Implementing case management in alcohol and drug treatment

The addition of case management to standard alcohol-and drug-treatment programs is promising for the improvement of client outcomes (Sullivan, Jordan, & Dillon, in press; Sullivan, Wolk, Hartmann, 1992). Realization of that promise, however, requires the employment of an array of managerial behaviors and protocols to facilitate the implementation process.

The alcohol-and drug-treatment field, like other human services, must continually evolve to adapt to changing political climates and consumer demands while utilizing new knowledge and technology. To effect change, the forces of resistance and inertia must be overcome. Accordingly, innovations must be embraced at multiple levels of an organizational hierarchy.

This article describes the effort of the Missouri Division of Alcohol and Drug Abuse (MDADA) to introduce case management as a viable component of treatment services. This effort is the cornerstone of a new approach to alcohol and drug treatment, the Comprehensive Substance Treatment and Rehabilitation (C-STAR) Program. Early experience with the program, as revealed in case-management training and on-site consultation, underscored the critical role played by direct-practice supervisors, or middle managers, in the implementation process. To provide a conceptual framework to illustrate this observation, Patti's (1974) model of organizational change and resistance is used as a framework to reveal the obstacles inherent in the implementation process and to identify implications for middle-level managers. To further clarify these challenges, Mintzberg's (1973) typology of management roles and Patti's (1978) paradigm of middle-management practice are used to specify the range of behaviors required to effect change at the direct-practice level.

THE C-STAR PROGRAM

The C-STAR Program is a radical departure from standard alcohol and drug treatment offered in Missouri (Sullivan et al., in press). Specifically, C-STAR is a continuum-of-care model that devotes equal attention to chemical use and the problems in living faced by consumers. Services may be offered for up to two years; when coupled with options for safe housing for those who need it, C-STAR replaces traditional inpatient and outpatient models of care. Thus, C-STAR represents a departure from standard time-limited programs (i.e., 28-day inpatient programs or 6-week intensive outpatient services), conceptualizing treatment within a social as well as a medical frame of reference. Since C-STAR's initiation in 1991, 33 alcohol-and drug-treatment programs, including hospital-based services, outpatient clinics, an residential programs, have adopted the model. By August 1992, more than 6,100 clients had entered C-STAR programs, with 85% of these individuals treated on an outpatient basis. These programs are designated as general adult, adolescent, or women's services.

Targeting social functioning as a significant factor in the etiology of the problem and a significant target for interventive efforts alters the type and range of services offered. For example, this expanded focus of treatment has resulted in the addition of outreach case managers to the treatment team. The primary focus of these case managers is to enhance client functioning in such areas as vocational activity, stability in residential status, and leisure-time use. Furthermore, these efforts are seen as essential to the recovery of the client.

Perhaps the most controversial aspect of the C-STAR plan is its emphasis on community-based care and the concomitant reduction in fiscal supports for inpatient treatment. It is anticipated that the beneficial aspects of inpatient care can be replicated in the community if a wide range of supportive services is offered. Consequently, the removal of the institutional safety net has resulted in an increased emphasis on relapse prevention, after-care services, aggressive outreach, and community networking. These focal services require a host of new behaviors by treatment personnel and call forth a fresh set of expectations for middle managers, who must guide and monitor the behavior of their charges.

IMPLEMENTING CASE-MANAGEMENT SERVICES

One of the vexing problems facing the human services professions is ensuring that practitioners have the best available methods to address consumer concerns and that they use them. Various methods can be employed to enhance the diffusion of promising technology. Indeed, the use of multiple marketing approaches optimizes the likelihood of successful implementation of innovative treatment programs (Sullivan & Rapp, 1991). The MDADA staff organized case-management training sessions for community-support workers, clinical supervisors, counseling staff, and executive directors. In addition, independent consultants provide on-site technical assistance. Consultation services have been particularly helpful in identifying difficulties in the innovation process. Audits have been conducted for adolescent, women's, and general adult programs.

The strengths-based case-management model introduced in Missouri is based on several principles that, when operationalized, provide consultants with tools to assess the implementation process to date (Sullivan, 1991). First, case management, as outlined in this model, is offered in vivo and employs aggressive outreach. Various methods are used to monitor performance, including time logs, progress notes, and more unusual methods such as mileage-reimbursement figures. Second, resource acquisition is designated as a prime case management activity. Specifically, naturally occurring community resources, as opposed to specialty treatment services, are targeted for acquisition. Again, case plans, conversations with consumers and case managers, and time logs provide measures for operationalizing community resources. In addition, consultants contact key community resource brokers to assess whether they are aware of the local C-STAR Program and its case managers. The third principle reflects the commonly held premise that helping interventions are most successful when they are individually tailored to the needs of the client. Consultants review individual treatment plans and attend case conferences to ascertain if individualized goals and appropriate intervention strategies have been devised. Finally, the overarching principle guiding this model is that case managers should identify and optimize client strengths, particularly when the goal is to enhance the optimum social functioning of clients. To this end, all available documents, observations, and interviews are used to operationalize this standard.

COMPROMISES IN THE EXECUTION OF CASE MANAGEMENT

On-site consultations revealed a standard set of implementation problems that were subsequently corroborated by the MDADA staff, including field-support personnel and the director of treatment services. These observations formed the basis of the recommendations offered in this article and stimulated renewed emphasis on workshops and training sessions geared to executive directors as well as clinical and case-management supervisors.

In general, staff have not done enough to promote outreach services, which seems to reflect a dominant attitude that community-based services are less important than are treatment groups and individual counseling sessions. This perspective is often held by both case managers and counseling staff. In reality, of the initial cohort of case managers, many were drawn from former counselors and group leaders. It appears that many of these individuals have difficulty making the transition to case-management services and instead provide those services with which they are familiar. New case managers are currently being hired and trained, many of whom have little experience in the alcohol-and drug-treatment field. us, greater emphasis on outreach may emerge.

Given the general finding described above, it is not surprising that resource-acquisition activities have been restricted. Although case managers regularly contact basic social service agencies, efforts to identify and access nonstandard resources are largely absent. It is important to note that these findings are not a function of reimbursement schedules in that resource-acquisition activities and outreach in the service of client goals are billable units in the C-STAR model. What appears to be lacking are creative problem-solving skills.

Again, in a fashion consistent with the data provided above, evidence suggests that case plans need to be individualized instead of being focused on the use of standard group and treatment protocols. This finding is critical, because case-management services target sets of outcomes different from those targeted by standard protocols. Simply put, goals in the areas of vocational activity, residential stability, and leisure-time use should be omnipresent. Even in those settings in which a specialized-strengths assessment was used, little connection was apparent between the identified needs and goals identified in assessment and the final case plan.

Finally, the exclusive focus on individual pathology still exerts a firm grip on many case managers. It was difficult to distinguish the case managers from other staff in treatment-planning conferences; as a result, case managers offered minimal input and direction in their appropriate areas. In addition, case managers seemed to agree that community-support interventions should proceed after sobriety was attained. Conceptually, case-management services are designed to occur simultaneously with other helping interventions.

ASSESSING THE POINTS OF RESISTANCE

Patti (1974) provided a scheme for uncovering the potential points of resistance to change efforts that emanate from lower rungs of the organization hierarchy. Although the innovation described here presents a topdown implementation problem, Patti's model is equally informative. When analyzing a change proposal, according to Patti, the generality and depth of innovation are directly related to the magnitude of organizational resistance.

The C-STAR initiative represents a system-wide innovation; that is, an innovation that is pervasive and global in scope. Thus, proper implementation requires fundamental changes in the basic rules of operation. Included are disparate organizational activities such as the actual behavior of those providing services and daily tasks such as documentation of service and determining billable units. The MDADA explicitly directed that the primary focus of service must shift from inpatient services to community-based programming. To underscore this shift, inpatient services, with the exception of short-term detoxification, are no longer reimbursable via public funds. Therefore, the very survival of these treatment programs depends on the accurate implementation of the C-STAR model.

The extent of the innovation encompassed by the C-STAR initiative represents what Patti calls a basic change in that it significantly alters the mission and philosophy of treatment programs. Clearly, the C-STAR effort, symbolized most dramatically by the focus on case management, is geared to effect an expanded set of focal outcomes. Most important, abstinence and reduced substance use simply become part of an interrelated complex of goals, including employment, stable independent living and personal relationships, and positive use of leisure time. Although the importance of this shift has been discussed in the professional literature, professionals have varying levels of agreement with this perspective.

MANAGING CASE MANAGEMENT

Although proper implementation of an innovation requires the support of a wide range of actors, middle managers play a crucial role in that they serve as the link between administration and direct-service practitioners. Early experience in the Missouri program indicates that middle managers are indeed critical to the success or failure of C-STAR. Mintzberg's (1973) typology of managerial roles (identified as equally relevant for those in middle-management positions) may be combined with Patti's (1978) insight that these roles are differentially important during times of program stability and program change. An understanding of these roles, and when to adopt them, can benefit the middle manager entrusted to oversee the adoption of a promising innovation.

Turbulent environments and unexpected change require flexibility on the part of organizations that hope to survive. As discussed above, the C-STAR Program represents a basic and system-wide change in the manner in which alcohol- and drug-treatment programs operate. In reality, the impetus for change emanates from the MDADA and represents a topdown innovation. Thus, the MDADA has impinged on host organizations in a manner that requires that they successfully adapt or perish, which places additional pressures on middle managers who are directly responsible for staff performance.

Any effort to implement an innovation in an existing service structure requires managers to pay close attention to both external and internal processes. Patti (1978) noted that to the extent that organizational actors perceive an innovation as a threat to their domain, resources, and expertise, their level of resistance increases. In contrast, cooperation is enhanced if the innovation is perceived as complementing existing operations.

The addition of community-support services created a multidisciplinary treatment team that brings together a diverse group of practitioners whose roles, primary activities, problem conceptualization, and methods may be diametrically opposed to one another. Traditional treatment services in the substance abuse field, whether inpatient, residential, or outpatient, are guided by the disease concept of chemical dependence. Accordingly, treatment services are designed to respond to the perceived universality of the addiction experience, the natural history of the disease, and the common life scripts of chemically dependent people. Conversely, strengths-based case management, although it does not reject the legitimacy of the traditional perspective, is based on a radically different set of assumptions. Its goal is to enhance the optimum social functioning of clients. Adherents of this perspective believe that this goal is best accomplished by identifying and building on client strengths.

Burkhardt and Brass (1990) noted that although technological innovation can lead to significant alterations in organizational structure and power, such change is not guaranteed. The potential always exists that those in control may work to reshape the innovation in a manner that does not result in redistribution of power. Certainly, early observations of the C-STAR Program suggested that the case-management role had been compromised in execution. Case managers served as errand runners, mobile therapists, and group leaders. This situation was influenced, in large measure, by the manner in which case management was understood and articulated by direct-service supervisors.

The implementation of case management in alcohol and drug treatment not only requires a blending of philosophical agendas, but also results in the hiring of new personnel who may initially appear to be organizational mavericks. Managers must create a team out of individuals who are likely to have different experiences and ideological orientations. Mintzberg (19?3) describes this role as that of internal disturbance handler. For example, tension generally exists between college-educated case managers, who often lack personal experience with substance abuse, and program counselors, who may be in recovery. Another example of this phenomenon stems from the different roles of team members. The case manager is pressured by the community to integrate services and the primary therapist focuses on the cognitive and emotional processes of the client. The team approach requires explicit recognition of the value of both approaches. If the supervisor is unsuccessful in mediating conflicts between the two, the potential benefit of a two-pronged approach to treatment, mixing medical and social strategies, is lost. Again, early observations suggest that the input of case managers in the treatment-planning process has been minimal. Unfortunately, case-management services are often viewed as ancillary and not essential to the recovery process.

Beyond the ideological distinctions between case managers and primary counselors, another important organizational dynamic may emerge. Patti's (1974) model suggested that system-wide and basic change spawns increased levels of resistance and anxiety. Furthermore, such innovation potentially alters the real or imagined organizational chart. In drawing from the C-STAR experience, successful implementation of the model requires that case managers hold a position of equal stature with counseling staff. However, case managers are often viewed as competing for the same valuable resources treasured by existing staff. Managers must become, in the words of Mintzberg (1973), "resource allocatars." Consultation revealed that case managers, compared with other staff, are often poorly paid, discounted in treatment planning, and lacking in support resources such as office space, telephone access, and secretarial staff. Managers who fail to rectify these disparities indicate lack of commitment to the innovation.

Although maintenance of intergroup dynamics is a common managerial charge, case-management services enlarge the responsibilities of middle managers in alcohol- and drug-treatment services. Case managers in a C-STAR program are encouraged to form alliances with those in the public welfare system, employers, landlords, recreation services, local schools, and other relevant community actors. Drawing from Mintzberg's typology, the middle manager must serve as a "boundary spanner," or liaison, at times mending fences with this wide array of community and regulatory figures.

At this juncture, it is difficult to assess whether implementation errors in Missouri are the result of resistance or a lack of clarity about key role functions. Nonetheless, a supervisor can monitor the implementation process.

The manager who values outreach community work will review staff-contact logs, mileage figures, and reports from community actors to assess execution of case-management services. Appraising how efficiently staff perform will also require a different measure. For example, time investment for direct client contact should not be the same for each case but should vary widely based on the need of the individual client. Time logs that regularly report weekly, one-hour sessions with clients may indicate that staff are not implementing community-support services as designed. Additionally, greater emphasis should be placed on collateral contact hours as well as resource acquisition and development activities.

Performance appraisal should also mirror the intent of case-management services. Abstinence and relapse rates are critical indicators of success. However, case managers should establish individual case goals in a wide range of daily-life domains; these outcomes are important to monitor. To date, it appears that these simple measures of program impact are rarely collected. Such data may well determine who will and who will not be paid for services and thus are critically important.

Establishing case-management services in a traditional alcohol-and drug-treatment program requires a middle manager who is committed to innovation and who initiates and encourages change (Kanter, 1983; Peters Waterman, 1982). In Mintzberg's entrepeneurial role, the manager must scan the environment, both internally and externally, and initiate projects that can strengthen the organization's performance and problem-solving ability. In Missouri, innovative managers and program directors seek the advice of consultants and regularly communicate with MDADA staff to share successes and concerns and to seek guidance.

The manager as disseminator may use various strategies to sell the innovation to staff. In C-STAR, techniques include sharing reports on successful programs and holding workshops on how community-support services can be conducted. Managers can also stress the added prestige that comes when practitioners operate at the cutting edge of new technology as well as indicate any economic advantages that might be realized (Delbecq, 1978).

Given this new set of tasks to be performed, the manager must ensure that staff have these requisite skills and must monitor professional performance in this wide range of behaviors. If skills are lacking, the manager must arrange for necessary training and continuing-education opportunities. When hiring staff, new applicants must be assessed on their ability to perform functions germane to case management. In practice, this may signal a need for more staff with formal education in disciplines such as social work.

CONCLUSION

Recently, the National Institute of Drug Abuse noted that case management may represent the wave of the future (Greenhouse, 1992). Not surprisingly, the innovation process described above, given the magnitude of the effort and the newness of the program, has been uneven. In fact, the early experience is reminiscent of the struggles faced by those who advocated for similar innovations in mental health services over the past three decades (Sullivan et al., in press). To be successful, an innovation such as C-STAR must be embraced at multiple organizational levels, from state-level departments and regional and executive directors of programs to supervisors and direct-service workers. Too often, large-scale training efforts are initiated with the hope that system change can begin at the ground floor.

Likewise, middle managers, the focus of this discourse, cannot be expected to effect system change singlehandedly. Nonetheless, given their direct influence on the behavior of direct-service workers, middle managers remain in a prime position to monitor the faithful execution of new treatment methods. Conscious reflection on the presenting challenge and the necessary tasks to lead staff in new directions is critical to fostering change. Mintzberg (19?3) suggested that the ability to integrate individual and organizational goals is the mark of a leader. Indeed, middle managers must move beyond the role of clinical supervisor and embrace a leadership role for community-support services if such services are to survive in the alcohol- and drug-treatment field.

REFERENCES

Burkhardt, M., & Brass, D. (1990, March). Change patterns or patterns of change: The effects of a change in technology on social network structure and power. Administrative Science Quarterly, 35, 104-127.

Delbecq, A. (1978). e social political process of introducing innovation in human services. In R. Saari & Y. Hasenfeld (Eds.), The management of human services (pp. 309-339). New York: Columbia University Press.

Greenhouse, C. (1992, July-August). Case management may be the wave of the future for drug abuse treatment. NIDA Notes, 6-7.

Kanter, R. (1983). The change masters. New York: Simon & Schuster.

Mintzberg, H. (1973). The nature of managerial work. New York: Harper Row

Patti, R. (1974). Organizational resistance and change: The view from below. Social Services Review, 48, 367-383.

Patti, R. (1978). Toward a paradigm of middle-management practice in social welfare programs. In R. Saari & Y. Hasenfeld (Eds.), The management of human services (pp. 262-288). New York: Columbia University Press.

Peters, T., & Waterman, R. (1982). In search of excellence. New York: Harper & Row.

Sullivan, W. P. (1991). Case management in alcohol and drug treatment: Conceptual issues and practical applications. Springfield, MO: Center for Social Research, Southwest Missouri State University

Sullivan, W. P., Jordan, L., & Dillon, D. (in press). Comprehensive drug and alcohol treatment programming: A bold new approach. Health and Social Policy.

Sullivan, W. P., Rapp, C. (1991). Improving client outcomes: The Kansas technical assistance consultation project. Community Mental Health Journal, 27, 327-336.

Sullivan, W. P., Wolk, J., & Hartmann, D. (1992). Case management in alcohol and drug treatment: Improving client outcomes. Families in Society, 73, 195-203.

William Patrick Sullivan is Associate Professor, School of Social Work, Indiana University, Indianapolis, Indiana; David J. Hartmann is Associate Professor and Director, Center for Social Research, Southwest Missouri State University, Springfield, Missouri; Dick Dillon is Director of Agency Development, Bridgeway Counseling Services, St. Charles, Missouri; and James L. Wolk is Professor, Department of Social Work, Southwest Missouri State University.

Copyright Family Service America Feb 1994
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