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 self-help 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 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 agency-based 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
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 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, 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.
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
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
goal-setting 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 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.
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 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 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 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 community-based 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.