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Case Management and Referral Performance Domain Back to Course Index

 

 

 

Case Management

Case management is the coordination of community-based services by a professional or team to provide individuals the quality care that is customized accordingly to the client’s setbacks or persistent challenges and aid them to their recovery.  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. 

This course will explore the principles and competencies necessary to implement case management functions, and the relationship between those functions and the substance abuse treatment continuum. 

Providing treatment and support for individuals battling substance abuse is challenging. Despite the wide range of programs available, 40-50% of individuals who receive treatment for chemical dependency will relapse at some point and most within the first year.  This makes the continuum of care including aftercare services that much more important. Case management is a valuable tool in ensuring that those seeking and receiving treatment for substance abuse and addiction have lasting positive outcomes.

Remove External and Internal Barriers to Treatment 

One of the goals of case management is to attempt to reduce internal and external barriers to treatment. For many clients that might begin with providing for simple, immediate needs and building trust with the case manager.

Providing a pair of shoes, a translator or a ride to the doctor not only reduces the stress of an individual’s immediate concerns but opens the door for a case manager to begin building trust. Since many resources have waiting lists or drawn-out intake procedures, these simple services can help ensure early, frequent opportunities for case managers to interact with clients in a positive, supportive way.

A good initial relationship between the client and the case manager is an important foundation.  When the client experiences difficulties and challenges later in the treatment process they have already formed a working relationship where they see the case manager as an ally.

Helping Clients Access Services Independently

The focus of substance abuse case management is to help individuals to access social services. Most case management assessments will identify the needs of the individual for a range of those services, from medical interventions to family support and employment services. But ultimately, the goal of a substance abuse case management approach is to help clients learn how to obtain those services and function more independently.

An assessment should consider two types of skills:

  • Ability to access service skills
  • Employment or vocational skills. 


Ability to access service skills include the following:

  • Ability to obtain and follow through on medical service
  • Ability to apply for benefits
  • Ability to obtain and maintain safe housing
  • Skill in using social services agencies
  • Skill in accessing mental health and substance abuse treatment services

Employment and vocational skills focus on an individual’s potential for independence. Case managers should evaluate the following skills and abilities as part of their assessments:

  • Basic reading and writing skills
  • Skills in following instructions
  • Transportation skills
  • Manner of dealing with supervisors
  • Timeliness, punctuality
  • Telephone skills

In developing a substance abuse case management strategy, case managers can use the process of connecting a client with needed services as an opportunity for teaching individuals how to obtain similar services in the future. They can also integrate ongoing and long-term employment training and services where needed.

 

Advocacy

Advocacy is an important means of raising awareness on mental health and substance abuse issues and ensuring that these topics are on the national agenda.

Finally getting into treatment for a mental health disorder can be life-changing.  Why then is it so difficult for some to seek treatment?

Experts overwhelmingly agree that getting help is the best way to manage a mental illness. Yet research shows the negative attitudes about mental health, both self-imposed and from others, can prevent people from seeking support.  Not to mention the fact that data shows that access to this kind of care is becoming increasingly more difficult, specifically in rural areas.

Below are some stats everyone should know about the way we treat mental health conditions today. If anything, the data is proof this subject needs way more attention.

1 in 5

The number of American adults who will be diagnosed with a mental health disorder in a given year.

300 Million

The number of people globally who have depression, according to the World Health Organization. The prevalence of the condition has increased by 18 percent in the last decade.

56 Percent

The percentage of the U.S. adults with a mental health condition who do not receive proper treatment according to a 2016 Mental Health America report. 

6 in 10

The number of young people in the U.S. with major depression who will not receive any treatment, according to the Mental Health America report.

24 Percent

The rate of increase in suicides in a 15 year period, according to 2016 data from the CDC. Those who die by suicide are often dealing with un-diagnosed, untreated or under-treated mental health issues.

1 in 5

The number of people who have taken a prescribed psychiatric drug, such as an antidepressant, at least once.  

25 Percent

The percentage of people living with a mental health issue who feel like others are not caring or sympathetic about their condition, as noted by the CDC. That implies a majority of people with a mental illness may feel shamed or judged. As mentioned above, studies show stigma is a very real problem and stands in the way of people seeking treatment.

Getting treatment should be embraced, not denied. It’s time to do better ― with each other and as a country.

The human costs of an underfunded behavioral health care system are tragic.  While millions of individuals wait for affordable treatment they are suffering from depression, schizophrenia,  substance use disorder and a host of other issues that take a toll on their ability to work, go to school, attend to their physical health and maintain personal relationships and at times put others at risk.

While treating these disorders can certainly be expensive, the cost of not treating them is far greater. Mental illness and substance abuse are the leading causes of disability, job absenteeism and lost productivity.

Employers, taxpayers, and health care providers shoulder these costs. Local indigent health care programs, prisons, and governments work to fill the service gaps created by systemic underfunding. For hospitals specifically, the costs of an underfunded behavioral health care system manifest themselves in reduced emergency department capacity, uncompensated care, and preventable hospital re-admissions.

Because of the shortage of inpatient psychiatric beds statewide, hospital emergency departments often cannot immediately transfer patients with mental illness once they are stabilized. These patients may end up in an emergency department bed for 48 hours or more while they wait for appropriate treatment to become available. This practice, known as holding or boarding, has multiple causes: 

(1) the shortage of state hospital beds;

(2) the lack of insurance coverage for behavioral health conditions;

(3) shortage of mental health  professionals;

(4) the increasing number of forensic commitments; and

(5) the lack of a strong system of community-based care that keeps people with mental illness out of a crisis.

Boarding both delays the patient’s ability to be treated in the appropriate setting and strains the emergency department’s capacity to treat other patients. A busy, crowded emergency department is not conducive to treating a patient with a behavioral health condition.

The devastating effects of an underfunded behavioral health care system are felt most profoundly by individuals living with untreated disorders.

Advocacy is hard work. Collaboration is perhaps even harder work. Advocacy for and collaboration on efforts to promote effective approaches to mental health and alcohol and other drug treatment can be particularly challenging in light of the stigma that surrounds these issues and the difficulty in finding resources (money) to meet the demands of competing for public health priorities.  It may seem as if, more often than not, we make little to no progress in advancing the priorities of the mental health and substance use treatment fields. 

The good news is there are many examples of the well-informed and prepared individuals making a difference, when the opportunity presents itself, to advocate for the right thing.  This course will explore how to advocate for the mental health and substance abuse fields.

Concept of mental health advocacy  

The concept of mental health advocacy has been developed to promote the human rights of persons with mental disorders and to reduce stigma and discrimination. It consists of various actions aimed at changing the major structural and attitudinal barriers to achieving positive mental health outcomes in populations.

Advocacy in this field began when the families of people with mental health issues and substance abuse issues first made their voices heard. The individuals in treatment then added their own contributions. Gradually, these people and their families were joined and supported by a range of organizations, many mental health workers and their associations, and some governments. Recently, the concept of advocacy has been broadened to include the needs and rights of persons with mild mental disorders and the mental health needs and rights of the general population.

Advocacy is considered to be one of the eleven areas for action in any mental health policy because of the benefits that it produces for people with mental disorders and their families.

The areas through which advocacy takes place include:   

  • Awareness-raising
  • Information
  • Education
  • Training
  • Mutual help
  • Counseling
  • Mediating
  • Defending
  • Denouncing

Drawing attention to barriers for mental health and substance abuse treatment

In most parts of the world, unfortunately, mental health and mental disorders are not regarded with anything like the same importance as physical health. Among the issues that have been raised in mental health advocacy are the following:

Lack of mental health services

Some Americans have poor access to mental health care services because they live in a rural environment. Others cannot logistically get to treatment because of lack of transportation or overwhelming work and home responsibilities. In some areas, a mental health professional is available, but inpatient psychiatric hospitalization is not. Inner-city clinics may have such long waiting lists that mentally ill people give up on receiving care.

Unaffordable cost of mental health care through out-of-pocket payments

Many people do not seek mental health care for financial reasons. A lack of health insurance coverage, or coverage that leaves a large amount owed by the patient, leads many to avoid seeking care. Many Americans are unaware of the free or discounted mental health services available to them in the city, county, state, private or Veterans Administration clinics and facilities. A report from former Surgeon General David Satcher, M.D., PhD., states that racial, age, cultural and gender disparities exist in the seeking of services, mostly linked to financial issues.

Lack of parity between mental health and physical health

Unlike physical illnesses, it is the nature of many mental illnesses that the patient does not realize he is ill. Believing his behavior, emotions and mental status are normal, he may experience a lifetime of disordered thinking that could be greatly improved with appropriate treatment. Family intervention is critical to successful illness stabilization in these cases.

Poor quality of care in mental hospitals and other psychiatric facilities

Not always the case, but staffing ratios can be too low. When you have a population that does not have a voice the treatment can be poor. With funding being a concern the facilities can be in bad condition. All of these factors and more leave some with the question, is medication replacing care at mental health facilities?

Need for alternative, consumer-run services

Again, because of treatment availability alternatives are needed in rural and inner-city areas.

Right to self-determination and need for information about treatments

Violations of human rights of persons with mental disorders

Human rights violations against people with mental disorders occur in communities throughout the world in mental health institutions, hospitals, and in the wider community.

The stigma associated with mental disorders, resulting in exclusion

The Community Action Network reports that many patients feel a stigma exists regarding the mentally ill and that negative stereotypes could damage their careers or relationships. Embarrassment and fear of what others may think prevent many from seeking or continuing the services they need.

Absence of promotion and prevention in schools, workplaces, and neighborhoods

Insufficient implementation of mental health policy, plans, programs, and legislation

A study titled “Perceived Barriers to Mental Health Service Utilization in the United States, Ontario and the Netherlands” reported that attitudinal barriers commonly caused Americans to not seek mental health care. These barriers include believing that the mental illness will resolve on its own and not believing that psychiatric care is beneficial.

Once we, and the public and policymakers, are aware of these barriers we can begin to break them down. The emergence of mental health and substance abuse advocacy movements in several countries has helped to change society’s perceptions of persons with disorders. Consumers have begun to articulate their own visions of the services they need. They are increasingly able to make informed decisions about treatment and other matters in their daily lives. Consumer and family participation in advocacy organizations may also have several positive outcomes.

 

Roles of different groups in advocacy 

Consumers and families

Consumer groups have played various roles in advocacy, ranging from influencing policies and legislation to providing help for people with mental disorders. Consumer groups have sensitized the general public about their cause and provided education and support to people with mental health and substance abuse disorders. They have denounced some forms of treatment that are believed to be negative. They have denounced poor service delivery, inaccessible care and involuntary treatment. Consumers have also struggled for improved legal rights and the protection of existing rights.

The roles of families in advocacy overlap with many of the areas taken on by consumers. However, families have the distinctive role of caring for persons in treatment. In many places they are the primary care providers and their organizations are fundamental as support networks. In addition to providing mutual support and services, many family groups have become advocates, educating the community, increasing the support obtained from policy-makers, denouncing stigma and discrimination, and fighting for improved services. 

Nongovernmental organizations

These organizations may be professional, involving only mental health professionals, or interdisciplinary, involving people from diverse areas. In some nongovernmental organizations, mental health professionals work with persons who have mental disorders, their families and other concerned individuals.

Nongovernmental organizations fulfill many of the advocacy roles described for consumers and families. Their distinctive contribution to the advocacy movement is that they support and empower consumers and families.

General health workers and mental health workers

In places where care has been shifted from psychiatric hospitals to community services, mental health workers have taken a more active role in protecting consumer rights and raising awareness for improved services. In traditional general health and mental health facilities, it is not unusual that workers feel empathy for persons with mental disorders and become advocates for them over some issues. However, there can also be conflicts of interest between general health workers or mental health workers and consumers.

 

  • Some specific advocacy roles for mental health workers relate to:
  • clinical work from a consumer and family perspective;
  • participation in the activities of consumer and family groups;
  • supporting the development of consumer groups and family groups;
  • planning and evaluating programs together.

 

Principal steps for supporting consumer groups, family groups, and nongovernmental organizations

Step 1: Seek information about mental health consumer groups, family groups and nongovernmental organizations in the country or region concerned.

Task 1: Develop a database with consumer groups, family groups, and nongovernmental organizations.

Task 2: Establish a regular flow of information in both directions.

Task 3: Publish and distribute a directory of these organizations.

 

Step 2: Invite representatives of consumer groups, family groups, and nongovernmental organizations to participate in activities at the ministry of health.

Task 1: Formulate and evaluate policy, plans, programs, legislation or quality improvement standards.

Task 2: Establish committees, commissions or other boards.

Task 3: Take educational initiatives.

Task 4: Conduct activities with the media.

Task 5: Organize public events in order to raise awareness.

 

Step 3: Support the development of consumer groups, family groups and nongovernmental organizations at the national or regional level.

Task 1: Provide technical support.

Task 2: Provide funding.

Task 3: Support evaluations of consumer groups, family groups and nongovernmental organizations.

Task 4: Enhance the alliances and coalitions of consumer groups.

 

Step 4: Train mental health workers and general health workers to work with consumer and family groups.

 

Step 5: Focus activities in advocacy groups.

Task 1: Identify the principal features of consumer groups.

Task 2: Identify the principal features of family groups.

Task 3: Identify the principal features of nongovernmental organizations.

 

Principal steps for supporting general health workers and mental health workers

Step 1: Improve workers mental health:

Task 1: Build alliances with trade unions and other workers associations.

Task 2: Ensure that basic working conditions exist for general health and mental health workers.

Task 3: Implement mental health interventions for workers.

 

Step 2: Support advocacy activities with mental health workers

Task 1: Train mental health workers.

Task 2: Encourage community care and community participation.

Task 3: Facilitate interactions with consumer groups, family groups and nongovernmental organizations.

 

Step 3: Support advocacy activities with general health workers

Task 1: Define the role of general health workers in the field of mental health.

Task 2: Train general health workers in mental health.

Task 3: Establish joint activities with mental health specialists.

Task 4: Set up demonstration areas.

 

It is also vital to support advocacy activities with policy-makers and planners. The principal objective in respect of policy-makers and planners is to give appropriate attention to mental health on national agendas. This helps to enhance the development and implementation of mental health policy and legislation.

 

Principal steps for supporting policy-makers and planners

Step 1: Build technical evidence

Task 1: Determine the magnitude of mental disorders.

Task 2: Highlight the cost of mental disorders.

Task 3: Identify effective mental health interventions.

Task 4: Identify cost-effective interventions.

 

Step 2: Implement political strategies

Task 1: Identify themes ranking high in public opinion.

Task 2: Demonstrate the success of these themes.

Task 3: Empower alliances among mental health advocates.

 

Stigma associated with mental health and substance abuse treatment

What is stigma?

Stigma is something about a person that causes her or him to have a deeply compromised social standing, a mark of shame or discredit.

The stigma associated with mental health and addiction treatment is one of the biggest challenges to recovery.

Common misconceptions about people in treatment for mental health issues or addiction:

People with disorders are often thought to be:

  • lazy
  • unintelligent
  • worthless
  • stupid
  • unsafe to be with
  • violent
  • out of control
  • always in need of supervision
  • possessed by demons
  • recipients of divine punishment

 

How to combat stigma

  • Community education on mental disorders (prevalence, causes, symptoms, treatment, myths and prejudices)
  • Anti-stigma training for teachers and health workers
  • Psycho-education for consumers and families on how to live with persons who have mental disorders
  • Empowerment of consumer and family organizations
  • Improvement of mental health services (quality, access, deinstitutionalization, community care)
  • Legislation on the rights of persons with mental disorders
  • Education of persons working in the mass media, aimed at changing stereotypes and misconceptions about mental disorders
  • Development of demonstration areas with community care and social integration for persons with mental disorders.

 

Importance of advocacy 

The advocacy movement has led to major changes in the way persons who seek treatment are regarded. Consumers have begun to articulate their own vision of the services they need and want. They are also making increasingly informed decisions about treatment and other matters affecting their daily lives.

Advocacy has helped consumers make their voices heard and to show the real people behind the labels and diagnoses. Those who have been diagnosed with mental illness are not different from other people, and want the same basic things out of life: adequate incomes; decent places to live; educational opportunities; job training leading to real, meaningful jobs; participation in the lives of their communities; friends and social relationships; and loving personal relationships.

Consumer and family participation in advocacy organizations may also have several positive effects decreases in the duration of inpatient treatment and in the number of visits to health services. There has been a reinforcement of knowledge and skills acquired through contact with services. Other possible beneficial effects of advocacy are the building of self-esteem, feelings of well-being, enhanced coping skills, the strengthening of social support networks and the improvement of family relationships. These findings were reinforced by the United States Surgeon Generals report on mental health (Department of Health and Human Services, 1999). Consumer advocates and consumer researchers participated in planning, contributing to, and reviewing sections of this report.

Because many barriers prevent people in most countries from gaining access to mental health services, advocacy represents an essential area for action in national or regional policy. Advocacy can help the development and implementation of programs on mental health promotion for the general population and on the prevention of mental disorders for persons with risk factors. It can also help with treatment programs for persons with mental disorders and with the rehabilitation of persons with mental disabilities.

Moreover, advocacy by consumer groups, family groups, and non-governmental organizations can make valuable contributions to improving and implementing mental health legislation, and improve the financing, quality and organization of services.

State Rankings for Mental Health Treatment

Mental Health America (MHA) released its annual State of Mental Health Report, which ranks all 50 states and the District of Columbia based on several mental health and access measures. The results show a country that is more insured but still falling dramatically short in meeting the needs of those with mental health concerns. 

  • Health care reform has reduced the rates of uninsured adults with mental health conditions—19 percent remain uninsured in states that did not expand Medicaid, 13 percent remain uninsured in states that did expand Medicaid.
  • Over 40 million Americans are dealing with a mental health concern—more than the populations of New York and Florida combined.

  • There are over 1.2 million people currently residing in prisons and/or jails with a mental health condition and lack of access to mental health care is linked with higher rates of incarceration.

  • 56 percent of adults still don’t receive treatment.

  • Youth mental health problems are on the rise, and 6 out of 10 young people with major depression do not receive ANY mental health treatment.

  • In states with the lowest workforce, there’s only 1 mental health professional per 1,000 individuals—that includes psychiatrists, psychologists, social workers, counselors and psychiatric nurses combined.

  • In the overall rankings, Connecticut came out as #1, while Nevada landed at #51.

“Once again, our report shows that too many Americans are suffering, and far too many are not receiving the treatment they need to live healthy and productive lives,” said Paul Gionfriddo, president and CEO, Mental Health America. “Mental illness touches everyone. We must improve access to care and treatments, and we need to put a premium on early identification and early intervention for everyone with mental health concerns.”

In developing the report, MHA looked at 15 different measures to determine the rankings. MHA hoped to provide a snapshot of mental health status among youth and adults for policy and program planning, analysis, and evaluation; to track changes in prevalence of mental health issues and access to mental health care; to understand how changes in national data reflect the impact of legislation and policies; and to increase the dialogues and improve outcomes for individuals and families with mental health needs.

States in order of ranking:  

The first being the best at access and use and the last being worst.

Connecticut
Massachusetts
Vermont
South Dakota
Minnesota
New Jersey
Iowa
North Dakota
Pennsylvania
Maine
Delaware
New York
Alaska
Maryland
Illinois
Hawaii
Michigan
District of Columbia
Kentucky
New Hampshire
Kansas
New Mexico
California
Oklahoma
Colorado
Ohio
Nebraska
Florida
Wyoming 
Washington
Missouri
Texas
North Carolina
Georgia
Wisconsin
Rhode Island
South Carolina
Virginia
Montana
Utah
Tennessee
Louisiana
West Virginia
Mississippi
Indiana
Alabama
Arkansas
Idaho
Oregon
Arizona
Nevada

Each one of us can make a difference by advocating for mental health and addiction recovery. Reduce the stigma by telling your story, if you have one. Listen to those in need and support their efforts. Speak kindly regarding treatment options and support systems. 

Whether you are a mental health or substance abuse professional, have a friend or family member in treatment, or just care about mental health care, consider getting involved in advocacy.

By becoming involved, you can:

  • help erase the remaining stigma surrounding mental health
  • help others learn from your experiences
  • suggest improvements or changes
  • lobby your representatives on mental health issues

 

Community Resources/Services 

12 Step programs, community mental health programs, religious organizations, community centers, and community coalitions all work to provide easy to access affordable community support.  These are crucial to the ongoing long term treatment and stability of managing mental health issues and recovery from addictions.

12 Step Programs

One of the most well-known and commonly used types of support used in the community setting is the 12-Step model. Just about everyone has heard of these meetings and/or of the organization that originated the idea – Alcoholics Anonymous. Twelve-Step programs remain a commonly recommended and used treatment modality for various types of addiction and mental health issues.

These meetings are readily available in public facilities such as schools, churches or community centers, and correctional facilities.  They are easily accessible and most often free to join. They offer a forum for individuals to share their stories, including past struggles and triumphs, with those in similar situations. 

Used by millions of people around the world, 12-step programs encourage members to adopt a set of guiding principles called the 12 Steps. Following the steps in order has helped people achieve and maintain abstinence from behavioral problems such as substance use disorders, gambling addiction, and eating disorders. The bonds formed and lessons learned during these meetings can last a lifetime.

  1. We admitted we were powerless over our addiction, that our lives had become unmanageable.
  2. Came to believe a Power greater than ourselves could restore us to sanity.
  3. Made a decision to turn our will and our lives over to the care of God as we understand God.
  4. Made a searching and fearless moral inventory of ourselves.
  5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
  6. Were entirely ready to have God remove all these defects of character.
  7. Humbly asked God to remove our shortcomings.
  8. Made a list of all persons we had harmed and became willing to make amends to them all.
  9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
  10. Continued to take personal inventory and when we were wrong, promptly admitted it.
  11. Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for the knowledge of God’s will for us and the power to carry that out.
  12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to other addicts and to practice these principles in all our affairs.

Alcoholics Anonymous (AA) is the most popular 12-step program in the world. This resource for alcoholics comprises nearly 2 million members in the United States. 

Researchers estimate that as many as 10 percent of people in the United States have attended an AA meeting.

Narcotics Anonymous, also known as NA, helps members focus on recovering from various substances, including alcohol. NA hosts more than 67,000 meetings every week in 139 countries. According to demographic surveys, the average age of an NA member is 48, and 74 percent of members are Caucasian.

Programs patterned after Alcoholics Anonymous

  • AA – Alcoholics Anonymous
  • ACA – Adult Children of Alcoholics
  • Al-Anon/Alateen, for friends and families of alcoholics
  • CA – Cocaine Anonymous
  • CLA – Clutterers Anonymous
  • CMA – Crystal Meth Anonymous
  • Co-Anon, for friends and family of addicts
  • CoDA – Co-Dependents Anonymous, for people working to end patterns of dysfunctional relationships and develop functional and healthy relationships
  • COSA – an auxiliary group of Sex Addicts Anonymous
  • COSLAA – CoSex and Love Addicts Anonymous
  • DA – Debtors Anonymous
  • EA – Emotions Anonymous, for recovery from mental and emotional illness
  • FA – Families Anonymous, for relatives and friends of addicts
  • FA – Food Addicts in Recovery Anonymous
  • FAA – Food Addicts Anonymous
  • GA – Gamblers Anonymous
  • Gam-Anon/Gam-A-Teen, for friends and family members of problem gamblers
  • HA – Heroin Anonymous
  • MA – Marijuana Anonymous
  • NA – Narcotics Anonymous
  • N/A – Neurotics Anonymous, for recovery from mental and emotional illness
  • Nar-Anon, for friends and family members of addicts
  • NicA – Nicotine Anonymous
  • OA – Overeaters Anonymous
  • OLGA – Online Gamers Anonymous
  • PA – Pills Anonymous, for recovery from prescription pill addiction.
  • SA – Sexaholics Anonymous
  • SAA – Sex Addicts Anonymous
  • SCA – Sexual Compulsives Anonymous
  • SIA – Survivors of Incest Anonymous
  • SLAA – Sex and Love Addicts Anonymous
  • SRA – Sexual Recovery Anonymous
  • UA – Underearners Anonymous
  • WA – Workaholics Anonymous

 

Community Mental Health Programs

Community mental health programs are important for every community. These programs offer access to essential mental health and substance abuse treatment and resources to those who may not have health care or the financial means to pay for appointments and medication.

Community-based mental health services are often provided at little or no cost to individuals that meet certain requirements that may include gross income limits, unemployment, residence within certain postal codes and insurance criteria.

Services are often provided at community health centers located within high-need areas or at offices of counselors within a network. The community centers may offer classes, assessments, counseling appointments and pharmaceutical services in one location at a discounted price or even free of charge. Other services these centers may provide include support groups, group counseling, and classes that cover topics such as PTSD, coping skills, parenting, relationships, and resource generation.

These centers may also provide emergency or court-ordered substance abuse services along with mental health services. Substance abuse services may be court-mandated or voluntary, but often include assessments, drug and alcohol classes, counseling, support groups, and drug testing services.

 

Community Coalitions

Community coalitions include professional and grassroots members committed to working together to influence long-term health and welfare practices in their community. By using existing resources in the community and bringing together many different local organizations, these coalitions are considered to be sustainable over time. 

Coalition strengths:

  • Experience using a public health framework to address substance use concerns
  • Ability to ensure representation of diverse sectors, as it is essential to ensure that integrated healthcare meet the unique needs of all community members
  • Access to a wealth of local data to understand the conditions that contribute to a community’s substance abuse issues and knowledge of how and where to access additional data when needed
  • Skill in developing and implementing comprehensive community-wide plans, in collaboration with a variety of
    community sectors and stakeholders
  • A broad membership of volunteers representing the community’s diverse sectors with varied backgrounds, expertise, and community connections

With these assets, coalitions are well-prepared to serve as leaders in breaking down organizational silos and encouraging a collaborative environment among all community sectors.  

Coalitions focus on:

  • Promoting Collaboration
  • Educating 
  • Engaging in Outreach
  • Supporting 

These recommended activities capitalize on the existing strengths and capacities of community substance abuse prevention coalitions and build on the work they are already doing.


Promote Collaboration

Local mental health and substance abuse prevention coalitions can use their existing strengths in grassroots organizing to
identify and initiate collaborations with other coalitions and/or community-based groups that are addressing the physical and behavioral health of vulnerable populations, including individuals living with mental and substance use conditions, to build a shared agenda and approach.


Educate

Coalitions can initiate and facilitate programs to educate the community, behavioral health consumers (including their
families and support systems), and other coalition members about care options and key provisions in the health reform law. 


Engage in Outreach Activities

Coalitions can engage in outreach activities by collecting input from consumers and their families on the strengths and weaknesses of proposed approaches as well as gaining a better understanding on where needs in the community are and how these can be better met.  

Support

Coalitions can provide support to state Medicaid agencies, local accountable care organizations, and providers seeking to become treatment facilities.  They can work with managed care organizations and providers to ensure that state health home plans and contracts include care for persons with mental health and substance use disorders.

They can conduct or cosponsor support groups, education groups, or other community-based resources for people with mental health and substance use disorders and/or their families and support systems.

They can offer to provide or help providers obtain in-service education on cultural competency, community -based services, mental health, and substance abuse prevention services, screening, brief intervention and referral to treatment training, and other topics of expertise to improve service delivery.

Coalitions can educate primary care and mental health providers in the identification and prevention of substance abuse related issues. Many have not yet developed these skills and since coalitions already educate the community, they can help providers modify their training programs to meet these new educational needs.

Faith-Based Initiatives

Churches are often the first place people go when they’re struggling. When a family member is ill, pastors visit the hospital, and church members provide meals. When a loved one dies, they comfort the family and help perform the funeral. When a congregant loses a job, they rally around to help them through tough financial times.

One of the more nuanced issues churches and their leaders face today is that of mental illness and addiction. These struggles are not always as cut and dry as things like physical illness and death, and the stigma that surrounds mental health and addiction can get in the way of proper treatment. With the right tools and mindset, however, churches can be an integral part of helping people in their community who struggle with these issues.

Churches provide a strong sense of belonging and community for their members. This sense of community can be invaluable for people struggling with mental health and addiction issues.

Isolation is a huge contributing factor for mental illness and addiction, and the ability to reach out for help is a key step in recovery. Pastors or members of church small groups are often the first to hear of these issues and can, therefore, be instrumental in getting people the help they need.

Faith-based grant programs and initiatives promote a variety of funding mechanisms and programs carried out by faith-based organizations including mental health services, substance use prevention, addiction treatment, and violence prevention.  Some of the programs you can find at local faith organizations include:

  • Youth Violence Prevention
  • Domestic Violence Prevention
  • Substance Abuse Treatment
  • Support Groups (Specific to diagnosis, family members, etc)

There are programs that target specific populations, programs to address the prevention of and programs that offer treatment.  Many of these are a reduced fee or free.  

Reducing Homelessness

The Projects for Assistance in Transition from Homelessness (PATH) provides funds from SAMHSA Center for Mental Health Services to states and territories that, in turn, allocate money to local agencies, for services to persons with serious mental illnesses, including those with co-occurring substance abuse disorders who are homeless or at risk of becoming homeless. Many of the organizations that receive PATH funds are faith-based. The PATH program is unique since all locally-funded agencies must coordinate their services with faith-based and community organizations serving homeless people with serious mental illnesses.

Crisis Counseling

The faith community played an important role in responding to the tragedy of September 11, 2001. In the past, faith organizations have participated in disaster response programs, among them: Catholic Charities during the Oklahoma bombing, Lutheran Social Services in tornado-related disasters, and the Virgin Islands Baptist Church in responding to hurricanes and other disasters.

Religious organizations can do the most good by helping to end the stigma of mental illness even though it’s a difficult issue to address and understand and recognize that there are people in every church who struggle with it.  They can create a safe place for people who struggle. Love extends to everyone, even those who are difficult to understand and those that seemingly make destructive choices.   

Making Referrals

Effective referral relationships are critical for case managers.  Referrals might be made for high acuity patients, medical issues, individuals with specific insurance coverage needs, and the need for specialty services as well as a myriad of other reasons.  

The first critical step is to get written consent from the individual for the release of information. There are local and national guidelines and protections that must be adhered to.  The use of a referral form can be helpful.  The form can specify the information that the client is consenting to the release of.  This can include current medications, labs the name of the treating professional, the process the outside agency is permitted to use to contact the client and many other items.

All certified and licensed professionals are held to confidentiality standards for mental health and substance abuse treatment.  When making a referral it is important to understand these regulations.  The primary regulations that affect substance abuse treatment confidentiality are title 42 of the Code of Federal Regulations (CFR) and HIPAA.  There are individual Codes of Ethics for certified and licensed practitioners, as well.  

On January 2, 2018, the Substance Abuse and Mental Health Services Administration (“SAMHSA”) amended 42 C.F.R Part 2 (“Part 2”), creating new changes to the federal rules governing confidentiality and disclosures of patient substance use disorder (“SUD”) records for the first time since 1987. Part 2 protects the confidentiality of SUD records, which are a subset of HIPAA protected health information (PHI). This means that these records are subject to HIPAA, but are also protected by Part 2, which contains additional (and more stringent) federal protections.

42 CFR Part 2 applies to any individual or entity that is federally assisted and holds itself out as providing and provides, alcohol or drug abuse diagnosis, treatment or referral for treatment. Most drug and alcohol treatment programs are federally assisted. For-profit programs and private practitioners that do not receive federal assistance of any kind would not be subject to the requirements of 42 CFR Part 2 unless the State licensing or certification agency requires them to comply. However, any clinician who uses a controlled substance for detoxification or maintenance treatment of a substance use disorder requires a federal DEA registration and becomes subject to the regulations through the DEA license.

A program is “federally-assisted” if it:

(a) Receives federal funds in any form, whether or not the funds directly pay for alcohol or drug abuse services; or

(b) Is being carried out under a license, certification, registration, or other authorization granted by the federal government (e.g. licensed to provide methadone, certified as a Medicare provider); or

(c) Is assisted by the IRS through a grant of tax-exempt status or allowance of tax deductions for contributions; or

(d) Is conducted directly by the federal government or by a state or local government that receives federal funds which could be (but are not necessarily) spent for alcohol or drug abuse programs.

The Federal Drug and Alcohol Confidentiality Law – 42 CFR Part 2 states that any information that would identify a patient as having an alcohol or drug problem, either directly or indirectly, is protected.  

The Federal Drug and Alcohol Confidentiality Law – 42 CFR Part 2 42 CFR Part 2’s prohibition on disclosing patient-identifying information has very few exceptions. The following are the general categories of exceptions:

  • written consent
  • internal program communications
  • removal of all patient-identifying information
  • medical emergency
  • court order
  • crime on program premises or against program personnel
  • research
  • audits and evaluations
  • child abuse

The best way to ensure communications are permissible under 42 CFR Part 2 is to have the individual sign a consent/authorization form that complies with the requirements of both HIPAA and 42 CFR Part 2.  

The elements of a consent/authorization form that must be included are listed below.  In addition, also include applicable state law as well.

  • Name or general designation of the program or person permitted to make the disclosure
  • Name or title of the individual or name of the organization to which disclosure is to be made
  • Name of the patient
  • Purpose of the disclosure
  • How much and what kind of information is to be disclosed
  • Signature of the patient (and, in some states, a parent or guardian)
  • The date on which consent is signed revocation at any time except to the extent that the program has already acted on it
  • Date, event, or condition upon which consent will expire if not previously revoked

 

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA privacy and security regulations include provisions for the punishment of individuals and/or organizations that fail to protect the confidentiality of patient information.  

The HIPAA Act requires that covered entities comply with the regulations.  Most health care providers, clearinghouses and health plans are covered entities.  Whether your work setting falls under the regulations or not you should be committed to protecting patient privacy and confidentiality.  When an employee compromises patient information and/or records by not adhering to the policies regarding privacy, there is a potential impact to both the hospital or practice and when appropriate, their license to practice.  It is the employee’s responsibility to carefully review and become knowledgeable of the privacy policy and to comply with the requirements.

The guiding principle for communication with or about patient information should be based on the concept of the need to know or who needs the information for treatment and/or health care operations.

A significant departure from the standard practice is the handling of psychotherapy notes.  These notes have more stringent protection as they generally contain the personal notes of the treating psychotherapist which may be damaging to the individual should the information become available to the general public.

HIPAA requires specific authorization for the release of psychotherapy notes.

Whether a case manager works for an agency that is federally funded (42CFR) or a covered entity (HIPAA) they should be committed to protecting client privacy and confidentiality.  The information included should be truthful, appropriate and necessary to the referral.

Methods Of Protecting Confidentiality 

The minimum necessary standard for protection of confidentiality is that a reasonable effort is made by health care workers to use or disclose only the protected health information needed to do their job. Experienced health care workers can make these reasonable effort decisions more professionally as they are more aware of good business practices. Needless to say, it is an ongoing challenge to maintain the proper balance between patient privacy and comprehensive and timely patient treatment. One should always ask, “is this needed to do my job” and if the answer is no, act accordingly.

Protect client privacy in the following ways:

  • Hold private conversations with patients or referral professionals. Close room doors when possible.
  • Speak softly in semi-private or ward areas and close curtains or other privacy items when possible
  • Avoid discussions of patient information in public places such as the cafeteria, elevators, restrooms, etc.
  • Restrict the use of answering machines to non-confidential information and when appropriate get approval to leave a message
  • Limit paging information to non-confidential information

Every patient has a right to privacy; consequently, it is essential to the success of this hospital to adhere to the privacy rules and to also encourage co-workers to follow the rules.

Referral Process

The primary goal of a referral is to identify an appropriate treatment program and to facilitate engagement of the patient in treatment. Referring can be a complex process involving coordination across different types of services. It requires a proactive and collaborative effort between the case manager and those providing specialty treatment to ensure that a client, once referred, has access to and engages in the appropriate level of care. To facilitate patient engagement providers may use motivational enhancement techniques to help patients with any ambivalence toward treatment, provide transportation to intake appointments, follow up with patients after an appointment, and maintain contact with the specialty treatment provider.

Strong referral linkages are critical, as is tracking these patient referrals. The referral process should track the status of the referral over a specified period of time.  For example, if a referral is made for outpatient counseling upon discharge from an inpatient setting the referral once made should be followed up on after the first session, at 2 weeks, and them 4 weeks and so on base on acuity.  The status of any referral should be documented in the progress notes.  The release should facilitate communication between the case manager and the referral agency.

Case managers should develop referral procedures that both motivate clients to enter treatment and connect them with
convenient, accessible specialty treatment programs.   

Considerations:

• Initiation of onsite treatment (at the screening facility)
• Provider-initiated appointments
• Peer/mentor health educator support
• Transportation to treatment facilities
• Negotiation for dedicated treatment slots

Prearranged referral relationships ensure smooth transitions for clients at the appropriate level of care and
facilitate followup. Cultivating collaboration across systems—such as medical,  substance abuse treatment, mental health service centers, and criminal justice—is important for the successful implementation of a referral process. Most case managers developed referral relationships with a range of community treatment resources to ensure that referrals were appropriate to clients’ needs and cultural backgrounds.

It is also important to develop a record-keeping procedure and evaluation plan for referrals.  

  • Did the client follow through on the referral?
  • Did the client benefit from the referral?  How specifically?
  • Was the referral easy to make?
  • Did the client review the provider positively?
  • Did the client engage?

 

Levels of Care

Care is provided in many different settings.  Case management applies clinical criteria using the philosophy that the most appropriate level of care for clients should be the safest and least restrictive setting possible.

Level of care determination proceeds in a logical progression to confirm:

  • The presence of a properly diagnosed psychiatric or substance use disorder amenable to treatment
  • Symptoms of sufficient severity to meet the required criteria for admission are present
  • The illness by accepted medical standards is expected to improve significantly through medically necessary and appropriate care as it relates to the level of care requested, and
  • Clinical requirements for continuing care at that level.

Outpatient Care

12-Step Programs and Support Groups (Community-based and free)

Outpatient Care 

  • Individual counseling
  • Medication evaluation and management
  • Group Therapy

Partial Hospitalization

  • Intense structured program
  • Typically consists of 5-7 days per week for 6 hours each day
  • Similar to IOP, includes group, individual, and family therapy when appropriate
  • Often includes an evaluation by a psychiatrist, who may prescribe or adjust medications
  • Often recommended for those who have actively participated in lower levels of care, yet continue to experience serious emotional and behavioral problems
  • Beneficial for those at risk of hospitalization, or as a step-down for those who have been
    hospitalized


Inpatient Care

Inpatient Acute Care

  • Intended for people who need 24-hour care and daily doctor visits in a hospital setting to stabilize
    psychiatric issues
  • Often recommended for people who aren’t able to care for themselves, or may be a risk to the
    safety and well-being of themselves or others
  • Can last for a few days
  • Goal is to stabilize a crisis
  • Includes group therapy and meeting with a team of professionals, including a psychiatrist
  • A family session is important prior to discharge to discuss aftercare plans

Inpatient Residential

  • Should only be considered when all available and appropriate outpatient approaches, including
    intensive outpatient treatment and partial, have been tried first
  • Intended to be a short-term placement to stabilize the person until they can return to the community
  • Treatment should be as close to the person’s home as possible
  • Intended for people who do not need medical attention
  • Not appropriate for people who are unmotivated for change and recovery
  • Primary treatment offered is group, individual, and family therapy in a supportive environment
  • Should include weekly family therapy

Every client has different needs when it comes to mental health and substance abuse treatment. When patients first enter therapy, it is important they are assigned to the proper level of care.

This approach to treatment ensures that patients receive adequate care upon admission and are smoothly transitioned to a higher or lower level of care as needed. According to the American Society of Addiction Medicine, there are five main levels of treatment in the continuum of care for substance abuse treatment:

Level 0.5: Early Intervention Services
Level I:  Outpatient Services
Level II:  Intensive Outpatient/Partial Hospitalization Services
Level III:  Residential/Inpatient Services
Level IV:  Medically Managed Intensive Inpatient Services

The continuum of care was developed to ensure uniformity through the treatment process. This makes what happens in treatment more efficient for patients who transition from one level of care to the next.

When to Consider a Higher Level of Care

A higher level of care should be considered in the following situations:

  • When a current lower level of care (such as outpatient treatment) isn’t able to address the needs of the person receiving treatment
  • If a person’s level of functioning continues to decrease, even though they have been actively
    participating in a lower level of care

 

Special Population Needs

Most individuals with mental health issues and/or chemically dependent individuals can benefit from case management services, but certain groups benefit most from a more complex, integrated approach to treatment and support services. 

  • Young adults, due to their chronological age and limited life experience, may require additional assistance in the area of life skills development. They also tend to benefit from the additional supervision a case manager can provide.
  • Individuals with long histories of treatment and recovery attempts will also profit from the supplemental assistance of a case manager.
  • Clients who are only able to function well within the confines of a residential setting may have particular difficulty meshing their recovery needs and non-clinical needs on an outpatient basis.
  • Individuals with co-occurring diagnoses (e.g., depression, anxiety, bipolar disorder, eating disorders, ADD/ADHD) have multiple areas that need ongoing consideration and management.
  • Chemically dependent individuals with medical and legal difficulties associated with their previous abuse of substances will likely need additional support in problem-solving in these areas.
  • Older adults benefit from having a case manager to effectively coordinate their overall medical and psychological care. The need for a primary point of contact when working with older adults is critical as many providers may be part of the treatment team and ongoing communication among them is necessary.