Case Management in Substance Use Disorder Treatment

By Rob Pleiman, Senior Director of Systems, and Carl Kelley, Regional Director, Eastern Pennsylvania, Pinnacle Treatment Centers

Navigating the healthcare system in the United States can be tricky.

That’s true for simple issues and complex issues. We’re all familiar with the hoops we need to jump through to get the care we need. There are times when it’s easy, and times when it’s challenging and time consuming. Sometimes getting appropriate care involves one trip to one doctor, then one stop at one pharmacy on the way home. If we’re lucky, it can happen in a couple of hours, or a day at most.

However, it doesn’t always work like that.

Sometimes we need to see a primary care physician, then a specialist, and then perhaps another specialist, and then another provider such as a physical therapist – even for something as straightforward as a sprained ankle.

That can get confusing and tiring.

And we haven’t mentioned the challenges around scheduling, insurance, and prescriptions.

Now imagine what it’s like for a person with a chronic medical condition, such as a substance use disorder, and a co-occurring mental health disorder. Now add an additional medical condition such as cancer or diabetes.

Imagine coordinating everything necessary to make appointments, get insurance approval, manage a dosage schedule for various medications, ensure that you get medications on time and show up for every scheduled check-in, test, or therapy session.

Now go further: imagine juggling all that while in the earliest stages of recovery from an alcohol or substance use disorder. Some of us may be able to do it. In fact, millions have, over the past several decades. But it’s also important to recognize that these issues – which some people may think of as minor bureaucratic headaches – can prevent someone from continuing treatment or starting treatment in the first place.

That’s where case managers come in.

What is Case Management?

One way to think about case managers is that while you focus on treatment, they focus on everything else. And as we indicate above, there can be a lot to focus on where medical issues are concerned – especially when the medical issue is a substance use disorder (SUD).

Why?

Because SUDs often occupy a space at the intersection of physical health and emotional health. Data from Substance Abuse and Mental Health Services Administration (SAMHSA) show that in 2019:

• 9.5 million adults met criteria for SUD and an additional mental health disorder
  • When a person has SUD and a mental health disorder, they receive a dual diagnosis and have what mental health professionals call co-occurring disorders.
• Of the 9.5 million adults with SUD:
  • 3.6 million had a serious mental illness

In addition, the National Institute on Drug Abuse (NIDA) identifies the following physical conditions – called comorbidities – reported by people with substance use disorder:

• Cardiovascular disease
• Hepatitis
• Sexually transmitted disease/infection
• Tuberculosis

Co-occurring disorders, comorbidities, and the complexity of the healthcare system combine to create the necessity for case managers. They’re an important part of the recovery picture for people in treatment for SUD.

So what do they do, exactly?

Here’s how the Substance Abuse and Mental Health Services Administration (SAMHSA) define case management:

“Case management is 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. 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.”

In other words, they handle the details while you heal. They make sure important details don’t fall through the cracks and facilitate a smooth transition through various levels and modes of care so there are no gaps in treatment, and each individual in treatment experiences an efficient journey through their entire continuum of care.

Why Case Management?

In some circumstances, a person in treatment for SUD needs a wide range of support services beyond treatment for substance use. However, in many communities, cities, and states, services are fragmented and not coordinated, which makes it difficult for people in need to access the full suite of support services available to them.

Factors that contribute to the fragmented state of care include:

• Funding is not integrated. Funding for critical social support services, including SUD treatment, come from a variety of sources. The specific criteria for accessing the following resources can result in an uncoordinated, “piecemeal approach to programming,” which allows people in need to fall through the cracks:
  • Block grants
  • Competitive grants
  • State and local programs
  • Criminal justice programs
  • The different requirements or goals of these sources can result in a piecemeal approach to programming
• A focus on short-term acute needs rather than long-term, systemic restructuring
• A focus on single approaches to treatment rather than a comprehensive, integrated continuum of care
• Long wait times for treatment and support due to lack of funding
• Poor communication between systems:
  • Mental health providers and substance use treatment providers
  • Criminal justice programs and mental health/substance use treatment programs
• Misaligned incentives:
  • Many programs reward process measures for programs, rather than outcome measures for individual participants

Case managers can help individuals who need to access modes of support delivered by agencies, programs, or initiatives that are not fully integrated and not equipped for seamless collaboration. An additional set of factors driving the need for case management services – related to the fragmented state of funding for SUD – are the social determinants of health (SDOH).

What Are the Social Determinants of Health?

Here’s how the U.S. Department of Health and Human Services (HHS) define the SDOH:

“The social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

The SDOH include five distinct domains:

1. Economic Stability
2. Education Access and Quality
3. Health Care Access and Quality
4. Neighborhood and Built Environment
5. Social and Community Context

Examples of how the SDOH impact the lives of people are directly related to the state of inequity or equity present in any given community. The following SDOH can have a positive or negative effect on individuals, families, and communities:

• Safe and healthy neighborhoods with access to affordable housing and transportation: positive effect
• Community violence discrimination, and racism: negative effect
• Access to employment, income, and education: positive effect
• Access to healthy foods: positive effect
• Opportunity to engage in safe outdoor recreation: positive effect
• Polluted air and water: negative effect
• Language and literacy skills: positive effect

In some situations, case managers evaluate and assess the impact of the SDOH on an individual in SUD treatment. They collaborate with the individual, treatment providers, and sources of support to develop a plan that leverages the positive effects of the SDOH and mitigates the negative effects of SDOH caused by fragmented support systems – see above – and preexisting structural inequities.

We can think of case managers as proactive advocates who help an individual in treatment access all the available resources they need for a successful recovery. Here’s how the Case Management Society of America (CMSA) defines the value of case management:

“When an individual reaches the optimum level of wellness and functional capability, everyone benefits: the individuals being served, their support systems, the health care delivery systems and the various reimbursement sources.”

Everyone benefits. That’s a perspective we need more of, and one reason case managers play a vital role in SUD treatment. When they help individuals, their work expands outward, and affects both the people they help and the systems they work within.

We’ve now discussed what case management is, why we need case management, and some of the issues case managers help people with.

So how do they do it?

The Principles of Case Management: Support in Action

Proactive, compassionate, informed, expert advocacy: that’s what case managers do. Case managers anticipate problems and collaborate with people in treatment to address problems with practical solutions. That means a case manager needs to be detail oriented and also skilled at managing bureaucracies. They also need to be good with people: a case manager interacts with people from all walks of life, every day, builds and maintains relationships, and always leaves the door open – figuratively speaking – for the people they advocate for and the organizations they partner with.

That’s a broad job description – but case managers don’t have to make it up as they go. Their job is informed by a set of principles codified by SAMHSA, and described in detail in two publications: the first, published in 2015, is the “Comprehensive Case Management for Substance Abuse Treatment: Treatment Improvement Protocol (TIP) Series 27.” The second, published in 2020 –  the “Substance Abuse and Mental Health Services Administration Advisory: Case Management for Substance Use Disorder Treatment – is an updated version of the original 2015 publication.

Here are the foundational principles of case management, as defined by SAMHSA:

Principles of Case Management

Simplify the Process for People in Treatment

• CM offers the patient a single contact person to navigate the health and social services system
• CM assumes responsibility for coordinating services from various resources
• The CM replaces a confusing, complex process of referrals with a single, structured service

Put the Person First

• The CM emphasizes each person’s right to self-determination
• CM is familiar with their experiences and real-world living situation
• The CM uses this knowledge to identify psychosocial stressors and anticipate the need for specific services
• CM works with the patient to set treatment goals and access necessary support services

Work in the Community

• CM helps people in treatment access and integrate formalized and informal support services in their home communities
• CM helps people in treatment overcome barriers to services in their home communities
• The CM helps people transition from on type of service to another
• Each CM engages at different levels in the community. For example:
  • One CM may offer a list of support meetings and times for a patient to attend
  • Another CM may accompany patients to those same meetings

Prioritize Equity

• CM addresses exigent and tangible needs related to the social determinants of health, such as:
  • Stable and safe housing
  • Food
  • Childcare
  • Income
• CM understands some individuals lack adequate access to life-enhancing resources and recognizes that resolving access to these resources may be necessary before an individual can focus on or commit to treatment

Advocate for Patient Needs

• A CM works to promotes the best interest of the person in treatment
• CM may educate service providers about circumstances patients face
• CM may negotiate for reduction or increase in services
• A CM may recommend actions to providers or representatives of the judicial system, such as:
  • Increasing frequency of treatment
  • Requesting remedies other than jail time
• A CM may act on behalf of a patient who is refused treatment based on discrimination, or help a patient access essential needs, such as food, housing, or clothing

Demonstrate Cultural Competency

• The CM learns all they can about the culture of the person they support
• The CM connects with resources in the home community of the person they support and facilitates contact
• CM models non-stigmatizing language, behavior, and attitude for other service providers

Create Practical Solutions

• The CM offers resources that are pragmatic and, in most cases, immediately useful
• In some cases, CMs bolster recovery skills such as assertive communication that help with daily life
• CM may teach skills directly, or model these skills through behavior in their interactions with the patient, and during interactions with service providers that occur in the presence of patient

In order to put these principles into action, case managers need experience in a variety of healthcare and social service/social support situations. That’s why most case managers start as nurses, social workers, or addiction counselors. The list above indicates they not only need to be the most organized person in any room they walk into, but they also need practical training in the areas where their patient and clients need support. Therefore – in addition to their original training – case managers participate in case management accreditation courses that prepare them to meet the needs of the job.

Case Managers: SUD Treatment Superheroes

While many people in treatment have family support, or the help of friends, some don’t. For these people, case managers are quite literally superheroes. Of course, people with family support and friends need case managers, too. However, when a person has no outside support, a case manager can help them through the early stages of treatment and handle things family members or friends might otherwise handle. During treatment, a case manager can arrange access to community support groups and other social services that allow an individual to build a support system that can sustain them after their time in structured treatment.

Support on that level is invaluable to a person in treatment, who may feel alone, inadequate, and unable to manage all the details related to treatment that aren’t the treatment itself. Having a case manager in their corner can make all the difference in the world. We mean that: when you consider the fact that a case manager can help a person in treatment find food support, housing support, vocational assistance, and a sober social network – and have many of those supports in place when they complete treatment – you may agree when we say that case managers do vital work that helps families, improves communities, and saves lives.