Case Management

Case management is intended to help patients engaged in substance abuse take advantage of community services that have the potential to enhance their treatment experience. The hope is that patients who access these services will be more engaged in treatment which will reduce drop-outs and increase retention. In addition to addiction, patients in substance abuse treatment often have significant problems in other areas of their lives. Case management has the potential to help patients access the community support they need to stabilize their lives so they are able to focus on treatment.

Often times when reviewing literature relating to substance abuse treatment a large proportion of studies focus on outcomes. This was also true when looking at the effects of case management. But there is a growing body of research focusing on the ability of case managers to engage patients in treatment while increasing retention. A study by Mejita et al (1997) reviewed a case management approach which involved 360 intravenous drug users (IDU’s) pursuing treatment through a central intake facility. Participants were randomly assigned to either the case management group or a control group which followed the standard referral procedure for the central intake facility. Patients in the control group were given primary responsibility for making contact with a treatment center, obtaining an intake appointment as well as obtaining any necessary paperwork. Patients in the case management group were assigned a case manager at the point of first contact. The case manager would assess the needs of the patient and identify potential barriers to treatment entry. The case manager would work with the patient to determine treatment needs and locate a provider with an available time slot. The case manager stayed engaged with the client during the referral and admission process which entailed securing intake appointments, providing transportation and purchasing substance abuse treatment services when necessary. Of the 160 patients in the case management group 157, or 98%, entered treatment. Of the 156 control group patients, 89, or 57% entered treatment. The case managed group also had a shorter wait to enter treatment (17 day average) then the control group (188 day average). Case management also had a positive effect on retention. The length of the study was 36 months. Case management clients stayed in treatment for an average of 27 months. Control group clients stayed in treatment for an average of 14 months. In this instance, case management led to better outcomes in all the areas defined by NIATx as essential to increasing access to treatment.

Schwartz et al (1997) studied the effects of adding 66 case managers to publicly funded substance abuse treatment programs in Boston. Collecting data from over 20,000 clients they attempted to answer whether or not case management was effective in keeping clients in treatment and reducing short term relapse. A program-based model of case management was implemented in which case managers were integrated with existing treatment staff. Citywide case management protocols were developed and activities were coordinated and monitored across the city. Reviewing admission and discharge forms from the Massachusetts Bureau of Substance Abuse Services management information system the authors were able to determine the effectiveness of case management across four different levels of care: short-term residential, long-term residential, outpatient, and detox. Clients who received case management services stayed in treatment longer ( an average 30% increase over non case managed clients in all modalities), were less likely to be admitted to detox within 90 days of discharge and in the case of detox clients, more likely to transition to post-detox treatment within 30 days of discharge. One limitation of the study is that the authors were unable to define which case management services had the greatest impact. The authors do conclude that even small amounts of case management has a positive impact on client retention in treatment.

Increasing entry and retention in treatment among pregnant substance abusers was the focus of a study by Laken & Ager (1996). Case management services were provided to 255 pregnant women. Case managers performed home visits, phone counseling, provided transportation and referrals to treatment. 100% of the women involved in the study contacted a treatment facility and 56% obtained treatment during pregnancy. Five characteristics were identified as predictors of treatment entry: History of protective services involvement, number of drugs ever used, currently receiving methadone, intensity of case management and receiving transportation to drug treatment appointments.

The Chicago Target Cities project evaluated the effect of case management on treatment engagement and outcomes (Scott et al, 2002). The study included participants in several different treatment settings: drug-free outpatient, outpatient methadone maintenance, intensive outpatient, short-term residential, long-term residential and halfway house. The goal was to have 100 participants from each group. Only the halfway house level of care had not reached the target number. Participants assigned to the Case Management (CM) condition were assigned a case manager upon completion of the centralized intake unit (CIU) assessment. The case managers developed referrals for ancillary services in response to needs identified during the CIU assessment. Case managers kept in contact with the participants to encourage them to follow through with their referrals to treatment. Patients in the CM condition showed for treatment at a statistically higher rate than the non-CM group (78.9% vs. 71.8%). Also, case management had more of an impact on younger participants showing to treatment. As for treatment retention, there was no statistically significant difference between the groups.

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