MODULE 13
CASE MANAGEMENT

Table Of Contents

TABLE OF CONTENTS…………………………………………………………...………………	II
MODULE 13: CASE MANAGEMENT………………………...……………………………………...	1

	BACKGROUND ………… ……………………………………………………………………………………………..	1
Emergency needs…………………………………………………………………………………………………...	2
Case management needs……………………………………………………………………………………………	2
	INTRODUCTION………… …………………………………………………………………………………….............	2
Discuss rationale…………………………………………………………………………………………………...	3
SET THE AGENDA ……………….…………………………………………………………………………………….	3
	IDENTIFY NEEDS………… …………………………………………………………………………………………....3
PRIORITIZE NEEDS ……………….……………………………………………………………………………………4
WORK IN STEPS..………………………………………………………………………………………………………	4
DISCUSS BARRIERS TO FOLLOWING THROUGH WITH PLANS……………………………………………..…	5
Practical Barriers………………………………………………………………………………………………….	5
Interpersonal barriers………………………………………………………………………………………………	6
DEVELOP REFERRAL LISTS..…………………………………………………………………………………….…	6
AFFIRM CLIENT EFFORTS……………………………………………………………………………………………	8
SUMMARIZE SESSION ……………….……………………………………………………………………………….	8
	COMPLETE AGENCY SPECIFIC TASKS ………… …………………………………………………………………	8
REVIEW HOME ASSIGNMENT ……………….……………………………………………………………………...	8
END SESSION ……………….………………………………………………………………………………………....	9

APPENDIX A: SESSION MATERIALS ……………………………………………………………...	10

	CLIENT NEEDS ASSESSMENT………… ……………………………………………………………………………	11
CASE MANAGEMENT GOAL SHEET…………….……………………………………………………………….....	12
MODULE 13 SESSION CHECKLIST……………….……………………………………………………………….....	13

Module 13: Case Management

The objectives of this module are to: 1) assess whether there are emergent or important situations in the client’s life that will interfere with his or her ability to stop alcohol or drugs or maintain abstinence and build a healthier life, 2) develop a plan to address emergent or case management needs, and 3) address barriers to additional care.

=====╣Module Outline╠===========================================

Target Discussion Points

	Introduction
	Set the agenda
	Discuss emergency needs
	Discuss the client’s case management needs
Develop a plan to address needs
	Discuss barriers to seeking additional services
	Summarize session
	Conduct agency-specific tasks
	Preview next session
	Review home assignment 
	End Session

Background
When clients enter alcohol or drug treatment they may have a number of other problems in their lives (e.g., medical, psychiatric, legal, financial, vocational, family, or social) that have the potential to interfere with them maintaining abstinence and working toward the development of a more fulfilling and healthier lifestyle.  Some of the other problems that clients face may be immediately apparent; other problems may surface as the client progresses in treatment.  Problems may be directly related to their previous or current alcohol or drug use, or in some cases, may have little to do with substance use, but impact their ability to stop using alcohol or drugs.

Many clients with other problems do not have resources available, or have not made use of available services to address these needs prior to entering treatment.  However, it can be very difficult for clients to focus on treatment for alcohol or drug use without addressing the context of people’s lives and in particular, addressing the basic need for food, shelter and safety.  Helping clients obtain safe housing, employment or job counseling, financial assistance, psychiatric evaluation and treatment, medical coverage 

or assistance, HIV testing/ counseling, and/or referrals to parenting or community support groups may be critical to helping them to remain in treatment and turn their lives around. 

In most cases therapists will not be able to address these additional needs within the context of therapy with the client and will need to develop appropriate referral sources.  The therapist can help the client practice how to make contact with the referrals and follow up with the client to make certain the referrals are completed.

It will be essential for the therapist to determine whether the client is willing to address some of these other issues.  In some cases the therapist may see a need that the client does not identify or have the interest in addressing.  If the client has multiple needs the therapist will should help the client to prioritize which are most important to address and in what order they should be addressed.

Emergency needs
Instances in which the therapist may be required to intervene in other areas of the client’s life, regardless of the client’s wishes, include those in which there is a potential threat for harm to the safety of the client or others (i.e., suicidal or homicidal ideation) or a report of child/elder abuse.  The therapist should be aware of local laws requiring breach of confidentiality and mandated reporting and also of the procedures of their agency for handling such problems (e.g., where would the client need to be hospitalized, how would one contact DSS).  The client may not fully understand the therapist’s requirements for acting in these situations and there is potential for fracturing the therapeutic relationship.

There may also be situations in which the therapist is not required by law to act, but that do appear to warrant immediate attention due to the life threatening nature of the situation such as domestic violence or recent exposure to medical risks (e.g., HIV infection).  For situations that have the potential to become life threatening (e.g., loss of housing in the middle of winter for a person with few financial resources) the therapist may need to persuade the client to seek additional services but can not require it.

Case management needs
Clients may need assistance with a wide range of problem areas such as housing, employment/school, medical issues, finances, or legal problems.  They may request referrals for additional therapy or psychopharmacology management for co-occurring psychiatric problems (e.g., depression or posttraumatic stress disorder), parenting classes, self-help groups in the community for matters unrelated to substance use (e.g., victims of violence, bereavement), or for medical or legal services.  Some clients may want information on job retraining courses, loans for school, or volunteer opportunities.

Introduction
It is important for the therapist to convey the idea to the client that the goal of treatment is twofold – to help the client stop using alcohol or drugs, and to build a less stressful and more satisfying life.  Addressing more than just drinking or drug use should help to improve quality of client’s life.  Although many of these problem areas can not be addressed within the treatment sessions, the therapist may be able to help the client find assistance with them outside of treatment and make a referral to the appropriate person or place for assistance.

“When you filled out the Client Needs Assessment you identified several areas in which you thought you could use some help.  I think it’s important for use to try to address some of these other areas so that we can help you build a more satisfying life without the drinking.  Today we can talk about some of these other problem areas and make some plans for getting you some assistance with some of these things.  Sound OK?”

Discuss rationale
It is important to convey to the client why it may be necessary to talk about his or her other needs in a treatment program for alcohol and drug use.

“Talking about the other problems in your life will help us get a sense of some of the things that get in the way of you stopping use of alcohol or  drugs.  We want to help you build a more satisfying life for yourself and that’s likely to help you remain abstinent.  It can be hard to quit using alcohol or drugs if there’s too much stress you are trying to handle from other problems in your life.  If we can work together to get you some help with these other problems, you’ll may feel some relief and have more energy to focus on changing your substance use.”

Set the agenda

“So if it’s OK with you, let’s go over the problem areas you identified in the Client Needs Assessment and see where you might need some assistance.  How does that sound?”

Identify needs
The therapist should review the needs already identified by the client on the Client Needs Assessment (Appendix A) that was completed before treatment planning (Module 3).  This form defines some of the potential problem areas such as housing, employment, legal assistance, medical problems, child-care, transportation, or psychiatric problems.  These are needs that if left unmet will often interfere with the client remaining abstinent, or building a life that will be satisfying.  Once the needs are identified it will be possible to prioritize them and begin to develop a plan to address the client’s needs.

Beyond identifying a general need (e.g. needing assistance with housing or psychiatric care) it will be important for the therapist to help the client define specific needs.  For example, is the client interested in moving from a shelter to a community halfway house where clients are expected to remain sober and work?  Is the client already in sober housing but interested in finding out about more permanent subsidized housing for someone on disability? Is the client interested in speaking to a psychiatrist about medication for depression or does the client have an interest in speaking to a therapist about a trauma history?  Being as specific as possible will help the therapist identify the appropriate referral sources.

Prioritize needs
Due to the multiple needs that many clients have it is often essential for the therapists to prioritize the client’s request for assistance by asking the client what he or she is most interested in addressing.

“We’ve talked about a number of different problems that you’re having right now that you feel are getting in the way of you getting your life in order, even if you were to stop using drugs.  You have a court case that is hanging over your head and you haven’t gotten a lawyer to help you with this.  You also think it’s too risky to go back to your job because other people were using drugs on the job but you’re not sure what else to do.  And you also mentioned that you are having some trouble in your marriage.  We can’t tackle them all at once so I’m wondering, of the problem areas you mentioned, which one would you be the most interested in addressing first?  If you had to start with the one that would have the biggest impact on your life right now, what do you think it would be?”

It is important for the client to be able to identify why it is important to focus on a specific area and to request a referral to assist with a specific problem.  To help the client prioritize the areas that he or she wants to focus on, the therapist may want to ask the client to consider the following:

•	How will focusing on this area help the client with his or her sobriety?
•	What impact will it have on your life if you work on this?
•	Are you committed to considering the options and making some changes to address this problem?

If the client is able to identify a priority and the reasons it will be helpful the therapist should reflect an understanding of this in his or her statements to the client.

“It sounds like you may want to begin with the lawyer because that is the most stressful thing you’re facing right now.  You believe that getting this straightened out will take some pressure off you and make it easier for you to stay drug-free.  So, shall we take a look at some of the options for legal referrals?”

Work in steps
The therapist will need to work with the client to establish realistic goals for the course of treatment and to work in steps to help him or her achieve certain goals.  Some of the solutions that the therapist may propose to the client while he or she is in treatment will be short-term rather than long-term solutions.  For example, the immediate need for a client who suddenly becomes homeless might be the identification of a shelter; the long-term goal might be seeking admission to a sober house in a safe neighborhood. Similarly, for a client who has suffered an injury and is unable to return to work, job retraining may be the initial goal and seeking better employment would be the long-term goal.   It will be important for the therapist to convey to the client an understanding of the client’s long-term objectives even when they cannot be achieved within the timeframe of treatment.
“You mentioned that you’ve been out of work for awhile and you are not optimistic about finding work.  One option you’ve thought of this going to an employment agency, but you will probably get placed in the same type of job that made it hard for you to stay sober.  Another possibility to consider is to look into job re-training.  There may some jobs that would be less risky for continuing to use that you could be trained for based on the skills you have.  Is there something you would be interested in learning more about?”

“You mentioned that you think it would be helpful if you could get some help with PTSD.  You stopped drinking in the past and found that memories got a lot worse.  You are willing to consider starting therapy or medication to help you with PTSD symptoms.  We could start by getting you in for an evaluation with a counselor, and consider making an appointment with a psychiatrist after you have started treatment.  How does that sound to you?”

Develop a plan
The client and therapist should complete a Case Management Goal Sheet (Appendix A: Client handouts) when a problem are is identified and there is an active plan in place to address the problem.  The sheet should work with the client to identify the general goal, specific objective, referral information, and task that the client will try as homework before next session.  Providing a copy of the detailed plan will not only provide the client with the necessary information to make the call, but will also serve as a reminder to the client between sessions of what he or she s to accomplish.  It will also make it easy to follow up in future sessions to determine if the client had difficulties following through with plan.

Case Management Goal Sheet

General goal	Specific Objective	Referral Information	Homework	

Find healthcare	
Make appointment with primary care provider	
Healthcare for Homeless Telephone number to call is
617-xxx-xxxx	
Call for an appointment before my next session 
On 2/21/07	

Discuss barriers to following through with plan
For clients who have not been leading organized lives or sometimes get easily discouraged if they are not able to complete a referral immediately, it is important to consider barriers to completing referral ahead of time and how the  client will address these.  Discussing potential barriers ahead of time may help the client to overcome them.

Practical Barriers
Some of the practical barriers that may need to be addressed are:
•	How does client communicate with employers or providers without a telephone?
•	How does the client get to appointments without funds for transportation?
•	Who will take care of a client’s children during medical appointment?

Often there are no simple solutions to these problems and the therapist and client will need to problem-solve to determine how best to address them.  Addressing these barriers could require a request for additional services prior to being able to address the problem a client is interested in addressing. For example, if a client is interested in regular treatment at a facility not near his or her home, he or she may first need to apply for reduced MBTA fare based on disability to help with transportation costs.

Interpersonal barriers
There may also be some interpersonal barriers that interfere with the client carrying out his or her plan.

•	What should the client do if his or her spouse is not interested in family therapy even if it is indicated?
•	What should the client do if he or she feels threatened by bringing up a certain topic at home?
•	What should the client do if someone close to him or her is trying to sabotage them?

In some cases the therapist may be able to discuss and role-play assertive communications skills that the client may use when asking for assistance from family members.  Similarly, if clients find that they are attempting to make some changes and a family member or spouse is not supportive, the therapist may need to help the client practice how to address this with the individual, and also how to maintain safety during the process.  This is especially true if there has been any previous violence in the home or between the client and his or her partner.

Develop referral lists
To address the varied needs that clients may have requires a very large network of referral sources. Most agencies will have some of this information already available (e.g., list of therapists who might be available to see clients as reduced fees for psychiatric problems, telephone number at state agency where client applies for food stamps).  Therapists may also need to play an active role in seeking more information to help clients address many of their needs.  Therapists should feel free to tell client that they will find out the information by the next session if it is not at their fingertips.  If resources are available for the client to find the information (e.g., using computers in public library to investigate free legal services in the community), and the client is willing to do some research, the therapist may consider assigning this as a homework.

Follow-up with the client
After a plan is made it is therapist should follow up with the client to determine if the plan has been carried out.  When clients have been unable to follow-through with plans,
time should be taken to explore barriers, troubleshoot other problems, and reformulate a plan.

Troubleshooting
If the client has not followed through with the plan that was agreed upon by the designated date (e.g., made necessary telephone calls between sessions to complete a referral for medical care or counseling) there could be several reasons for this.  It is possible the client is not genuinely committed to the goal.  If there are concerns about motivation to complete the goal the therapist can explore motivation.

“When we talked about you calling a therapist to meet with you and your husband last week you seemed very interested in making the call so you could get some help in your marriage.”

“What makes this important to work on right now?”

“If you decide not to follow-through with the plan we came up with, is there anything you are worried about happening?”

If the client is not committed to the goal that was agreed upon, the therapist may want to consider changing the focus of case management to a different problem area.  If the therapist is concerned that the client is not addressing a specific problem (e.g., domestic violence) he or she can express this concern and utilize motivational enhancement strategies to try to encourage the client to address the problem.  It is always the client’s choice unless it is truly an emergency need (see above under section on Emergency Needs).

For clients who seem committed to the goal, the therapist should consider the possibility that other problems including practical barriers or skills deficits interfered with the client’s progress in reaching the goal.  If the client is intimidated by a task or disorganized, the therapist may want to discuss with the client the possibility of enlisting the help of a supportive person in the client’s life to complete the task with him or her.  Alternatively, the therapist may want to encourage the client to gain experience through in session role-plays.

Some clients may benefit from having the therapist model the behavior.  The therapist may also want to consider having the client make the call in session so that the therapist can provide support, especially if the client is not able to think of anyone in his or her natural environment who would be able to serve this role.  Searching for information together in session is another way to model skills.  Finally, the therapist may want to encourage the client to plan a reward for after the goal is achieved.

“It sounds like you really wanted to make the call to find out more about the job that was posted on the board at the church where you go for A.A.  meetings but you couldn’t find the time because your kids were home sick from school and your husband was working everyday.”

“You really didn’t have too much time to yourself this week and that makes and you wonder whether anyone would want to hire you because you have been out of
work for a while. You sound committed to getting a part-time job so perhaps we could brainstorm a way to get it done this week.”

“Is there anyone who you can think of that might be able to come over for an hour this week and watch the kids while you make the call?”

“Perhaps we could talk about what you might say to if you asked your neighbor for some help.”

Affirm client efforts
It is very important to affirm the client’s willingness to share these other problems with you and to try to address them in treatment.

“I just want to tell you I’m really glad you were willing to share with me what else is going on in your life that makes if difficult for you right now and to put in the effort to begin to work on these things.  It really seems as if you’re determined to build a better life for yourself.  I think if we can begin to work on these problems while you’re also working on stopping your drug use, you’ll have a much better chance of staying off drugs and being more satisfied with your life.”

Summarize session
The therapist should provide a closing summary of the session highlighting major accomplishments made during the session, reviewing any commitments the client has made to try out new strategies, and recognizing the client’s efforts.

“I want to thank you again for coming in today.  We covered a lot of ground talking about the problems that you’re having in your life with finances, your children’s schedule, and PTSD. It sounds like you have had some success in the past dealing with these problems but right now you are feeling overwhelmed.  You said that the biggest priorities are getting some financial assistance and working on childcare problems.  We can start with these right now.  After that you’d like to see if you can get some help with PTSD.  Does this sound about right to you?”

Complete agency specific tasks
Complete any agency specific paperwork with the client as needed.

Preview next session
Provide a brief preview of what will be covered in the next session.

Review home assignment
The client will have a home assignment to complete a task related to case management issues.  The therapist will follow through in the next session to see if the client has completed the task.
End session

“I think we have made some good progress in today’s session.  Do you have any other questions, concerns or thoughts before we end today?”

APPENDIX A
CASE MANAGEMENT
SESSION MATERIALS

Client Needs Assessment

Please indicate whether you need assistance with any of the following areas in your life:

1.	Housing								YES		NO
2.	Career (employment, training, education)			YES		NO
3.	Finances (assistance programs, debt counseling, budgeting)	YES		NO
4.	Medical health							YES		NO
5.	Mental health (counseling, medication)				YES		NO
6.	Dental care							YES		NO
7.	Legal issues							YES		NO
8.	Support (Self-help and support groups)				YES		NO
9.	Personal safety (domestic violence or abuse)			YES		NO
10.	Daily necessities (food, clothing, heat, water)			YES		NO
11.	Family/ Marital problems					YES		NO
12.	Childcare problems						YES		NO
13.	Other ___________________________________________	YES		NO
14.	Other ___________________________________________	YES		NO
15.	Other ___________________________________________	YES		NO
16.	Other ___________________________________________	YES		NO

General goal	
Specific objective	
Referral information	
Home Assignment	

				

				

Case Management Goal Sheet

	

PREPARATION	•		
  Session checklist		
  Agency-specific paperwork		
  Client Needs Assessment		
  Case Management Goal Sheet		
GETTING STARTED		
  Introduce the topic		
  Discuss rationale		
  Set the agenda		
IDENTIFY NEEDS		
  Review Client Needs Assessment		
  Define specific needs		
ADDRESSING CLIENT NEEDS		
  Prioritize needs		
  Establish realistic short- and long-term goals		
  Develop a plan		
  Complete Case Management Goals Sheet		
DISCUSS BARRIERS		
  Consider practical and interpersonal barriers		
  Troubleshoot as  needed		
FOLLOWING UP		
  Develop referral lists		
  Follow-up with client as needed		
COMPLETING AGENCY SPECIFIC TASKS		

WRAP UP		
  Summarize session		
  Preview next session		
  Assign home exercise		

Module 13 Session Checklist
Case Management