during 

interactions between case manager and client. 

Case management is anticipatory. Case 

management requires an ability to understand 

the natural course of addiction and recovery, to 

foresee a problem, to understand the options 
Case Management and Treatment 

15

available to manage it, and to take appropriate 

action. In some instances, the case manager may 

intervene directly; in others, the case manager 

will take action to ensure that another person on 

the care team intervenes as needed. The case 

manager, working with the treatment team, lays 

the foundation for the next phase of treatment. 

Case management must be flexible. Case 

management with substance abusers must be 

adaptable to variations occasioned by a wide 

range of factors, including co-occurring 

problems such as AIDS or mental health issues, 

agency structure, availability or lack of 

particular resources, degree of autonomy and 

power granted to the case manager, and many 

others. The need for flexibility is largely 

responsible for the numerous models of case 

management and difficulties in evaluating 

interventions. 

Case management is culturally sensitive. 

Accommodation for diversity, race, gender, 

ethnicity, disability, sexual orientation, and life 

stage (for example, adolescence or old age), 

should be built into the case management 

process. Five elements are associated with 

becoming culturally competent: (1) valuing 

diversity, (2) making a cultural self-assessment, 

(3) understanding the dynamics of cultural 

interaction, (4) incorporating cultural 

knowledge, and (5) adapting practices to the 

diversity present in a given setting (Cross et al., 

1989). 

Case Management 

Practice—Knowledge, 

Skills, and Attitudes 

All professionals who provide services to 

substance abusers, including those specializing 

in case management, should possess particular 

knowledge, skills, and attitudes, which prepare 

them to provide more treatment-specific 

services. The basic prerequisites of effective 

practice include the ability to establish rapport 

quickly, an awareness of how to maintain 

appropriate boundaries in the fluid case 

management relationship, the willingness to be 

nonjudgmental toward clients, and certain 

“transdisciplinary foundations” created by the 

Addiction Technology Transfer Centers (ATTCs) 

(see page 6). These foundations—

understanding addiction, treatment knowledge, 

application to practice, and professional 

readiness—are articulated in 23 competencies 

and 82 specific points of knowledge and 

attitude. Examples of competencies include 

 Understanding a variety of models and 

theories of addiction and other problems 

related to substance use 

 Ability to describe the philosophies, 

practices, policies, and outcomes of the most 

generally accepted and scientifically 

supported models of treatment, recovery, 

relapse prevention, and continuing care for 

addiction and other substance-related 

problems 

 Recognizing the importance of family, social 

networks, and community systems in the 

treatment and recovery process 

 Understanding the variety of insurance and 

health maintenance options available and the 

importance of helping clients access those 

benefits 

 Understanding diverse cultures and 

incorporating the relevant needs of culturally 

diverse groups, as well as people with 

disabilities, into clinical practice 

 Understanding the value of an 

interdisciplinary approach to addiction 

treatment (CSAT, 1998) 

Even though case managers have not always 

enjoyed the same stature accorded other 

specialists in the substance abuse treatment 

continuum, they must possess an equally 

extensive body of knowledge and master a 

complex array of skills in order to provide 

optimal services to their clients. Case managers 
Chapter 2 

16

must not only have many of the same abilities as 

other professionals who work with substance 

abusers (such as counselors), they must also 

possess special abilities relating to such areas as 

interagency functioning, negotiating, and 

advocacy. In recognition of the specific 

competencies applicable to conducting case 

management functions, two of the eight core 

dimensions—referral and service coordination—

provide critical knowledge, skills, and attitudes 

pertinent to case management. Below are the 

activities covered under those dimensions. 

Referral 

 Establish and maintain relations with civic 

groups, agencies, other professionals, 

governmental entities, and the community at 

large to ensure appropriate referrals, identify 

service gaps, expand community resources, 

and help to address unmet needs 

 Continuously assess and evaluate referral 

resources to determine their appropriateness 

 Differentiate between situations in which it is 

more appropriate for the client to self-refer to 

a resource and those in which counselor 

referral is required 

 Arrange referrals to other professionals, 

agencies, community programs, or other 

appropriate resources to meet client needs 

 Explain in clear and specific language the 

necessity for and process of referral to 

increase the likelihood of client 

understanding and follow-through 

 Exchange relevant information with the 

agency or professional to whom the referral 

is being made in a manner consistent with 

confidentiality regulations and professional 

standards of care 

 Evaluate the outcome of the referral 

Service Coordination 

Implement the treatment plan 

 Initiate collaboration with referral source 

 Obtain, review, and interpret all relevant 

screening, assessment, and initial treatmentplanning information 

 Confirm the client’s eligibility for admission 

and continued readiness for treatment and 

change 

 Complete necessary administrative 

procedures for admission to treatment 

 Establish realistic treatment and recovery 

expectations with the client and involved 

significant others including, but not limited 

to 

♦ Nature of services 

♦ Program goals 

♦ Program procedures 

♦ Rules regarding client conduct 

♦ Schedule of treatment activities 

♦ Costs of treatment 

♦ Factors affecting duration of care 

♦ Client rights and responsibilities 

 Coordinate all treatment activities with 

services provided to the client by other 

resources 

Consulting 

 Summarize the client’s personal and cultural 

background, treatment plan, recovery 

progress, and problems inhibiting progress 

for purpose of ensuring quality of care, 

gaining feedback, and planning changes in 

the course of treatment 

 Understand terminology, procedures, and 

roles of other disciplines related to the 

treatment of substance use disorders 

 Contribute as part of a multidisciplinary 

treatment team 

 Apply confidentiality regulations 

appropriately 

 Demonstrate respect and nonjudgmental 

attitudes toward clients in all contacts with 

community professionals and agencies 

(CSAT, 1998) 
Case Management and Treatment 

17

Almost 200 specific knowledge items, skills, and 

attitudes are associated with these dimensions: 

They can be found in Appendix B. 

The Substance Abuse 

Treatment Continuum 

and Functions of Case 

Management 

Substance Abuse Continuum of 

Care 

Substance abuse treatment can be characterized 

as a continuum arrayed along a particular 

measure, such as the gravity of the substance 

abuse problem, level of care—inpatient, 

residential, intermediate, or outpatient (Institute 

of Medicine, 1990)—or intensity of service 

(ASAM, 1997). The continuum in this TIP is 

arranged chronologically, moving from case 

finding and pretreatment through primary 

treatment, either residential or outpatient, and 

finally to aftercare. Inclusion of case finding and 

pretreatment acknowledges the wide variety of 

case management activities that take place 

before a client has actually become part of the 

formal treatment process. 

While distinct goals and treatment activities 

are associated with each point on the 

continuum, clients’ needs seldom fit neatly into 

any one area at a given time. For example, a 

client may need residential treatment for a 

serious substance abuse problem, but only be 

motivated to receive assistance for a housing 

problem. Case management is designed to span 

client needs and program structure. 

Case finding and pretreatment 

The case-finding aspect of treatment is generally 

of paramount concern to treatment programs 

because it generates the flow of clients into 

treatment. Pretreatment has changed 

enormously in the past five years as programs 

have closed, resources have dwindled, and 

services available under managed care plans 

have been severely curtailed. Many individuals 

identified as viable treatment candidates cannot 

get through the gate, and pretreatment may in 

fact constitute brief intervention therapy. 

Treatment programs may undertake casefinding activities through formal liaisons with 

potential referral sources such as employers, law 

enforcement authorities, public welfare 

agencies, acute emergency medical care 

facilities, and managed care companies. Health 

maintenance organizations and managed care 

companies often require case finding when 

hotlines are called. General media campaigns 

and word of mouth also lead substance abusers 

to contact treatment programs. 

Some treatment programs operate aggressive 

outreach street programs to identify and engage 

clients. Outreach workers contact prospective 

clients and offer to facilitate their entry into 

treatment. Although treatment admission may 

be the foremost goal of the worker and the 

treatment program, prospective clients 

frequently have other requests before agreeing 

to participate. Much of the assistance offered by 

outreach workers resembles case management 

in that it is community-based, responds to an 

immediate client need, and is pragmatic. 

A pretreatment period is frequently the 

result of waiting lists or client reluctance to 

become fully engaged in primary treatment. In 

a criminal justice setting, it may be a time to 

prepare clients who are not ready for primary 

treatment because they do not have support 

systems in place and lack homes, transportation, 

or necessary work and living skills. The 

pretreatment period may be when clients lose 

interest in treatment. When the appropriate 

services are provided, however, it may actually 

increase the commitment to treatment at a later 

time. Numerous interventions⎯role induction 

techniques, pretreatment groups, and case 

management⎯have been instituted to improve 

outcomes associated with the pretreatment 
Chapter 2 

18

period (Alterman et al., 1994; Gilbert, 1988; Stark 

and Kane, 1985; Zweben, 1981). 

Primary treatment 

Primary treatment is a broad term used to define 

the period in which substance abusers begin to 

examine the impact of substance use on various 

areas of their lives. The American Society of 

Addiction Medicine (ASAM) delineates five 

categories of primary treatment, characterized 

by the level of treatment intensity: early 

intervention, outpatient services, intensive 

outpatient or partial hospitalization, residential 

or inpatient services, and medically managed 

intensive inpatient services (ASAM, 1997). 

Whatever the setting, an extensive 

biopsychosocial assessment is necessary. This 

assessment provides both the client and the 

treatment team the opportunity to determine 

clinical severity, client preference, coexisting 

diagnoses, prior treatment response, and other 

factors relevant to matching the client with the 

appropriate treatment modality and level of 

care. If not already established during the case 

finding/pretreatment phase, this assessment 

should also consider the client’s needs for 

various resources that case management can 

help secure. 

Aftercare 

Aftercare, or continuing care, is the stage 

following discharge, when the client no longer 

requires services at the intensity required during 

primary treatment. A client is able to function 

using a self-directed plan, which includes 

minimal interaction with a counselor. 

Counselor interaction takes on a monitoring 

function. Clients continue to reorient their 

behavior to the ongoing reality of a pro-social, 

sober lifestyle. Aftercare can occur in a variety 

of settings, such as periodic outpatient aftercare, 

relapse/recovery groups, 12-Step and self-help 

groups, and halfway houses. Whether 

individuals completed primary treatment in a 

residential or outpatient program, they have at 

least some of the skills to maintain sobriety and 

begin work on remediating various areas of 

their lives. Work is intrapersonal and 

interpersonal as well as environmental. Areas 

that relate to environmental issues, such as 

vocational rehabilitation, finding employment, 

and securing safe housing, fall within the 

purview of case management. 

If different individuals perform case 

management and addictions counseling, they 

must communicate constantly during aftercare 

about the implementation and progress of all 

service plans. Because case managers interact 

with the client in the community, they are in a 

unique position to see the results of work being 

done in aftercare groups and provide 

perspective about the client’s functioning in the 

community. Recent findings suggest that the 

case management relationship may be as 

valuable to the client during this phase of 

recovery as that with the addictions counselor 

(Siegal et al., 1997; Godley et al., 1994). 

Aftercare is important in completing treatment 

both from a funding standpoint (many funders 

refuse to pay for aftercare services), as well as 

from the client’s perspective. 

Case Management Functions and 

the Treatment Continuum 

In this section, case management functions are 

presented against the backdrop of the substance 

abuse continuum of care to highlight the 

relationship between treatment and case 

management. The primary difference between 

the two is case management’s focus on assisting 

the substance abuser in acquiring needed 

resources. Treatment focuses on activities that 

help substance abusers recognize the extent of 

their substance abuse problem, acquire the 

motivation and tools to stay sober, and use those 

tools. Case management functions mirror the 

stages of treatment and recovery. If properly 

implemented, case management supports the 

client as she moves through the continuum, 
Case Management and Treatment 

19

encouraging participation, progress, retention, 

and positive outcomes. The implementation of 

the case management functions is shaped by 

many factors, including the client’s place in the 

continuum and level of motivation to change, 

agency mission, staff training, configuration of 

the treatment or case management team, needs 

of the target population, and availability of 

resources. The fact that not all clients move 

through each phase of the treatment continuum 

or through a particular phase at the same pace 

adds to the variability inherent in case 

management. 

Engagement 

Case finding and pretreatment 

Engagement during the case 

finding/pretreatment phase is particularly 

proactive. The case manager frequently needs 

to provide services in nontraditional ways, 

reaching out to the client instead of waiting for 

the client to seek help. Engagement is not just 

meeting clients and telling them that a particular 

resource exists. Engagement activities are 

intended to identify and fulfill the client’s 

immediate needs, often with something as 

tangible as a pair of socks or a ride to the doctor. 

This initial period is often difficult. 

Motivation may be fleeting and access to 

services limited. In many jurisdictions, there is a 

significant wait to schedule an orientation, 

assessment, or intake appointment. Third 

parties responsible for authorizing behavioral 

health benefits may be involved, and client 

persistence may be a key factor in accessing 

services. 

Additional factors may come into play with 

clients referred from the criminal justice system. 

They may be angry about their treatment by the 

criminal justice system and may resent efforts to 

help them. Clients who begin treatment after 

serving time in jail or prison have significant life 

issues that must be addressed simultaneously 

(such as safe housing, money, and other 

subsistence issues) as well as resentment, 

resistance, and anger. Others may have active 

addictions or be engaged in criminal activity. 

Requirements imposed by the criminal justice 

system must also be met; these can present 

conflicts with meeting other goals, including 

participation in substance abuse treatment. 

Potential clients may be unfamiliar with the 

treatment process. Their expectations about 

treatment may not be realistic, and they may 

know very little about substance abuse and 

addiction. It is not uncommon for people at this 

stage to minimize the impact substance use or 

abuse has on their lives. These factors often 

manifest in client behaviors such as missing 

appointments, continued use, excuses, apathy, 

and an unwillingness to commit to change. 

 The goal of case management at this stage is 

to reduce barriers, both internal and external, 

that impede admission to treatment. Client 

reluctance to enter into services can be reduced 

by (1) motivational interviewing approaches; (2) 

basic education about addiction and recovery; 

(3) reminding clients of past and future 

consequences of continued substance abuse; (4) 

assistance in meeting the client’s basic survival 

needs; and (5) commitment to developing the 

case manager-client relationship. Prescreening 

for program eligibility, coordinating referrals, 

and working to reduce any administrative 

barriers can facilitate access to services. 

The process of motivating a client, beginning 

the education process, identifying essential 

needs, and forming a relationship can begin 

during a prescreening or screening interview. 

The motivational approaches suggested by 

Miller and Rollnick encourage client 

engagement through exploratory rather than 

confrontational means (Miller and Rollnick, 

1991). Recognizing that not every client enters 

treatment with the same motivational levels, 

they build on Prochaska and DiClemente’s 

stages of motivation for treatment. The stages 

move from the client’s non-recognition of a 
Chapter 2 

20

problem (precontemplation) to contemplation of 

a need for treatment, to determination, to action, 

and finally, to the maintenance of attained goals 

(Prochaska and DiClemente, 1982). Case 

management can use this framework to engage 

the client with stage-appropriate services. This 

means that clients who have not decided to 

address their substance abuse can often be 

“hooked” into more intensive treatment by 

providing basic practical supports. Providing 

these supports can have the additional effect of 

reducing the perceived desirability of continued 

substance use and the lifestyles associated with 

it. 

A structured interview provides the client 

the opportunity to discuss her drug use and 

history with the case manager and to explore the 

losses that may have resulted from that use. For 

some clients, this history may reveal a pattern of 

increasing loss of control (and perhaps loss of 

freedom). Review and discussion of losses can 

serve to motivate clients to proceed to treatment. 

Listening empathetically and showing genuine 

concern about a client’s well-being can facilitate 

the beginning of a meaningful, supportive 

relationship between the client and the case 

manager and can serve to motivate the client as 

well. A good initial relationship between client 

and case manager can also be invaluable when 

the client experiences difficulties later on in 

treatment (Miller and Rollnick, 1991). 

In addition to information regarding 

substance abuse and the treatment process, 

clients must be informed about requirements 

and obligations of the case manager or case 

management program, and about requirements 

they will be expected to meet once they are 

admitted to treatment. This type of discussion 

presents another opportunity to solidify the 

client’s commitment to participate in treatment. 

Even at the earliest stages, clients should be 

reminded that permanent changes are necessary 

for recovery. Finally, any questions the client 

has should be addressed. This can be 

particularly important for clients referred by the 

criminal justice system, who may be somewhat 

confused about that system’s requirements, the 

consequences of noncompliance, and the 

difficulties they encounter in meeting those 

requirements. 

While case management in the pretreatment 

phase may be intended to route clients to a 

particular program, engagement is not just a 

“come-on” to treatment. Many prospective 

clients will not formally enter treatment within 

an agency-defined period, but, within flexible 

limits, case management services should still be 

made available to these individuals. The 

transition from engagement to planning is a 

gradual one and does not lend itself to agencycreated distinctions such as “pretreatment” and 

“primary treatment.” 

Primary treatment 

For clients who elect to enter treatment, 

engagement serves to orient the client to the 

program. Orientation involves explaining 

program rules and regulations in greater detail 

than was possible or necessary during 

pretreatment. The provider elicits the client’s 

expectations of the program and describes what 

the program expects of the client. The person 

responsible for delivering case management to a 

particular client is in a unique position to assist 

in the match between individual and treatment. 

During primary treatment, the case manager can 

serve as one of the client's links with the outside 

world, assisting the client to resolve immediate 

concerns that may make it difficult to focus on 

dealing with the goal of primary treatment—

coming to grips with a substance abuse 

problem. 

In addition to orienting clients to treatment 

programs, case managers can orient treatment 

programs to the clients they refer. Sharing 

information gathered during the pretreatment 

phase can provide support for the treatment 

process that ensues upon program admission. 
Case Management and Treatment 

21

Aftercare 

While in treatment, most of a client’s time is 

spent dealing with substance use. Although 

discharge plans may have been considered, it is 

not until discharge that the day-to-day realities 

of living assume the most urgency. Because of 

their relationship with their clients and their 

community ties, case managers are well 

positioned to help clients make this delicate 

transition. Case management serves to 

coordinate all aspects of the client’s treatment. 

This coordination occurs within a given 

treatment program, between the program and 

other resources, and among these other 

resources. The extent of the case manager’s 

ability to work on the client’s behalf will be 

guided both by the formal authority vested in 

the individual by the service providers involved 

and by the individual’s informal relationships. 

The case manager’s extensive knowledge of 

the client’s real-world needs can help the client 

who is no longer using. Clients in aftercare have 

an array of needs, including housing, a safe and 

drug-free home environment, a source of 

income, marketable skills, and a support system. 

Many have postponed medical or dental care; in 

recovery, they may seek it for the first time in 

years. Once an individual is in recovery, 

physician-prescribed medication for pain 

management can become a major problem, an 

issue that may require coordination and 

advocacy. 

Assessment 

The primary difference between treatment and 

case management assessments lies in case 

management’s focus on the client’s need for 

community resources. The findings from the 

assessment, including specific skill deficits, basic 

support needs, level of functioning, and risk 

status, define the scope and focus of the service 

plan. 

Case finding and pretreatment 

Depending on the structure and mission of the 

program providing case management, 

assessment may begin when engagement 

begins. It is case management’s role to explore 

client needs, wants, skills, strengths, and deficits 

and relate those attributes to a service plan 

designed to address those needs efficiently. If 

the client is not eligible for a particular case 

manager’s program, the case manager links the 

client with appropriate external treatment 

resources. This process includes assessing the 

client’s eligibility and appropriateness for both 

substance abuse and other services and for a 

specific level of care within those services. If the 

client is both eligible and appropriate for the 

program, the case manager’s role is to engage 

the client in treatment. 

Primary treatment 

For clients who enter primary treatment, the 

case management assessment function, which is 

primarily oriented to the acquisition of needed 

resources, is merged with an assessment that 

focuses on problems amenable to 

therapy⎯substance use, psychological 

problems, and family dysfunction. Ideally both 

assessments are integrated into a 

biopsychosocial assessment (Wallace, 1990). 

This biopsychosocial assessment should, at a 

minimum, examine the client’s situation in the 

life domains of housing, finances, physical 

health, mental health, vocational/educational, 

social supports, family relationships, recreation, 

transportation, and spiritual needs. Detailed 

information should be gathered on drug use, 

drug use history, health history, current medical 

issues, mental health status, and family drug 

and alcohol use. This assessment, used in 

conjunction with the needs assessment, assists 

the treatment team in developing a formal 

treatment plan to be presented to, modified, and 

approved by the client. Whether one person or 

several conduct these two assessments is largely 
Chapter 2 

22

irrelevant. Where a team approach exists, all 

members of the team, including the case 

manager or other professional identified in that 

role, should bring their expertise to the 

assessment. Discharge planning and long-range 

needs identification, particularly with current 

funding limitations, begins at treatment 

admission. Because of this, intensive case 

management for substance abuse clients, 

regardless of the level of care, is imperative. 

As the individual responsible for 

coordinating diverse services, the case manager 

must take a broad view of client needs, look 

beyond primary therapy to the impact of the 

client’s addiction on broader domains, and 

assess the impact of these domains on the 

client’s recovery. He also must assess specific 

areas of functional skill deficits, including 

personal living skills, social or interpersonal 

skills, service procurement skills, and vocational 

skills. Individuals performing this function 

need to have strong knowledge of and 

experience in the field of substance abuse. The 

greater the number of problems the case 

manager can help the client identify and manage 

during primary treatment, the fewer problems 

the client must address during aftercare and 

ongoing recovery⎯and the greater the chances 

for treatment success. 

A case management assessment should 

include a review of the following functional 

areas (Harvey et al., 1997; Bellack et al., 1997). 

These items are not exhaustive, but demonstrate 

some of the major skill and service need areas 

that should be explored. The assessment of 

these areas of functioning gives evidence of the 

client’s degree of impairment and barriers to the 

client’s recovery. The case manager may have to 

perform many services on behalf of the client 

until skills can be mastered. 

Service procurement skills 

While the focus of case management is to assist 

clients in accessing social services, the goal is for 

clients to learn how to obtain those services. 

The client should therefore be assessed for 

 Ability to obtain and follow through on 

medical services 

 Ability to apply for benefits 

 Ability to obtain and maintain safe housing 

 Skill in using social service agencies 

 Skill in accessing mental health and 

substance abuse treatment services 

Prevocational and vocation-related 

skills 

In order to reach the ultimate goal of 

independence, clients must also have vocational 

skills and should therefore be assessed for 

 Basic reading and writing skills 

 Skills in following instructions 

 Transportation skills 

 Manner of dealing with supervisors 

 Timeliness, punctuality 

 Telephone skills 

The case management assessment should 

include a scan for indications of harm to self or 

others. The greater the deficits in social and 

interpersonal skills, the greater the likelihood of 

harm is to self and/or others, as well as 

endangerment from others. The case manager 

should also conduct an examination of criminal 

records. If the client is under the supervision of 

the criminal justice system, supervision officers 

should be contacted to determine whether or not 

there is a potential for violent behavior, and to 

elicit support should a crisis erupt. 

Aftercare 

The client’s readiness to reintegrate into the 

community is a focus of case management 

assessment throughout the treatment 

continuum. Because the case manager is often 

out in the community with the client, she is in an 

excellent position to evaluate this important 

indicator. During aftercare, her assessment may 

reveal new, recurring, or unresolved problems 

the client must deal with before they interfere 

with recovery. The potential for relapse is a 
Case Management and Treatment 

23

particularly significant challenge, and the client 

must be able to identify personal relapse triggers 

and learn how to cope with them. Because case 

managers are familiar with the community, 

clients, and substance abuse treatment issues, 

they can spot such triggers and intervene 

appropriately. If, for example, a case manager 

fears that a client’s decision to return to a 

familiar neighborhood could result in contact 

with drug-using friends that could jeopardize 

sobriety, a new residence may be necessary. 

Planning, goal-setting, and 

implementation 

Flowing directly and logically from the 

assessment process, planning, goal-setting, and 

implementation comprise the core of case 

management. Based on the biopsychosocial or 

case management assessment, the client and 

case manager identify goals in all relevant life 

domains, using the strengths, needs, and wants 

articulated in the assessment process. Service 

plan development and goal-setting are 

discussed in detail in numerous works on 

substance abuse and case management (Ballew 

and Mink, 1996; Rothman, 1994; Sullivan, 1991). 

These authors agree on several points: Each 

goal in service plans should be broken down 

into objectives and possibly into even smaller 

steps or strategies that are behaviorally specific, 

measurable, and tangible. Distinct, manageable 

objectives help keep clients from feeling 

overwhelmed and provide a benchmark against 

which to measure progress. Goals, objectives, 

and strategies should be developed in 

partnership with the client. They should be 

framed in a positive context—as something to be 

achieved rather than something to be avoided. 

Time frames for completing the objectives and 

strategies should be identified. Abbreviated, 

user-friendly treatment planning templates 

make client participation in development of a 

service plan more likely. The availability of staff 

to assist in the planning, goal-setting, and 

implementation of the case management aspects 

of the treatment plan is crucial. 

Successful completion of an objective should 

provide the client the satisfaction of gaining a 

needed resource and demonstrating success. 

Failure to complete an objective should be 

emphasized as an opportunity to reevaluate 

one’s efforts. In the latter situation, the case 

manager should be prepared to help the client 

come up with alternative approaches or to begin 

an advocacy process. 

A deliberate, carefully considered approach 

to identifying client goals offers benefits that go 

beyond the actual acquisition of needed 

resources. Clients benefit by 

 Learning a process for systematically setting 

goals 

 Understanding how to achieve desired goals 

through the accomplishment of smaller 

objectives 

 Gaining mastery of themselves and their 

environment through brainstorming ways 

around possible barriers to a particular goal 

or objective 

 Experiencing the process of accessing and 

accepting assistance from others in goalsetting and goal attainment 

These and other individually centered 

outcomes make the planning and goal-setting 

process as important as the final outcome in 

some cases. This is the action stage of case 

management, when the client participates in 

many new or foreign activities and may have 

multiple requirements imposed by multiple 

programs or systems. Many significant and 

stressful transitions may be involved—from 

substance use to abstinence, from 

institutionalization or residential placement to 

community reintegration, and from a drug- or 

alcohol-using peer group to new, abstinent 

friends. As clients struggle to stop using, many 

will relapse, sometimes after a significant period 

of abstinence. They may feel overwhelmed, and 
Chapter 2 

24

it is not uncommon for clients in recovery to 

experience feelings of isolation and depression 

as they develop new peer associations and 

lifestyle patterns, and come to grips with their 

losses. In addition, the very real pressures of 

finances, employment, housing, and perhaps 

reunifying with and caring for children can be 

very stressful. 

Case finding and pretreatment 

During the pretreatment phase the planning 

function of case management focuses on 

supporting clients in achieving immediate needs 

and facilitating their entry into treatment. 

Ideally, the professional implementing case 

management meets with the client to plan the 

goals and objectives for the service plan. While 

planning and goal setting are important in this 

early stage of treatment, it may be difficult to 

follow traditional approaches given the 

immediacy of clients’ needs and the possibility 

that they are still using alcohol or other drugs. 

The case manager may decide to complete a 

formal plan after an action is undertaken and 

present it to the client as a summary of work 

that was accomplished. If a client’s capacity is 

diminished by substance abuse and the presence 

of multiple, serious life problems, the case 

manager may have to delay teaching and 

modeling for the client, and instead trade on his 

own contacts, resources, and abilities. As the 

client progresses through the treatment 

continuum, the case manager can turn more and 

more of the responsibility for action over to the 

client. 

Clients who are using addictive substances 

while receiving case management services 

present a significant dilemma for the case 

manager. On the one hand, the client may not 

be willing or able to participate in treatment; on 

the other, treatment providers normally expect 

some commitment to sobriety before clients 

begin the treatment process. As a result, the 

case manager frequently needs to negotiate 

common ground between client and program. 

For example, a case manager might require the 

client to identify and make progress toward 

mutually understood goals pending entry into 

treatment. Structured correctly, such an 

approach fosters a win-win situation. 

Attainment of these goals either eliminates the 

client’s need for treatment or prepares him to 

accept treatment more willingly. Even if the 

client is unwilling or unable to achieve those 

goals, the case manager and treatment program 

have additional information to use in attempting 

to motivate the client to seek treatment. 

Primary treatment 

During primary treatment, the case manager 

and client develop a service plan that identifies 

and proposes strategies to meet the client’s 

short- and medium-term needs. The case 

management plan should reflect the level and 

intensity of the service along with the client’s 

specific objectives. Virtually all clients have 

multiple needs; consequently, the service plan 

should be structured to enable clients to focus 

on addressing their problems while they 

participate in treatment. The idea that one can 

put lack of housing, employment issues, or a 

child’s illness aside to concentrate exclusively on 

addiction treatment and recovery is unrealistic 

and sets up both the treatment provider and the 

client for failure. At the same time, it is often 

necessary for the client and case manager to 

prioritize problems. 

During primary treatment, the case manager 

must (1) continue to motivate the client to 

remain engaged and to progress in treatment; 

(2) organize the timing and application of 

services to facilitate client success; (3) provide 

support during transitions; (4) intervene to 

avoid or respond to crises; (5) promote 

independence; and (6) develop external support 

structures to facilitate sustained community 

integration. Case management techniques 

should be designed to reduce the client’s 

internal barriers, as well as external barriers that 

may impede progress. 
Case Management and Treatment 

25

Providing ongoing motivation to clients is 

critical throughout the treatment continuum. 

Clients need encouragement to commit to 

entering treatment, to remain in treatment, and 

to continue to progress. The case manager must 

continually seek client-specific incentives. 

Clients are encouraged by different factors, and 

the same client may respond differently 

depending on the situation. For instance, many 

clients referred by the criminal justice system 

will be initially motivated to try treatment in 

order to avoid a jail sentence; they may be 

motivated to stay in treatment for very different 

reasons (e.g., they start to feel better, they hope 

to regain custody of children). The treatment 

process is difficult, and many clients become 

discouraged after their initial enthusiasm. 

Recovery may require them to explore 

uncomfortable issues. Physical discomfort, as 

well as depression, can ensue. Case managers 

can provide support during these periods by 

supplying information on coping techniques 

such as exercise, diet, and leisure activities. If 

depression is significant, case managers can 

work with substance abuse counselors to have a 

mental health evaluation conducted, and, if 

appropriate, enable the client to seek additional 

therapeutic support for the depression. 

Continued empathetic caring can also motivate 

clients. 

Disincentives may also be used. For 

example, the case manager might remind clients 

of the outcome of terminating treatment—for 

some, this might mean a return to prison, for 

others it might mean dealing with the health or 

safety consequences of addictive behaviors. For 

clients under the control of the criminal justice 

system, sanctions, including possible jail stays, 

may be necessary to regain commitment and 

motivation. 

In criminal justice settings, particularly drug 

courts, regular “status hearings” before a judge 

may motivate the client. In status hearings, the 

judge is informed of the client’s progress (or lack 

thereof), and engages the client in a dialogue. 

The judge can then apply rewards 

(encouragement, or reduction of criminal 

sanctions), adjust treatment requirements, or 

apply sanctions. Sanctions vary, but may 

include warnings, community service, short jail 

stays, or ultimately, termination from the 

program and incarceration. 

Another fundamental role of case 

management during the active treatment phase 

is to coordinate the timing of various 

interventions to ensure that the client can 

achieve his goals. The case manager has to work 

with the client to balance competing interests, 

and to develop strategies so the client can meet 

basic survival needs while in treatment. For 

example, a case manager may have to negotiate 

between probation and treatment to ensure that 

the client can attend treatment sessions and 

meet with his probation officer. Some activities 

require staging to ensure that they are applied at 

the right time and in the correct order. Clients 

who are unemployed and lack employment 

skills, for instance, should begin job readiness 

and training activities after they are stabilized in 

treatment; they will need additional support for 

seeking and maintaining employment. It is not 

uncommon for clients to feel they can take on 

the world once they are stabilized in treatment. 

If this is the case, the job of the case manager is 

to encourage clients to go slowly and take on 

responsibility one step at a time. This can be 

particularly critical for women anxious to 

reconnect with their children. The financial and 

emotional responsibilities are great, and the case 

manager should work with the woman and 

child protective services to transition these 

responsibilities in manageable ways. 

Transition among programs—from 

institutional programming to residential 

treatment; from residential treatment to 

outpatient; or to lower level services within an 

outpatient setting — is always stressful, and 

frequently triggers relapse. In order to avoid 
Chapter 2 

26

crises during transitions, case managers should 

intensify their contact with clients. Case 

managers should work to ensure that service is 

not interrupted. When possible, release dates 

should be coordinated to coincide with 

admission to the next program. 

If the client is under the control of the 

criminal justice system, the case manager should 

work to ensure that supervision activities 

remain the same or increase when treatment 

activity decreases. Too frequently, a client 

completes a treatment program and is moved to 

a lower level of supervision at the same time. 

This pulls out support all at once. If possible, 

supervision and treatment activities should be 

coordinated to promote gradual movement to 

independence in order to reduce the likelihood 

of relapse. 

In addition to activities designed to avoid a 

crisis or relapse, the case manager should be 

available to respond to relapses and crises when 

they do occur. In many cases, the case manager 

leads the response effort. Case managers should 

be in frequent contact with the treatment 

program to check on client attendance and 

progress. Lapses in attendance and/or poor 

progress can signal an impending crisis, and a 

case conference should be held. The case 

conference can resolve problems and prevent 

the client’s termination from the program. 

While violence toward staff or other patients is 

obviously adequate grounds for immediate 

program termination, other infractions do not 

necessarily warrant expulsion. The case 

management team and client should work 

together to develop alternatives that will keep 

the client engaged in treatment. If removal from 

the program is absolutely necessary, it may be 

possible to have the client readmitted after he 

“adjusts his attitude” and re-commits to 

treatment and to obeying the rules. 

The Treatment Alternatives for Safe 

Communities (TASC) Project has developed a 

special form of case conference, known as 

“jeopardy meetings” for treatment clients 

involved in the criminal justice system. These 

meetings are attended by the case manager, 

treatment counselor, probation officer, client, 

and anyone else involved in the case. The 

purpose of the meeting is to confront the client 

with the problem, and to discuss its resolution 

as a team. The client must agree to the proposed 

resolution in writing. The jeopardy meeting 

provides a clear warning to the client (three 

jeopardy meetings can result in client 

termination); reduces the “triangulation” or 

manipulation that can occur if all parties aren’t 

working in a coordinated fashion; and brings 

together the skills and resources of multiple 

agencies and professionals. (For more on 

jeopardy meetings, including structure and 

format, see the TASC Implementation Guide

(Bureau of Justice Assistance, 1988). 

Aftercare 

One of the anticipatory roles for case 

management during primary care is to plan for 

aftercare, discharge, and community reentry. 

During primary care and into aftercare, the case 

manager helps the client master basic skills 

needed to function independently in the 

community, including budgeting, parenting, 

and housekeeping. Short-term goals 

increasingly become supplanted by long-term 

goals of integrating the individual into a 

recovery lifestyle. When appropriate, service 

plans should reflect an ever-increasing emphasis 

on clients’ accepting greater responsibility for 

their actions. The case management 

intervention may increase or decrease in 

intensity, depending on client response to 

independence and progress toward community 

reintegration. 

Linking, monitoring, and advocacy 

Some findings suggest that while persons with 

substance abuse problems are generally adept at 

accessing resources on their own without case 

management, they often have trouble using the 
Case Management and Treatment 

27

services effectively (Ashery et al., 1995). This is 

where the linking, ongoing monitoring, and, in 

many cases, advocacy, of case management can 

be valuable. An additional crucial function of 

case management is coordinating all the various 

providers and plans and integrating them into a 

unified whole. 

Linking goes beyond merely providing 

clients with a referral list of available resources. 

Case managers must work to develop a network 

of formal and informal resources and contacts to 

provide needed services for their clients. 

Case finding and pretreatment 

Case managers may be especially active in 

providing linking and advocacy during the 

pretreatment phase of the treatment continuum. 

As with each of the case management functions, 

the roots of linking begin much earlier, while 

conducting an assessment with the client and in 

creating goals in which the client is vested. The 

authors of one primer on case management 

identify five tasks related to linking that should 

be undertaken with the client before actual 

contact with a needed resource even occurs. 

Case managers must (1) enhance the client’s 

commitment to contacting the resource; (2) plan 

implementation of the contact; (3) analyze 

potential obstacles; (4) model and rehearse 

implementation; and (5) summarize the first 

four steps for the client (Ballew and Mink, 1996). 

Primary treatment 

After the linkage is made, the case manager 

moves on to monitoring the fit and relationship 

between client and resource. Monitoring client 

progress, and adjusting services plans as 

needed, is an essential function of case 

management. Coupled with monitoring is the 

need to share client information with relevant 

parties. For instance, if a client who is involved 

in the criminal justice system tests positive for 

drugs, both the treatment counselor and the 

probation officer may need to know. If the case 

manager is aware that the client is having 

problems at work, this information may need to 

be shared with the treatment provider, within 

the constraints of confidentiality regulations. 

Case managers who are responsible for 

offenders in treatment may oversee regular drug 

testing. This is an effective way to obtain 

objective information on a client’s drug use, as 

well as to structure boundaries for the client to 

help prevent relapse. 

Monitoring may reveal that the case manager 

needs to take additional steps on the client’s 

behalf. Simply put, advocacy is speaking out on 

behalf of clients. Advocacy can be precipitated 

by any one of a number of events, such as 

 A client being refused resources because of 

discrimination, whether discrimination is 

based on some intrinsic aspect of the client, 

such as gender or ethnicity, or on the nature 

of the client’s problems, such as addiction 

 A client being refused services despite 

meeting eligibility requirements 

 A client being discharged from services for 

reasons outside the rules or guidelines of that 

service 

 A client being refused services because they 

were previously accessed but not utilized 

 The case manager’s belief that a service can 

be broadened to include a client’s needs 

without compromising the basic nature of 

the service 

Advocacy on behalf of a client should always 

be direct and professional. Advocacy can take 

many forms, from a straightforward discussion 

with a landlord or an employer, to a letter to a 

judge or probation officer, to reassuring the 

community that the client’s recovery is stable 

enough to permit reentry. Advocacy often 

involves educating service providers to dispel 

myths they may believe about substance 

abusers, or ameliorating negative interactions 

that may have taken place between the client 

and the service provider. This is particularly 

important for certain groups with whom some 
Chapter 2 

28

programs are reluctant to work, such as clients 

with AIDS/HIV or clients involved in the 

criminal justice system. 

More complicated advocacy involves, for 

example, appealing a particular decision by a 

service staff member to progressively higher 

levels of authority in an organization. The 

highest, most involved levels of advocacy 

include organizing a community response to a 

particular situation or initiating a legal process. 

Modrcin and colleagues provide an advocacy 

strategy matrix that can help case managers 

systematically plan advocacy efforts (Modrcin et 

al., 1985). In this view of advocacy, the levels at 

which advocacy can be effected (individual, 

administrative, or policy) are weighed against 

varying approaches (positive, negative, or 

neutral). Three guidelines for advocating on 

behalf of a client are getting at least three “No’s” 

before escalating the advocacy effort, 

understanding the point of view of the 

organization that is withholding service, and 

consulting with supervisory personnel regularly 

before moving to the next level of advocacy 

(Sullivan, 1991). 

Client advocacy should always be geared 

toward achieving the goals established in the 

service plan. Advocacy does not mean that the 

client always gets what she wants. Particularly 

for clients whose continued drug use or 

cessation of treatment will present considerable 

negative consequences such as incarceration or 

death, advocacy may involve doing whatever it 

takes to keep them in treatment, even if that 

means recommending jail to get them stabilized. 

It is not uncommon, in fact, for clients to state 

their preference for jail when treatment gets 

difficult. Even when advocating for clients, the 

case manger must respect system boundaries. 

For example, a case manager might negotiate 

hard to keep an offender client in communitybased treatment, but agree to inform the 

probation office of positive drug tests or 

suspected criminal behavior. While advocacy 

for certain client populations is essential, 

concern for the client should not override goals 

of public safety. Effective, client-centered 

advocacy may put the case manager in a 

position of conflict with co-workers, program 

administrators, or even supervisors. Case 

managers who advocate for an extension of 

benefits for their clients may put themselves and 

their supervisors in jeopardy with funding 

sources. A coordinated infrastructure with 

existing policies and procedures for client 

centered collaboration will help. 

Disengagement 

Disengagement in the case management setting, 

as with clinical termination, is not an event but a 

process. In some ways, the process begins 

during engagement. For both client and case 

manager, it entails physical as well as emotional 

separation, set in motion once the client has 

developed a sense of self-efficacy and is able to 

function independently. To a significant degree, 

this decision can be based on progress defined 

by the service plan. If the plan has truly been 

developed with the client’s active involvement, 

there will be a great deal of objective 

information that will help both the case manager 

and client decide when disengagement is 

appropriate. It is preferable that disengagement 

be planned and deliberate rather than have the 

relationship end in a flurry of missed 

appointments, with no summary of what has 

been learned by the client and professional. 

Formal disengagement gives clients the 

opportunity to explore what they learned about 

interacting with service providers and about 

setting and accomplishing goals. The case 

manager has a chance to hear from clients what 

they considered beneficial—or not beneficial—

about the relationship. Reviewing and 

summarizing client progress can be an 

important aspect of consolidating clients’ gains 

and encouraging their future ability to access 

resources on their own. 
29

3 Case Management in the 

Community Context: An 

Interagency Perspective

he goal of interagency case management 

is to connect agencies to one another to 

provide additional services to clients. 

All organizations have boundaries; case 

managers or “boundary spanners” move across 

them to facilitate interactions among agencies 

(Steadman, 1992). While numerous researchers 

have investigated the nature of these 

connections (Tausig, 1987; Van de Ven and 

Ferry, 1980; DiMaggio, 1986), a 1994 network 

analysis of the “cracks in service delivery 

system” provides especially useful insights into 

the function and impact of various types of 

community linkages (Gillespie and Murty, l994). 

According to Gillespie and Murty, agencies can 

be categorized by the connections they maintain 

with other community-based agencies. Isolates, 

the first category of agencies or programs, 

operate self-sufficiently and establish no 

connections to other organizations in the 

community. Peripherals establish single or 

limited linkages with other agencies and social 

providers. A third category of agencies, which 

the investigators leave unnamed, form effective 

multiple connections with other organizations. 

Applying Gillespie and Murty’s classification 

scheme to substance abuse case management 

yields three interorganizational models. The 

three models are 

 The single agency 

 The informal partnership 

 The formal consortium 

The single agency model is used by such 

traditional community-based organizations as 

grassroots domestic violence programs and 

numerous medically oriented substance abuse 

treatment agencies. In the single agency model, 

the case manager personally establishes a series 

of separate relationships on an as-needed basis 

with professional colleagues or counterparts in 

other agencies. The case manager retains full 

and autonomous control over the case and is 

accountable only to the parent agency. 

In the informal partnership model, staff 

members from several agencies work 

collaboratively, but informally, as a temporary 

team constituted to provide multiple services for 

needy clients on a case-by-case basis. The 

partnership can involve case managers from two 

programs or agencies who consult with one 

another on problematic cases and exchange 

resource information. The partnership also can 

consist of case managers and other types of 

providers from two or more agencies who meet 

on an informal basis to integrate and coordinate 

services in response to clients’ needs. 

Responsibility for a client’s well-being is shared, 

T 
Chapter 3 

30

although accountability for the actual services 

provided remains with the individual agencies. 

The formal consortium model links case 

managers and service providers through a 

formal, written contract. Agencies work 

together for multiple clients on an ongoing basis 

and are accountable to the consortium. To 

ensure coordination among consortium 

members, a single agency typically takes the 

lead in coordinating activities and maintains 

final control over selected resources and 

interagency processes (Cook, l977). A formal 

consortium can enhance the systems of care for 

substance abuse clients. For example, 

Providence, Rhode Island’s Project Connect 

sponsors a Coordinating Committee that meets 

monthly on behalf of shared clients. Substance 

abuse treatment programs, child welfare staff, 

managed care providers, health care providers, 

and representatives from the domestic violence 

community come together to exchange 

information and coordinate services. This 

forum offers all participants an opportunity to 

get to know each other, collaborate, and 

advocate on behalf of substance abuse-affected 

families. 

Characteristics of the 

Three Models 

All three models describe arrangements for 

interagency case management services and 

methods for dispensing them. The most 

appropriate model for a particular agency or 

program hinges on its own history and mission, 

the needs of its clients, and the environment in 

which it operates. In developing a model, it is 

important to remember that neither 

organizations nor environments are static, and 

interagency models may evolve in complexity 

from the single agency to the informal 

partnership to the formal consortium. Although 

each model has advantages and disadvantages, 

a model’s fit with its clients, the agency, and 

environmental conditions determines its 

effectiveness for a particular program (Rothman, 

1992). Figure 3-1 summarizes the characteristics, 

advantages, and disadvantages of each 

organizational model. 

Each model offers distinctive strengths 

suitable for a particular organizational 

environment. For example, in rural areas that 

depend on “one-stop shopping” social service 

programs, the relatively low-cost single agency 

focus, with its capacity to respond quickly and 

authoritatively, may be the optimal choice. On 

the other hand, the informal partnership tends 

to deliver more diverse services, so it is better 

suited to culturally diverse communities. In 

communities dominated by managed care, a 

gatekeeper must make referrals for every 

service, and a formal consortium may be the 

best choice to supply the necessary 

documentation. 

Besides determining resource acquisition, 

organizational environments impinge on 

program decisions in other, less obvious ways. 

In a volatile environment, a single focus agency 

with its rapid startup and minimal up-front 

investment may provide the only sensible 

alternative. Where shared services can produce 

savings through economies of scale, the 

partnership arrangement may maximize scarce 

resources. In an environment in which program 

operations are routinely disrupted by political 

upheaval, a formal consortium with its 

mandated procedures may provide the stability 

and continuity necessary to ensure that case 

management services survive. 
Interagency Case Management 

31

Figure 3-1 

Characteristics of the Three Interagency Models 

Single Agency 

Characteristics 

 Small grassroots agency or major provider of services for a single problem or to a single population 

(may be “the only game in town“) 

 Tends to control a niche in the social service market by default (other agencies are not interested or 

refuse to serve clients), history, design, or funding mandate 

 Often developed in response to an “acute” situation and implemented quickly 

 Less focused on organizational process than other case management models; more focused on clientrelated tasks 

 Interagency case management services built on informal agreements 

 Case manager hired by and accountable solely to the single agency 

Positive Features 

 Responds to crises quickly 

 Tends toward more cohesive or homogeneous values than other models 

 Tends to have single point of access to substance abuse treatment or other services for clients 

 Agency maintains sole control over implementation and coordination of case management program 

 Clients relate to a single individual concerning all problems 

 Often can respond more flexibly to individual client needs 

 Has the opportunity to exercise a broad range of skills 

 Is self-determining and self-accountable (monitors its own services) 

Negative Features 

 Less control over social environment (e.g., policies and funding) and accessibility to services 

 Less influence over broad policies affecting case management services 

 Without a broad constituency and widespread community support, more vulnerable when funding 

wanes or ends 

 More responsibility or burden on front-line case management staff to establish connections with 

other community agencies 

 Case manager may feel especially burdened or taxed by having sole responsibility for client 

 Can require considerable training to equip case manager to deal autonomously with the diverse 

needs of clients 

 Limited mix of services available to clients 

 Limited array of outcomes or solutions for client problems 
Chapter 3 

32

Figure 3-1 Continued 

Informal Partnership 

Characteristics 

 Establishes and maintains informal partnerships or networks to respond to the needs of multiple 

populations with multiple problems 

 Initial motivation for forming partnerships may have been funding-driven as well as need-driven 

 Front-line case management staff from partnership agencies meet informally as a group (and without 

a formal contractual obligation) to discuss client cases 

 Supervisors and other staff also may become involved and form relationships to share client-related 

concerns 

 Staffing decisions are made internally by individual agencies 

 May evolve from a single agency model or be the model of choice from program inception 

 Less likely to have a lead agency than a formal consortium 

Positive Features 

 Meets and functions only as needed 

 Avoids overlap of services 

 Has access to broader set of resources than single agency model 

 Coordinates care better among agencies at client level 

 Counters staff’s feelings of isolation by sharing burden of client responsibility 

 Shares information and possibly resources with partner agencies 

Negative Features 

 Multiple problem orientations of partnership members may conflict with one another 

 More opportunity to compromise individual agency goals with respect to clients 

 Not as quick to respond to emerging problems as single agency model case management 

 Investment of staff and time resources greater than for single agency models (e.g., time to attend 

meetings) 

 Possible breakdown of service coordination among multiple providers may result in service gaps 

and fragmented care 

 Clients may find it difficult to relate to multiple providers 

Formal Consortium 

Characteristics 

 Two or more providers linked by a formal contractual arrangement 

 Represents multiple values and philosophies 

 Agencies cooperate and work together for a common purpose, which is formalized in the contractual 

relationship 

 Agencies represent or cover multiple resources (e.g., housing and employment) in a particular social 

service market 

 Typically identifies a lead agency (often the agency that funds or obtained the funds for case 

management services) to coordinate the consortium’s case management services 

 The case manager may be supported through pooled resources from members of the consortium or 

by the lead agency 
Interagency Case Management 

33

Figure 3-1 Continued 

 The lead agency generally hires the case manager, although multiple agencies within the consortium 

may participate in the selection process 

 Accountability is shared across agencies 

 Case manager is accountable to the consortium 

 Entities primarily responsible for building and supporting the consortium (e.g., United Way; State, 

county, or city government; National Institutes of Health; or Centers for Disease Prevention and 

Control) may impose conditions or constraints on the case management process (e.g., mandated 

community involvement) 

 Takes time and effort to develop; requires substantial up-front investment 

 Focuses more on organizational process than other interagency case management models 

 Tends to have a longer-term or more chronic orientation than other case management models 

Positive Features 

 Access to more resources 

 Broader structure of constituent, political, and community support when resources are limited or the 

economy is strained 

 More control in shaping the environment in which services are provided (e.g., more input into and 

control over policies, funding, and the kind of case management interventions and services that are 

offered) 

 More opportunities for coordination of care among agencies at both client and system level 

 Regularized contact between agencies increases occasions for strengthening service integration 

 Enhanced coordination across providers can decrease duplication of services 

 Consortium participants share information regarding changes in the organizational environment, 

available and declining resources, and treatment information 

Negative Features 

 Can be slow to respond due to problems of coordination 

 Must contend with multiple definitions of a problem or solution that may spark conflict among 

consortium members 

 Time devoted to organizational process may reduce time given to client-related tasks 

 Clients may find it difficult to relate to multiple providers 

 Clients may need to travel to several locations for services 

 Multiple agency participation per case may involve higher costs and less intense personnel/agency 

involvement, without added benefit to client 

 Potential systemic conflict over which agency takes lead and whose philosophy prevails when 

differences occur 

Forging the Linkages 

Interagency case management arrangements are 

designed to help providers connect with each 

other to improve client services and enhance the 

efficiency of their respective organizations. In 

addition to trading useful information, agencies 

also may exchange services, money, clients, and 

client service slots. In the area of substance 

abuse treatment, some case managers and 

addiction specialists may be former users 

themselves and may have known one another in 

their former lives (Brown, l991). These ties often 

strengthen or facilitate interagency exchanges 
Chapter 3 

34

and relations. Seasoned case managers tend 

over time to form personal working 

relationships with others in the field and often 

trade on prior contact, previous service 

reciprocities, and favors owed to get services for 

clients (Levy et al., l992). Informal “quid pro 

quo” arrangements are common, as are shared 

resources to effect economies of scale. 

While this system of informal exchange or 

“social service bartering” is intrinsic to case 

management, a more formalized connection 

among agencies sometimes may be required. 

Examples include memoranda of understanding 

(MOUs) and interagency agreements and 

contracts. Each of these methods for formalizing 

expectations can be used in single agency 

models, informal partnerships, and formal 

consortia. 

MOUs are a means to structure a relationship 

among agencies. When agencies rely heavily on 

each other’s services and function primarily as 

brokers for their clients, MOUs are essential. 

They specify such crucial information as the 

number of service slots that agencies will make 

available to one another’s clients and the 

consequences for failure to implement or 

comply with specified activities or procedures. 

Program managers, rather than case managers, 

typically draft MOUs and other formal 

agreements and contracts with staff input. They 

are particularly useful for 

 Ensuring continuity of services during staff 

turnover 

 Clarifying lines of authority and control over 

various aspects of the case management 

process 

 Recording commitments for providing or 

funding case management resources (e.g., 

staffing, operating funds, client referrals) 

 Providing a formal record of agencies’ 

agreements and responsibilities 

 Holding agencies accountable 

MOUs and formal agreements have special 

appeal when crediting or reporting the outcome 

or delivery of case management services. 

Among agencies and service providers that are 

reimbursed for services on a per capita basis, 

MOUs can be used to specify which agency or 

personnel will receive credit. When services are 

delivered as part of a research project, MOUs 

can specify who has access to data and who may 

claim authorship when research results are 

published. 

Some agencies also use Qualified Service 

Organization Agreements (QSOAs) when an 

agency or official outside the program provides 

a service to the program itself. QSOAs might be 

used, for example, when the program uses an 

outside entity for laboratory analyses or data 

processing. MOUs cannot be supplanted by 

QSOAs. 

MOUs and QSOAs are not the only type of 

formalized agreements available to case 

managers. Some programs use cooperative 

service agreements to define what the parties 

deliver to and receive from each other, and to 

monitor the programs. A legal contract may be 

needed when the lead agency in a formal 

consortium subcontracts to other communitybased case management agencies to provide 

specific services. Many case management 

agencies also enter into agreements with 

funding sources, including those providing 

Federal entitlement benefits. Although some 

experts question whether case managers should 

function as payees (that is, accept and monitor 

entitlement payments on their clients’ behalf), a 

substantial number of case managers take on 

that role. Until agencies become familiar with 

such documents and procedures, obtaining 

counsel prior to signing may be prudent. 
Interagency Case Management 

35

Identifying Potential 

Partners 

For any case management plan to be successful, 

a provider must take a hard, objective look at 

community resources. What form do they take? 

What are the barriers to access? Who makes the 

decisions about how they are used, how are 

these decisions made, and how can they be 

obtained? If housing is a major client concern, 

for example, a community assessment should 

ascertain if housing assistance is available and 

how case management efforts might help clients 

attain it. Similarly, a client’s legal status can 

affect both the number and kinds of services 

needed (e.g., client involvement in the criminal 

justice system or with child protective services 

agencies). Such legal pressures, in turn, 

determine the range and type of agencies with 

which a case management program must 

interact and the conditions for these 

relationships. Thus, depending on the legal 

needs of its clients, a case management program 

may need to identify and forge relationships 

with such service providers as battered women’s 

shelters, public assistance programs, legal aid, 

churches, 12-Step groups, and other relevant 

organizations. 

Not all needed services are available, of 

course, and at times the successful case manager 

must create them. In other cases, needed 

resources may exist but prove inaccessible or 

unacceptable to clients. Ideally, case 

management agencies or programs want to 

provide or facilitate the full range of services 

required by their clients. From a feasibility 

standpoint, however, most providers must 

confront painful realities during the assessment 

process and be prepared to scale back 

expectations. 

Fortunately, most communities already have 

tools to assist case management programs in 

identifying resources, possible provider 

linkages, and potential gaps in services. Public 

Health Departments, United Way, and county 

governments frequently produce directories of 

social, welfare, health, housing, vocational, and 

other services offered in the community. These 

often include detailed information about hours, 

location, eligibility, service mix, and costs; some 

directories are computerized and regularly 

updated. Although the costs associated with 

purchasing these automated directories can be 

steep (and should be considered when planning 

the program budget), their timeliness and 

convenience may justify the investment. In 

many areas, the Yellow Pages serve as an 

excellent resource for obtaining initial contact 

information on a variety of health and social 

services. 

Another solid source of information is 

geomapping, an automated package that assists in 

resource identification. Philadelphia has 

developed software that not only provides basic 

program information but also indicates whether 

a particular program has any openings. 

Traditional paper maps or maps equipped with 

overlays can fulfill the same function. 

While directories and other service rosters 

provide a useful starting point in identifying 

potential resources and service providers, 

additional work is required to determine which 

listings will prove fruitful. There are often 

delays in publishing and updating such 

directories, so that they may be out of date even 

before dissemination. It is critical that they be 

updated on a consistent, timely basis. 

Directories may not list all agencies or 

programs, and more than one directory may be 

necessary because an agency’s focus can shift. 

 Ouellet and colleagues report some 

limitations in using directories, encountered 

when they developed a case management 

program for HIV-infected injection drug users 

(Ouellet et al., 1995). Initially, during startup, 

staff attempted to link clients to services solely 

using a service directory, followed by contact 

with organizations expressing willingness to 
Chapter 3 

36

provide support. Some resulting linkages were 

found to be “largely useless” because 

 Some organizations misrepresent the number 

or types of services they actually offer or 

have available 

 Many services are poorly financed and 

disappear quickly 

 Some organizations are incompetent or too 

poorly managed or staffed to provide 

adequate services 

 Some agencies are too far away for clients to 

use (Ouellet et al., 1995) 

In addition, Ouellet noted that some 

organizations, such as hospitals, stigmatized 

and treated injection drug users so badly that 

clients didn’t want the services at all. Also, 

many providers genuinely interested in service 

collaboration underestimated the number of 

people seeking help and the breadth of 

expressed needs, and thus were unable to 

handle the deluge of service requests. Other 

organizations had the capability to work with 

these clients but were unwilling to do so. 

To counter such limitations, case 

management programs often conduct “snowball 

surveys” in their communities, using one 

interagency contact to lead to another. This 

technique can yield insider information about 

other programs and agencies, their capabilities, 

and experiences in service use. Identifying and 

documenting resources and entitlements may be 

best undertaken during the early phases of 

program startup, when caseloads are low. 

Experienced case management personnel 

also recommend visiting the programs to which 

clients will most likely be referred. Onsite visits 

impart a wealth of information that may confirm 

or refute the impression conveyed in written 

materials. They also provide an opportunity to 

establish valuable contacts with agency 

personnel who can facilitate client services once 

the case management collaboration is under 

way. 

Accurate, current information about 

entitlements is essential for sound interagency 

case management programs and often can be 

obtained through local governments. New York 

City, for example, posts menus of entitlements 

on electronic kiosks. Many public libraries and 

local government offices display updated 

entitlement information regularly. Federal 

Regional Offices of agencies such as the 

Administration for Children and Families are 

another resource for entitlement information. 

As case managers compile and document 

resources, they should also identify gaps in 

services so that they and others understand 

what is available in the community and where 

advocacy efforts are needed. It is also important 

to publicize case management programs 

throughout the community. Brochures, fliers, 

and simple one-page fact sheets can be used to 

advertise or explain a program. 

Announcements on the Internet, in community 

newspapers, on bulletin boards, and in local 

civic and professional club newsletters are 

inexpensive methods for promoting new 

services. Apprising local police of a new 

program’s existence and the availability of 

services may be particularly important as their 

support can prove quite helpful with clients 

involved in criminal justice matters. 

The Agency Environment 

Exploring the environment in which an agency 

operates is essential in determining the 

feasibility of mounting an interagency case 

management effort. Several factors influence 

the provider’s ability to conduct case 

management within the community, including 

 Social service agencies’ number, type, 

historic responsiveness to clients with 

substance abuse problems, openness to case 

management, and relationships with each 

other. Communities with abundant social 

service resources that address a wide range 
Interagency Case Management 

37

of human necessities typically are better able 

to meet the diverse needs of substanceabusing clients than less endowed 

communities. Similarly, social service 

infrastructures in which providers are 

willing to accept substance abusers as clients 

and to accommodate innovative approaches 

to addressing their problems are more likely 

to welcome an agency’s case management 

initiatives than more restrictive 

organizational structures. 

 Community leaders’ support for or neglect 

of substance abuse treatment and their 

response to case management concepts. 

Advocacy may be necessary because support 

or pressure from community and political 

leaders can facilitate a substance abuse 

agency’s efforts to institute case 

management. Conversely, implementation 

can be stalled for months and sometimes 

stopped entirely in communities when 

leadership is opposed to substance abuse 

treatment or case management services for 

substance abuse clients. Identifying 

proponents and adversaries is essential in 

planning strategies that capitalize on support 

or overcome/sidestep resistance to a case 

management program. To form a strong 

supportive voice within a community, 

provider consortiums are often formed. 

 The economic situation in the community. 

The more economically stable a community, 

the more resources members of the civic, 

governmental, and corporate power 

structure have to bring to the table in 

negotiations with other power brokers on 

behalf of a case management program or 

agency. 

 Social climate. Community acceptance of 

substance abuse treatment and clients can 

influence some agencies, particularly those 

with a grassroots orientation, to accept and 

cooperate with a case management program. 

Bottom-up community acceptance can exert a 

powerful force in gaining agency leadership 

cooperation, although this outcome may take 

time. 

 Geographic considerations (distance, 

terrain, isolation of the target population 

from mainstream services). Availability of 

case management services makes little 

difference when clients cannot access 

services because of transportation and other 

barriers. In fact, accessibility may determine 

the specific agencies with which programs 

are able to connect on behalf of clients. 

 Legal and ethical issues affecting 

implementation. Some communities have 

zoning laws and other legal restrictions 

specifying which, if any, social service 

programs can be established within their 

perimeters or near schools and other public 

facilities. These statutes need to be clarified 

before investing in program startup. In 

addition, clients’ possible involvement in the 

criminal justice system can raise issues of 

confidentiality and other legal concerns 

when creating cooperative arrangements 

with other agencies. Special care needs to be 

taken when an agency works with clients 

who are involved with the criminal justice 

system or who are in any way being coerced 

or pressured into treatment. Issues that can 

affect the transfer of confidential or sensitive 

information need to be carefully worked out 

before clients are actually admitted for 

service. Policies and procedures should be 

regularly reviewed in the face of experience 

and adjusted accordingly. 

 Funding for program startup and program 

continuation. Amount and type of available 

funding (e.g., multiyear grant, limited 

foundation support for project startup, and 

matching or challenge grants) directly bear 

on the nature and organizational complexity 

of an agency’s case management program. 

Multiyear funding permits substantial 

advance planning prior to program 
Chapter 3 

38

implementation. It also enables agencies to 

bring current and projected resources into 

negotiations with other community 

organizations. Continuing funds also allow 

interagency linkages to develop and improve 

over time. In contrast, restricted, one-year 

funding may argue for front-loading 

resources and selecting a case management 

model that can be implemented quickly and 

with immediate short-term payoff. 

 Incentives for entering into an interagency 

agreement. Stakeholders who recognize the 

benefits to their agencies will help facilitate 

case management. Also, cooperative 

relations tend to be more stable when 

participating agencies have much to gain by 

working together. 

 Volatility of the political, economic, or 

social environment, such as the recent 

introduction of Medicaid managed care. 

Support for new initiatives can be difficult to 

obtain in a climate in which reimbursement 

criteria are being altered, State and Federal 

funding is being redirected, or political 

leadership is changing and the new players 

are unknown. In an uncertain environment, 

it is critical to justify the cost of a new service 

with compelling evidence. When chaotic 

conditions prevail, introducing a case 

management program gradually protects 

valuable resources while testing feasibility 

before full implementation. 

Agency administrators, whether they are 

chief executive officers, executive directors, or 

program directors, must develop working 

relationships with the other social and human 

services agencies with which the case managers 

will be interacting. To be effective, case 

management requires that connections be made 

at the administrative/director levels of agencies. 

Because case managers may be expected to 

coordinate and implement a complex service 

plan in an interagency environment, the case 

manager needs sufficient power to implement 

the plan. This comes from the explicit 

endorsement of an agency’s top level 

administration. 

An honest appraisal of the community 

environment equips an agency or program to 

make key decisions about interagency case 

management. Some potential cooperating 

agencies cannot interact effectively with the 

larger community or can only provide on-site 

services. Other agencies may be willing to 

cooperate, but their organizational missions 

differ so radically from the case management 

program’s that collaboration is impossible 

(Ridgely and Willenbring, l992). Part of the 

environmental assessment involves identifying 

such providers to avoid creating linkages that 

will ultimately prove unworkable. 

Analysis of the community environment is 

one in a series of ongoing assessments aimed at 

understanding the changes that occur among 

clients, within the program, and in the 

community. As is true of other agency activities, 

case management takes place within a dynamic 

social service environment in which agencies are 

in constant flux (Rothman, l992). Programs 

considering interagency efforts must devise 

coping strategies to respond to change while 

providing necessary continuity for the client. In 

addition, interagency networks are fragile and 

frequently develop through personal trust 

established between case managers. Staff 

turnover disrupts such relationships and 

threatens the case management system unless 

guidelines or procedures exist to facilitate a 

smooth transition (Levy et al., l995). 

Because social environments for delivering 

services do change over time, flexibility and 

individuation are hallmarks of effective case 

management. When programs become rigid in 

their conceptualization, case management 

services suffer. Regular reevaluation of 

community resources helps ensure continued 

relevance. 
Interagency Case Management 

39

Finally, the philosophical orientation of a 

program can affect the efficacy of any 

interagency arrangements. Understanding a 

program’s history and philosophy helps staff 

members determine the type of interagency case 

management services they offer their clients. 

Compatibility in both program philosophy and 

organizational structure in forging interagency 

cooperation is essential, because services suffer 

when the two clash. 

Potential Conflicts 

The potential for conflict exists whenever two 

agencies or service providers work together. 

Tension may be present from the very onset of 

the collaboration. For example, existing social 

service agencies may view a new project as 

competition for scarce resources (Perl and 

Jacobs, l992). Or, social pressures or the need to 

maximize resources can force public agencies 

into joint ventures even if they don’t mesh well 

or have a history of competitiveness (Alter and 

Hage, l993). Tensions also can develop in the 

course of delivering services. Interagency 

collaboration may result in a client having two 

case managers, each of whom handles a 

specialized problem, for example, a case 

manager from a treatment program and a 

probation officer. In such instances, 

manipulative clients may pit one case manager 

against another—a situation that can become 

tense for all involved. 

Recognizing potential triggers for 

interagency conflict and antagonism is a 

necessary first step to dealing with it. When 

problems do erupt, case managers and other 

agency personnel can use both informal and 

formal communication mechanisms to clarify 

issues, regain perspective, and refocus the 

interagency case management process. The 

following list highlights some of the common 

sources of conflict that may arise as a result of 

interagency case management. 

 Unrealistic expectations about the services 

and outcomes that case management 

linkages can produce 

 Unrealistic expectations of other agencies 

 Disagreements over resources 

 Conflicting loyalty between agency and 

consortium or partnership 

 Final decisionmaking and other authority 

over the management of a case 

 Disenchantment after the “honeymoon” 

period ends 

 Differences in values, goals, and definitions 

of the problem, solutions, or roles (e.g., 

conflict could arise when police officers 

working with social service personnel 

perceive that they are being asked to function 

as “social workers“ and vice versa) 

 Dissatisfaction with case handling or other 

agency’s case management performance 

 Clients who pit one case manager against 

another 

 Inappropriate expectations of case managers 

(improper demands, “asking too much”) 

 Resentment over time spent on 

documentation, in meetings, or forging and 

maintaining agency relationships rather than 

on providing client services 

 Stratification, power, and reward 

differentials among various agency case 

managers 

 Differences in case manager credentials and 

status among agencies 

 Unclear problem resolution protocols for 

agency personnel 

The solution to interagency conflict is open, 

frank communication by personnel at all levels. 

Frequent meetings and other activities that bring 

people together foster such communication. In 

the long run, the client’s welfare is a shared 

objective, and the difficulties that are likely to 

arise can be successfully resolved. 

41

4 Evaluation and Quality 

Assurance of Case Management 

Services 

ubstance abuse treatment programs, 

including those that receive public 

assistance, are increasingly operating in a 

managed care environment. Policymaking and 

clinical decisionmaking in a managed care 

environment depend on outcome data that have 

traditionally described the impact of case 

management and substance abuse treatment 

interventions in terms of services used and 

money spent. (See Chapter 6 for more on 

implementing case management in a managed 

care setting.) An additional demand for data 

comes from public and private payers who want 

services linked to specific outcomes. 

In the past, public sector substance abuse 

programs were not paid to collect such data and 

were discouraged from using funds designated 

for service delivery to conduct evaluations. 

Consequently, evaluation services often were 

available only through demonstration grants or 

through the efforts of university-based 

evaluators. Today, however, many providers 

plan, fund, and perform their own evaluations. 

This reflects both the mandates of funding 

organizations and agencies’ desire to refine or 

improve their services. To prepare treatment 

programs to get involved in these efforts, this 

chapter first presents findings from previous 

evaluation efforts and then proposes a 

framework for facilitating quality improvement 

and other evaluative efforts that consider 

multiple stakeholders and focus on myriad 

outcomes and data sources. 

A Brief Overview of the 

Research Literature 

Researchers only recently have begun to assess 

the effectiveness of case management. Studies 

conducted thus far have suffered from 

significant methodological problems that 

include small sample sizes, poorly defined or 

implemented case management interventions, 

problems in evaluation design and 

measurement, lack of distinction between case 

management and comparison interventions, 

poor timing, and unaccounted-for contextual 

factors in communities where case management 

was studied (Orwin et al., 1994). Problems in 

research design are more than an academic 

concern⎯they render results that may be 

misleading, difficult to interpret, and unreliable 

for use in developing case management 

programs or policy. 

Although problems in research design affect 

other kinds of addiction treatment research, case 

management is especially difficult to evaluate 

because contextual factors play a critical role in 

program operations. Case management 

programs do not function in isolation. A key 

S 
Chapter 4 

42

component of a successful case management 

intervention is the establishment of linkages to 

other agencies in a service network. Some 

researchers have suggested that the effectiveness 

of case management may have more to do with 

the environment in which it functions than with 

the functions of the program per se (Ridgely and 

Willenbring, 1992; Morlock et al., 1988). 

However, in spite of these difficulties, some 

useful findings have emerged from work in the 

mental health and substance abuse fields. 

Much of the research on case management 

has been conducted in the mental health field. 

Reviews of its effectiveness are mixed (Bond et 

al., 1995; Chamberlain and Rapp, 1991; Rubin, 

1992; Soloman, 1995), revealing the need to 

identify specific program models and 

expectations about which type of case 

management works for particular populations 

and at what cost (Bond et al., 1995). The 

Assertive Community Treatment (ACT) model 

currently appears to have the strongest research 

base for persons with initially high rates of 

psychiatric hospitalization, both in terms of 

increased retention in community based 

treatment programs and in reduced psychiatric 

in-patient days (Stein and Test, 1980). This 

model includes a team of case managers who 

work with clients in an intensive manner to 

address problems of daily living and who have 

a long-term commitment to providing services 

to clients as long as their needs exist (McGrew 

and Bond, 1995). While the model appears to be 

effective in reducing psychiatric hospitalization, 

there is little evidence that the approach results 

in improved quality of life or level of 

functioning for the client (Bond et al., 1995; 

McGrew and Bond, 1995; Olfson, 1990; Soloman, 

1992; Test, 1992). 

Evaluation of so-called administrative 

models in which case managers coordinate 

services but provide little specific clinical care is 

inconclusive. Some of these programs improved 

clients’ quality of life but did not interrupt 

patterns of rehospitalization. However, at least 

one study revealed that administrative case 

management both increased the use of services 

and increased costs for clients without a 

concomitant measure of improvement in clients’ 

lives (Willenbring et al., 1991). 

Few studies have been undertaken on case 

management in the substance abuse field, and it 

is difficult to generalize the findings of those 

studies that have. One study in Canada found 

results similar to those in mental health studies: 

There are positive, measurable effects of case 

management, especially for clients with poor 

prognostic indicators at admission (such as 

heavy consumption of alcohol and other drugs, 

previous treatment failures, and lack of social 

support) (Lightfoot et al., 1982). 

Other studies of case management in the 

substance abuse field have reported few or no 

differences for case managed clients compared 

to those in treatment who do not receive case 

management services (Inciardi et al., 1994; Falck 

et al., 1994; Hasson et al., 1994). The authors of 

those studies, however, speculate that 

implementation and population issues may have 

affected outcome. Other studies attribute some 

of these negative findings not to poor case 

management interventions, but rather to 

methodological problems in the evaluations 

(Orwin et al., 1994). 

Even in light of the implementation and 

methodological concerns about case 

management research, all the studies together 

with the findings of other addiction research 

suggest that case management can be an 

effective enhancement to intervention in and 

treatment of substance abuse. This is especially 

true for clients with other disorders, who may 

not benefit from traditional substance abuse 

treatments, who require multiple services over 

extended periods of time, and who face 

difficulty gaining access to those services. 

In addition, research suggests two reasons 

why case management may be effective as an 
Evaluation and Quality Assurance 

43

adjunct to substance abuse treatment. First, 

treatment may be more likely to succeed when 

“drug use is treated as a complex of symptom 

patterns involving various dimensions of the 

individual’s life” (Inciardi et al., 1994, p. 146). 

Case management focuses on the whole 

individual and stresses comprehensive 

assessment, service planning, and service 

coordination to address multiple aspects of a 

client’s life. Second, retention in treatment is 

associated with better outcomes, and a principal 

goal of case management is to keep clients 

engaged in treatment and moving toward 

recovery and independence (Institute of 

Medicine, 1990). Studies looking at treatment 

retention and case management posit a positive 

relationship between the two (Siegal, 1997; Rapp 

et al., in press). 

Case management’s ambitious scope is one 

of the reasons its effectiveness is difficult to 

measure. Ashery and others have 

recommended that practitioners in the field 

maintain reasonable expectations for case 

management, pay attention to the 

implementation of programs, and understand 

the enhancing or limiting factors of the 

particular service context in which the case 

management programs are implemented 

(Ashery, 1994). The field should consider not 

only how to best research case management but 

what to expect from it. 

Evaluating Case 

Management Programs 

In order for substance abuse programs to 

ascertain if case management works, the 

program and its various stakeholders (including 

funding and regulatory agencies) must specify 

and measure outcomes they regard as indicators 

of success. 

This section presents options for basic 

evaluative methods, including documentation of 

the case management program’s progress and 

measurement of system and individual client 

outcomes. It concludes by identifying the data 

needs of various stakeholders. Whether an 

evaluation is conducted internally by agency 

personnel, or by experts hired from outside, 

front-line case managers are the key source of 

information. 

In documenting a case management effort, it 

is important to start with benchmarks⎯

expectations that are made concrete as 

measurable statements (e.g., “case managers 

spend 60 percent of their time in face-to-face 

contact with their clients”). Some of the sources 

that programs can use to establish benchmarks 

include 

 Policy and procedure manuals 

 Federal, State, and local case management 

standards 

 Agency case management program 

descriptions and mission statements 

 Literature on program models (if the 

program under evaluation is a replication) 

 Consultants 

If no written manuals or protocols are 

available, or if it is clear that the program has 

drifted from its original design, the program 

managers and staff may use a consensusdevelopment process to arrive at benchmarks. 

Measuring Practice 

Once the process benchmarks are defined in 

measurable terms, the next step is to develop 

and implement a method for measuring 

practice⎯to answer the question, “What are 

case managers doing and how does their 

practice conform to the benchmarks?” One 

approach is to maintain a simple staff log that 

measures case managers’ activities by contact. 

The information should be comparable to the 

benchmarks and brief enough to ensure 

compliance and quality of data. Staff log 

instruments such as the one used by John 

Brekke and his colleagues (Brekke, 1987) have 
Chapter 4 

44

been widely adapted and used in the mental 

health field. They usually record the client’s 

name, location of the contact, duration of the 

contact, activity, and whether other individuals 

participated (e.g., staff of other agencies or 

family members). The brevity and frequency of 

case managers’ contacts with clients makes this 

measure extremely burdensome, and as a result 

many programs use time-limited or sampling 

measures (for example, over a two-week period) 

to get a “snapshot” of activities. 

If time and resources permit, it may be 

valuable to use several methods of 

documentation to compare their usefulness and 

sensitivity. Other methods and purposes 

include 

 Reviews of case manager client records (to 

evaluate how service planning and referrals 

adhere to protocols and procedural 

expectations) 

 Interviews or surveys of case managers or 

clients and their family members (to collect 

information on activities in which case 

managers engage, to gauge how clients’ and 

case managers’ views of those activities 

differ) 

 Analysis of data from the agency’s 

management information system (to examine 

patterns on type, number, and duration of 

case manager contacts with different target 

populations) 

In addition to using multiple methods of 

documentation, it is important to review case 

manager activities over time because programs 

may drift from innovative to familiar patterns of 

service delivery. In addition, the timing of data 

collection is crucial. New programs need time 

to stabilize, and new staff members need a 

period of orientation before a true picture of 

program activities can be established. 

The key informant survey 

Evaluators can use a key informant survey to 

examine the operations of a program’s case 

management activities. The survey is a fixed 

series of questions about the functioning of both 

the case management program and the system 

of care and is administered to a variety of 

stakeholders in the community. Different 

stakeholders are identified by each agency, 

depending on its particular case management 

model and the system of care within which it 

works. Appropriate stakeholders may include, 

but are certainly not limited to 

 Agency staff 

 Staff from other substance abuse and human 

service agencies, homeless shelters, and 

hospital emergency rooms 

 Clients and their family members 

 Criminal justice and law enforcement 

personnel 

Survey participants might be asked about 

their awareness of case management services, 

their use of these services, types of ongoing 

contact with the case management program, and 

their perception of the impact of these services 

on the community. To ensure a cross section of 

informed opinion at various points in time, all 

stakeholders are asked the same questions, and 

the survey is repeated at several intervals. Such 

surveys have been used to evaluate systems 

change in the mental health field (Morrisey et 

al., 1994) and could be adapted for use in case 

management programs. 

Client satisfaction 

Knowing how clients perceive the services they 

receive is essential to evaluative activities. One 

can argue that satisfaction with service is related 

to treatment retention. It is also important to 

know whether the service provider—in this 

instance the case manager—and client share a 

common view of the services being offered and 

their benefits. For example, did the client feel 

that the case management services actually led 

to needed resources? Other questions might 

focus on client perceptions about those 

providing the service: Did the case manager 
Evaluation and Quality Assurance 

45

understand their needs and have the skills and 

experience necessary to help them accomplish 

their goals? 

Such process data have direct utility for 

program management and development. They 

may help programs with defining staff training 

needs and assuring that the needs of the 

population they are working with are being 

addressed. Such data are also quite useful for 

those who have the responsibility for funding 

programs. 

Measuring System Outcomes 

Many programs in the managed care 

environment control access to services through 

what is called “case management,” in which 

gatekeeping procedures are used to limit clients’ 

use of expensive services such as hospitalization 

and residential treatment. These programs may 

be particularly interested in measuring systemlevel outcomes to see whether case management 

has a systemic effect on the delivery of 

substance abuse and allied services (e.g., change 

in patterns of service utilization or costs). Thus, 

a net reduction in the number of inpatient 

admissions for substance abuse treatment 

would, by itself, be defined as a positive 

outcome. This, of course, may not reflect the 

needs of all clients. 

If the goal is preventing clients from “falling 

through the cracks” between discharge from 

detoxification and entry into outpatient 

substance abuse treatment, a system-level 

outcome might be measured by continuity of 

care. Greater continuity could be defined as 

fewer clients with no outpatient treatment 

episode after a detoxification discharge, patterns 

showing shorter periods of time between 

detoxification discharge and outpatient 

treatment admission, and fewer people with 

“revolving door” detoxification admissions. 

Another case management program may aim for 

increased access to care for certain target 

populations (for example, cocaine-abusing 

pregnant women). In this instance, it would be 

useful to compare the number of admissions in 

the target population to all admissions during a 

specified time period. 

In order to measure most system outcomes, it 

is necessary to track clients within a 

comprehensive service agency and, if a 

program’s mandate includes managing care 

across a network of agencies, to gather data on 

encounters and costs and analyze them. Access 

to a computerized management information 

system (MIS) is essential for complete analyses. 

Although these systems vary widely in their 

level of sophistication, for this purpose, one 

must be able to document more than units of 

service information and should be able to link 

encounter, claims, and cost data and produce 

information quickly and easily. Over a period of 

time, a comprehensive MIS tracks changes in 

patterns of service utilization and changes in 

costs, which gives the agency information 

crucial to management and planning. For 

example, an MIS that combines utilization and 

cost data could help identify high utilizers for a 

program that focuses on clients who use 

numerous or expensive services. A later section 

in this chapter describes how a program can 

evaluate and enhance its MIS system. 

Measuring Client Outcomes 

While most would agree that “evaluation” is 

generally worthwhile, there is considerably less 

agreement about the measurement and 

documentation of specific outcomes for 

individual clients. When trying to evaluate case 

management in an ongoing service agency 

setting, additional challenges—conceptual, 

methodological, and ethical—are posed. The 

field has seen a long-standing and often strident 

debate about what kinds of outcomes should be 

measured. Some claim a single measure such as 

sobriety or complete abstinence from any drug 

use is the only meaningful measure of treatment 

success. Others assert that treatment success is 
Chapter 4 

46

most appropriately measured by a constellation 

of factors, including diminished alcohol and/or 

other drug use, improved family functioning, 

improved occupational functioning, less deviant 

and/or criminal activity, fewer contacts with the 

criminal justice system, and improvement on a 

range of psychological variables. The debate 

will continue. In the meantime, programs 

should carefully consider treatment objectives to 

articulate and then operationalize those outcome 

variables they want to measure. 

Another significant complication arises when 

trying to evaluate case management activities 

and client outcomes. A program must be able to 

articulate the role of case management and how 

it meshes with other program activities. 

However, when “standard” client outcomes—

such as reduced substance use or fewer contacts 

with the criminal justice system—are measured, 

it is very difficult to separate the effects of 

substance abuse treatment activities from the 

effects of case management activities. 

Finally, conducting research in communitybased treatment/service organizations presents 

significant challenges. Experimentation, that is, 

comparison and control, is at the heart of any 

scientific research study. One group—typically 

defined as the “experimental group”—receives 

one kind of treatment and the control group 

does not. The two groups are then compared, 

and conclusions can be reached about the 

efficacy of the treatment. However, in the 

context of community-based treatment, a 

potentially beneficial service like case 

management cannot be withheld from some 

clients. This makes it extremely difficult to 

definitively attribute specific client outcomes to 

case management or some other service. 

Anticipating Quality Assurance 

Data Needs 

The types of data required for an evaluation of 

case management, how the data are collected, 

and the manner in which data are put to use 

vary among different stakeholders. It is 

important to understand the types of data that 

various stakeholders need to evaluate the 

program. Structured feedback loops should be 

established to ensure that the data gathered are 

returned to various stakeholders in some 

meaningful way so that they have an impact on 

shaping future program development (and 

future data needs). One of the benefits of the 

case management approach is that it can be 

adapted to meet the sometimes contradictory 

needs of the various stakeholders. 

Data needs of case managers 

Although the data needs of case managers may 

vary from agency to agency, rapid access to data 

in three particular areas is critical: 

 Information about clients currently on the 

caseload (roster management), including 

outcome data so case managers have 

feedback on their performance 

 Data that allow case managers to track clients 

through various services 

 Data that produce “flags” for follow-up 

letters, aftercare, and other time-sensitive 

functions 

In addition to these elements, case managers 

with gatekeeping or budgeting responsibility 

need overall service utilization and cost figures 

by client in order to manage services within a 

budget. To evaluate process, case managers 

need access (preferably computerized) to 

referral networks, bed allocation systems, 

progress notes, and data related to the daily 

conduct of their jobs. In terms of outcome data, 

case managers may want rapid access to client 

status, especially if it would prompt additional 

efforts. 

Data needs of program managers 

Program managers must ensure that the data 

collected reflect the program mission and 

facilitate the program’s management. While the 

case manager focuses on individual clients, the 
Evaluation and Quality Assurance 

47

program manager analyzes data elements to see 

patterns and to flag and investigate “outliers”—

those who deviate drastically from the statistical 

norms of the population. 

The initial data needs of program managers 

reflect concerns with concrete aspects of 

program operation. To program managers, case 

management essentially begins when the phone 

rings, and therefore, their data needs are filled 

by asking the following basic questions: 

 How many inquiries are we getting about 

services? 

 Are we getting clients? 

 From what area are our clients? 

 Are clients entering care once they make 

contact? 

 Are we responsive to clients’ needs from first 

contact forward? 

 Is the type of client changing? 

In addition to collecting these initial data, 

program managers must be able to track clients 

through their services so they can decide how to 

alter service provision. Important questions 

include 

 Who is in what level of care at what time? 

 How does the service fit with their treatment 

plans? 

 Is the program meeting clients’ different 

cultural needs? 

 Who is dropping out, and why? 

 What service not currently provided is 

requested most frequently? 

 How much money is being spent on a 

particular service? 

Other questions relate to the program 

manager’s administrative functions, including 

 What are the case managers doing? What are 

their caseloads? 

 What are the results of internal monitoring? 

 Are we reaching the target populations? 

 Are clients retained at the appropriate level 

of care? 

Data needs of community 

policymakers 

Community policymakers may be local 

government officials, members of community 

coalitions, representatives of local law 

enforcement agencies, school board members, or 

other interested community-based stakeholders. 

Since they are not often directly associated with 

treatment programs, they may not have a very 

sophisticated understanding of program goals 

and may think of outcomes in terms of questions 

like “Is the client sober or not?” or “Is there less 

crime?” They tend to be less interested in 

improved scores on standardized measures of 

client functioning than in easily defined and 

observable outcomes that affect the community, 

principally 

 Taxes⎯Reducing costs to taxpayers in the 

areas of incarceration, unemployment, and 

welfare enrollment and reducing costs of 

case management and substance abuse 

treatment by substituting a costly treatment 

with a less expensive one 

 Safety⎯Reducing neighborhood crime and 

the number of homeless persons loitering in 

business districts 

 Social costs⎯Increasing the number of 

substance abusers who are working and 

improving care for children of substance 

abusers 

Data needs of directors of State 

alcohol and drug abuse agencies 

Directors of State substance abuse agencies 

value data elements that describe the overall 

accessibility, quality, and cost of the substance 

abuse treatment system. In addition, these 

directors require data to track and contain the 

growth of Medicaid and public sector behavioral 

health care expenditures, to put managed care 

systems in place, and to evaluate the effect of 

managed care (including the provision of case 

management) on the delivery of behavioral 

health care services. 
Chapter 4 

48

Key data elements that State directors often 

want to see in evaluation efforts include 

 Patterns of service utilization and costs, 

including the use of public hospital and 

residential treatment centers 

 Numbers of clients working and 

withdrawing from welfare and Medicaid 

 Numbers of clients avoiding prison, reducing 

child welfare cases and costs, and reducing 

food stamp usage 

 Numbers of appeals and grievances by 

clients 

 Number and characteristics of substance 

abuse patients accessing other publicly 

funded social services 

Increasingly, State directors of substance 

abuse agencies are becoming less isolated and 

are beginning to look for opportunities to 

exchange data among previously independent 

departments (e.g., mental health departments, 

Medicaid offices, and criminal justice offices). 

Some State agencies share access to statewide 

data sets. In addition, the movement toward 

managed behavioral health care has prompted 

more integration of data between State Medicaid 

offices and State substance abuse and mental 

health authorities. 

Data needs of third party payers 

Third party payers such as insurance companies 

need data that justify case management as a cost 

above and beyond the direct costs of treatment 

services (see Chapter 6). In addition, when case 

management is used to coordinate care, third 

party payers want to know whether clients are 

receiving the right services, at the right level of 

care, and in the right sequence, and to ensure 

that clients who are no longer in need are no 

longer receiving services. To that end, 

important data elements include 

 The severity of the client’s illness 

 Assignment to levels of care 

 Patterns of service utilization 

 Use of free self-help or volunteer 

organization services 

 Urinalysis results, use of other drugs, and 

scores on standardized outcome indicators 

 Discharge determinations 

Data needs of clients and family 

members 

Clients and family members may serve on 

advisory or governing boards of local programs 

or may be involved in family or peer support 

groups within the community. They may use 

outcome data, especially results of client 

satisfaction surveys, to change programs and 

policies or to choose services and providers. 

They may be less interested in patterns of 

service utilization or standardized scores on 

outcome evaluations than in how the system 

functions from the user’s perspective. In fact, 

clients might consider a program successful if it 

is supportive, reliable, and easily accessible, as 

opposed to “efficient.” 

Data elements important to clients and 

family members include 

 The availability and accessibility of services 

 The freedom of choice (of services and 

providers) that the system allows 

 The use and effectiveness of the appeals and 

grievance process 

 The influence of input from consumers and 

family members 

 Effectiveness of treatment 

 Acceptability of treatment among the 

targeted populations 

Specifically, clients seek answers to the 

questions 

 Am I getting the right services, in the right 

setting? 

 Are there systems I can access myself? 

 How appropriate is my care? 
Evaluation and Quality Assurance 

49

Management Information Systems 

The management information system contains 

all this information and allows stakeholders to 

use it. Managed care has provided the 

behavioral health care field with an example of 

how to manage far-flung data on clients. 

One evaluation task for local programs is 

determining how to use data already routinely 

collected by a statewide MIS or managed care 

company-based MIS, saving the program from 

duplicating primary data collection. Another 

important task is to develop or enhance 

program-level MIS that track data the program 

needs locally, integrate with other computerbased or paper-based systems, and supply data 

required by third party payer and governmental 

bodies. All staff members of a specific program 

should be stakeholders in the MIS, which 

increases both system accuracy and the 

likelihood that a broad array of staff members 

will use it. If an agency does not have the 

resources to develop a sophisticated system, it 

should be able to automate at least a minimum 

amount of client information through 

commercially available software. 

Local programs that are part of a managed 

care network undoubtedly will be included in a 

larger MIS sponsored by the umbrella provider. 

Providers who are not part of these networks 

may need to assess their readiness to take on 

managed care activities by evaluating their 

current MIS capabilities. Today, it is critical that 

an MIS be designed with the data requirements 

of managed care organizations in mind. The 

following guidelines, adapted from a Federal 

technical assistance publication, may help a 

program determine whether its existing MIS is 

sophisticated enough to support managed care 

operations. A program’s MIS will suffice if it 

does each of the following: 

 Retrieves patient information online or in 

less than an hour 

 Cross-matches client records, use of services, 

and financial and insurance information 

 Permits individual inquiries from managed 

care organizations 

 Produces information that is used by 

clinicians, supervisors, and managers 

 Integrates information from other programs 

and sites 

 Allows client and service information to be 

reported to all major payers 

 Generates patient invoices (CSAT, 1995d) 

An existing MIS that can perform all of the 

above functions will likely support managed 

care and program demands; if it cannot, the 

program needs to strengthen deficient areas. 

Changes and advancements in data collection 

and access to patient information must be 

accompanied by appropriate protections for 

client confidentiality. 

Future Research 

Research focused on case management in the 

substance abuse field is limited and offers many 

opportunities for local substance abuse 

programs to make significant contributions to 

the field. Suggested directions for future 

research include the following: 

 Key ingredients of successful programs, 

especially for hard-to-reach populations 

 Relative cost-effectiveness of particular case 

management models, including cost outcome 

results within systems incorporating full 

parity of substance abuse with other health 

care, outcome results when a full continuum 

of care is available to patients, and outcome 

results associated with use of standardized 

guidelines for placement, continued stay, 

and discharge for substance abuse patients 

 Improved methodology to investigate 

research questions in “real world” settings 

 Development of brief versions of valid and 

reliable research outcome instrumentation 

 The effect of particular forms of case 

management on societal costs of substance 

abuse and its treatment 
Chapter 4 

50

 Cost shifting among health, behavioral 

health, criminal justice, and other systems 

that can be accessed by the target population 

 Creative ways to use secondary data sets 

(such as Medicaid and Medicare) to 

determine trends and patterns of care 

 Research questions from broader sociological 

or multi-disciplinary perspectives 
51

5 Case Management for Clients 

With Special Needs 

ase management is an appropriate 

intervention for substance abusers 

because they generally have trouble 

with other aspects of their lives. This is 

especially true for those clients whose problems 

or issues can be overwhelming even for nonaddicted people. Among these special treatment 

needs are HIV infection or AIDS, mental illness, 

chronic and acute health problems, poverty, 

homelessness, responsibility for parenting 

young children, social and developmental 

problems associated with adolescence and 

advanced age, involvement with illegal 

activities, physical disabilities, and sexual 

orientation. 

In an ideal world, case managers would be 

knowledgeable about all those problems and 

needs. However, understanding the 

ramifications of even one can be a staggering 

task. For example, a case manager dealing with 

a client who has AIDS would need to be 

conversant in epidemiology, transmission 

routes, the disease’s clinical progression, 

advances in treatment regimens, financial and 

legal ramifications, available social services, as 

well as psychotherapeutic approaches to AIDS 

patients’ grief and fear. Given the many other 

special needs the case manager confronts, it is 

apparent that no one individual can be an expert 

in every area. In the absence of such 

comprehensive knowledge, several general 

attitudes and skills provide a basic foundation 

for the professional delivering case management 

services to “special needs clients.” The case 

manager serving special needs clients should 

 Make every effort to be competent in 

addressing the special circumstances that 

affect clients typically referred to a particular 

substance abuse treatment program 

 Understand the range of clients’ reactions to 

the challenges associated with particular 

special circumstances 

 Remain aware of the limits of one’s own 

knowledge and expertise 

 Evaluate personal beliefs and biases about 

clients who have special problems 

 Maintain an open attitude toward seeking 

and accepting assistance on behalf of a client 

 Know where additional information on 

special problems can be accessed 

While it is impossible to discuss all the 

special needs that case managers confront, 

several occur repeatedly. This information is 

not intended to be a comprehensive treatment of 

any of these areas, but rather an introduction to 

the issues that most directly relate to the 

implementation of case management.

Minority Clients 

Demographic realities in the United States 

dictate that case managers will be called on to 

work with individuals of different gender, color, 

C 
Chapter 5 

52

ethnicity, and sexual orientation. Some will be 

persons of color; some will be poor, not 

conversant in English, disadvantaged, and overrepresented in many areas of the social services 

system. Case managers must “respond 

proactively and reactively to racism, 

ethnocentrism, anti-Semitism, classism, and 

sexism . . . ageism and ‘ableism’” (Rogers, 

1995, p. 61). 

There are five elements are associated with 

becoming culturally competent: (1) valuing 

diversity, (2) making a cultural self-assessment, 

(3) understanding the dynamics when cultures 

interact, (4) incorporating cultural knowledge, 

and (5) adapting practices to the address of 

diversity (Cross et al., 1989). According to 

Rogers, culturally competent case managers 

have the 

 Ability to be self-aware 

 Ability to identify differences as an issue 

 Ability to accept others 

 Ability to see clients as individuals and not 

just as members of a group 

 Willingness to advocate 

 Ability to understand culturally specific 

responses to problems (Rogers, 1995)

Case managers should either speak any 

foreign languages common in their locale or 

refer non-English speakers to someone who 

does. It is also crucial for the case manager to be 

aware of what may inhibit minorities’ 

participation in the substance abuse treatment 

continuum. For example, while “accepting 

one’s powerlessness” is a central tenet of 12-Step 

self-help programs, members of oppressed 

groups may not accept it, given their own 

societal powerlessness. The case manager must 

always be sensitive to such cultural differences 

and identify recovery resources that are relevant 

to the individual’s values. Some minority group 

members may be inclined to seek help for a 

substance abuse problem from sources outside 

the treatment continuum, such as clergy, group 

elders, or members of their own social support 

networks. Others may prefer to be treated in a 

program that uses principles and treatment 

approaches specific to their own cultures. Case 

managers must advocate for culturally 

appropriate services for their clients. 

Clients With HIV 

Infection and AIDS 

The usual functions and activities associated 

with case management in substance abuse 

treatment—engagement, helping orient the 

client to treatment, goal planning, and especially 

resource acquisition—are made more difficult in 

dealing with clients who have HIV or AIDS by 

 Providers’ and other clients’ fear of 

contracting HIV 

 The dual stigma of being a person with both 

a drug abuse problem and HIV 

 The progressive and debilitating nature of 

the disease 

 The complex array of medical, especially 

pharmacological, interventions used to treat 

HIV 

 The onerous financial consequences of the 

disease and of treatment 

 The hopelessness—and lack of motivation for 

treatment—among the terminally ill 

Case managers who provide services to this 

population must be prepared to work with “a 

base of diverse resources, enhancement or 

adaptation of the capabilities of existing 

resources, or the development of new service 

programs specifically designed to address [the 

HIV-infected individual’s] needs” (Sonsel et al., 

1988, p. 390). The Linkage Program in 

Worcester, Massachusetts, is typical of this 

arrangement. It engaged 19 diverse agencies—

including drug treatment programs, area 

churches, AIDS advocacy and support agencies, 

the city’s department of public health and a 

regional medical center—in a consortium of care 
Clients With Special Needs 

53

for substance abusers who also had HIV 

infection (McCarthy et al., 1992). The Worcester 

consortium and other linkage programs 

demonstrated a positive relationship between 

the amount of case management services 

provided and the receipt of drug abuse, health 

care, and other services (Schlenger et al., 1992). 

While one person should assume primary 

case management responsibility for clients with 

HIV or AIDS, a team approach is particularly 

useful in combating the feelings of frustration, 

abandonment, grief, over-identification with the 

client, and anger that frequently confront 

professionals in this setting (Shernoff and 

Springer, 1992). To avoid staff burnout, 

providers should avoid designating the same 

individual as case manager for all clients with 

AIDS and HIV infection. 

The overwhelming nature of life for a person 

with two life-threatening conditions—AIDS and 

addiction—cannot be overstated. The 

magnitude of even daily tasks holds significant 

stress for both the client and the case manager. 

Addicted people with AIDS or HIV need help 

with physical functioning, interpersonal 

relationships, adjustment to the treatment 

program, housing, and practical and 

psychological adjustment to the two conditions. 

Part of the case manager’s linking function in 

working with an HIV-positive client is to 

educate the network of service providers, 

including substance abuse treatment staff, to 

recognize the competing demands of staying 

sober and dealing with the social and physical 

sequelae of HIV disease. 

Clients With Mental 

Illness 

Almost 40 percent of people with an alcohol 

disorder meet criteria for a psychiatric disorder, 

and more than half of those with other drug 

disorders report symptoms of a psychiatric 

disorder (Regier et al., 1990). Not unexpectedly, 

the prevalence of coexisting disorders is 

significantly higher in treatment populations 

than in the general population, approaching 80 

percent in some studies of substance abuse 

patients (Khantzian and Treece, 1985; Ross et al., 

1988; Kosten and Kleber, 1988). Given those 

high comorbidity rates, substance abuse 

treatment staff must be prepared to address the 

problems of dual-diagnosis clients. 

Treatment services for clients with a dual 

diagnosis are organized in sequential, parallel, 

or integrated models (CSAT, 1994b). In the 

integrated model, both disorders are dealt with 

at the same time and in the same program. Case 

management’s primary role includes facilitating 

clients’ transition from residential programs to 

the community, helping them identify and 

access needed resources, and providing longterm support for their functioning in the 

community. 

In the case of sequential treatment, the case 

manager helps the client move from either 

substance abuse to mental health treatment or 

from mental health to substance abuse 

treatment. In parallel treatment, the case 

manager must facilitate communication and 

service coordination between two agencies 

whose treatment approaches may be based on 

different assumptions. Examples of the possible 

issues the case manager may have to address on 

behalf of a client in mental health treatment 

programs include the following: 

 Bias against substance abusers affects the 

provision of mental health services 

 Many inpatient facilities establish an 

arbitrary minimum number of days of 

sobriety for their clients 

 Some service providers will not accept clients 

who are on medication, including methadone 

Conversely, issues in substance abuse 

treatment programs that might be 

counterproductive to mental health treatment 

include 
Chapter 5 

54

 Treatment approaches may rely on insight 

and introspection that some mental health 

clients are intrinsically incapable of achieving 

 The approach used in substance abuse 

treatment may be too confrontational 

 The treatment program and other clients may 

reject clients taking psychotropic medication 

Many of the special case management issues 

for clients with mental illness center on the 

client’s use of prescription drugs to stabilize 

mood and reduce the negative effects of the 

mental disorder. Some substance abuse 

treatment providers oppose the use of any 

psychotropic drugs, fearing that they will 

interfere with the recovery process and become 

a new source of chemical dependency or that the 

prescribing physician is not adequately aware of 

the client’s problems with addiction. Some 

treatment programs unwittingly precipitate a 

client’s relapse by requiring the client to stop 

taking all medications as a condition of 

acceptance to a treatment program. Participants 

in 12-Step meetings may pressure clients to be 

free of the “crutch” of prescription drug use. 

As substance abuse treatment providers 

become familiar with prescribed neuroleptic 

drugs, they are more likely to accept the medical 

management of the client’s illness and 

communicate more with the professionals 

providing the client’s medical care. To manage 

client symptoms and behaviors, anticipate 

problems, and reinforce the medical 

management of the client, all staff who work 

with dual-diagnosis clients need some 

knowledge of the benefits of commonly 

prescribed drugs, their potential side effects, 

actual abuse potential, and their interactions 

with other drugs. 

Aftercare tends to be long-term for clients 

with mental illness because of the continuing 

possibility that the client will stop taking 

medications when he begins to feel more stable 

and then take illicit drugs to cope with the reemergent symptoms of mental illness. 12-Step 

programs such as Double Jeopardy, Double 

Trouble, and Dual Recovery Anonymous 

designed specifically for people with mental 

health and substance abuse problems can be 

valuable sources of support.

While case managers may not be experts in 

the treatment of any one of these disorders, it is 

vital that they know enough to work with the 

client in identifying her needs and be able to 

translate and coordinate those needs with the 

two types of treatment. 

Homeless Clients 

Alcoholism rates among the nation’s homeless 

are estimated to be as much as two to four times 

the levels for individuals of the same gender in 

the general population. Besides alcohol, the 

substances most frequently used by homeless 

people are marijuana, cocaine, and crack cocaine 

(National Institute on Alcohol Abuse and 

Alcoholism, 1989). Crack use in particular has 

increased in the last 10 years, primarily among 

younger homeless people (Crystal, 1982). 

Numerous efforts at engaging homeless 

individuals in substance abuse treatment have 

been undertaken, many involving case 

management as a central component (Braucht et 

al., 1995; Conrad et al., 1993; Sosin et al., 1995; 

Stahler et al., 1995). 

The need for case management with this 

population is obvious. Clients need suitable 

short- and long-term housing; many have 

mental disorders. Homeless individuals 

frequently suffer from significant health 

problems secondary to their lifestyle, including 

tuberculosis, HIV, and AIDS. Unemployment is 

high. This constellation of tangible needs can 

best be addressed by one individual at the 

interface between the streets and social service 

agencies. 

A case manager always begins by working 

on issues the client feels are most pressing, and 

the need for stable shelter may not be at the top 
Clients With Special Needs 

55

of the client’s list. Many homeless people feel 

safer and more comfortable on the streets than 

in a shelter because the streets are familiar to 

them and because they have established 

routines and a network of people to watch out 

for them. While this setting is hardly ideal, it 

may be one in which the client can function well 

enough to benefit from treatment. However, 

some programs may claim they cannot help 

homeless individuals until their other life 

problems are solved, requiring the case manager 

to advocate on the client’s behalf (Sosin et al., 

1994). 

The case manager’s rapport-building skills 

are critical to break through the many defensive 

behaviors and protective attitudes that clients 

develop to survive in shelters and on the streets. 

These behaviors⎯looking tough, acting with 

bravado, wariness of social services, 

maintaining a hard exterior, and letting go of 

social graces⎯make homeless clients difficult to 

engage and interfere with their ability to 

succeed in treatment or maintain stable housing. 

One solution to this difficulty in engaging 

homeless clients is through the use of peer case 

managers: homeless individuals who are in 

recovery themselves and are based in shelter 

care facilities. In one such setting, peer case 

managers proved to be as successful as degreed 

professionals or an intensive residential 

treatment program in assisting homeless 

individuals in the areas of substance use, 

housing stability, employment, and 

psychological functioning (Stahler et al., 1995). 

In addition, clients were more satisfied with the 

services provided by the peer case managers 

than by the degreed professional case managers. 

This finding may be explained by clients’ beliefs 

that case managers who have experienced 

homelessness first-hand are more likely to 

provide needed services.

To meet their linking and advocacy 

responsibilities, case managers must recognize 

that some services generally available to 

substance abusers are not available to homeless 

people and that new services may need to be 

created to fill those gaps. For example, 

Louisville’s Project Connect used case 

management to help homeless alcoholic and 

drug abusing men move from a sobering-up 

shelter (the pretreatment phase of the treatment 

continuum) through a vocational program at the 

exit point of treatment (Bonham et al., 1990). 

Another substance abuse program at the 

Coatesville Veterans’ Affairs (VA) Medical 

Center picks up homeless veterans at local 

shelters, takes them in vans to the VA for day 

treatment, feeds them, and takes them back to 

the shelter. This has helped to keep veterans 

engaged in treatment as they await placement in 

a VA domicile or other housing arrangement. 

The Department of Veterans' Affairs conducts 

stand-downs in its homeless program, during 

which veterans temporarily housed in tents 

receive medical services and are assessed for 

treatment needs. They are brought into 

residential care for treatment as needed.

The delivery of social services is complicated 

by the fact that homeless clients usually are 

turned out of shelters from 9:00 a.m. until 4:00 

p.m. The client’s social network during these 

hours consists of other people, often not sober, 

who are also out of the shelter. Providers may 

find it useful to provide a day room with snacks 

and a television where clients can stay during 

the day or some sort of day work where clients 

can earn a few dollars. Case finding can be 

accomplished by mobile case management 

teams who seek out homeless substance abusers 

in shelters and other areas where they sleep and 

congregate (Rife et al., 1991). 

Women With Substance 

Abuse Problems 

Case-finding is an especially important case 

management activity with female substance 

abusers, who seem to follow a different path to 
Chapter 5 

56

treatment than males. Because women are often 

referred by other service providers (Beckman 

and Amaro, 1986), case managers affiliated with 

substance abuse treatment programs must help 

their counterparts in other social service 

agencies identify women in need of treatment. 

Women with children are likely to be involved 

in numerous child-related services; women who 

have been victims of domestic violence present 

for services at battered women shelters; other 

women may appear at mental health centers and 

women’s health centers. A significant number 

of women clients have suffered physical, verbal, 

psychological, or sexual mistreatment (Miller 

and Rollnick, 1991; Mondanaro et al., 1982), and 

many who present for treatment live in an 

unsafe environment. 

 Once identified, women with substance 

abuse problems may be difficult to engage in 

treatment. Society judges substance-abusing 

women more harshly than male substance 

abusers. A woman’s substance abuse problem is 

likely to have progressed significantly before 

being identified, and treatment may be 

complicated by factors like psychological 

functioning, situational realities, and systemic 

barriers (Wildwind, 1984). Other issues such as 

sexual abuse, victimization, and emotional 

dependency are frequently associated with 

women who have substance abuse problems 

(Markoff and Cawley, 1996). Transportation is a 

common barrier, especially in primary 

outpatient and aftercare treatment. 

Women substance abusers who have 

children confront these problems and more 

when considering treatment. A mother’s 

decision to enter treatment means the case 

manager must either identify a program that 

will take both the woman and her children or 

assist the woman in finding appropriate child 

care. These mothers may avoid treatment out of 

guilt and shame for the activities in which they 

have engaged to acquire drugs and the 

situations in which they have placed their 

children. Compounding a mother’s shame is the 

fear that authorities will take her children away 

from her. As a result, an assessment of such a 

mother’s needs is complicated by the fact that 

she is likely to lie to the case manager about her 

addiction and the way her family lives. 

The basic functions and tenets of case 

management are well suited to improving 

retention and outcomes for women in treatment. 

There is evidence that women in particular do 

not adequately focus on their substance use and 

recovery until their needs for such resources as 

housing, food, medical care, and personal safety 

are adequately addressed (Hepburn, 1990). 

Case managers should assist female clients in 

developing a safety plan setting out welldefined steps to take should she fear, or be 

subjected to, violence. It is imperative to 

determine if women are living in a safe 

environment. Women who have children are 

even more extensively involved, or need to be, 

with community resources, including the school 

system, pediatric physicians, and children’s 

protective services if their substance use has 

resulted in neglect or abuse. Case managers are 

responsible for facilitating the acquisition of 

these resources as their clients more through the 

treatment continuum. 

A woman’s involvement with community 

resources frequently places the case manager in 

a position to advocate for her needs. Advocacy 

means securing resources not only outside the 

treatment program, but also within the program, 

especially if the program primarily treats male 

clients (Brindis and Theidon, 1997). Advocacy 

not only improves the woman’s acquisition of 

needed resources, but also empowers her to 

become more assertive on her own behalf and 

builds a closer relationship with the case 

manager. Advocacy cannot, however, stop the 

case manager from fulfilling her legal obligation 

to report child abuse or neglect. 

Two excellent sources of information on the 

role that case management plays in the 
Clients With Special Needs 

57

treatment of women substance abusers are 

Pregnant, Substance-Using Women (CSAT, 1993) 

and Case Management in Substance Abuse 

Treatment: Improving Client Outcomes (Sullivan et 

al., 1992). 

Adolescent Substance 

Abusers 

Substance use and dependence are significant 

problems among adolescents in the United 

States. Some substance use is due to a 

developmental tendency to experiment, results 

in few consequences, and abates with maturity. 

However, a number of adolescents progress to 

the point of substance abuse or dependence. 

Because of the problems associated with abuse 

and dependence these adolescents are 

frequently involved with multiple systems, 

including child welfare, juvenile justice, mental 

health, and special education (CSAT, 1993). 

A case manager is in a unique position to 

help adolescents and their families interact with 

those systems. The case manager of a teenager 

must have a thorough understanding of the 

developmental issues pertinent to adolescence, 

an ability to establish rapport with young 

people, a knowledge of family dynamics, and 

the ability to provide support and skills training.

The case manager working with adolescents 

will almost inevitably provide extensive case 

management services to the entire family as 

well. Problems such as poverty, child neglect, or 

parental substance abuse cannot be ignored. 

Acquiring an entire family as clients has 

numerous implications for caseload size, 

available resources, confidentiality, and whether 

the client is the adolescent, the family, or both. 

Challenges can arise in numerous contexts, for 

instance when an adolescent tells the case 

manager she plans to have an abortion. When 

State or Federal laws do not provide explicit 

guidance, the case manager must carefully 

consider who is actually the client and what are 

the best interests of the adolescent. 

One case management model describes a 

three-phase approach, providing services during 

pre-treatment/screening, residential treatment, 

and continuing care (Godley et al., 1994). The 

goal of case management services during pretreatment/intake is to improve access to 

services, provide initial orientation to the 

treatment process, and begin skills training. 

Case management for clients in residential 

programs links the client to needed services 

outside the residential facility and ensures a 

coordinated response by multiple agencies 

involved in an adolescent’s life. During 

aftercare, the professional implementing case 

management continues the linkage and 

monitoring process and provides booster 

relapse prevention skills training with the goal 

of decreasing the likelihood of relapse or 

interrupting a relapse episode. 

Family engagement in transition and 

aftercare activities is paramount for the 

adolescent juvenile justice client. The transition 

work with the family needs to begin before the 

end of the primary treatment episode, and 

preferably occurs throughout the treatment 

episode. 

Clients in Criminal 

Justice Settings 

The number of substance abusers in the criminal 

justice system is staggering. The Drug Use 

Forecasting Project, which tested arrestees in 26 

major U.S. cities for illicit drug use, found 

positive results ranging from 48 percent to 80 

percent. In one jurisdiction, 80 percent of all 

women arrested tested positive for at least one 

illicit drug. The Bureau of Justice Statistics (U.S. 

Department of Justice, 1991) reported that 54 

percent of State prisoners reported drug use at 

the time of the offense, and 52 percent reported 

use during the previous month. 
Chapter 5 

58

 Case management for substance abuse 

clients in the criminal justice system evolved in a 

unique fashion, bringing together two complex 

systems with different goals and philosophies. 

While the criminal justice system is interested in 

the rehabilitation of offenders, its main focus is 

on public safety, which is maintained with 

punishment and legal sanctions. Likewise, 

while the substance abuse treatment system 

supports public safety goals, its primary mission 

is to change individual behaviors. These goals 

are not mutually exclusive; in fact, experience 

has demonstrated that integrating the 

techniques of these two systems can have a 

powerful effect on reducing the drug use and 

criminal activity of drug-involved offenders. 

Because participation in substance abuse 

treatment and other social services is often 

mandated, case managers have the opportunity 

to engage clients over a longer period of time 

and may be more likely to effect successful 

change. 

Integrating the two systems requires some 

effort, however. The need to establish and 

maintain a therapeutic relationship with clients 

while integrating the sanction and control 

obligations of the criminal justice system poses 

particular challenges. Ambiguities about the 

case manager’s role in client supervision and 

confidentiality considerations surface 

frequently. 

The criminal justice system is fragmented 

into numerous components through which 

offenders may be assigned. In most 

jurisdictions, supervision can be provided for 

certain pretrial offenders who have not yet gone 

to trial. In other jurisdictions, such offenders 

may be given the option of diversion, in which 

successful completion of certain activities will 

avoid a conviction. Convicted offenders may be 

sentenced to county jails, state prisons, or 

probation; probation can include halfway house 

supervision, intensive probation, or electronic 

monitoring. Released offenders may be on 

parole or some other sort of post-incarceration 

supervision; in some jurisdictions probation 

sentences may follow sentences of incarceration. 

Linkages between prison and probation, or 

between county jails and community-based 

supervision, may be weak; databases are often 

not connected; and entities often report to 

different management structures. For example, 

probation offices are part of the court system in 

some jurisdictions, the corrections department 

in others. Case management efforts are critical 

to ensuring continuity when offenders move 

from one supervision level to the next, or 

between one status or location and another. 

Managing offenders who are changing status 

within this system while they are participating 

in substance abuse treatment services (both 

inside institutions and in the community) is 

exponentially more complicated. 

Case management with offender populations 

may be implemented at any point in the 

criminal justice continuum. Case management 

can assist offenders in securing resources that 

are not only vital to their recovery and overall 

well-being, but also required by their deferred 

sentencing or probation. Establishing 

appropriate housing that will facilitate sobriety 

and helping the offender develop job-seeking 

skills are but two of the specific activities that 

may form the basis of the case management 

relationship. Offenders incarcerated in State 

and local correctional facilities frequently need 

assistance in managing their lives as they reenter 

the larger community. Institutional life is highly 

regimented, presenting special problems when 

offenders are released. In working with paroled 

individuals, the case manager must recognize 

that prison life encourages behaviors that are 

not appropriate on the outside. Parolees who 

have been imprisoned longer than a year may 

require more time in a semi-structured setting 

(for example, a halfway house) in order to make 

the transition from institution to community. 
Clients With Special Needs 

59

 The case manager should address the needs 

of clients released from institutions in order of 

importance. The first priority is immediate 

stability, which can be facilitated by safe 

housing, access to either primary substance 

abuse treatment or aftercare, and social 

networks that facilitate positive behavior. 

Second, the case manager should either provide 

or make referral to sources of skills training, 

since individuals who have served lengthy 

sentences will likely need either habilitation or 

rehabilitation training in the areas of job 

searches, interactions with non-offender social 

groups, and problem-solving strategies. Third, 

the case manager should train or find training in 

setting and accomplishing short- and long-term 

goals. Incarceration often leads offenders to 

believe that the locus for control of their lives 

lies totally with other persons or institutions. 

While goal-setting is important to any client 

group, it is particularly important to clients who 

have had most basic needs provided for them. 

Ideally, the case manager will begin providing 

these services several weeks or months before a 

scheduled release, then follow the offender into 

the community. Lastly, the case manager can 

advocate for the offender both in the treatment 

environment and the criminal justice system. 

In order to maximize effectiveness, several 

configurations of case management functions 

have been attempted, including: 

Case management provided by the justice 

system. Justice system case managers are 

assigned caseloads at specific stages of the 

system, such as probation or parole. An 

advantage of this model is that justice system 

officials are invested in the process because their 

staff members are implementing it and 

reporting back to them. Major disadvantages 

are the expense and the fact that there may be 

conflicts between the philosophies and goals of 

the substance abuse and criminal justice 

systems. Another issue in this model is whether 

the case manager has actual training in 

substance abuse treatment approaches and 

community referral techniques, as opposed to 

primarily correctional interventions. 

Case management provided by a treatment 

agency. The advantage of a community-based 

treatment model is that the case manager has a 

thorough understanding of the substance abuse 

treatment process. The disadvantages include, 

again, the expense and the possibilities that the 

case manager may not be familiar with the 

criminal justice system or that the treatment 

agencies may not have the resources for 

effective case management. 

Case management provided by an agency 

separate from the treatment and justice 

systems. To reduce costs, a case management 

coordinator may be employed, with or without a 

caseload, to conduct intake interviews and 

supervise paraprofessional staff. The 

disadvantages of this approach include the 

addition of another agency to the collaboration. 

 Case management provided by a 

coordinator from the justice system who 

provides consulting services and technical 

assistance to support existing criminal justice 

case management. One advantage of this model 

is system ownership. A coordinator, with or 

without a caseload, oversees the work of a 

paraprofessional staff. The coordinator can 

move the criminal justice system toward a 

greater awareness of treatment issues by 

providing technical assistance that demonstrates 

service coordination. 

Case management provided by 

multidisciplinary groups in the criminal 

justice system for offender management. This 

type of group may meet regularly and during 

crises. This model is the most inexpensive; 

however, it is the most difficult to successfully 

operate because no one is assigned overall 

responsibility for the offender (CSAT, 1995b). 

One of the earliest models for case 

management services in the criminal justice 

system was created in 1972, when the White 
Chapter 5 

60

House launched a demonstration program 

known as Treatment Alternatives to Street 

Crime (TASC) to divert offenders from the 

criminal justice system into substance abuse 

treatment. (The program name has since been 

changed to Treatment Alternatives for Safe 

Communities.) TASC was initially designed to 

identify appropriate offenders from the criminal 

justice system, assess their needs for drug and 

alcohol treatment, refer them to treatment 

services, monitor their progress in treatment 

(including conducting regular and random 

urinalysis testing), and report that progress back 

to the criminal justice system. In order to meet 

its goals of ensuring continuous treatment for 

offender clients, increasing treatment retention, 

improving treatment outcomes, and reducing 

criminal recidivism, TASC developed a set of 

core functions or critical elements, including 

 Organizational Elements 

♦ A broad base of support within the justice 

system with a protocol for continued and 

effective communication 

♦ A broad base of support within the 

treatment system with a protocol for 

continued and effective communication 

♦ An independent TASC unit with a 

designated administrator 

♦ Policies and procedures for required staff 

training 

♦ A data collection system for program 

management and evaluation 

 Operational Elements 

♦ Agreed-upon offender eligibility criteria 

♦ Procedures for the identification of 

eligible offenders that stress early justice 

and treatment intervention 

♦ Documented procedures for assessment 

and referral 

♦ Documented policies and procedures for 

random urinalysis and other physical 

tests 

♦ Procedures for monitoring offenders, 

including criteria for success/failure, 

required frequency of contact, schedule of 

reporting and notification of termination 

to the justice system 

One helpful development is that recent 

research has convincingly documented the 

success of compulsory and coerced treatment for 

drug involved offenders (Leukenfeld and Tims, 

1988; Hubbard et al., 1989; Platt et al., 1988; 

DeLeon, 1988). TASC clients tend to remain in 

treatment longer than other criminal justicereferred clients and than voluntary clients; 

retention in treatment is linked to better 

treatment outcomes (Toborg et al., 1976).

TASC programs have been successful in 

identifying a large number of offenders in need 

of substance abuse services (Cook, 1992). The 

TASC evaluation conducted in 1976 stated that 

various programs had achieved success in 

identifying a large number of offenders 

qualified for TASC services and that self reports, 

urinalysis, and referrals from lawyers and 

judges seemed to increase client flow (Toborg, 

1976). 

This type of structured case management 

between the criminal justice and treatment 

systems has facilitated the traditional goals of 

each system. Case management benefits the 

criminal justice system by 

 Increasing supervision through drug testing 

 Reducing drug use and criminal behavior 

 Broadening the range of sanctions available 

to the criminal justice system 

 Providing systems of graduated 

interventions 

 Offering treatment in lieu of or in 

combination with punishment 

 Providing information to the criminal justice 

system 

 Providing a basis for judicial decisionmaking 

 Extending the power of the court to influence 

drug-using behavior 
Clients With Special Needs 

61

Case management has benefited the 

treatment system by 

 Increasing treatment outreach 

 Providing assessments and making 

appropriate referrals 

 Utilizing resources more effectively 

 Orienting clients to treatment 

 Retaining clients in treatment by utilizing 

criminal justice leverage 

 Supporting treatment compliance 

 Facilitating access to additional services 

 Providing a framework and structure for 

managing criminal justice clients (Cook, 

1997)

Over the years, the TASC model has been 

expanded to include offenders throughout the 

criminal justice system, including mixed 

offender populations and specific populations 

such as women or adolescents. Depending on a 

TASC program’s administrative and 

programmatic structure, the approach to 

delivery of services may vary. The various 

models include operation as a separate 

administrative entity within a court system or 

functioning as a separate nonprofit organization. 

Acknowledging the diversity of program 

design, Cook noted: 

“There are clear variations in the 

management of TASC clients. Some TASC 

programs are more ‘system centered’ as an 

extension of criminal justice system control. 

Other TASC programs are more ‘client 

centered,’ focusing on the rehabilitation needs of 

the offender. A mix of both seems to produce a 

healthy symbiosis of criminal justice system 

leverage, access to treatment, and therapeutic 

tension” (Cook, 1997). 

The TASC model has also been adapted and 

incorporated in recent innovations such as drug 

courts, which began managing drug-involved 

offenders in the late 1980s, and have now been 

implemented in more than 300 jurisdictions. 

Judges, prosecutors and defense attorneys, 

treatment professionals, case managers, and 

pretrial or probation departments together 

apply continuous oversight of participants as 

they undergo substance abuse treatment as part 

of or in lieu of a criminal sentence. Key 

components include 

 Integration of alcohol and other drug 

treatment services with justice system case 

processing 

 Prosecution’s and defense counsel’s 

promotion of public safety while protecting 

participants’ due process rights, using a 

nonadversarial approach 

 Eligible participants identified early and 

promptly placed in the program 

 Access to a continuum of alcohol, drug, and 

other related treatment and rehabilitation 

services 

 Frequent alcohol and other drug testing 

 Coordinated strategy governing responses to 

participants’ compliance 

 Ongoing judicial interaction with each 

participant 

 Measurement through monitoring and 

evaluation the achievement of program goals 

and gauge effectiveness; continuing 

interdisciplinary education promotes 

effective planning, implementation and 

operations 

 Forging partnerships among drug courts, 

public agencies, and community-based 

organizations generates local support and 

enhances drug court effectiveness 

See TIP 23, Treatment Drug Courts: Integrating 

Substance Abuse Treatment With Legal Case 

Processing (CSAT,1996a) for more on drug 

courts. 

While TASC programs have been designed 

with the interaction of treatment and criminal 

justice systems in mind, case managers in nonTASC settings must be careful not to encourage 

or support goals or objectives that place the 

offender in conflict with expectations of the 
Chapter 5 

62

criminal justice system. The roles of the criminal 

justice official (usually a probation officer) and 

the case manager should be defined in advance 

in agreements forged at the highest levels of 

both the court and the agency providing 

services. Typically, the case manager negotiates 

with the parole or probation officer for sanctions 

that make clinical sense. Such a relationship 

affords the case manager the opportunity to 

educate a representative of the justice system 

about the value of treatment and case 

management. An upcoming TIP, Transition from 

Incarceration to Community-Based Treatment, 

addresses treatment for recently released 

offenders. It will be available in 1998. 

Clients With Physical 

Disabilities 

Chemical dependency is a coexisting problem 

for many people with physical disabilities 

(Moore and Polsgrove, 1991). Some 15 to 30 

percent of all people with disabilities have a 

substance abuse problem, more than twice the 

rate in the general population. Among 

disabilities, rates of substance abuse are highest 

among people with traumatic brain injury, 

spinal cord injury, mental illness, and learning 

disabilities (Rehabilitation Research and 

Training Center on Drugs and Disability, 1997). 

The case manager delivering services to this 

population must know and understand those 

conditions as well as blindness, deafness, and 

chronic disease. Other suggested areas of 

knowledge are 

 The etiology and course of various physical 

disabilities 

 Effective treatment options, both group and 

individual 

 The difference between appropriate 

disability accommodations and enabling 

“handicapped” behavior 

 How disability acceptance and anger affect 

substance abuse treatment 

Because many social service professionals 

still assume that people with disabilities are too 

helpless or too removed from the world to gain 

access to drugs, the case manager’s role may lie 

chiefly in education—both about physical 

disabilities and about substance abuse 

treatment. Clients with disabilities may not 

recognize their need for substance abuse 

treatment or may expect to be denied treatment. 

Once in treatment, they may be misunderstood, 

or singled out for mobility or communication 

problems (Rehabilitation Research and Training 

Center on Drugs and Disability, 1996). The 

Americans with Disabilities Act (ADA) provides 

support for treatment programs oriented to this 

population by mandating that facilities be 

physically accessible to people with disabilities 

and that treatment professionals have an 

understanding of disability issues. 

Assessment includes many issues unique to 

physically disabled persons. The case manager 

should explore the relationship between the 

client’s disability, substance abuse, and recovery 

potential. For example, clients who had a 

significant substance abuse problem before 

becoming disabled need different treatment 

approaches than those who started using to cope 

with a new disability. An individual with a 

disability that predates his substance abuse may 

be obsessively focused on his “disability” and 

not be aware of the functional limitations 

imposed by the chemical dependency. Others 

may have acquired a disability as a direct result 

of substance abuse, but without “sober” time for 

understanding the disability they may not be 

aware of their functional limitations and how 

their current functioning levels make it difficult 

to learn or perform certain tasks. Mentors who 

have disabilities or physical rehabilitation 

professionals can assist newly disabled 

individuals in understanding their disability. 

Treatment programs may need to be 

expanded to accommodate clients’ disabilities. 

The case manager may also need to educate 
Clients With Special Needs 

63

other service providers about the needs of 

people with disabilities. To reach those with 

physical disabilities, 12-Step groups must be 

willing to use hearing enhancement equipment 

(e.g., hearing loops) in meetings and to hold 

meetings in accessible places. The case manager 

should become familiar with special equipment 

in order to help organizations purchase or 

borrow appropriate resources as required under 

the ADA. 

The person in a wheelchair who must take 

medication for chronic pain from an injury may 

prompt resistance from recovery-oriented selfhelp groups. Similarly, some vocational 

programs within a treatment setting require 

clients to be sober for some time before they can 

be placed in a training setting. As a result, 

vocational rehabilitation services, while 

appropriate, are not available to individuals 

receiving pharmacotherapy for opiate addiction 

within those programs that do not consider such 

people drug-free. A case manager from either 

the disability field or the substance abuse field 

should educate members of other disciplines on 

how to structure treatment appropriately. The 

Center for Substance Abuse Treatment is 

producing a TIP on persons with disabilities 

who have substance abuse problems, which will 

be available in late 1998. 

Gay, Lesbian, 

Transgendered, and 

Bisexual Clients 

Gay, lesbian, transgendered, and bisexual 

cultures are often associated with substance use 

in general and alcohol use in particular. 

Findings suggest that both gay men and lesbians 

are more likely to be involved in the use of 

alcohol, marijuana, and cocaine than 

heterosexual members of all age cohorts 

(McKirnan and Peterson, 1989; Skinner, 1994), 

with the differences particularly pronounced 

among younger people. Gay and lesbian clients 

may also find their sexual partners in areas 

prevalent with drugs, increasing the risk of 

contracting the AIDS virus. The prevalence of 

use, coupled with homophobia, makes the 

recognition and treatment of substance abuse 

problems more difficult. 

Given the emotionally charged atmosphere 

that often surrounds sexuality, case managers 

must be especially aware of their own feelings 

and beliefs. The link between personal beliefs 

and interviewing skills is especially important in 

the assessment of these clients, who may be 

reluctant to discuss health problems or issues 

related to sexual practices. The case manager 

must know the context of the client’s life and 

ideally, the specialized language used to 

describe sexual practices in the client’s 

community. The interviewer should gather 

precise information regarding the nature of the 

individual’s sexual practices and number of 

sexual partners, unless a client is particularly 

vulnerable, in crisis, or might otherwise see the 

inquiry as intrusive or inappropriate. 

To help gay or lesbian clients gain access to 

services, the case manager must know more 

than just an agency’s formal stance toward 

them. Some agencies that are officially 

accepting are in fact hostile to homosexual 

clients, or simply are not familiar enough with 

their special needs to serve them effectively. A 

case manager should know which 12-Step 

meetings, clinics, and other resources are 

available, knowledgeable, and accommodating 

to the gay and lesbian communities. As with 

any client, treatment planning includes helping 

the gay client identify and develop social 

opportunities that do not involve drugs and 

alcohol. Advocacy for gay clients includes 

helping clients seek treatment for injuries and 

infections sustained through sexual activity and 

seeing that clients’ needs are taken seriously.
Chapter 5 

64

Case Management in 

Rural Areas 

The delivery of case management services in 

rural areas presents unique challenges. Social 

services may be lacking or so geographically 

dispersed that effective access and coordination 

is difficult. In addition, case managers working 

in rural areas must frequently deal with a 

culture in which “everyone knows everyone 

else,” from both the client’s and the service 

provider’s standpoint. 

Given the scarcity of resources, agencies, and 

specialty services, the professional in this setting 

is more likely to be a generalist. Case 

management is more likely to provide both 

service and service coordination. The substance 

abuse case manager must be a tireless source of 

information and education about substance 

abuse problems, not just for the client, but for 

the community as well. Perhaps the most 

difficult function of the case manager in a rural 

setting is advocacy. In a close-knit environment, 

advocating for a client may mean challenging 

the decisions of other service providers. On the 

other hand, the professional’s close relationships 

with those providers may benefit the client. 

Case management in a rural setting can take 

one of several forms. Telecommunication and 

video-conferencing practice models have been 

used to allow clients relatively easy access to 

providers and to facilitate providers’ 

communication and recordkeeping (Alemi et 

al., 1992). Where the client lives far away from 

the program, services may be provided in an 

intensive manner, for example, daylong sessions 

with a particular client. A lack of formal 

services can be mitigated by the use of informal 

helping networks such as Alcoholics 

Anonymous. However, in using informal 

networks, the case manager will have to deal 

with the unique challenges to confidentiality 

occasioned by the rural environment. 
65

6 Funding Case Management in a 

Managed Care Environment 

anaged care is “an organized system 

of care which attempts to balance 

access, quality, and cost effectively 

by using utilization management, intensive case 

management, provider selection, and costcontainment methods” (CSAT, 1995d). Despite 

the antipathy that many public sector health 

care providers feel toward managed care, those 

providers are actually striving toward the same 

ends using similar means as managed care 

organizations (MCOs). Many substance abuse 

treatment providers have been working within a 

managed care framework for decades, that is, 

looking at utilization data and developing a 

continuum of care. Substance abuse treatment 

providers, particularly those who use case 

management, have historically recognized the 

importance of connecting disparate services to 

meet the needs of clients. 

Whatever treatment providers’ attitudes 

toward managed care, they will have to learn to 

operate within its bounds. More than half the 

States are currently in the process of adopting 

some form of managed care to provide 

behavioral health care services, and more than 

one-third have received Federal waivers to 

implement Medicaid managed behavioral health 

programs, with other waivers planned or 

pending. Some experts predict that many 

substance abuse programs, already accustomed 

to scarcity of resources, will make a smooth 

transition to a managed care environment. 

However, many programs, particularly those 

that operate the least like businesses, may find 

this an extremely challenging time. The need to 

be accountable for outcomes, particularly in the 

face of a tax-conscious public, will undoubtedly 

increase in the managed care era. 

To adapt to the world of managed care, 

treatment programs must assess how their 

services are currently delivered and identify 

which elements should be preserved and which 

should be modified. They also must have a firm 

grasp on how changes in Federal and State 

reforms will affect their current and future 

funding mechanisms. 

Funding Case 

Management in a 

Managed Care World 

Despite the promise of case management as an 

important adjunct to substance abuse services, it 

will not survive without empirical data that 

support its efficacy. Key decisionmakers must 

believe that case management is an integral 

component of treatment service before they will 

incorporate it into the funding structure. This is 

especially true of States choosing to offer 

services through managed Medicaid HMOs. It 

is also true for people who receive services 

through Medicare HMOs. (See Chapter 4 for a 

discussion of program evaluation and 

measuring outcomes.) 

M 
Chapter 6 

66

Controlling costs while providing care offers 

program administrators and case managers an 

opportunity to demonstrate case management’s 

utility to a newly engaged managed care 

company. For example, clients with long-term 

or chronic conditions may be required to move 

from residential facilities to the community 

before some treatment providers believe they 

are ready. In this scenario, case management 

can prove its value by providing the clients with 

wraparound or supportive services to aid in a 

successful transition. As another example, 

outreach case management can help in the area 

of relapse prevention and aftercare and thus 

avert the need for high-cost services like 

inpatient treatment. 

Managed care tools—clinical pathways, 

standardized assessments, and treatment 

protocols—can work well in a case management 

context. The challenge then lies in tailoring 

services to the unique needs of each consumer 

and avoiding “cookie cutter” services. Use of 

these tools can increase case management’s 

attractiveness to program administrators who 

operate in capitated or other forms of sharedrisk environments. 

The true test is to develop a comprehensive 

case management system within a managed care 

framework with the inherent flexibility and 

resources necessary to eventually show tangible 

savings. Only then will an MCO be able to 

clearly justify case management as a 

reimbursable service. 

Who Decides? 

The decision to include case management in the 

array of treatment services usually rests with a 

primary funding source or at the program level. 

As many traditional public sector providers 

overhaul their delivery systems to participate in 

managed care, they must recognize the 

importance of case management as a key 

element of effective treatment and communicate 

that to the funding source. If the primary source 

of funding (usually a State agency) expects or 

requires specific outcomes that go beyond 

sobriety or cost containment, then a program 

administrator must develop ways to measure 

those outcomes. 

To undertake scientifically valid outcomes 

studies is beyond the reach of most treatment 

programs. Providers can, however, increase the 

chances of having case management activities 

reimbursed if they measure everything that 

helps the client, such as consumer-run support 

groups, drop-in centers, or “Compeer” 

programs, in which volunteers help clients 

maintain sobriety and manage other aspects of 

their lives. Keeping good records will allow 

managed care companies to determine exactly 

what’s being provided—and what constitutes 

case management.

Funding Models 

The multiple players involved in funding public 

substance abuse treatment have posed complex 

and ongoing problems for program 

administrators. Each funding stream has its 

own eligibility rules, service conditions, and 

reporting requirements, which frequently differ 

from those of other agencies supporting a 

program’s operations. Case management 

services are no exception and have traditionally 

been funded through a variety of sources as 

well. These include 

 Block grants from Federal agencies 

 Medicaid, which included options that allow 

for non-medical services (e.g., the Medicaid 

Rehabilitation Option) 

 Medicare and Supplemental Security Income 

(SSI) for disabled clients 

 Migrant health funds 

 Private foundations and funds, such as 

United Way 

 State and/or local tax dollars 

 Private insurance 
Funding in a Managed Care Environment 

67

Far too often, the disparate mandates of these 

funders have exacerbated system and service 

fragmentation. Integration of funding streams 

has emerged as a strategy to meld services and 

provide continuity of care. Some States, in fact, 

have used Medicaid managed care initiatives as 

the catalyst for blending funding streams, 

particularly in full capitation models. 

As States gain more freedom to allocate 

Medicaid dollars as they see fit, the prospect of 

increased flexibility in services offered at the 

program level improves. Programs that can 

account for funds received in terms of positive 

client outcomes will be better able to structure 

their service mix in response to clients’ specific 

needs rather than to the dictates of funding 

agencies removed from the service delivery 

level. 

Managed care is frequently used as a vehicle 

for integrating funding streams and for fostering 

collaboration among health care providers. For 

example, many managed care organizations 

establish (or will only contract with) integrated 

provider networks that 

 Offer a full range of services 

 Extend coverage over a wider geographical 

or population area (thus increasing the 

number of potential enrollees and sharing 

the financial risk among more providers) 

 Maximize efficiencies in areas like 

management information systems 

When providers are organized in such a 

manner, administrative service organizations 

are engaged to handle a wide range of business 

duties for the network. 

Blended funding approaches, especially 

those that give providers the necessary freedom 

to make clinical decisions while still holding 

them fiscally accountable, can preserve and 

support the case management function as an 

integral facet of modern substance abuse 

treatment. Capitation or enrollment rates based 

on genuine costs associated with providing 

treatment and “stop-loss” clauses that cover 

such contingencies as reimbursement for longer 

or more intensive treatment than anticipated 

may help satisfy the providers’ desire for 

flexibility and the payer’s demand for fiscal 

responsibility. 

Substance abuse treatment services are 

treated in different ways depending on which 

overarching health care delivery model is 

implemented by the State or by the managed 

care organization(s) contracted to provide 

behavioral healthcare. The two models 

currently prevailing are the carve-in model and 

the carve-out model. 

Carve-in models 

The carve-in model integrates physical (e.g., 

traditional medical services) and behavioral 

(e.g., mental health and substance abuse 

services) health care and is often the model 

chosen to manage a State’s Medicaid population. 

Although the purchaser of services may elect a 

carve-in approach, frequently the MCO may 

elect to carve out behavioral health care by 

contracts with managed care organizations. 

This is because behavioral health care tends to 

be the most expensive cost center of treatment 

within an integrated, managed care model of 

treatment. The carve-in model generally 

appeals to providers because many individuals 

with mental illness and substance abuse 

problems also have serious physical health 

problems. Integrating the two also underscores 

the notion that since body and brain are part of 

the same system, mental illness and substance 

abuse are bona fide health problems. 

However, in such a model, case management 

is often administrative in nature and involves 

clinical oversight and activities such as 

utilization review and prior authorization 

procedures. The primary care physician 

functions as the case manager or gatekeeper 

who assesses the range of services the client 

needs and, ideally, refers him to network 

providers who offer specialty services. This 
Chapter 6 

68

happens when the physician is ill-equipped to 

provide the often labor-intensive, client-specific 

case management functions needed to 

successfully manage the client/member. 

This model for behavioral health care has 

two major drawbacks. First, primary care 

physicians may underdiagnose substance abuse 

problems, especially in populations such as 

women (in whom depression is often diagnosed 

but seldom tied to substance abuse) and the 

elderly. Lack of knowledge or the desire to hold 

down costs also may lead to underutilization of 

services, with consumers denied access to 

needed care. 

Second, since the course and overall 

treatment costs of behavioral health problems 

are less predictable than many physical health 

problems, the ability to establish firm 

enrollment or capitated rates is difficult. If rates 

are too low, the problem of inadequately 

treating or excluding those most in need of 

costly or long-term care (e.g., clients needing 

residential treatment) becomes a legitimate 

concern. When services are subcontracted, 

skimming may become a problem. In this 

situation, the opportunity exists to cost-shift 

“difficult” clients to subcontractors who receive 

only a percentage of the capitated rate. Not only 

are funds insufficient to provide proper 

treatment when this happens, but the 

subcontracting provider’s resources are strained 

to the maximum. 

Carve-out models 

In carve-out arrangements, behavioral health care 

is considered distinct from other physical 

problems and is handled either as a separate 

contract or is intentionally excluded from a 

managed care plan. If behavioral health care is 

carved out and handled as a separate managed 

care account, it is possible to develop capitation 

or enrollment fees specifically tailored to this 

population. Carve-outs also provide States with 

a mechanism to monitor and control the use of 

substance abuse or mental health funds and 

some assurance that those problems are being 

addressed. Ideally, carve-out managed care 

organizations will have expertise in substance 

abuse services or will work jointly with 

providers who possess that expertise. In all 

cases, State officials must develop specific 

contract language to carefully define their 

responsibilities (CSAT’s Technical Assistance 

Publication Purchasing Managed Care Services for 

Alcohol and Other Drug Treatment offers 

suggestions for assessing managed care 

approaches and structuring effective contracts 

for managed care services.)

Case management in a carve-out model is 

likely to remain a service function, particularly if 

the responsibility for behavioral health care is 

delegated to the public sector. Given the trends 

in behavioral health care, the public sector might 

be advised to learn from the example of the 

proprietary, more precise matching of clients 

and service packages through management 

information capabilities, some aspects of 

utilization review procedures, and the 

development of clinical pathways. These efforts 

also help providers use their resources wisely 

and ensure that appropriate and cost-effective 

services are available to individual consumers. 

Unfortunately, this method lacks integration 

with the physical medicine side of treatment, 

which can lead to ineffective case management 

and duplication of services by the behavioral 

health provider and the primary care physician. 

Preparing a Program for 

Managed Care 

To adjust their current operations to meet new 

demands, programs need to assess their 

systems, appraise their readiness to operate in a 

managed care environment, and position 

themselves and their case management services 

in a competitive market by identifying market 

niches and preparing for increased staff 

licensing and accreditation. 
Funding in a Managed Care Environment 

69

Systems Assessment 

As discussed in Chapter 1, case management 

assumes different forms depending on its setting 

and organizational context. Before integrating 

with managed care, program directors and 

administrators need to understand how case 

management is practiced in their program. 

Administrators must identify potential buyers of 

case management services and must stay abreast 

of plans to integrate Medicaid with public funds 

and efforts to secure private vendors to manage 

public behavioral health care services. 

Administrators also need to ascertain exactly 

who their program is serving, the nature and the 

range of clients’ problems, and the gaps between 

what the program offers and what clients need. 

They must be able to articulate how these gaps 

are hindering the successful execution of their 

programs’ mission. 

With the blending of systems via managed 

Medicaid and Medicare, providers are now 

forced to compete directly with each other. 

Eventually, all services now delivered by 

traditional community providers will be 

delivered within a managed care framework. 

Currently, many public sector providers of 

services to people under Medicaid managed 

care guidelines (for managed care companies) 

are providing administrative and clinical case 

management services for a “fixed,” “blended,” 

or “bundled” rate. That rate is a small piece of 

the pie that comprises the total per-member 

capitation payment the provider receives and 

usually is not assigned a specific dollar value. 

What is the program doing? 

As a first step in organizational assessment, 

administrators must clearly define the case 

management model(s) being used in the 

program. At the agency level, community needs 

and available resources must be reviewed. 

Often case management services are subsumed 

under the general category of “the costs of doing 

business.” Under managed care, it is important 

to know precisely what services are being 

offered, what they cost, and what outcomes can 

reasonably be expected. Case management 

must be scrutinized both as a stand-alone 

activity and as part of a total package of services 

potentially available to consumers. The 

importance of auditing the costs and revenues 

associated with various services cannot be overemphasized, particularly if a system is moving 

toward a capitated or shared-risk paradigm. 

Case management, whether a direct service or 

administrative function, must add value and 

provide cost benefit to justify its inclusion in the 

total array of services. 

Clinical case management must demonstrate 

direct or indirect benefits above those that 

consumers can expect from traditional services. 

The gatekeeping function in administrative-level 

case management limits the discretion and 

treatment planning authority of a substance 

abuse professional. Offsetting this 

disadvantage, ideally, are two systemwide 

advantages: reduced costs by denying 

unnecessary services and by providing support 

for people in the community so that they do not 

need more expensive residential or inpatient 

care, and better clinical decisionmaking. The 

gatekeepers’ decisions are based on established 

clinical pathways and protocols—the goals of 

this standardization being improved care as well 

as lowered costs. 

Who is paying for case management? 

Reimbursement for the case management 

aspects of treatment may come from one or all of 

the following sources: 

 Private managed-care organizations (MCOs) 

 Fee-for-service clients 

 Private payers such as corporate employee 

assistance programs, foundations, and grant 

funding 

 Volunteer and local sources 

 Courts and criminal justice funding 

 Social service providers (e.g., child welfare) 
Chapter 6 

70

 User taxes and State and federally 

appropriated funds 

Providers should understand exactly how 

these funding streams are integrated or 

separated, as well as the inherent flexibility in 

their use. Such knowledge will help design a 

case management program and will also help in 

advocacy efforts to shape State policy on 

funding streams. 

How does the program model fit 

within the system? 

It is equally important for providers to 

understand how case management is defined in 

their State’s managed care contract, if at all. 

What specific activities are considered case 

management and are they reimbursable? If they 

are reimbursable, are there limits on the number 

of billable units per consumer? Is there a finite 

pool of funds available on a fee-for-service 

basis? Given the melding of clinical and fiscal 

functions at the provider level, it is also critical 

to consider who benefits from case management 

and who does not. What is a reasonable length 

of time to offer services to a consumer? It is 

imperative that program staff grapple with these 

questions to best allocate available resources. 

Readiness Review 

In some cases, conversion to managed care must 

be accomplished in as little as six months after 

the enactment of legislation or by corporate 

decree, so providers must assess their readiness 

to make this transition rapidly and effectively. 

Tools and surveys can help administrators 

do a readiness review by providing a clear 

picture of what models they are using and how 

they fit in the changing environment. One such 

tool is the Managed Healthcare Organizational 

Readiness Guide and Checklist reproduced in 

Appendix C. This and similar tools can help 

agencies evaluate their current operations 

within each of the following areas 

 Program services and structure 

 MIS capacities 

 Fiscal/financial structures 

 Utilization review capabilities 

 Program evaluation and quality management 

 Staff development and training needs 

 Board and management structure 

 Marketing 

 Licensure and accreditation (CSAT, 1995d) 

Identifying Market Niches 

In the managed care environment, programs 

will have to function as businesses and therefore 

must position themselves and their case 

management services in a competitive market 

(Brokowski and Eaddy, 1994). By focusing on 

the establishment of a market niche like the 

treatment of special populations (e.g., drug 

users, criminal justice clients, older adults, 

clients with HIV and AIDS), an agency can be a 

player in the transition to managed care. In 

addition, issues such as staffing, pricing, and 

salaries can be revisited within the market 

framework. 

Despite its inefficiencies, the public system of 

behavioral health has more experience and 

expertise than private programs do in caring for 

the most seriously disabled populations and in 

providing services that focus on their everyday 

life problems, such as employment and housing. 

Since this chronically needy clientele is least 

likely to be covered by private employer health 

plans, it offers a natural market niche for publicsector service providers. 

Providers who serve Medicaid and Medicare 

recipients will see an increase in commercial 

business as a result of managed care contracts 

but will primarily be paid indirectly. MCOs will 

become the main source of revenue for the 

providers, as opposed to the local or state 

government. Medicaid and Medicare revenues 

will flow from the government to the managed 

care company to the service provider. Highvolume providers, who are successful at 

delivering high-quality, cost-effective services 
Funding in a Managed Care Environment 

71

may even find themselves acquired by the 

managed care company. 

State and Federal governments, in 

anticipation of the changing public sector 

system, have been disseminating resources to 

help publicly funded treatment providers 

survive and compete in a marketplace 

dominated by managed care organizations. The 

Federal Government is also currently designing 

programs and projects via the Center for 

Substance Abuse Treatment (CSAT) and the 

Center for Substance Abuse Prevention (CSAP). 

The National Leadership Institute Coordinating 

Center (NLICC) will provide resources, 

technical assistance, and materials to assist 

public sector providers in making the internal 

changes necessary to compete. 

Licensing and Accreditation 

One of the most controversial aspects of case 

management is the issue of licensing. Many 

believe that case managers should have earned 

at least a master’s degree. Others argue that 

some of the best addictions counselors have 

received their education through overcoming 

their own substance abuse. 

While both viewpoints—and the many in 

between—are valid, managed care will 

increasingly require higher levels of education 

as case management becomes a common 

ingredient in its mix of services. Case 

management functions were performed by 

paraprofessionals in the 1980s and early 1990s. 

Today, however, credentialing standards of 

managed care organizations and other providers 

require that case management be performed by 

people with master’s degrees in social work or 

education. All case managers may need to earn 

advanced degrees to perform reimbursable case 

management in the near future.

Provider profiling and performance reviews 

of individual practitioners are commonplace in 

managed care systems. Because data drive so 

many managed care decisions, any outlier, 

whether the cost of one consumer’s care or the 

performance level of an organization or 

professional, is likely to prompt a closer look. It 

seems likely that, as managed care organizations 

gain greater influence in the substance abuse 

world, there will be an increased demand for 

more professionally trained treatment personnel 

and for provider organizations to gain 

accreditation from national organizations such 

as the Joint Commission on Accreditation of 

Healthcare Organizations (JCAHO), the 

Rehabilitation Accreditation Commission 

(CARF), Community Mental Health Services 

(CMHS), SAMHSA, or the National Committee 

for Quality Assurance (NCQA). 

Future Directions 

The profound changes in reimbursement 

patterns have sent shock waves through the 

substance abuse treatment field. And change 

clearly will persist. Payers and those who 

allocate resources will continue to demand that 

the efficacy of services be demonstrated. On the 

programmatic level this will necessitate 

evaluating each service component and 

determining how it contributes to overall 

objectives. Programs must articulate their 

service expectations and decide what kinds of 

training and experience a practitioner must have 

to successfully deliver them. 

What is needed now is more research on case 

management. Several promising lines of 

research, presented in Chapter 4, suggest that 

certain forms of case management activities 

improved client outcomes, resulting in fewer 

employment problems, increased income, longer 

treatment retention, and diminished drug use. 

Other studies focusing on a criminal justice 

population suggest far-ranging benefits. 

However, the applicability of those studies to 

the population outside prison and jail has yet to 

be established. 
Chapter 6 

72

This research should be undertaken in a 

variety of settings and should address issues 

that demonstrate the efficacy of case 

management activities. What approaches work 

best for what populations in which kind of 

setting? While such questions are typically 

investigated by university researchers through 

demonstration projects, the research community 

must work with community-based programs in 

this case. It will require hands-on experience to 

fully understand how case management 

functions, what benefits it achieves for program 

clients, and how much it costs to provide this 

service. Case managers must be able to follow 

their clients from pretreatment to aftercare to 

determine if treatment and services have 

succeeded. Quantifying its benefits is the most 

compelling argument for case management. 
73

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Appendix B 

Practice Dimensions

Referral and service coordination are the two practice dimensions of addiction counseling that involve

case management, according to the Addiction Technology Transfer Centers (ATTC). The following list of 

attributes that help a case manager perform these functions is excerpted from the ATTCs’ publication

Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice (CSAT, 1998). 

This material also appears as an upcoming Technical Assistance Publication (TAP), Number 21, available 

through the SAMHSA's Publications Ordering Web page at http://store.samhsa.gov or by calling 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español). The document can be downloaded from the 

KAP Web site at http://kap.samhsa.gov.

Referral 

The process of facilitating the client's utilization of available support systems and community resources 

to meet needs identified in clinical evaluation and/or treatment planning. 

1. Establish and maintain relations with civic 

groups, agencies, other professionals, 

governmental entities, and the communityat-large to ensure appropriate referrals, 

identify service gaps, expand community 

resources, and help to address unmet needs 

Knowledge 

a. The mission, function, resources, and quality 

of services offered by such entities as the 

following 

♦ civic groups, community groups, 

neighborhood organizations; and 

religious organizations 

♦ governmental entities 

♦ health and allied health care systems 

(managed care) 

♦ criminal justice systems 

♦ housing administrations 

♦ employment and vocational rehabilitation 

services 

♦ child care facilities 

♦ crisis intervention programs 

♦ abused persons programs 

♦ mutual and self-help groups 

♦ cultural enhancement organizations 

♦ advocacy groups 

♦ other agencies 

b. Community demographics 

c. The community's political and cultural 

systems 

d. Criteria for receiving community services, 

including fee and funding structures 

e. How to access community agencies and 

service providers 

f. State and Federal legislative mandates and 

regulations 
Appendix B 

88

g. Confidentiality regulations 

h. Service gaps and appropriate ways of 

advocating for new resources 

i. Effective communication styles 

Skills 

a. Networking and communication 

b. Using existing community resource 

directories including computer databases 

c. Advocating for clients 

d. Working with others as part of a team 

Attitudes 

a. Respect for interdisciplinary service delivery 

b. Respect for both client needs and agency 

services 

c. Respect for collaboration and cooperation 

d. Patience and perseverance 

2. Continuously assess and evaluate referral 

resources to determine their 

appropriateness 

Knowledge 

a. The needs of the client population served 

b. How to access current information on the 

function, mission, and resources of 

community service providers 

c. How to access current information on 

referral criteria and accreditation status of 

community service providers 

d. How to access client satisfaction data 

regarding community service providers 

Skills 

a. Establishing and nurturing collaborative 

relationships with key contacts in 

community service organizations 

b. Interpreting and using evaluation and client 

feedback data 

c. Giving feedback to community resources 

regarding their service delivery 

Attitudes 

a. Respect for confidentiality regulations 

b. Willingness to advocate on behalf of the 

client 

3. Differentiate between situations in which it 

is most appropriate for the client to selfrefer to a resource and instances requiring 

counselor referral 

Knowledge 

a. Client motivation and ability to initiate and 

follow through with referrals 

b. Factors in determining the optimal time to 

engage client in referral process 

c. Clinical assessment methods 

d. Empowerment techniques 

e. Crisis intervention methods 

Skills 

a. Interpreting assessment and treatment 

planning materials to determine 

appropriateness of client or counselor 

referral 

b. Assessing the client's readiness to participate 

in the referral process 

c. Educating the client regarding appropriate 

referral processes 

d. Motivating clients to take responsibility for 

referral and follow-up 

e. Applying crisis intervention techniques 

Attitudes 

a. Respect for the client's ability to initiate and 

follow-up with referral 

b. Willingness to share decision-making power 

with the client 

c. Respect for the goal of positive selfdetermination 

d. Recognition of the counselor's responsibility 

to carry out client advocacy when needed 

4. Arrange referrals to other professionals, 

agencies, community programs, or other 

appropriate resources to meet client needs 

Knowledge 

a. Comprehensive treatment planning 
Practice Dimensions 

89

b. Methods of assessing client's progress 

toward treatment goals 

c. How to tailor resources to client treatment 

needs 

d. How to access key resource persons in 

community service provider network 

e. Mission, function, and resources of 

appropriate community service providers 

f. Referral protocols of selected service 

providers 

g. Logistics necessary for client access and 

follow through with the referral 

h. Applicable confidentiality regulations and 

protocols 

i. Factors to consider when determining the 

appropriate time to engage client in referral 

process 

Skills 

a. Using written and verbal communication for 

successful referrals 

b. Using appropriate technology to access, 

collect, and forward necessary 

documentation 

c. Conforming to all applicable confidentiality 

regulations and protocols 

d. Documenting the referral process accurately 

e. Maintaining and nurturing relationships 

with key contacts in community 

f. Maintaining follow-up activity with client 

Attitudes 

a. Respect for the client and the client's needs 

b. Respect for collaboration and cooperation 

c. Respect for interdisciplinary, comprehensive 

approaches to meet client needs 

5. Explain in clear and specific language the 

necessity for and process of referral to 

increase the likelihood of client 

understanding and follow through 

Knowledge 

a. How treatment planning and referral relate 

to the goals of recovery 

b. How client defenses, abilities, personal 

preferences, cultural influences, presentation, 

and appearance effect referral and follow 

through 

c. Comprehensive referral information and 

protocols 

d. Terminology and structure used in referral 

settings 

Skills 

a. Using language and terms the client will 

easily understand 

b. Interpreting the treatment plan and how 

referral relates to progress 

c. Engaging in effective communication related 

to the referral process 

♦ negotiating 

♦ educating 

♦ personalizing risks and benefits 

♦ contracting 

Attitudes 

a. Awareness of personal biases toward referral 

resources 

6. Exchange relevant information with the 

agency or professional to whom the referral 

is being made in a manner consistent with 

confidentiality regulations and generally 

accepted professional standards of care 

Knowledge 

a. Mission, function, and resources of the 

referral agency or professional 

b. Protocols and documentation necessary to 

make referral 

c. Pertinent local, State, and Federal 

confidentiality regulations, applicable client 

rights and responsibilities, client consent 

procedures, and other guiding principles for 

exchange of relevant information 

d. Ethical standards of practice related to this 

exchange of information 
Appendix B 

90

Skills 

a. Using written and verbal communication for 

successful referrals 

b. Using appropriate technology to access, 

collect, and forward relevant information 

needed by the agency or professional 

c. Obtaining informed client consent and 

documentation needed for the exchange of 

relevant information 

d. Reporting relevant information accurately 

and objectively 

Attitudes 

a. Commitment to professionalism 

b. Respect for the importance of confidentiality 

regulations and professional standards 

c. Appreciation for the need to exchange 

relevant information with other professionals 

7. Evaluate the outcome of the referral 

Knowledge 

a. Methods of assessing client's progress 

toward treatment goals 

b. Appropriate sources and techniques for 

evaluating referral outcomes 

Skills 

a. Using appropriate measurement processes 

and instruments 

b. Collecting objective and subjective data on 

the referral process 

Attitudes 

a. Appreciation of the value of the evaluation 

process 

b. Appreciation of the value of inter-agency 

collaboration 

c. Appreciation of the value of interdisciplinary 

referral 

Service Coordination 

The administrative, clinical, and evaluative activities that bring the client, treatment services, community 

agencies, and other resources together to focus on issues and needs identified in the treatment plan. 

Service coordination, which includes case management and client advocacy, establishes a framework 

of action for the client to achieve specified goals. It involves collaboration with the client and significant 

others, coordination of treatment and referral services, liaison activities with community resources and 

managed care systems, client advocacy, and ongoing evaluation of treatment progress and client needs. 

Implementing the Treatment Plan 

1. Initiate collaboration with referral source 

Knowledge 

a. How to access and transmit information 

necessary for referral 

b. Missions, functions, and resources of 

community service network 

c. Managed care and other systems affecting 

the client 

d. Eligibility criteria for referral to community 

service providers 

e. Appropriate confidentiality regulations 

f. Terminologies appropriate to the referral 

source 

Skills 

a. Using appropriate technology to access, 

collect, summarize, and transmit referral data 

on client 

b. Communicating respect and empathy for 

cultural and lifestyle differences 

c. Demonstrating appropriate written and 

verbal communication 

d. Establishing trust and rapport with 

colleagues in the community 

e. Assessing level and intensity of client care 

needed 
Practice Dimensions 

91

Attitudes 

a. Respect for contributions and needs of 

multiple disciplines to treatment process 

b. Confidence in using diverse systems and 

treatment approaches 

c. Open-mindedness to a variety of treatment 

approaches 

d. Willingness to modify or adapt plans 

2. Obtain, review, and interpret all relevant 

screening, assessment, and initial 

treatment-planning information 

Knowledge 

a. Methods for obtaining relevant screening, 

assessment, and initial treatment-planning 

information 

b. How to interpret information for the purpose 

of service coordination 

c. Theory, concepts, and philosophies of 

screening and assessment tools 

d. How to define long- and short-term goals of 

treatment 

e. Biopsychosocial assessment methods 

Skills 

a. Using accurate, clear, and concise written 

and verbal communication 

b. Interpreting, prioritizing, and using client 

information 

c. Soliciting comprehensive and accurate 

information from numerous sources 

including the client 

d. Using appropriate technology to document 

appropriate information 

Attitudes 

a. Appreciation for all sources and types of data 

and their possible treatment implications 

b. Awareness of personal biases that may 

impact work with client 

c. Respect for client self-assessment and 

reporting 

3. Confirm the client’s eligibility for 

admission and continued readiness for 

treatment and change 

Knowledge 

a. Philosophies, policies, procedures, and 

admission protocols for community agencies 

b. Eligibility criteria for referral to community 

service providers 

c. Principles for tailoring treatment to client 

needs 

d. Methods of assessing and documenting client 

change over time 

e. Federal and State confidentiality regulations 

Skills 

a. Working with client to select the most 

appropriate treatment 

b. Accessing available funding resources 

c. Using effective communication styles 

d. Recognizing, documenting, and 

communicating client change 

e. Involving family and significant others in 

treatment planning 

Attitudes 

a. Recognition of the importance of continued 

support, encouragement, and optimism 

b. Willingness to accept the limitations of 

treatment for some clients 

c. Appreciation for the goal of selfdetermination 

d. Recognition of the importance of family and 

significant others to treatment planning 

e. Appreciation of the need for continuing 

assessment and modifications to the 

treatment plan 

4. Complete necessary administrative 

procedures for admission to treatment 

Knowledge 

a. Admission criteria and protocols 

b. Documentation requirements and 

confidentiality regulations 
Appendix B 

92

c. Appropriate Federal, State, and local 

regulations related to admission 

d. Funding mechanisms, reimbursement 

protocols, and required documentation 

e. Protocols required by managed care 

organizations 

Skills 

a. Demonstrating accurate, clear, and concise 

written and verbal communication 

b. Using language the client will easily 

understand 

c. Negotiating with diverse treatment systems 

d. Advocating for client services 

Attitudes 

a. Acceptance of the necessity to deal with 

bureaucratic systems 

b. Recognition of the importance of cooperation 

c. Patience and perseverance 

5. Establish accurate treatment and recovery 

expectations with the client and involved 

significant others including, but not limited 

to 

♦ nature of services 

♦ program goals 

♦ program procedures 

♦ rules regarding client conduct 

♦ schedule of treatment activities 

♦ costs of treatment 

♦ factors affecting duration of care 

♦ client rights and responsibilities 

Knowledge 

a. Functions and resources provided by 

treatment services and managed care 

systems 

b. Available community services 

c. Effective communication styles 

d. Client rights and responsibilities 

e. Treatment schedule, time frames, discharge 

criteria, and costs 

f. Rules and regulations of the treatment 

program 

g. Role and limitations of significant others in 

treatment 

h. How to apply confidentiality regulations 

Skills 

a. Demonstrating clear and concise written and 

verbal communication 

b. Establishing appropriate boundaries with 

client and significant others 

Attitudes 

a. Respect for the contribution of clients and 

significant others 

6. Coordinate all treatment activities with 

services provided to the client by other 

resources 

Knowledge 

a. Methods for determining the client’s 

treatment status 

b. Documenting and reporting methods used 

by community agencies 

c. Service reimbursement issues and their 

impact on the treatment plan 

d. Case presentation techniques and protocols 

e. Applicable confidentiality regulations 

f. Terminology and methods used by 

community agencies 

Skills 

a. Delivering case presentations 

b. Using appropriate technology to collect and 

interpret client treatment information from 

diverse sources 

c. Demonstrating accurate, clear, and concise 

verbal and written communication 

d. Participating in interdisciplinary team 

building 

e. Participating in negotiation, advocacy, 

conflict-resolution, problem solving, and 

mediation 

Attitudes 

a. Willingness to collaborate 
Practice Dimensions 

93

Consulting 

1. Summarize client’s personal and cultural 

background, treatment plan, recovery 

progress, and problems inhibiting progress 

for purpose of assuring quality of care, 

gaining feedback, and planning changes in 

the course of treatment 

Knowledge 

a. Methods for assessing client’s past and 

present biopsychosocial status 

b. Methods for assessing social systems that 

may affect the client’s progress 

c. Methods for continuous assessment and 

modification of the treatment plan 

Skills 

a. Demonstrating clear and concise written and 

verbal communication 

b. Synthesizing information and developing 

modified treatment goals and objectives 

c. Soliciting and interpreting feedback related 

to the treatment plan 

d. Prioritizing and documenting relevant client 

data 

e. Observing and identifying problems that 

might impede progress 

f. Soliciting client satisfaction feedback 

Attitudes 

a. Respect for the personal nature of the 

information shared by the client and 

significant others 

b. Respect for interdisciplinary work 

c. Appreciation for incremental changes 

d. Recognition of relapse as an opportunity for 

positive change 

2. Understand terminology, procedures, and 

roles of other disciplines related to the 

treatment of substance use disorders 

Knowledge 

a. Functions and unique terminology of related 

disciplines 

Skills 

a. Demonstrating accurate, clear, and concise 

verbal and written communication 

b. Participating in interdisciplinary 

collaboration 

c. Interpreting written and verbal data from 

various sources 

Attitudes 

a. Comfort in asking questions and providing 

information across disciplines 

3. Contribute as part of a multidisciplinary 

treatment team 

Knowledge 

a. Roles, responsibilities, and areas of expertise 

of other team members and disciplines 

b. Confidentiality regulations 

c. Team dynamics and group process 

Skills 

a. Demonstrating clear and concise verbal and 

written communication 

b. Participating in problem solving, decision 

making, mediation, and advocacy 

c. Communicating about confidentiality issues 

d. Coordinating the client’s treatment with 

representatives of multiple disciplines 

e. Participating in team building and group 

process 

Attitudes 

a. Interest in cooperation and collaboration 

with diverse service providers 

b. Respect and appreciation for other team 

members and their disciplines 

4. Apply confidentiality regulations 

appropriately 

Knowledge 

a. Federal, State, and local confidentiality 

regulations 
Appendix B 

94

b. How to apply confidentiality regulations to 

documentation and sharing of client 

information 

c. Ethical standards related to confidentiality 

d. Client rights and responsibilities 

Skills 

a. Explaining and applying confidentiality 

regulations 

b. Obtaining informed consent 

c. Communicating with the client, family and 

significant others, and with other service 

providers within the boundaries of existing 

confidentiality regulations 

Attitudes 

a. Recognition of the importance of 

confidentiality regulations 

b. Respect for a client’s right to privacy 

5. Demonstrate respect and non-judgmental 

attitudes toward clients in all contacts with 

community professionals and agencies 

Knowledge 

a. Behaviors appropriate to professional 

collaboration 

b. Client rights and responsibilities 

Skills 

a. Establishing and maintaining nonjudgmental, respectful relationships with 

clients and other service providers 

b. Demonstrating clear, concise, accurate 

communication with other professionals or 

agencies 

c. Applying the confidentiality regulations 

when communicating with agencies 

d. Transferring client information to other 

service providers in a professional manner 

Attitudes 

a. Willingness to advocate on behalf of the 

client 

b. Professional concern for the client 

c. Commitment to professionalism 

Continuing Assessment And 

Treatment Planning 

1. Maintain ongoing contact with client and 

involved significant others to ensure 

adherence to the treatment plan 

Knowledge 

a. Social, cultural, and family systems 

b. Techniques to engage the client in treatment 

process 

c. Outreach, follow-up, and aftercare 

techniques 

d. Methods for determining the client’s goals, 

treatment plan, and motivational level 

e. Assessment mechanisms to measure client’s 

progress toward treatment objectives 

Skills 

a. Engaging client, family, and significant 

others in the ongoing treatment process 

b. Assessing client progress toward treatment 

goals 

c. Helping the client maintain motivation to 

change 

d. Assessing the comprehension level of the 

client, family, and significant others 

e. Documenting the client’s adherence to the 

treatment plan 

f. Recognizing and addressing ambivalence 

and resistance 

g. Implementing follow-up and aftercare 

protocols 

Attitudes 

a. Professional concern for the client, the 

family, and significant others 

b. Therapeutic optimism 

c. Recognition of relapse as an opportunity for 

positive change 

d. Patience and perseverance 

2. Understand and recognize stages of change 

and other signs of treatment progress 
Practice Dimensions 

95

Knowledge 

a. How to recognize incremental progress 

toward treatment goals 

b. Client’s cultural norms, biases, unique 

characteristics, and preferences for treatment 

c. Generally accepted treatment outcome 

measures 

d. Methods for evaluating treatment progress 

e. Methods for assessing client’s motivation 

and adherence to treatment plans 

f. Theories and principles of the stages of 

change and recovery 

Skills 

a. Identifying and documenting change 

b. Assessing adherence to treatment plans 

c. Applying treatment outcome measures 

d. Communicating with people of other 

cultures 

e. Reinforcing positive change 

Attitudes 

a. Appreciation for cultural issues that impact 

treatment progress 

b. Respect for individual differences 

c. Therapeutic optimism 

3. Assess treatment and recovery progress 

and, in consultation with the client and 

significant others, make appropriate 

changes to the treatment plan to ensure 

progress toward treatment goals 

Knowledge 

a. Continuum of care 

b. Interviewing techniques 

c. Stages in the treatment and recovery process 

d. Individual differences in the recovery 

process 

e. Methods for evaluating treatment progress 

f. Methods for re-involving the client in the 

treatment planning process 

Skills 

a. Participating in conflict resolution, problem 

solving, and mediation 

b. Observing, recognizing, assessing, and 

documenting client progress 

c. Eliciting client perspectives on progress 

d. Demonstrating clear and concise written and 

verbal communication 

e. Interviewing individuals, groups, and 

families 

f. Acquiring and prioritizing relevant 

treatment information 

g. Assisting the client in maintaining 

motivation 

h. Maintaining contact with client, referral 

sources, and significant others 

Attitudes 

a. Willingness to be flexible 

b. Respect for the client’s right to selfdetermination 

c. Appreciation of the role significant others 

play in the recovery process 

d. Appreciation of individual differences in the 

recovery process 

4. Describe and document treatment process, 

progress, and outcome 

Knowledge 

a. Treatment modalities 

b. Documentation of process, progress, and 

outcome 

c. Factors affecting client’s success in treatment 

d. Treatment planning 

Skills 

a. Demonstrating clear and concise oral and 

written communication 

b. Observing and assessing client progress 

c. Engaging client in the treatment process 

d. Applying progress and outcome measures 
Appendix B 

96

Attitudes 

a. Appreciation of the importance of accurate 

documentation 

b. Recognition of the importance of 

multidisciplinary treatment planning 

5. Use accepted treatment outcome measures 

Knowledge 

a. Treatment outcome measures 

b. Understand concepts of validity and 

reliability of outcome measures 

Skills 

a. Using outcome measures in the treatment 

planning process 

Attitudes 

a. Appreciation of the need to measure 

outcomes 

6. Conduct continuing care, relapse 

prevention, and discharge planning with 

the client and involved significant others 

Knowledge 

a. Treatment planning process 

b. Continuum of care 

c. Available social and family systems for 

continuing care 

d. Available community resources for 

continuing care 

e. Signs and symptoms of relapse 

f. Relapse prevention strategies 

g. Family and social systems theories 

h. Discharge planning process 

Skills 

a. Accessing information from referral sources 

b. Demonstrating clear and concise oral and 

written communication 

c. Assessing and documenting treatment 

progress 

d. Participating in confrontation, conflict 

resolution, and problem solving 

e. Collaborating with referral sources 

f. Engaging client and significant others in 

treatment process and continuing care 

g. Assisting client to develop a relapse 

prevention plan 

Attitudes 

a. Therapeutic optimism 

b. Patience and perseverance 

7. Document service coordination activities 

throughout the continuum of care 

Knowledge 

a. Documentation requirements including, but 

not limited to 

♦ addiction counseling 

♦ other disciplines 

♦ funding sources 

♦ agencies and service providers 

b. Service coordination role in the treatment 

process 

Skills 

a. Demonstrating clear and concise written 

communication 

b. Using appropriate technology to report 

information in an accurate and timely 

manner within the bounds of confidentiality 

regulations 

Attitudes 

a. Acceptance of documentation as an integral 

part of the treatment process 

b. Willingness to use appropriate technology 

8. Apply placement, continued stay, and 

discharge criteria for each modality on the 

continuum of care 

Knowledge 

a. Treatment planning along the continuum of 

care 

b. Initial and ongoing placement criteria 

c. Methods to assess current and ongoing client 

status 
Practice Dimensions 

97

d. Stages of progress associated with treatment 

modalities 

e. Appropriate discharge indicators 

Skills 

a. Observing and assessing client progress 

b. Demonstrating clear and concise written and 

verbal communication 

c. Participating in conflict resolution, problem 

solving, mediation, and negotiation 

d. Tailoring treatment to meet client needs 

e. Applying placement, continued stay, and 

discharge criteria 

Attitudes 

a. Confidence in client’s ability to progress 

within a continuum of care 

b. Appreciation for the fair and objective use of 

placement, continued stay, and discharge 

criteria 

,

99

Appendix C 

Managed Healthcare 

Organizational Readiness Guide 

and Checklist: Special Report 

By James B. Bixler, M.S. 

This material first appeared in the Center for Substance Abuse Treatment's Technical Assistance 

Publication (TAP) 16, Purchasing Managed Care Services for Alcohol and Other Drug Treatment: Essential 

Elements and Policy Issues.

anaged care has become a primary 

method of organizing and financing 

healthcare services in the United 

States, and the delivery of substance abuse 

treatment services is being significantly affected. 

Introduction 

A majority of the Fortune 500 companies and 

more than half of the health maintenance 

organizations (HMOs) now use managed care 

arrangements for purchasing substance abuse 

treatment. Thirty-six State Medicaid programs 

were using managed care approaches as of early 

1993, and another 13 States planned to 

implement managed care programs by 1994 

(U.S. General Accounting Office 1993). Several 

States have "carved out" substance abuse as well 

as mental health services for Medicaid 

recipients. 

Publicly funded substance abuse treatment 

providers must adapt to meet the challenge of 

managed care, which will expand as the 

healthcare system changes in response to market 

forces and as healthcare reform discussions 

continue in Washington. 

Purpose 

The guide and checklist have been prepared to 

assist publicly funded treatment providers 

become more competitive in a managed care 

environment. The document is intended 

especially for use by treatment providers 

receiving financial support from State funds, 

Medicaid, and the Federal Substance Abuse 

Prevention and Treatment Block Grant. 

M 
Appendix C 

100

Goals and Objectives 

The goal of the checklist is to assist State 

substance abuse agencies and publicly 

supported treatment providers to design and 

implement strategies that will result in these 

providers being able to participate successfully 

in managed care programs. 

Background 

The readiness checklist was developed for the 

technical assistance program of the Center for 

Substance Abuse Treatment's Division of State 

Programs. It built upon the Managed Care 

Readiness Inventory developed in 1993 by the 

Oregon community mental health providers and 

the National Community Mental Healthcare 

Council. 

The checklist was first used at a workshop on 

managed care issues for project directors, part of 

the Fall Training Institute of the Pennsylvania 

Office of Drug and Alcohol Problems. Attendees 

completed the checklist, and the presenter 

conducted an interactive discussion about the 

importance of the issues identified. 

After this pilot effort, the checklist was 

refined during its use in workshops conducted 

in Oregon, Arkansas, and Tennessee. The guide 

was added to provide additional information 

and to help treatment providers use the 

checklist as a freestanding self-assessment 

instrument. 

Ways To Use the Guide 

and Checklist 

The checklist can be very effective as part of a 

workshop for treatment providers. Such a 

workshop would include substantial discussion 

of strategies for meeting the challenges of 

healthcare reform, changes in the organization 

and financing of health care, and the expanded 

use of managed care. 

The guide and checklist can also be used: 

 In meetings of regional or local networks of 

providers 

 By providers or networks and their 

consultants 

 By providers as a self-assessment tool 

The checklist can be an important part of the 

development of an organization's strategic plan, 

as a treatment provider or service network 

decides how to improve service delivery and 

position itself for a more successful future. 

Why Prepare for Managed Care? 

The healthcare system is undergoing very rapid 

change in response to several fundamental 

economic forces. 

1. Healthcare expenditures consumed 13.2 

percent of the Gross Domestic Product (GDP) 

of the United States in 1991 (Letsch 1993) and 

rose to more than 14 percent in 1993, which 

means that almost $1 of every $7 is spent for 

healthcare services. 

2. The growth rate of healthcare expenditures 

in 1991 was four times the growth rate of the 

national economy (Letsch 1993). 

3. Some experts estimate that national 

healthcare expenditures will reach 18 to 19 

percent of the GDP by 1998. 

4. Medicaid expenditures, an important source 

of payment for substance abuse services, 

doubled between 1988 and 1992. By 1992, the 

$199 billion cost of Medicaid equaled the 

total cost of the Medicare program (Holahan 

et al. 1993). 

5. State Medicaid expenditures have grown 

until they are second only to the combined 

State costs of elementary and secondary 

education (Holahan et al. 1993). 

High inflation in healthcare expenditures has 

led employers and States to seek ways to limit 

the growth of their insurance premiums, benefit 

costs, and Medicaid programs. 

Substance abuse treatment services and costs 

increased during the 1980s for many reasons: 
Managed Care Checklist 

101

 Increased public acceptance of the need for 

care 

 Increased benefit coverages in many health 

plans 

 State activities to include substance abuse 

services in State Medicaid programs 

 A rapid growth in inpatient hospital-based 

substance abuse and psychiatric units, 

supported by benefit plans that paid for 

inpatient treatment and a surplus of hospital 

beds 

 Increases in State and Federal funding of 

community services, such as the Substance 

Abuse Prevention and Treatment Block 

Grant program 

Some employers perceived that mental 

health and substance abuse treatment costs were 

"out of control" and that service delivery was 

fragmented. Claire Wilson, in a 1993 article on 

substance abuse and managed care, wrote: "The 

skyrocketing utilization and costs of substance 

abuse treatment during the last 10 years have 

alarmed corporate benefit managers" (Wilson 

1993). 

England and Vacarro (1991) identified 21 

percent increases in 1990 healthcare 

expenditures to employers/purchasers as the 

impetus behind managed care, despite cost 

containment efforts spanning more than a 

decade. They said: "Mental health and chemical 

dependency services, with reported cost 

increases of up to 60 percent per year, are a 

prime target for managed care." 

These perceptions also were shared by some 

insurance carriers and HMOs, forcing payers to 

seek ways to coordinate care and control costs. 

The result is greater use of HMOs, preferred 

provider arrangements, increased competition, 

and—for substance abuse and mental health 

services—the development of behavioral health 

managed care organizations (MCOs). 

These firms have expanded rapidly in the 

last 10 years, with the three largest MCOs each 

reporting more than 10 million persons enrolled, 

a total of almost 40 million persons for these 

three firms alone (Oss 1994). 

A survey conducted in January 1994 

determined that more than 102 million 

Americans, 45.9 percent of those with health 

insurance, are enrolled in some type of managed 

behavioral healthcare program (Oss 1994). The 

survey did not separate managed care for 

substance abuse from mental health services; 

however, almost all behavioral MCOs use an 

integrated approach. There were: 

 20.0 million in employee assistance programs 

(EAPs) 

 6.6 million in integrated managed behavioral 

health/EAPs 

 20.5 million in risk-based behavioral health 

network programs 

 15.0 million in nonrisk-based network 

programs 

 37.0 million in stand-alone behavioral health 

utilization review programs (Oss 1994) 

What Is Managed Care and How Is 

It Changing? 

Managed care approaches, such as utilization 

review and second opinions, have been in place 

for more than a decade for medical-surgical 

insured health benefits. Their general purpose is 

to assure payers that consumers receive the 

appropriate level of care and that excessive, 

inappropriate, or unnecessary care is not 

delivered or reimbursed. These practices arose 

to regulate the functioning of the fee-for-service 

system, where financial incentives tend to 

encourage the delivery of more health services 

and more expensive procedures. 

Another way to define managed care is by 

the organizational structures used to deliver 

treatment. Health maintenance organizations 

are "managed care," because clinical 

management and financial incentives exist 

within staff HMOs and independent-practice 

model HMOs to encourage preventive care and 

to reduce cost increases. 
Appendix C 

102

Feldman and Goldman (1993) indicated that 

the behavioral health managed care industry 

"arose as a response to the economic imperatives 

of spiraling unmanaged mental health and 

substance abuse costs. In light of escalating 

costs, payers were essentially faced with two 

alternatives–cut benefits (which many have 

done) or manage them so as to control costs and 

ensure quality." 

In addition to concerns about costs, 

purchasers identified several quality-related 

problems: 

 Overuse of hospitalization 

 Purchase of services without any indication 

of clinical effectiveness–making it difficult to 

identify good care and good providers 

 Incentives in traditional benefit plans to use 

hospitalization rather than outpatient 

alternatives 

 Fragmented service delivery and the lack of 

coverage for case management services in 

traditional indemnity plans (England and 

Vacarro 1991). 

Without a doubt, the industry has grown 

rapidly. In general, it has gone through three 

major phases since the mid-1980s. 

1. The first generation of MCOs managed 

access to health care, with a primary focus on 

utilization review (UR). Access was 

controlled by limiting benefits and requiring 

significant co-payments to contain costs. 

MCOs also introduced such administrative 

barriers as preadmission certification. 

2. The second generation of managed care 

focused on managing benefits. MCOs added 

fee-for-service provider networks, selective 

contracting, and treatment planning to the 

UR function. 

3. The current generation of MCOs focuses on 

managing care, performing utilization 

management instead of utilization review–

with a greater emphasis on treatment 

planning, delivery of the most appropriate 

care in the most appropriate setting, and 

moving patients through a continuum of 

services. 

Managed care organizations expect 

development of a fourth-generation product in 

which they manage outcomes as part of an 

integrated services system, moving both public 

and private patients through a full continuum of 

treatment services (Waxman 1994). 

The impact on treatment providers over the 

last 10 years has been dramatic. Hospitals that 

deliver substance abuse care have reduced staff 

and closed units or have integrated their 

inpatient care for substance abuse within 

psychiatric units. Many hospitals have 

expanded ambulatory substance abuse services. 

Community agencies have scrambled to learn 

about managed care and to become members of 

MCO provider panels. 

These changes are likely to continue as the 

managed care industry increases its focus on 

Medicaid recipients, State and local 

governments, and services to other public 

clients. 

How Do Managed Care 

Organizations Select Treatment 

Providers? 

Behavioral health managed care organizations 

(MCOs) work for self-insured businesses, 

HMOs, insurance carriers, unions, State 

Medicaid agencies, and others. Prior to deciding 

which providers to select, they first listen to 

their customers. 

Some payers will dictate the qualifications of 

substance abuse treatment providers. These 

payers may require hospitals for residential care 

and require licensed professionals for outpatient 

treatment. Increasingly, MCOs are 

recommending that less expensive yet wellqualified community providers be included on 

the "provider panel." This enables MCOs to 

lower costs and to offer a more complete range 

of services. 
Managed Care Checklist 

103

The selection criteria of MCOs cover several 

areas: 

 Access to care and a provider's response 

time; i.e., the availability of inpatient and 

residential beds as needed, and access to 

outpatient services based on: 

♦ Emergencies: immediate access 

♦ Urgent services: 1-2 days 

♦ Routine services: 4-6 days 

 Minimal delays for patients transferring from 

one service to another, particularly within a 

single provider 

 Administrative and clinical responsiveness 

 Use of brief, problem-centered clinical 

approaches rather than long-term 

rehabilitative approaches 

 Positive practice profiles; i.e., providers who 

are pragmatic, innovative, team-oriented, 

consumer-oriented, case managementoriented, and outcomes-oriented 

 Cultural competence 

 Willingness to arrange for related social 

services as needed, e.g., housing or job 

placements 

What Strategies Should a Treatment 

Provider Consider? 

The specific strategies that a substance abuse 

provider adopts will depend on the level of 

readiness of the provider and the State and local 

managed care environment. 

The provider should develop an 

individualized plan that is specific to the 

circumstances and locality. The first step can be 

to complete the readiness checklist and consider 

potential change strategies within the 

organization. Providers may find it necessary to 

make changes in their clinical and management 

services in order to become more attractive to 

MCOs and other payers. 

Short-range strategies 

Short-range strategies could include: 

 Strengthening relationships with businesses 

through relationships with EAPs 

 Maximizing Medicaid reimbursements and 

positioning the provider organization to 

expand its participation in Medicaid as 

managed care arrangements are 

implemented 

 Becoming a preferred provider for several 

managed care organizations 

Longer range strategies 

Longer range strategies to be considered might 

include: 

 Determining the extent to which the provider 

organization will address a broad client 

group by delivering a range of services or by 

focusing on one or more niche markets, i.e., 

specialty services for a limited population 

 Joining or forming a regionally integrated 

substance abuse and/or behavioral health 

service network, which can seek preferred 

provider and other contracts 

 Marketing to primary care medical group 

practices and multipractice physician groups, 

which have an increasingly critical 

"gatekeeper/service manager" role in 

healthcare reform 

 Marketing directly to payers, such as HMOs, 

insurance carriers, and self-insured 

businesses 

 Integrating fully into the healthcare system 

by becoming part of a physician-hospital 

organization or an arm of a large physician 

group practice. 

Use the following checklist to assist you in 

developing your agency's individualized plan 

for future challenges. 
Appendix C 

104

Figure C-1 

Sample Selection Criteria 

First Mental Health, an MCO that operates the Medicaid substance abuse and mental health 

managed care program in Massachusetts as MHMA, Inc., looks for organizations and programs 

that: 

 Are consumer-oriented, e.g., have satisfaction surveys and use the information 

 Have no long waiting lists 

 Deliver focused treatment, e.g., an average of six outpatient sessions 

 Are part of a system that promotes clinical continuity, e.g., a consumer can move from service 

to service without interruption 

 Direct their attention to outcomes, e.g., functional levels and employment 

 Have an interest in innovation, with the ability to move rapidly and to be responsive 

Managed Healthcare 

Organizational Readiness 

Checklist 

Following is a managed care readiness checklist 

for publicly funded substance abuse treatment 

service providers, a vital segment of the health 

services system. The checklist is intended: 

1. To identify a program's strengths and 

weaknesses in specific areas, and 

2. To enhance a strategic planning process that 

will assist your organization to prepare for 

success in a managed care environment. 

Use of the checklist will help treatment 

providers anticipate the skills that will be 

needed to prosper in a changing healthcare 

system. 

Use of the checklist cannot substitute for an 

onsite assessment. However, it is likely to 

generate productive thought and discussion. 

It is not necessary to have a perfect score to 

secure a contract with a managed care firm for 

private or public patients. In general, the better 

prepared your organization, the more likely it is 

that you will be selected to provide services. 

Twelve areas are assessed: 

 Adult services 

 Adolescent services 

 Service characteristics 

 Quality assurance and utilization 

management 

 Managed care and employee assistance 

program experience 

 Management information system 

 Staff and staff training 

 Organizational relationships 

 Board and management 

 Marketing 

 Fiscal analysis 

 Business office 

There are survey questions for each area. In 

addition, there is a summary at the end of the 

checklist. 

Please answer each question using a whole

number, i.e. 1, 2, 3, 4, or 5. One is the lowest 

score, while 5 is the highest score. Use the 

following scale for your response. 

No, None, Never Very Limited, Not 

Often 

Partially, 

Frequently 

Mostly, Regularly Yes, Fully, Always 

1 2 3 4 5 
Managed Care Checklist 

105

No, None, Never Very Limited, Not 

Often 

Partially, Frequently Mostly, Regularly Yes, Fully, Always 

1 2 3 4 5 

Service Comprehensiveness 

For adults, do you deliver: Please circle the answer...

1. Centralized screening, assessment, intake, and crisis intervention services? 1 2 3 4 5 

2. Comprehensive outpatient services? 1 2 3 4 5 

3. Intensive outpatient services, or do you have strong network relationships 

with providers of such services? 

1 2 3 4 5 

4. Partial hospitalization/day treatment services, or do you have strong network 

relationships with providers of such services? 

1 2 3 4 5 

5. Short-term residential treatment, or do you have strong network relationships 

with providers of such services? 

1 2 3 4 5 

6. Inpatient treatment, or do you have strong network relationships with 

providers of such services? 

1 2 3 4 5 

For children and adolescents, do you deliver: 

7. Centralized screening, assessment, intake, and crisis intervention services? 1 2 3 4 5 

8. Outpatient services? 1 2 3 4 5 

9. Intensive outpatient services, or do you have strong network relationships 

with providers of such services? 

1 2 3 4 5 

10. Partial hospitalization/day treatment services, or do you have strong network 

relationships with providers of such services? 

1 2 3 4 5 

11. Short-term residential treatment, or do you have strong network relationships 

with providers of such services? 

1 2 3 4 5 

12. Inpatient treatment, or do you have strong network relationships with 

providers of such services? 

1 2 3 4 5 
Appendix C 

106

No, None, Never Very Limited, Not 

Often 

Partially, 

Frequently 

Mostly, Regularly Yes, Fully, Always 

1 2 3 4 5 

Service Characteristics Please circle the answer...

13. Do you have skilled clinical staff assigned to all aspects of the screening and 

assessment process, including initial telephone contacts? 

1 2 3 4 5 

14. Do your services ensure rapid access (1-2 days) to assessment services and 

initial placement? 

1 2 3 4 5 

15. Do your services have a brief intervention focus, e.g., six to eight sessions for 

outpatient care, for most patients? 

1 2 3 4 5 

16. Do you have internal case management services for focusing on repeating 

patients and others who have high utilization patterns? 

1 2 3 4 5 

17. Do you have ensured linkages with primary healthcare providers for needed 

healthcare? 

1 2 3 4 5 

18. Do you adapt standard services to meet the needs of special populations, such 

as mentally ill substance abusers, injecting drug users, and pregnant addicts? 

1 2 3 4 5 

19. Are service needs constantly reevaluated, and service plans modified, based on 

patient progress? 

1 2 3 4 5 

20. Are admission, treatment, and discharge criteria in place and used consistently 

by staff? 

1 2 3 4 5 

21. Do your admission, treatment, and discharge criteria take into consideration 

the practice standards of managed care firms with which you have (or hope to 

have) contracts? 

1 2 3 4 5 

22. Do your services ensure rapid linkage to succeeding levels of care? 1 2 3 4 5 

23. Do your services emphasize family involvement and use of natural support 

systems, including self-help groups? 

1 2 3 4 5 

24. Do your services focus on patient outcomes and satisfaction? 1 2 3 4 5 
Managed Care Checklist 

107

No, None, Never Very Limited, Not 

Often 

Partially, Frequently Mostly, Regularly Yes, Fully, Always 

1 2 3 4 5 

Quality Assurance (QA) and Utilization Management (UM) Please circle the answer...

25. Do you have QA and UM procedures that have been shared with clinical staff? 1 2 3 4 5 

26. Does the staff you have designated to perform the QA/UM function review 

clinical activities for consistent use of established admission, treatment, and 

discharge criteria? 

1 2 3 4 5 

27. Is the information from the QA/UM function received rapidly enough to assist 

clinicians during an episode of care? 

1 2 3 4 5 

28. Does the QA/UM function include maintaining records of managed care 

appeals, and suggest strategies for improving relationships and/or modifying 

service delivery to reduce denials? 

1 2 3 4 5 

29. Do you have sufficient staff assigned to the QA/UM function? 1 2 3 4 5 

30. To what extent is the QA/UM function designed to "stay ahead" of staff from 

managed care firms by anticipating their concerns? 

1 2 3 4 5 

31. Do clinicians, clinical supervisors, and management all receive and act on 

regular QA and UM reports? 

1 2 3 4 5 

32. Is the QA/UM function tied closely to your management information system? 1 2 3 4 5 

33. To what extent is the QA/UM function focused on patient outcomes? 1 2 3 4 5 

34. Are patient satisfaction surveys a regular function of QA/UM? 1 2 3 4 5 

Managed Care and Employee Assistance Program (EAP) 

Experience 

Please circle the answer...

35. Do you have contract(s) with managed care firms or EAPs as a preferred 

provider? 

1 2 3 4 5 

36. If yes to #35, are any of your contracts paid on a fee-per-case or a capitation 

basis? 

1 2 3 4 5 

37. Do you offer an employee assistance program which includes crisis 

intervention, assessment and linkage to service, followup to assure receipt of 

appropriate services, and coordination of benefits? 1 2 3 4 5 

38. Does your EAP provide consultation to management on policies and 

procedures, training to managers and supervisors, assistance with specific 

cases, employee education and orientation programs, critical incident 

debriefing, and reporting on utilization and effectiveness? 1 2 3 4 5 

39. Has your EAP business increased over the last 2 years? 1 2 3 4 5 
Appendix C 

108

No, None, Never Very Limited, Not 

Often 

Partially, Frequently Mostly, Regularly Yes, Fully, Always 

1 2 3 4 5 

Management Information Systems (MIS) Please circle the answer...

40. Do you have an MIS which can retrieve patient information either online or in 

less than 1 hour? 1 2 3 4 5 

41. Does your MIS have integrated functions for client information; service 

utilization; financial information, including payer type by client; and client 

records? 1 2 3 4 5 

42. To what extent does your MIS permit single-source response inquiries from 

managed care organizations? 

1 2 3 4 5 

43. To what extent does your MIS produce information that is used by clinicians, 

supervisors, and management? 

1 2 3 4 5 

44. To what extent does your MIS integrate information from various programs 

and sites? 

1 2 3 4 5 

45. Is your MIS designed so that client and service information can be reported to 

all major payers? 

1 2 3 4 5 

46. Does your MIS generate patient invoices? 1 2 3 4 5 

Staff and Staff Training 

47. Do clinical staff accept shared responsibility with case managers from 

managed care organizations for clinical decisions? 

1 2 3 4 5 

48. Are staff informed concerning the funding and managed care environment, 

including managed care criteria for admission and discharge? 

1 2 3 4 5 

49. Have clinical and supervisory staff resolved concerns about cost, service 

quality, access, and managed care? 

1 2 3 4 5 

50. Do you have an ongoing staff training program that includes brief service 

intervention skills, patient assessment and reassessment, and instructions on 

how to respond to managed care organizations? 1 2 3 4 5 
Managed Care Checklist 

109

No, None, Never Very Limited, Not 

Often 

Partially, Frequently Mostly, Regularly Yes, Fully, Always 

1 2 3 4 5 

Organizational Relationships Please circle the answer...

51. To what extent have you implemented referral and business arrangements 

with other behavioral healthcare organizations, e.g., mental health and 

substance abuse programs? 1 2 3 4 5 

52. To what extent have you implemented referral and business arrangements 

with primary or specialty healthcare organizations, e.g., hospital emergency 

rooms and physician group practices? 1 2 3 4 5 

53. To what extent have you been involved in economic arrangements with other 

healthcare? 

1 2 3 4 5 

Board and Management 

54. Do you have significant experience at contract negotiation and management? 1 2 3 4 5 

55. To what extent is the board oriented to service effectiveness and business 

success? 

1 2 3 4 5 

56. Are you experienced at strategic planning, modifying plans, and developing 

contingency plans to meet emerging opportunities and challenges? 

1 2 3 4 5 

57. How well informed are board members and top management concerning 

healthcare reform, managed care, financing options, and interorganizational 

arrangements? 1 2 3 4 5 

58. Are mechanisms in place which would allow for prompt shifts in response to 

business opportunities? 

1 2 3 4 5 

59. To what extent will the board and management be proactive and 

entrepreneurial in pursuit of managed care initiatives? 

1 2 3 4 5 
Appendix C 

110

No, None, Never Very Limited, Not 

Often 

Partially, Frequently Mostly, Regularly Yes, Fully, Always 

1 2 3 4 5 

Marketing Please circle the answer...

60. Do you have marketing plans that target payers, referral sources, and the 

general public? 1 2 3 4 5 

61. Do you have sufficient staff resources assigned to the marketing function? 1 2 3 4 5 

62. To what extent does your service line emphasize acute and primary services 

(rather than long-term, rehabilitative, and wraparound care)? 1 2 3 4 5 

63. Have you prepared a managed care capability statement? 1 2 3 4 5 

64. To what extent have you made marketing presentations to the large employers 

in your service area? 1 2 3 4 5 

65. Do your costs per episode and lengths of stay compare favorably with the 

competition? 1 2 3 4 5 

Fiscal Analysis 

66. To what extent is your revenue diversified? 1 2 3 4 5 

67. Do you have adequate liquid reserves for at least 2-3 months operating 

expenses? 1 2 3 4 5 

68. Have you accumulated (or can you access) venture capital sufficient to respond 

to a major business opportunity? 1 2 3 4 5 

69. Have you maximized Medicaid revenue? 1 2 3 4 5 

70. Does your fiscal system, in combination with the MIS, allow analysis of costper-unit of service, cost-per-episode of care, and cost by disability type and 

level of functioning? 

1 2 3 4 5 

71. Can the fiscal staff assist with pricing issues during contract negotiations, 

especially when capitated contracts are considered? 1 2 3 4 5 

72. Can the fiscal staff readily compare actual to anticipated revenue and expense 

by contract? 1 2 3 4 5 

Business Office 

73. Is the business office experienced at fee-for-service invoicing for Medicaid, 

preferred provider organization (PPO) contracts, insurance, patient fees, etc.? 1 2 3 4 5 

74. Does the business office conduct internal service audits to ensure that 

documentation of services in patient records can withstand an external audit? 1 2 3 4 5 

75. To what extent is the business office's invoicing function integrated into your 

MIS? 

1 2 3 4 5 
Managed Care Checklist 

111

Summary of Answers 

This section allows you to generate a score for each area. Add together the individual response scores for 

the questions in each of the 12 sections. Then divide the total by the number of questions in that section to 

generate a composite score for the section. Enter the composite score on the 1 to 5 scale at right. 

 Divide Weakest Strongest

Total by Composite Position Position

Adult Services Comprehensiveness 6 1 2 3 4 5 

Adolescent Services Comprehensiveness 6 1 2 3 4 5 

Service Characteristics 12 1 2 3 4 5 

QA and UM area 10 1 2 3 4 5 

Managed Care an EAP area 5 1 2 3 4 5 

MIS area 7 1 2 3 4 5 

Staff and Training 4 1 2 3 4 5 

Organizational Relations 3 1 2 3 4 5 

Board and Management 6 1 2 3 4 5 

Marketing 6 1 2 3 4 5 

Fiscal Analysis 7 1 2 3 4 5 

Business Office 3 1 2 3 4 5 

All scores 75 1 2 3 4 5 

This approach will show you the areas in which your organization is well prepared for managed care 

participation, the areas in which additional work may be needed, and the areas of relative weakness 

where immediate remedial activities can be targeted. 

It may also be helpful to inspect the variations in the scores among the various persons in your 

organization who complete the checklist. You may find a range of answers and perceptions on a specific 

question or within one or two sections. It might be illuminating to note the differences, for instance, 

between management, board members, and clinical staff. 
Appendix C 

112

Common Questions and 

Answers 

There were several common questions asked by 

treatment providers who attended workshops in 

which the checklist was used. This part of the 

guide gives answers to a few of those questions. 

QUESTION: Do I have to pay attention to these 

managed care issues? I have contracts with the State 

and revenue from fees, so won't my organization 

survive intact? 

ANSWER: Economic forces are leading to 

the use of managed care approaches by almost 

all payers. If you have secured a "niche market," 

where it is unlikely that other organizations will 

compete with you, then you may be in a unique 

situation where the payers will continue to buy 

your service. However, organizations that 

deliver basic outpatient and residential 

substance abuse care cannot ignore managed 

care. 

QUESTION: My organization delivers 

residential treatment. Should I add outpatient 

services or otherwise diversify? 

ANSWER: Managed care organizations 

frequently shift services from hospital inpatient 

to community residential facilities. A second 

strategy of MCOs is to then shift the location of 

care from brief residential services to intensive 

outpatient or outpatient care as quickly as 

possible. The best strategy would be to offer all 

needed services and plan to shift the balance 

between services as referral patterns and MCO 

practices change. 

QUESTION: What staff qualifications do 

managed care firms require for outpatient services, 

and are graduate degrees a necessity? 

ANSWER: There is considerable variation. 

Staff qualifications are frequently determined by 

the payer rather than the MCO. Some MCOs 

require State-licensed practitioners, while others 

accept all staff working within a licensed or 

State-approved program. 

QUESTION: How cost competitive is managed 

care? Will I be asked to accept reimbursement rates 

below my cost? 

ANSWER: Most MCOs attempt to secure 

discounted rates. It is important to know your 

costs and establish a level below which you will 

not negotiate. It is also important to be aware of 

the costs and rates of your competitors, in order 

to be able to judge the marketplace. 

QUESTION: Will managed care require my 

organization to change our clinical practices? 

ANSWER: As you market your services, 

carefully consider the types of services that 

managed care organizations want. Most will 

favor brief and focused counseling models, with 

rapid step-down to less intensive levels of care. 

You may have to modify your service 

practices in order to secure and maintain 

business. 

QUESTION: My staff are concerned about 

losing clinical control of our services to a gatekeeper 

or case manager. Is it necessary to give up clinical 

control if I get a contract? 

ANSWER: It's best to think of working with 

an MCO as a partnership where you exchange 

information about clients and determine a plan 

of treatment together. Most MCOs watch the 

length of treatment episode very carefully, 

either through a case manager or by reviewing 

your organization's practice patterns (based on 

the analysis of your organization's paid claims). 

QUESTION: We don't do outcome studies. How 

can I begin to focus on the impact of treatment? 

ANSWER: Implementing a consumer 

satisfaction survey is a good place to begin. It 

can provide feedback on access, staff, the most 

(and least) valuable components of services, and 

the value of care to clients and family members. 

QUESTION: Will it be necessary to create new 

alliances, join networks, establish joint ventures, or 

merge with another organization to be successful? 

ANSWER: It depends on your local situation 

and your organization's goals. There are many 

new relationships currently being established to 
Managed Care Checklist 

113

improve the likelihood of doing well as the 

healthcare system changes. You may find 

arrangements that strengthen your organization 

clinically and managerially. No organization 

should rule out considering these options. 

How Can We Design an 

Action Program for 

Change? 

The information you gained from completing 

the readiness checklist is a good start. There are 

several steps in classic organizational planning. 

The action planning steps are to: 

1. Assess Your Current Position 

 Assess your organization's strengths: What 

do you have going for you, and what should 

you be sure to maintain and/or expand? 

 Assess your organization's limitations: What 

areas need improvement, and what is your 

realistic capability to address these areas 

internally? 

 Assess the opportunities emerging in the 

marketplace: What are the commercial and 

public managed care developments in your 

State and locality? 

 Assess the competition and other challenges: 

What threatens your plans, how quickly will 

you need to implement changes, and what 

are your competitors planning which will 

impact on your future? 

2. Develop an Achievable Plan 

 Establish clear long-range goals: What 

changes are needed in the organization's 

mission and long-range targets, if any? 

 Chart 1-2 year objectives: What are the 

priority actions that will make the greatest 

difference as you penetrate the managed care 

market? 

 Develop targets: What are the numerical 

targets and the schedule to be used for each 

priority action? 

 Involve the staff and board: What steps must 

be approved and accomplished by the 

various actors, and what are the resource 

requirements? 

 Consider strategic partnerships: What new 

organizational relationships will strengthen 

your ability to reach your objectives, and 

what scarce skills or resources are essential to 

success? 

3. Implement the Plan 

 Assign the tasks: What are the expectations 

for all of the key persons and organizational 

units? 

 Coordinate the work: Manage the process 

and make the needed adjustments in day-today activities. 

4. Check Progress and Adjust the 

Targets 

 Review achievements against the objectives: 

What was accomplished and what were the 

deviations from the plan? 

 Reassess the environment: What has 

occurred in the business environment, with 

Medicaid managed care, in healthcare 

reform, or in your local service system that 

will impact on your success? 

 Change the strategic plan: What better 

strategies have been identified and how 

should the plan, targets, or timetable be 

modified based on your experiences? 

Summary and Conclusion 

This guide and checklist were developed for the 

Center for Substance Abuse Treatment (CSAT) 

to assist States and publicly funded substance 

abuse treatment providers to succeed in a 

managed care environment. The objectives are 

to increase managed care participation by 

expanding knowledge, assessing readiness 

through use of the checklist, and encouraging 

effective action planning. 
Appendix C 

114

Remember, the checklist will be helpful but 

should not be the only tool your organization 

uses to prepare for managed care participation. 

Providers should attend workshops, read, share 

ideas with colleagues, and participate in State 

association activities. 

Treatment providers seeking additional 

assistance should contact their State authority or 

CSAT's Quality Assurance and Evaluation 

Branch within the Division of State Programs. 

References 

England, M.J., and Vacarro, V.A. New systems 

to manage mental health care. Health Affairs

10(4): 129-137, 1991. 

Feldman, S., and Goldman, W., eds. Editors' 

Notes. New Directions for Mental Health 

Services: Managed Mental Health Care. San 

Francisco: Jossey-Bass, 1993. 

Holahan, J.; Rowland, D.; Feder, J.; and Heslan, 

D. Explaining the recent growth in Medicaid 

spending. Health Affairs 12(3):177-193, 1993. 

Letsch, S.W. National health care spending in 

1991. Health Affairs 12(1):94-110, 1993. 

Oss, M.E. Industry statistics: Managed 

behavioral health programs widespread 

among insured Americans. Open Minds: The 

Behavioral Health Industry Analyst 8(3), n.p., 

1994. 

U.S. General Accounting Office. Medicaid: States 

Turn to Managed Care to Improve Access and 

Control Costs. Washington, DC: GAO 

(GAO/HRD-93-46), 1993. 

Waxman, A.S. "Managed mental health care: 

How to survive in the next decade." 

Presentation at the 2nd Annual Managed 

Care Conference, Psychotherapy Finances, 

Palm Beach, Florida, 1994. 

Wilson, C.V. Substance abuse and managed 

care. In: Feldman, S. and Goldman, W., eds. 

New Directions for Mental Health Services: 

Managed Mental Health Care. San Francisco: 

Jossey-Bass, 1993. 

Additional Readings 

Ansoff, H.; DeClerk, R.; and Hayes, R., eds. From 

Strategic Planning to Strategic Management. 

New York: John Wiley and Sons, 1976. 

Bryson, John M. Strategic Planning for Public and 

Nonprofit Organizations. San Francisco: 

Jossey-Bass, 1988. 

Center for Substance Abuse Treatment, Division 

of State Programs. Managed Care and 

Substance Abuse Treatment: A Need for 

Dialogue. Rockville, MD: CSAT, 1992. 

Center for Substance Abuse Treatment, Division 

of State Programs. Reports on the Meetings of 

the Center for Substance Abuse Treatment 

(Executive Summary); September 9-10, 1993 

Kansas City, Missouri; January 12-13, 1994 

Cincinnati, Ohio; and February 24-25, 1994 

Phoenix, Arizona. Rockville, MD: CSAT, 1994. 

Harwood, H.J.; Thomsom, M.; Nesmith, T. 

Healthcare Reform and Substance Abuse 

Treatment: The Cost of Financing Under 

Alternative Approaches–A Final Report. LewinVHI, Inc., February 1994. 

Join Together: A National Resource for 

Communities Fighting Substance Abuse. 

Health Reform for Communities: Financing 

Substance Abuse Services. Boston: Join 

Together, 1993. 

Koteen, J. Strategic management explained. 

Strategic Management in Public and Non-profit 

Organizations. New York: Praeger Publishers, 

1989. 
115

Appendix D 

Resource Panel 

Robert E. Anderson 

Director 

Quality Assurance Programs 

National Association of State Alcohol and 

Drug Abuse Directors, Inc. 

Washington, D.C. 

Lynn Aronson 

Housing Resource Manager 

Homeless Programs Branch 

Center for Mental Health Services 

Division of State and Community Systems 

Development 

Rockville, Maryland 

James Brennan 

Senior Staff Associate 

National Association of Social Workers 

Washington, D.C. 

Peter J. Cohen, M.D., J.D. 

Special Expert 

Medications Development Division 

National Institute on Drug Abuse 

Rockville, Maryland 

Linda S. Foley, M.A. 

Member 

TIPS Editorial Advisory Board 

Director 

Treatment Improvement Exchange 

Health Systems Research, Inc. 

Washington, D.C. 

Helen Howerton, M.A. 

Director 

Child and Family Development 

Office of Planning, Research, and Evaluation 

Administration for Children and Families 

Washington, D.C. 

Mary Nakashian 

Vice President and Director of Program 

Demonstration 

National Center on Addiction and Substance 

Abuse 

Columbia University 

New York, NY 

Elizabeth Rahdert, Ph.D. 

Research Psychologist 

Treatment Research Branch 

Division of Clinical and Services Research 

National Institute on Drug Abuse 

Rockville, Maryland 

Larry Rickards, Ph.D. 

Director 

Intergovernmental Initiatives 

Homeless Programs Branch 

Center for Mental Health Services 

Rockville, Maryland 
Appendix D 

116

Barbara Roberts, Ph.D. 

Senior Policy Analyst 

Executive Office 

White House Office of National Drug 

Control Policy 

Washington, D.C. 

Santo Ruiz 

Project Officer 

Community Support Program 

Division of State and Community Systems 

Development 

Center for Mental Health Services 

 Rockville, Maryland 

Richard T. Suchinsky, M.D. 

Associate Chief 

Addictive Disorders 

Mental Health and Behavioral Sciences 

Services 

Department of Veterans Affairs 

Washington, D.C. 
117

Appendix E 

Field Reviewers 

Darlene Allen, M.S. 

Director 

Child Welfare Services 

Children's Friend and Services 

Providence, Rhode Island 

Andrea G. Barthwell, M.D. 

President 

Encounter Medical Group, P.C. 

Oak Park, Illinois 

Janice S. Bennett, M.S., C.S.A.C. 

Project Director 

Addiction Technology Transfer Center of 

Hawaii 

Honolulu, Hawaii 

Saroja A. Boaz 

Executive Director 

Intake Assessment and Referral Center 

Flint, Michigan 

Kim Bowman 

Director 

Government Services Center 

Chester County Department of Drug and and 

Alcohol Services 

West Chester, Pennsylvania 

Patricia Bradford, L.I.S.W., L.M.F.T., C.T.S. 

P.A. Bradford and Associates 

Columbia, South Carolina 

Mary Candace Burger, Ph.D. 

Assistant Professor 

Division of Geriatric Psychiatry 

Department of Psychiatry 

Vanderbilt Medical School 

Nashville, Tennessee 

Donna L. Caldwell, Ph.D. 

Senior Research Associate 

National Perinatal Information Center 

Providence, Rhode Island 

Donna H. Caum, M.S.S.W. 

Treatment Program Consultant 

Bureau of Alcohol and Drug Abuse Services 

Tennessee Department of Health 

Nashville, Tennessee 

Patrick R. Connelly 

Substance Abuse Program Consultant 

Division of Mental Health, Development 

Disabilities and Substance Abuse Services 

North Carolina Department of Health and 

Human Services 

Raleigh, North Carolina 
Appendix E 

118

Gary Cox, Ph.D. 

Research Associate Professor 

ADAI 

University of Washington 

Seattle, Washington 

Martin C. Doot, M.D. 

Chief 

Division of Addiction Medicine 

Addiction Medicine/ Family Practice 

Lutheran General Hospital Advocate 

Park Ridge, Illinois 

Larry W. Dupree, Ph.D. 

Professor 

Department of Aging and Mental Health 

Florida Mental Health Institute 

University of South Florida 

Tampa, Florida 

Mary E. Evans, R.N, Ph.D. 

Director of Research 

College of Nursing (MDC 22) 

University of South Florida 

Tampa, Florida 

Gary L. Fisher, Ph.D. 

Addiction Technology Transfer Center 

College of Education 

University of Nevada at Reno 

Reno, Nevada 

Steven L. Gallon, Ph.D. 

Program Director 

Office of Alcohol and Drug Abuse Programs 

Northwest Frontier Addiction Technology 

Transfer Center 

Salem, Oregon 

Theodore M. Godlaski, M.Div., I.C.D.C. 

Director of Community Treatment Project 

Center for Alcohol and Drug Research 

University of Kentucky 

Lexington, Kentucky 

Susan H. Godley, Ph.D. 

Senior Research Consultant 

Lighthouse Institute 

Chestnut Health Systems 

Bloomington, Illinois 

Darryl M. Grafton, M.Div., C.C.D.C. 

Clinical Supervisor 

Southeast Baltimore Center for Treatment 

Bayview Medical Center 

Johns Hopkins University 

Baltimore, MD 

Marge L. Hazen 

Systems and Funding Development 

Specialist 

Bureau of Substance Abuse Services 

Department of Health and Social Services 

State of Wisconsin 

Madison, Wisconsin 

Maya Hennessey, C.R.A.D.C. 

Women's Specialist 

Office of Special Programs 

Illinois Department of Alcoholism and 

Substance Abuse 

Chicago, Illinois 

Robert Holden, M.A. 

Program Director 

Partners in Drug Abuse Rehabilitation 

Counseling 

Washington, D.C. 

Deborah Horan 

Manager 

Special Issues 

American College of Obstetrics and 

Gynecology 

Washington, D.C. 

Mary Beth Johnson, M.S.W. 

University of Missouri at Kansas City 

Kansas City, Missouri 
Field Reviewers 

119

Patti Juliana 

Director of Clinical Services 

Division of Substance Abuse 

Albert Einstein College of Medicine 

Bronx, New York 

Linda Kaplan 

Executive Director 

National Association of Alcoholism and 

Drug Abuse Counselors 

Arlington, Virginia 

Karen Kelly-Woodall, M.S., M.A.C., N.C.A.C.II 

Cork Institute 

Morehouse School of Medicine 

Atlanta, Georgia 

Michael W. Kirby, Jr., Ph.D. 

Chief Executive Officer 

Arapahoe House, Inc. 

Thornton, Colorado 

Mark L. Kraus, M.D. 

Westside Medical Group 

Waterbury, Connecticut 

Jeffrey N. Kushner 

Drug Court Administrator 

22nd Judicial District 

Municipal Court of Saint Louis 

Saint Louis, Missouri 

Carl G. Leukefeld, D.S.W. 

Director 

Center on Drug and Alcohol Research 

University of Kentucky 

Lexington, Kentucky 

Sheera Lipshitz 

Director 

Assertive Treatment Team 

Brandywine Counseling, Inc. 

Wilmington, Delaware 

Bruce Lorenz, N.C.A.C. II 

Director 

Thresholds, Inc. 

Dover, Delaware 

Greg J. Madden, Ph.D. 

Research Associate 

Human Behavioral Pharmacology 

Laboratory 

University of Vermont 

Burlington, Vermont 

Jennifer Mankey, B.S.W., M.P.A. 

Project Director 

Denver Juvenile Justice Treatment Network 

Denver, Colorado 

Patrice Muchowski, Sc.D. 

Vice President 

Clinical Services 

Adcare Hospital of Worcester 

Worcester, Massachusetts 

Marlene O'Connell, R.N. 

Manager 

Behavioral Health Services 

Benefits Healthcare 

Great Falls, Montana 

Gennaro Ottomanelli, Ph.D. 

Director 

Division of Drug Dependence 

Kings County Addictive Disease Hospital 

Brooklyn, New York 

Elizabeth A. Peyton 

Executive Director 

National TASC 

Silver Spring, Maryland 

Ronald Pike, M.D. 

AdCare Hospital of Worcester 

Worcester, Massachusetts 
Appendix E 

120

Deborah Powers 

IDU/AIDS Treatment Specialist 

State Methadone Authority 

State Department of Health and Family 

Services 

Madison, Wisconsin 

Lynda A. Price, Ph.D., I.C.A.D.C. 

Treatment Coordinator 

National Drug Commission 

Global House 

Hamilton, Bermuda 

Anthony Quintiliani, Ph.D. 

Clinical Director, Chief Psychologist 

Drug and Alcohol Division 

Howard Center for Human Services 

South Burlington, Vermont 

Patricia Reihl 

Coordinator 

Spring House 

Paramus, New Jersey 

Margaret M. Salinger, M.S.N., R.N., C.A.R.N. 

National Nurses Society on Addiction 

c/o Department of Veterans Affairs Medical 

Center 

Coatesville, Pennsylvania 

Anna M. Scheyett, M.S.W. 

Program Coordinator 

Behavioral Health Care Resource Program 

School of Social Work 

University of North Carolina at Chapel Hill 

Chapel Hill, North Carolina 

Stephen Schoen, Ph.D. 

Director 

Alcohol and Drug Awareness Program 

Department of State 

Medical Services 

Washington, D.C. 

Rene W. Seidel 

Director 

HIV Services 

Tarzana Treatment Center 

Tarzana, California 

Michael R. Sosin, M.S.W., Ph.D. 

Professor 

School of Social Service Administration 

University of Chicago 

Chicago, Illinois 

Flo A. Stein, M.P.A. 

Acting Section Chief 

Division of Mental Health, Developmental 

Disabilities and Substance Abuse Services 

Alcohol and Drug Services 

Raleigh, North Carolina 

Richard T. Suchinsky, M.D. 

Associate Chief 

Addictive Disorders 

Mental Health and Behavioral Sciences 

Services 

Department of Veterans Affairs 

Washington, D.C. 

Suzan Swanton 

Clinical Supervisor 

Glenwood Life Counseling Center 

Baltimore, Maryland 

Donald L. Tomlin 

Specialist 

Nashville Area Indian Health Service 

Substance Abuse 

Indian Health Service 

Cherokee, North Carolina 

Robert Walker, M.S.W., L.C.S.W., B.C.D. 

Director 

Bluegrass East Comprehensive Care Center 

Lexington, Kentucky 
Field Reviewers 

121

Deborah Watson, Ph.D. 

Program Operations Manager 

Cleveland CARES Target Cities 

Alcohol and Drug Addiction Services Board 

Cleveland, Ohio 

Robert Whitney, M.D. 

Medical Consultant 

Office of Alcoholism and Substance Abuse 

Research Institute on Addiction 

Buffalo, New York 

Annette H. Wieser 

Regional Director 

Program Administration 

Texas Commission on Alcohol and Drug 

Abuse 

Austin, Texas 

Janet S. Woodburn 

President 

Bridgeway Counseling Services, Inc. 

Saint Charles, Missouri 
The TIPs Series                                                                            

TIP 2 Pregnant, Substance‐Using Women   BKD107

TIP 5 Improving Treatment for Drug‐Exposed Infants   BKD110

TIP 6 Screening for Infectious Diseases Among Substance Abusers   BKD131

TIP 11    Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases   BKD143

TIP 13   The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders   BKD161

TIP 14   Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment   BKD162

TIP 16   Alcohol and Other Drug Screening of Hospitalized Trauma Patients   BKD164

TIP 18   The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse Treatment Providers   BKD173

TIP 21   Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System   SMA 08‐4073

TIP 23   Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing   SMA 12‐3917

TIP 24   A Guide to Substance Abuse Services for Primary Care Clinicians   SMA 08‐4075

TIP 25   Substance Abuse Treatment and Domestic Violence   SMA 12‐4076

TIP 26   Substance Abuse Among Older Adults   SMA 12‐3918

TIP 27   Comprehensive Case Management for Substance Abuse Treatment   SMA 12‐4215

TIP 29   Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities   SMA 08‐4078

TIP 30   Continuity of Offender Treatment for Substance Use Disorders From Institution to Community   SMA 08‐3920

TIP 31   Screening and Assessing Adolescents for Substance Use Disorders   SMA 08‐4079

TIP 32   Treatment of Adolescents With Substance Use Disorders   SMA 08‐4080

TIP 33   Treatment for Stimulant Use Disorders   SMA 09‐4209

TIP 34   Brief Interventions and Brief Therapies for Substance Abuse   SMA 07‐3952

TIP 35   Enhancing Motivation for Change in Substance Abuse Treatment   SMA 09‐4212

TIP 36   Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues   SMA 08‐3923

TIP 37   Substance Abuse Treatment for Persons With HIV/AIDS   SMA 08‐4137

TIP 38   Integrating Substance Abuse Treatment and Vocational Services   SMA 06‐4216

TIP 40   Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction   SMA 07‐3939

TIP 41   Substance Abuse Treatment: Group Therapy   SMA 09‐3991

TIP 42   Substance Abuse Treatment for Persons With Co‐Occurring Disorders   SMA 08‐3992

TIP 43   Medication‐Assisted Treatment for Opioid Addiction in Opioid Treatment Programs SMA 08‐4214

TIP 44   Substance Abuse Treatment for Adults in the Criminal Justice System SMA 05‐4056

TIP 45   Detoxification and Substance Abuse Treatment SMA 08‐4131

TIP 46   Substance Abuse: Administrative Issues in Outpatient Treatment SMA 06‐4151

TIP 47   Substance Abuse: Clinical Issues in Outpatient Treatment SMA 06‐4182

TIP 48   Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery   SMA 08‐4353

TIP 49   Incorporating Alcohol Pharmacotherapies Into Medical Practice   SMA 09‐4380

TIP 50   Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment   SMA 09‐4381

TIP 51   Substance Abuse Treatment: Addressing the Specific Needs of Women   SMA 09‐4426

TIP 52   Supervision and the Professional Development of the Substance Abuse Counselor   SMA 09‐4435

TIP 53   Addressing Viral Hepatitis in People With Substance Use Disorders   SMA 11‐4656                                        

TIP 54   Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders   SMA 11‐4661

Other TIPs may be ordered by calling 1‐877‐SAMHSA‐7 (1‐877‐726‐4727) (English and Español)  

or visiting http://store.samhsa.gov.   

HHS Publication No. (SMA) 12‐4215

Substance Abuse and Mental Health Services Administration   

ȱPrinted 2000

Re 200 , 20 3, 20 6, 200 , 2 10, and 201