16 Comprehensive Case Management for Substance Use Disorder Treatment
The definition of case management varies by setting, but in general terms it is a coordinated, individualized approach that links patients[1] with appropriate services to address their specific needs and help them achieve their stated goals. Case management for patients with substance use disorders (SUDs) has been found to be effective because it helps them stay in treatment and recovery. Also, by concurrently addressing other needs, it allows patients to focus on SUD treatment. The types of settings offering SUD case management include specialty treatment programs, federally qualified health centers, rural health centers, community mental health centers, veterans’ health programs, and integrated primary care practices.
This Advisory is based on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Treatment Improvement Protocol (TIP) 27, Comprehensive Case Management for Substance Abuse Treatment. It surveys the underlying principles and models of case management, discusses reasons SUD treatment providers might consider implementing or expanding the use of case management, and lists some case management-related resources and tools.
Key Messages
- Case management is framed around screening to identify a patient’s medical, psychosocial, behavioral, and functional needs, and then working directly and/or through community resources to address these needs while the SUD is treated.
- Case management is increasingly used to support treatment engagement and retention while reducing the impact of SUDs on the community.
- The SUD treatment program can select a case management model that matches its treatment approach and best suits its patients and the service setting.
- In any type of case management model employed, all care team members should contribute to and endorse the patient’s treatment plan, and effectively communicate with each other as the plan is implemented.
Case Management Overview
The percentage of U.S. SUD treatment programs using case management has risen since 2000, from 66 percent of the 13,418 facilities then in operation to 83 percent of the 15,961 facilities operating in 2019 (SAMHSA, 2020c; SAMHSA, Office of Applied Studies, 2002).
Definitive statements about the overall effectiveness of case management cannot be made, because studies vary in their definitions of the term, methodology, study populations, intervention designs, and outcome measures. However, multiple analyses (Joo & Huber, 2015; Kirk et al., 2013; Penzenstadler et al., 2017; Rapp et al., 2014; Regis et al., 2020) have found positive outcomes for one or more measures, such as treatment adherence, overall functioning, costs, decreases in substance use, reductions in acute care episodes, and increased engagement in nonacute services. A 2019 meta-analysis comparing case management with treatment as usual showed a small yet statistically significant positive effect, which was greater for treatment-related tasks than for personal functioning outcomes such as improved health status and family relations and reductions in substance use and legal involvement (Vanderplasschen et al., 2019).
Principles of case management
It offers the patient a single point of contact with the health and social services system. The case manager assumes responsibility for coordinating the care of patients who receive services from multiple agencies. This replaces a haphazard process of referrals with a single, more well-structured service.
It is patient centered. Each patient’s right to self-determination is emphasized. The case manager is familiar with the patient’s experiences and world, and uses this understanding to identify psychosocial stressors and anticipate needs. The case manager works with the patient to set reasonable goals (see box) and helps the patient access the chosen services.
It is community based. The case manager helps the patient access and integrate formalized and informal care services, overcome barriers to services, and transition between services. Case managers vary in how much they are directly involved with community services (e.g., whether they make warm handoffs or accompany patients to meetings).
It is equity driven. Typically, the case manager begins by addressing a patient’s urgent and tangible needs, such as stable and safe housing, food, childcare, or income. The case manager does this work recognizing that when viewed through a social determinants of health (SDOH) lens (see box), some populations disproportionately lack such life-enhancing resources—and that for some patients, access to one or more of these resources may be a prerequisite for focusing on treatment.
It involves advocacy. The case manager promotes the patient’s best interests. This can include educating service providers, negotiating for services, and recommending actions (e.g., using sanctions instead of jail time for patients involved with the justice system). Advocacy can also involve speaking out and acting on behalf of a patient who is refused services (e.g., because of discriminatory attitudes toward people with SUDs) or who requires assistance with meeting basic needs.
It is culturally sensitive and nonstigmatizing. The case manager is knowledgeable and nonjudgmental about the patient’s culture. This enables the case manager to effectively connect with the patient and service providers in the patient’s community. Another key function of the case manager is to model nonstigmatizing language, attitudes, and actions for other service providers (Volkow, 2020).
It is pragmatic. The case manager may also teach skills helpful to recovery (e.g., assertive communication, collaboration with a team of providers, day-to-day skills for living in the community). These pragmatic skills may be taught explicitly, or simply modeled during interactions between the case manager and client.
Social Determinants of Health
SDOH have been defined as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (U.S. Department of Health and Human Services, n.d.), including risk for substance misuse and related health consequences (Office of the Surgeon General, 2016). Case managers can play a central role in assessing SDOH and in assisting to develop a plan that effectively takes them into account (Fink-Samnick, 2018).
Care management versus case management
“Care management” refers to services that help a patient manage one or more chronic diseases, such as diabetes or cardiovascular disease. Case management is usually more limited in scope and time commitment (Ahmed, 2016; Centers for Medicare & Medicaid Services, 2019). For example, a case manager may be involved in a patient’s care for only one or a few specific needs, such as transportation to treatment or help in applying for Medicaid (Case Management Society of America, 2020; Treiger, 2020). However, a patient with an SUD may need the kind of sustained help that is more like care management. Assistance from a case manager may be offered along the full continuum of care, and for as long as it benefits the patient.
Models of case management
Variations in the case manager’s role are illustrated in the “Models of Case Management” table, which compares four case management models across 11 activities. (See TIP 27, Introduction, pp. 9–11, for descriptions of each model.) Whichever model is used, all members of the care team should contribute to and endorse a shared care plan for the patient, and effectively communicate with each other as the plan is implemented (van Dongen et al., 2016). It is important to note that certification programs exist for case managers, but not all case managers are required to be certified by the relevant authorities (e.g., state Medicaid authorities and/or state mental health authorities).
| Primary Case Management Activities | Broker/Generalist | Strengths Perspective | Assertive Community Treatment | Clinical/ Rehabilitation |
| Conducts outreach and case finding | Not usually | Depends on agency mission & structure | Depends on agency mission & structure | Depends on agency mission & structure |
| Provides assessment and ongoing reassessment | Specific to immediate resource acquisition needs | Strengths-based; applicable to any of a patient’s life areas | Broad-based; part of a comprehensive (biopsychosocial) assessment | Broad-based; part of a comprehensive (biopsychosocial) assessment |
| Assists in goal planning | Generally brief; related to acquiring resources, possibly informal | Patient-centered; teaches how to set goals and objectives; goals may include any of a patient’s life areas | Comprehensive; goals may include any of a patient’s life areas | Comprehensive; goals may include any of a patient’s life areas |
| Makes referrals to needed resources | Initiates contact or patient may contact on own | Contacts resource or accompanies a patient, or patient may contact on own | Multiple resources, as needed, are integrated into a broad package of case management services | Contacts resource or accompanies a patient, or patient may contact on own |
| Monitors referrals | Makes follow-up checks | Closely involved in ongoing relationship between patient and resource | Closely involved in ongoing relationship between patient and resource | Closely involved in ongoing relationship between patient and resource |
| Provides therapeutic services beyond resource acquisition (e.g., therapy, skills teaching) | Provides referral to other sources for these services if requested | Usually limited to answering patient questions about treatment, helping management services | Provides many services within a unified package of treatment/case management services | Provides therapeutic activities central to the model |
| Helps develop informal support systems | No | Develops informal resources—neighbors, places of worship, family—a key principle of the model | Through implementation of drop-in centers and shelters | Stresses family & mutual-help support via therapeutic activities |
| Responds to crises | Responds to crises related to resource needs such as housing | Responds to crises related to mental health and resource needs; active in stabilization and then referral | Responds to crises related to mental health and resource needs; active in stabilization and then referral | Responds to crises related to mental health and resource needs; stabilizes situation, provides further therapeutic intervention |
| Engages in advocacy on behalf of individual patients | Usually only at level of line staff | Assertively advocates for patients’ needs with multiple systems, including agencies, families, legal systems, and legislative bodies | Assertively advocates for patients’ needs with multiple systems, including agencies, families, legal systems, and legislative bodies | Assertively advocates for patients’ needs with multiple systems, including agencies, families, legal systems, and legislative bodies |
| Engages in advocacy in support of resource development | Not usually | Usually in the context of specific patient needs | Advocates for needed resources or may create resources | Usually in the context of specific patient needs |
| Provides direct services related to resource acquisition (e.g., drop-in center, employment counseling) | Provides referral to resources that provide direct services | Helps prepare patient to acquire resources (e.g., by role-playing, accompanying patient to interviews) | Provides many direct services within a unified package of treatment/case management | Provides services that are part of a rehabilitation services plan; offers skill teaching |
Factors Underlying the Increased Use of Case Management for Patients With SUD
Reasons behind the increasing use of case managers in SUD treatment programs include the following:
Many patients with SUDs have co-occurring mental disorders and comorbid conditions that providers recognize need concurrent treatment. For example, in 2019, 9.5 million adults had both an SUD and a co-occurring mental illness, and of these individuals 3.6 million had a serious mental illness (SAMHSA, 2020b). Common comorbid diseases include cardiovascular disease, hepatitis, and HIV/AIDS (National Institute on Drug Abuse, 2020). The services of a case manager become especially important for patients with an SUD who must navigate complex health systems to obtain treatment for all their psychiatric and medical care needs or who must adhere to a medication regimen that may involve multiple prescriptions from one or more care providers. In such an instance, the case manager must be familiar with the patient’s full medication regimen (National Council for Behavioral Health, 2020).
Programs increasingly recognize that helping patients address basic needs, as determined by a comprehensive SDOH assessment, is essential to treatment (American Public Health Association, 2014). For example, based on needs identified in the comprehensive SDOH assessment, case managers may help patients apply for Medicare, obtain transportation vouchers, or receive housing assistance so that they are better positioned to engage in and benefit from treatment. (See Chapter 5 of TIP 27 for strategies on assisting special needs populations.)
The rate of acute health crises related to drug use continues to increase. Since 1999, U.S. deaths from opioid, other drug, and polysubstance use have trended upward (Centers for Disease Control and Prevention [CDC], 2019), increasing by 10 percent from March 2019 to March 2020 (Ahmad et al., 2020). The numbers of nonfatal overdoses, hospitalizations, and emergency department visits have also increased considerably (AHRQ, 2019, 2020; Vivolo-Kantor et al., 2020; Weiss et al., 2017). For people who enter the health system through emergency services for an SUD-related crisis, case managers can help access follow-up services and care (Sortedahl et al., 2018). For example, a hospital case manager can help coordinate a drug transition plan for a patient with pain seen in the emergency department for prescription opioid overdose. Often, peer recovery support specialists are embedded in these medical settings to help assist with the initial case management needs of patients with an SUD. These specialists have lived experience with recovery and are trained to help patients with SUDs engage in treatment and enter long-term recovery.
Multiple developments in healthcare and behavioral health services are expanding the use of case management (Ahmed, 2016). These include:
- More emphasis on medical and behavioral health integration, which creates a need for coordination of services—a need that case managers can fulfill.
- Greater use of screening, brief intervention, and referral to treatment (SBIRT) tools in care settings, which can involve case managers in implementation, follow-up, and coordination of care.
- Growing adoption of reimbursement for chronic care management and value-based care by Medicare and other insurers; case managers may be involved in monitoring, measuring, and evaluating outcomes achieved by the care team (Tahan et al., 2020).
- The development of health information technology solutions that facilitate care coordination and patient-centered care.
- Increased use of peer recovery support specialists, who can cost effectively extend the services of case managers by guiding people in SUD treatment on their journey through recovery-oriented systems of care (prevention, intervention, treatment, post-treatment).
- Recent changes to the federal regulations governing the confidentiality of SUD patient records that make it easier to use information in such records for case management and care coordination activities (SAMHSA, 2020a).
- The movement of health systems toward a population-based approach to behavioral health care and a systems-wide focus on health equity, cultural competence, and cultural responsiveness. Case managers may participate in community health assessments (CDC, n.d.), and they may also help educate the treatment team about how addressing SDOH can contribute to greater health equity and therefore better health.
Case management services can benefit the individual who needs short-term help in connecting to SUD treatment, or some specific ancillary service that facilitates access to treatment (e.g., transportation, child care). However, case management is especially helpful for people with complex or chronic health and social services needs. Ideally, case management supports the philosophy of “no wrong door.” This means that however people enter the healthcare and social services system (whether through the emergency department, a law enforcement encounter, hospitalization, a prevention program, an initial visit to a treatment program, a primary care visit, a shelter stay, or some other entry point), a case manager links them with the range of services they want or need.
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License and Attribution
Substance Abuse and Mental Health Services Administration. (2021). Comprehensive Case Management for Substance Use Disorder Treatment. Advisory.
This work resides in the public domain, unless otherwise indicated.
- This publication uses only the term “patients” to describe recipients or potential recipients of case management services. In practice, depending on the setting and the context, the terms “clients” or “participants” are also frequently used. ↵