A Case Management Model Utilizing In-Home Treatment Services for Rural AODA Clients: The Family and Children's Center Model

Kathleen M. Adams, M.S., C.A.D.C. III
Colin C. Ward, M.S., C.A.D.C. III
Family and Children's Center
La Crosse, Wisconsin

This paper describes the alternative alcohol and other drug abuse (AODA) treatment model developed at the Family and Children's Center in La Crosse, Wisconsin. This model grew out of the crucible of change created when we were challenged to create a better way of assessing needs and of developing and delivering services specific to the unique AODA needs of a rural clientele.

Content Area

Family and Children's Center (FCC) is a regional, private, not-for-profit mental health care agency that has served the needs of La Crosse and surrounding rural communities for more than 100 years. As part of a large continuum of programs designed to keep families together and promote individual well-being, FCC provides outpatient and in-home mental health and chemical abuse treatment services, as shown in figure 1.

Funding for services is broad based and includes the United Way, medical assistance, donations, private pay, and health insurance. In the mid-1980s, FCC began contracting with insurance companies to provide comprehensive managed mental health care services. Through selected affiliation with other mental health and medical services, we complemented our own already broad continuum of care. The components of this expanded continuum of care are shown in figure 2.

• Prospective and retroactive utilization review
• Quality assurance procedures
• Assumption of financial risk

Utilization review and quality assurance discussions quickly began challenging many of our assumptions about chemical dependency treatment. We discovered that traditional 28-day inpatient programs were overutilized and that criteria for inpatient admission were unclear and imprecise. Assessments that determined the presence and progression of "disease" were often done only after inpatient admission. The subsequent treatment plans were often rigid, with little if any consideration given to cost effectiveness. Hospital-based treatment programs failed to provide the accessibility needed to appropriately meet the demands of a rural clientele. Both distance and their daily commitment to farming activities made traditional AODA treatment services an ineffective match for the needs of rural clients.

As our traditional assumptions were being challenged, we explored the literature and progressive program trends, and our own philosophy of chemical dependency treatment began to evolve. We began developing an alternative model of treatment.

This alternative model of treatment was based on the assumptions that:

• The complex interaction of psychological, social, and biochemical factors leads to chemical abuse.
• Patterns of chemical abuse often begin as coping responses developed to manage emotional distress or trauma.
• Chemical abuse is a complex issue that seldom, if ever, exists independent of other psychosocial stresses.
• Chemical abuse problems vary greatly in their intensity.
• Chemical abuse problems are not necessarily progressive in nature.

Watching the needs of our rural and other clientele go unmet, it became clear that treatment interventions needed to be matched closely to each individual's needs. We focused on creating a service delivery model emphasizing:

• Accessibility of assessment and treatment
• Assessment focused on determining treatment recommendations rather than diagnosis
• Highly individualized treatment in the least restrictive environment
• Utilization of a broad continuum of medical and mental health services
• Aggressive case management

Methods

Managers of mental health care benefits are often viewed as "gatekeepers," whose function is to authorize and limit services. We developed a differing philosophy: that benefits management is a matter of quality assurance and preutilization review, not gatekeeping. Quality treatment, in the least restrictive environment, should be provided before insurance benefits are exhausted.

Case Management

In the context of this philosophy, the challenge was to provide quality clinical case management that was client centered and emphasized aggressively managed individualized treatment plans.

The case manager is someone who can initiate and maintain a process that can help substance abusers identify and access the right interventions at the right time. The assumption of case management is that most people with substance abuse problems can best be served by access to a range of resources, rather than by a single counselor/case manager trying to provide direct help with all the person's problems.
—Bois and Graham 1993

In their 1993 article, Bois and Graham described the basic principles of the case management approach. We have adapted them as follows:

• Empowerment: The client is involved in identifying his or her own needs and is actively involved in the entire process of assessment and treatment.
• Individualization: Because each client's strengths and needs are unique, each assessment and treatment plan is client centered and different.
• Adaptability: As the client and his or her environment changes, the case manager must reevaluate the client's treatment plan.
• Least restrictive: Assessments and interventions that work with the structures of the client's life will be most effective.
• Professional expertise: The case manager should have advanced training and professional expertise.
• Transformational: The case management model functions as a change agent both for the individual AODA client and for the AODA treatment system as a whole.

We created a model that utilizes existing rural support networks and medical services, combined with the added development of specialized AODA services. The additional services include outpatient detoxification services and home-based counseling services focused on AODA treatment. In emphasizing aggressively managed individualized treatment plans that utilize a broad continuum of services, we were freed to develop treatment options specific to the needs of our rural clients. This clinical case management approach soon demonstrated its clinical and fiscal value. The advantages of this approach were made available to all clients, regardless of funding source.

Assessment

Effective assessment is a process of exploration that empowers the client and effects change. Our experience was that an assessment process focused on diagnosis was of minimal value, often reducing the individual's level of motivation and promoting rigidity. Additionally, the diagnostically focused assessments seldom took into consideration the psychosocial stresses unique to rural clients.

Assuming that chemical use functions within the broader context of any individual's lifestyle, we developed a treatment-focused assessment process. This process is designed to develop a dynamic treatment plan individualized for each client. Diagnosis is secondary, and each client is actively involved in developing a treatment plan specific to his or her needs.

These comprehensive assessments are provided by a clinical case manager who has AODA certification at the highest level by the State of Wisconsin (Certified Alcohol Drug Counselor III) and more than 3,000 hours of supervised clinical experience beyond the master's degree. Comprehensive assessment is possible because assessments are done by a clinical case manager with solid mental health expertise in addition to chemical dependency training. In addition to exploring the history and pattern of substance abuse (amount, duration, and frequency of use), the case manager explores the following other essential areas with the client:

Physical health

• Assess for physical complications related to chemical use
• Explore withdrawal history
• Explore any chronic pain patterns related to chemical use history
• Refer to family physician for physical examination if the client has had no recent physical examination

Polydrug use

• Assess for use of multiple types of chemicals and use patterns
• Analyze the psychosocial component of problematic use

Self-medication

• Assess how chemical use facilitates the client's management of emotional and social discomfort

Stress management

• Assess the stresses, both internal and external, that appear to be alleviated by chemical use

High-risk situations

• Explore the individual's awareness of high-risk situations—situations specific to the individual in which that person's risk of abusing chemicals is high

Critical shift point

• Explore how the individual experienced the critical shift point—that point at which individuals become aware that their chemical use is a problem for themselves or others

Stated use goal

• Explore the individual's use goal—abstinence, occasional use, regular controlled use, etc.
• Understand and assess the language the individual uses to describe urges or moments of craving for chemicals—a source of valuable information about the function of the individual's chemical use. (Traditional thought interprets urges and cravings as statements of failure or as a first step toward relapse. We believe that urges can best be interpreted as statements expressing the individual's struggle to soothe unmet physical, psychological, social, and spiritual needs.)

Mental health

• Assess the client's mental health. In addition to the clinical interview, there are many excellent tools available for assessment of clinical depression and other mental health issues.

Social and family history

• Assess for trauma history and explore ways that chemical use may be functioning as a survival response

Availability for treatment

• Assess family, vocational, and travel dynamics that impact the individual's availability for differing treatment options

In-Home Individual and Family-Focused Services

Many rural clients experience problems of isolation and inaccessibility to treatment. A model of service delivery that emphasizes in-home treatment addresses these problems. In addition, home-based services facilitate the initial first step of accessing mental health services, a step that is often difficult for rural clients because of fears about social stigma or the scheduling demands of a farming lifestyle.

The FCC case manager is able to integrate any combination of the following in-home services into any treatment plan:

• Intense systemic AODA assessment to determine both emergent care issues and ongoing individual and family treatment needs
• Individual and/or family counseling
• Family support services focused on support or crisis intervention
• In-home detoxification, including home nursing care and ongoing medical monitoring by a registered nurse

Outpatient/In-Home Detoxification Program

The factors that determine a client's appropriateness for outpatient/in-home detoxification are:

• Physical condition
• Support system
• History of and intensity of withdrawal symptoms
• Accuracy of self-report information
• Client's comfort level

If it is determined that the client is appropriate for outpatient/in-home detoxification, the clinical case manager refers him or her to a physician for an immediate medical evaluation. A number of physicians have agreed to be on call for such circumstances. If the client has a primary care physician and wants this doctor to handle all medical services, the client's wishes are supported.

In consultation with the physician, the clinical case manager arranges an immediate schedule of home visits by a registered nurse. The home health care nurse will consult regularly with the physician and will provide ongoing monitoring of:

• Blood pressure
• Respiration
• Temperature
• Medication management
• Progression of withdrawal

Inpatient medical treatment is available at any time deemed necessary by the consulting physician.

The clinical case manager continues to provide ongoing coordination of services, therapeutic support, AODA and mental health assessment, and daily review with the home health care nurse. Additionally, all outpatient/in-home detoxification cases are contemporaneously reviewed by a psychiatrist.

Additional services, available outside the home, are typically coordinated with the in-home services. These outside services include:

• Individual, family, or group outpatient psychotherapy
• Psychiatric or psychological evaluation and medication management
• Intensively structured outpatient group treatment
• Intensive day treatment
• Residential treatment
• Treatment foster care services
• Inpatient medical treatment
• Support groups

The following case review demonstrates this case management model in action.

Case Review

A 9-year-old male was brought in to the emergency room by both of his parents, who were seeking to have him hospitalized for escalating behavioral problems and for threatening to harm himself and others. The hospital social worker did an initial assessment and telephoned the clinical case manager who was on call with the following information:

• The family had never accessed either inpatient or outpatient mental health services in the past.
• The father had a significant problem with alcohol abuse.
• The parents were divorced and shared custody and placement.
• There was one younger sibling.
• The mother had an unresolved history of childhood sexual trauma and clinical depression.
• There was significant conflict between the parents.

Additionally, the 9-year-old had recently been diagnosed with Attention Deficit Hyperactivity Disorder by his primary care physician, who had prescribed a medication intervention of methylphenidate hydrochloride (Ritalin). Because of perceived social stigma, the parents had been reluctant to follow through with medication management and had not administered the methylphenidate hydrochloride.

As the local hospitals do not have a psychiatric facility for children, hospital staff were eager to explore solutions other than the following limited options they were initially faced with:

• Admit the child to the adult psychiatric unit
• Refer the child to the State mental health institute 2-1/2 hours away
• Refer the child to the police and a secured juvenile detention facility

In consultation with the social worker and emergency room physician, the clinical case manager determined that the child needed:

• Stabilization in a secure environment
• Psychological evaluation
• Consultation with the family physician who had prescribed the methylphenidate hydrochloride
• Assessment of individual and family struggles with AODA and depression, and the impact of these on the current crisis

It was determined that these needs could be met in a less structured environment than the hospital, secured detention, or the State hospital. The following recommendations concerning assessment and treatment of the boy were made and followed:

• One week of stabilization and evaluation of the child in a licensed treatment foster home
• A psychological evaluation within 24 hours
• Consultation with the family physician
• In-home, family-focused assessment of the family dynamics, AODA, and other factors that enabled the crisis to develop
• Home-based family therapy upon the child's discharge from the treatment foster home; this family therapy would be designed to facilitate reintegration of the child into the family and to preclude future destabilization
• Outpatient psychotherapy recommended for the parents to address the father's chemical abuse patterns and the mother's maladaptive coping patterns

The treatment foster parents picked up the child in the emergency room and he remained in their home for 1 week. Exit interviews with the providers and the parents confirmed that this intensive, family-focused intervention of counseling and treatment foster care services was successful in stabilizing the patient and in providing psychological evaluation of individual and family issues. Secondarily, the funding saved was estimated to be at least $3,000 to $4,000. Home-based services and outpatient psychological and psychotherapy services were subsequently provided to the family.

Findings/Conclusions

The unique needs of rural AODA clients are best met by a broad continuum of services that emphasize outpatient and in-home service options. Psychotherapists and family physicians can utilize case-managed intensive outpatient and in-home services for both crisis intervention and ongoing AODA treatment. Structured quality assurance and utilization review (QAUR) procedures ensure that the Family and Children's Center maintains its commitment to excellence in clinical service. QAUR procedures also provide FCC with regular feedback, which is immediately integrated into the dynamic case management process.

Recommendations

The disease paradigm, and the consequent reliance on inpatient treatment, functioned to move chemical abuse problems out of the moral arena and into the medical arena. Looking to the future, it is important to recognize that chemical abuse problems are very complex, that they exist on a wide spectrum of intensity, and that the treatment arena must therefore include a wide spectrum of creative service responses. In rural America, and elsewhere, where the impact of chemical abuse is hard felt in the home, treatment services should be available in the home.

Reference

Bois, C., and Graham, K. Assessment, case management and treatment planning. In: Howard, B.M.; Harrison, S.; Carver, V.; and Lightfoot, L., eds. Alcohol and Drug Problems: A Practical Guide for Counselors. Toronto, Ontario: Addictions Research Foundation, 1993. pp. 87-102.

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