Comprehensive Case Management
A Model Approach for W-2/AODA Participants

The comprehensive case management model is a process not a program or a type of service. It represents a fundamental change in the way services are designed and delivered. In a comprehensive case management model, families in W-2 with substance abuse issues are to receive individualized wraparound services. It is value-based and has an unconditional commitment to customize services on a "one family at a time" basis to support normalized and inclusive options for families with complex needs. At its core, the comprehensive case management model is based on interventions, which are collaborative, community-based, emphasize the strengths of families, and include the delivery of highly coordinated, individualized services for families. This process addresses the unique needs of families with a focus on achieving positive and effective partnerships with families, the community, and agencies that provide children and family services.

For successful treatment programs that focus on recovery to work they should not only offer a continuum of services but also integrate these services within the larger community. Because many factors affect a woman's substance abuse problem, the purpose of a comprehensive case management approach is to address a woman's substance abuse in the context of her health and her relationship with her children and other family members, the community, and society. This type of case management can generally be described as a coordinated approach to the delivery of health, substance abuse, mental health, vocational, and social services, linking participants with appropriate services to address specific needs and stated goals. All services and supports must be culturally competent and tailored to the unique values and cultural needs of the family, and the culture that the family identifies with. When implemented to its fullest, comprehensive case management will enhance the scope of substance abuse treatment and the recovery continuum, and will stress the following:

• Provide the participant with a single point of contact for multiple health and social services systems.

• Advocate for the participant.

• Be flexible, community-based, and family-focused.

• Assist the participant with needs generally thought to be outside the realm of employment and training and substance abuse treatment.

• Develop a universal service plan that integrates activities from all service providers and is outcome based.

The plan is needs-driven rather than service-driven, although a plan may incorporate existing categorical services if appropriate to the needs of the participant. The initial plan should be a combination of existing or modified services, newly created services, informal supports, community resources, and should include a plan for a step-down of formal services. Plans must include a balance of formal services and informal community and family resource. This is inter-systems collaboration in its true sense; the goal of inter-systems collaboration is to expand the network of services available to participants. All of the organizations, or systems, have boundaries to what they can do, but inter-systems collaboration allows case managers within each system to facilitate interaction with other systems to best serve the family. This is a partnership where staff members from several agencies work as collaborative teams to share their areas of expertise and identify services within their agencies to best meet the needs of the family. Although informal exchange among different agencies is intrinsic to case management, a more formalized connection among agencies may be necessary to fulfill the W-2 work participation requirement. Monthly meetings between all of the service providers in a multi-disciplinary team approach should occur so the delivery of consistent information is seamless to the participant and her family.

Whenever agencies or service providers work together, there is a potential for conflict. Sometimes social pressures or the need to maximize resources can force public agencies into a joint venture. Tensions can also develop in the course of delivering services, for example inter-systems collaboration may result in a participant having two or more case managers. When this is the case, the AODA treatment provider should serve as case coordinator or hub when AODA treatment is the primary activity on the participant's Employability Plan. Although this is a deviation from W-2 practice as the FEP being the hub, the AODA treatment providers are doing this type of coordination and should remain in this role. However, while working with the Southeast Asian population, particularly Hmong, typically the clan leader will be the case coordinator throughout the entire duration of the participant's W-2 activities.

The AODA treatment provider can serve as the coordinator for obtaining all the necessary release of information forms to exchange information between the collaborating agencies. AODA treatment providers are in a position to explain to the participant the confidentiality law and why so many release forms must be signed in order for a comprehensive case management model to be utilized.

The majority of a participant's activities will be in recovery services until they move to a higher rung on the W-2 ladder. The AODA treatment provider will be able to more closely monitor the participant's progress, due to the amount of time in AODA activities, and provide immediate progress updates to all the systems involved in this case. The case coordinator or hub will undoubtedly change as a participant moves up the W-2 ladder.

A comprehensive case management model is shown in the diagram on the next page. The woman and the systems that she is working with drive this type of model. Even though there are a number of systems identified on the model, not all of the systems may be impacting her life at the same time. Inter-systems collaboration occurs as needed by the participant and her family. An example of a memorandum of understanding is included at the end of this section to identify agency roles and purposes in utilizing the comprehensive case management model.

COMPREHENSIVE CASE MANAGEMENT MODEL

• FEP & SSP

• Faith Community

• Family and Friends
  Support System

• Community
  Resources
• Vocational
  Rehabilitation
• Education and Literacy
• AODA Treatment Provider serves as Case Coordinator
• Employers
• Child Welfare and
  Safety Services
• Mental Health
• Criminal Justice
  System including
  Juvenile Justice
• HMO Providers
• Domestic Violence