Home > HRB drug and alcohol evidence review on case management.

Galvin, Brian (2017) HRB drug and alcohol evidence review on case management. Drugnet Ireland , Issue 60, Winter 2017 , pp. 15-17.

[img]
Preview
PDF (Drugnet Ireland 60)
1MB

The objective of the HRB’s recently published scoping review1 was to examine the peer-reviewed non-experimental literature on case management and substance use published between 2003 and 2013, and to answer specific research questions based on the literature. These comprised questions on the nature of case management, the outcomes studied, and gaps in the literature.

 

In a case management approach to service provision, clients are typically offered and receive, or are linked to, a range of services tailored to meet their specific, individual needs. The objective of linking clients to relevant medical and social services is a key characteristic of this approach. Case managers also frequently work as advocates for their clients. This advocacy work may involve liaising with housing associations to address accommodation needs or job centres to improve employability. The rationale behind the linkage and advocacy work is that clients frequently present with multiple needs or complications which impact on their recovery or rehabilitation. Developing and maintaining links with existing services can help to address these multiple needs and aid the recovery process. Case management is also used to increase client retention in services and improve treatment outcomes.

 

Case management: models and roles

Vanderplasschen et al. identified six basic models following their review of the case management literature up to 20032. These are outlined briefly below.

 

  • The brokerage model: Case managers act as ‘brokers’, assisting clients to identify their needs and gain access to other services or supports; generally, it involves a brief engagement with clients with only one or two meetings.
  • Generalist models: Case managers work with clients to identify needs and negotiate access to required services and supports; a longer-term and closer relationship with clients is developed over time.
  • Assertive community treatment (ACT): Case managers work in teams to help identify client needs and provide services directly to clients through assertive outreach.
  • Intensive case management (ICM): Case managers work on a more intensive, individual basis with clients and usually have a lower caseload; they identify needs, provide services directly and link clients with relevant services.
  • The strengths perspective: Case managers seek to empower the client to identify their own strengths to build on, rather than primarily focusing on correcting their deficits; this approach encourages the use of informal sources of support and help.
  • Clinical case management: Case managers provide direct clinical input to clients and combine that with assistance in accessing other resources, particularly from the health and social care sector. 

In recent years, the role of case management has been promoted in a number of important policy reports in Ireland, which include plans to improve service coordination for people in recovery from substance misuse. In 2007 the Report of the Working Group on Drugs Rehabilitation3 made a number of key recommendations and set out the structural arrangements required to implement them. One of these was the development of broad national protocols to facilitate interagency working; these cover issues such as confidentiality, common assessment tools, referral procedures, and conflict resolution between agencies. In 2010, the Health Service Executive (HSE) published the National Drugs Rehabilitation Framework (NDRF), setting out how services to current and former drug users were to be provided in the form of supported integrated care pathways (ICPs) with the cooperation of different service providers. The report recognised that service users may present with diverse needs, such as treatment, education, vocational training, employment support and accommodation, and that no single agency can cater for all possible needs. An individual care plan for each service user needs to be delivered by a multidisciplinary team. Where a service user has complex and multifaceted needs, a more intensive case management approach may be used. The framework stated that the provision of rehabilitation pathways is a shared responsibility of the education, training and employment sectors alongside the health, welfare and housing sector, non-governmental organisations, communities, families, and the individual themselves.

 

The ICP comprises four steps, linked to the four-tier model of service provision: initial contact, involving screening and referral; initial assessment and identification of appropriate service; comprehensive assessment, following which a case manager is identified to support the individual on their rehabilitation pathway; and implementation of the care plan.

 

The HRB’s scoping review was commissioned to examine the non-experimental research literature on case management and people in recovery from substance misuse. The objectives of the review were to explore the nature of case management as reported in the literature, document the outcomes associated with case management, and identify the gaps in the research literature. It is hoped that the report can be used by policy-makers and practitioners in Ireland to update their understanding and use of case management as an approach to improving service coordination and recovery.

 

In order to focus this review, three research questions were agreed at the outset:

  1. What additional knowledge regarding the nature of case management can we gain from a review of recent non-experimental research on the topic?
  2. What outcomes have been evaluated in the non-experimental research literature?
  3. What are the gaps in the literature?

What additional knowledge regarding the nature of case management can be gained from a review of recent non-experimental research on the topic?

Case management interventions tend to target clients experiencing extreme disadvantage relative to other substance misuse treatment clients, with a disproportionate amount applying to females. The groups of people being targeted by case management present with a multitude of personal and social problems, including substance misuse, homelessness, economic deprivation and mental health problems.

 

From the literature reviewed, it would appear that there are multiple objectives of case management, including reducing substance misuse and visits to hospital emergency departments, reducing hospital admissions, and improving social and psychological functioning. In addition, there are a number of objectives reported in the literature related to improving service coordination, such as providing linkages with medical and social services and retaining people in treatment. The identification of such a broad range of objectives points to the multiple needs of the client base and the expectations on case management as an intervention.

 

The review identified a number of features of case management delivery that were associated with improved outcomes reported in the evaluations. These included that duration and intensity of the intervention could be an important variable to consider both in future planning and evaluation of case management. Team-based case management and extensive engagement by case managers with the client group are also associated with positive outcomes.

 

What outcomes have been evaluated in the non-experimental research literature?

Of the 20 evaluations included in this review, 13 examined outcomes under the broad heading of psychosocial functioning, which, after substance use, is the second most frequent type of indicator in these studies. Two of these evaluations – one on a combination of ACT and ICM, and the other on using a community-based case management model – had a particular focus on quality-of -life issues, and both studies showed improvements in these outcome domains. Only three of the 20 evaluation studies in the review did not find sufficient evidence to support the claim that case management contributed to improved outcomes in at least one area. The improved outcomes reported in these studies may well be associated with the use of case management, or they may be due to unknown factors or influences which cannot be ruled out given the design of the evaluations reported. Only one-quarter of the evaluation studies used a comparison group; the rest of the evaluation studies used retrospective single groups and before-and-after designs.

 

What are the gaps in the literature?

Vanderplasschen et al. argue that there is a need to consider outcomes beyond drug use and other ‘socially acceptable outcomes’ and to take into account quality-of-life outcomes and clients’ subjective perceptions when evaluating the effectiveness of case management. They also noted that there is little information on the crucial features of case management and what specific aspects of this intervention contribute to specific outcomes. This is exacerbated by the lack of fidelity in implementation and the distance between the model chosen and its practical application.

 

The review identified similar gaps in the literature as those reported by Vanderplasschen et al. As pointed out above, in the 20 evaluations included in this review, two broad categories of outcomes were evaluated. The predominant use of these hard outcomes to evaluate case management suggests an overemphasis on using case management as a deficit-reduction intervention. Indeed, there is almost a complete absence in the literature of the strengths-based case management model being used and evaluated. This type of model prioritises the empowerment of the client group by emphasising their strengths and would be more amenable to evaluating the softer outcomes that may be associated with improvements in quality of life.

 

This review also identified a major gap in the literature around any attempt to identify what specific aspects of case management contribute to improved outcomes. In essence, both primary and secondary studies sought to determine whether case management works for people in recovery from substance misuse; in the main these studies and reviews have produced some evidence to suggest that case management is an effective intervention to use with this target group. While such study designs are important in determining the efficacy and effectiveness of an intervention, the authors suggest that the evidence base would also benefit from an evaluation approach that seeks to understand not only does it work, but for whom and under what conditions and contexts. They suggest that the realist approach to evaluation and synthesis may be an appropriate approach to consider for researchers and reviewers to use in future investigations of case management.

 

The authors suggested earlier that certain features of case management identified in this review ‒ notably the duration, intensity, the team-based nature of some of the work and the nature of the engagement between case managers and clients ‒ could be important variables that require further elaboration and evaluation. Although their observations are based on a small number of studies, the authors reiterate the point here and suggest that these features and perhaps many more could be investigated using the realist approach. The realist approach is a theory-driven approach to evaluation and synthesis; it seeks to uncover the processes or mechanisms that lead to particular outcomes, and the context within which this occurs.

 

A recent review in 2014 by Jackson et al.4 provides a useful example on how the realist approach may elucidate important learning about case management in future investigations4. This is a realist review and the methods used enabled the authors to draw certain conclusions about why an intervention may work sometimes and under what conditions. Its exploration of the literature in the area suggests that engagement with an intervention appears to be key to its success.

 

It could well be hypothesised that engagement is also a key mechanism that is associated with improved outcomes in clients of case management, for example, when the intervention is intensive, of longer duration, accompanied by a good working alliance between the case manager and client and with dedicated care plans. These components could well contribute to the client engaging with the intervention and ‘investing’ in their recovery and accruing some benefits. Further evaluation and synthesis of case management with people in recovery from substance misuse are needed to investigate the role of these potential features of case management in delivering improved outcomes for clients.

 

  1. Nic Gabhainn S, D’Eath M, Keane M and Sixsmith JA (2016) Scoping review of case management in the treatment of drug and alcohol misuse, 2003–2013. HRB Drug and Alcohol Evidence Review 3. Dublin: Health Research Board.
  2. Vanderplasschen W, Wolf J, Rapp RC and Broekaert E (2007) Effectiveness of different models of case management for substance-abusing populations. Journal of Psychoactive Drugs, 39(1): 81–95.
  3. Working Group on Drugs Rehabilitation (2007) National Drugs Strategy 20012008: rehabilitation. Report of the Working Group on Drugs Rehabilitation, May 2007. Dublin: Department of Community, Rural and Gaeltacht Affairs.
  4. Jackson LA, Buxton JA, Dingwell J, Dykeman M, Gahagan J, Gallant K, Karabanow J, Kirkland S, LeVangie D, Sketris I, Gossop M, Davison C (2014) Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: a realist synthesis of what makes interventions work. BMC Psychology, 2(1): 26.
Item Type:Article
Issue Title:Issue 60, Winter 2017
Date:January 2017
Page Range:pp. 15-17
Publisher:Health Research Board
Volume:Issue 60, Winter 2017
EndNote:View
Subjects:HJ Treatment method > General treatment method concepts
HJ Treatment method > Treatment outcome
J Health care, prevention and rehabilitation > Patient care management
J Health care, prevention and rehabilitation > Treatment and maintenance > Treatment factors
J Health care, prevention and rehabilitation > Health care delivery
MP-MR Policy, planning, economics, work and social services > Organisational development > Workforce / staff skills and training
T Demographic characteristics > Drug user
T Demographic characteristics > Drug or health care worker

Repository Staff Only: item control page