Case management concepts in military substance abuse treatment at Fort Jackson

Drug Rehabilitation Centers in Fort Jackson, South Carolina: Military Substance Abuse Treatment and Relapse

Substance abuse remains a major health concern within the military in spite of efforts by the Department of Defense to introduce substance abuse treatment programs for its personnel and retirees. One agency within the military that focuses on this problem is the Moncrief Army Community Hospital, located in Fort Jackson, South Carolina. Case management concepts have important implications for the treatment of substance abuse amongst military personnel. Based on observation and interview with one of the members of staff at the hospital, and with the support of peer reviewed sources, this research sought to evaluate the use of case management concepts in the agency. The interview established that the manner in which the hospital delivers substance abuse treatment services demonstrates adherence to case management concepts. The agency\'s services fairly exemplify the principles, goals, models, phases, and roles of case management. Even so, there is still room for improvement, especially in terms of continuity of care and forming peer support groups.

Introduction

Substance abuse remains a major health concern in the U.S., imposing a significant morbidity, mortality, economic, and psychological burden on individuals, families, communities, and even the government. The condition is often characterized by a greater risk of psychiatric hospitalization, co-morbidities, suicide, dangerous behaviors, as well as death (Decker et al., 2017). A group particularly affected by substance abuse is military personnel (both active service members and veterans). Estimates indicate that the prevalence of substance abuse among military personnel ranges from 6-9%, with those deployed to war being the most affected (Mooney et al., 2014). This group faces a higher risk of substance abuse due to factors such as combat-related posttraumatic stress disorder (PTSD), financial constraints, and family difficulties (Witkiewitz & Estrada, 2011; Allen, Crawford & Kudler, 2016). Commonly abused substances include alcohol, medications, and illicit drugs (Erdtmann, 2015). Although cognitive-behavioral and pharmacotherapeutic interventions have been shown to be quite useful in treating substance abuse disorders (Allen, Crawford & Kudler, 2016), the rate of relapse amongst military personnel is particularly alarming (Decker et al., 2017), underscoring the need for greater attention to relapse prevention.

On its part, the Department of Defense (DOD) acknowledges the widespread problem of substance abuse amongst its members. The Department has introduced a number of programs aimed at rehabilitating substance abusers within the military, such as the Army Center for Substance Abuse Programs (ACSAP) (ACSAP, 2009). Through agencies located in various parts of the country, ACSAP and other programs deliver a broad array of services relating to substance abuse, including screening, rehabilitation, risk reduction, deterrence, referral, as well as education and training. One such agency is the Moncrief Army Community Hospital. The agency has relied on case management concepts to enhance the delivery of substance abuse treatment services. Based on information obtained from observation and an interview with one of the members of staff at the agency, and with the support of peer-reviewed sources, this paper analyses the agency\'s application of case management concepts. Following a brief description of the agency, the paper pays attention to the principles and goals of case management, the three components of case management, models of case management, roles of the case manager, and the three phases of case management.

Agency Description

Abbreviated as MCXL-PHS ASAP, The Moncrief Army Community Hospital is an outpatient clinic located in Fort Jackson, South Carolina, primarily serving the Fort Jackson community as well as military personnel and their families. Operating under the DOD, the hospital was previously a general medical and surgical facility providing outpatient and inpatient services relating to medical, mental, and behavioral health. However, in mid-2016 the management of the hospital announced that the hospital would become an outpatient health clinic, focusing mainly on active service members, their families, and retirees. One of the areas the hospital focuses on is substance abuse rehabilitation. More specifically, the hospital provides substance abuse treatment and detoxification services to the Fort Jackson community, keen on enhancing the wellbeing of military personnel and veterans.

In addition to observation, an interview was held with one of the members of staff at the hospital with the aim of obtaining information about the management of substance abuse cases at the hospital. Attention was particularly paid to the hospital\'s application of case management concepts in providing substance abuse treatment. The findings of the observation and interview are presented in the following sections.

Principles and Goals of Case Management

The relevance of case management concepts in the treatment of substance abuse orders is immense. Case management is essentially:

A creative and collaborative process, involving skills in assessment, communication, coordination, consulting, teaching, modeling, and advocacy that aim to enhance the optimum social functioning of the client served and positive outcomes for the agency (Woodside & McClam, 2014, p. 8).

Indeed, case management constitutes an integral component of the health care service delivery process, with federal legislation even mandating it. Case management is guided by seven important principles: integration of services (providing holistic care); quality care (efficient and effective care); equal access to care (irrespective of gender, race, ethnicity, religion, sexual orientation, socioeconomic status, and other protected characteristics); continuity of care (providing uninterrupted, comprehensive care); client empowerment (respect for the client and fostering their participation in the service delivery process), self-determination (allowing clients to choose goals and interventions); and evaluation (assessment of processes and outcomes) (Woodside & McClam, 2014). These principles in essence constitute the goals case management seeks to achieve.

Based on observations and information obtained from the interviewee, the delivery of substance abuse interventions at MCXL-PHS significantly reflects the principles and goals of case management. For instance, the element of integration of services is embodied by the agency\'s focus on not only substance abuse, but also other underlying disorders and complications such as PTSD, depression, and history of abuse. Indeed, evidence demonstrates that substance abuse disorder may not often occur alone -- it is usually an indication of other underlying problems (Allen, Crawford & Kudler, 2016; Decker et al., 2017). In this regard, the agency seeks to promote holistic wellbeing by focusing their screening, assessment, and treatment processes beyond alcohol or drug dependence. Adherence to the principle of quality care is embodied by short wait times, affordable costs, as well as the agency\'s insistence on evidence-based practice. The agency specifically administers addiction counseling as well as pharmacotherapeutic interventions such as naltrexone. These interventions have been shown to be useful in treating substance abuse and preventing relapse (Mooney et al., 2014; Allen, Crawford & Kudler, 2016). One area in which the agency needs to improve on is continuity of care. Though comprehensive care is offered, it is important for case managers to increase their contact with patients outside the facility, i.e. follow-up (Woodside & McClam, 2014).

Three Components of Case Management

The three components of case management include: case review, documentation, and client involvement (Woodside & McClam, 2014). Case review entails examining the client\'s case on a periodic basis. This may be achieved through meetings between the client and the case manager, or between the case manager and other members of the interdisciplinary team. Case review ensures adherences to the set quality standards and effectiveness throughout the entire process of care delivery. At MCXL-PHS, case review is an important aspect of service delivery. For each case, the case manager meets fortnightly with other members of the interdisciplinary team in an effort to assess the progress made and identify areas that require improvement. The case manager also meets with the patient in an attempt to involve the patient in the design of the care plan.

Case review involves documentation, which essentially entails recording any information relating to the case -- from initial assessment to care planning and implementation, as well as case evaluation and termination (Woodside & McClam, 2014). Documentation is without a doubt crucial in healthcare delivery. The interviewee precisely indicated the immense value of documentation in the delivery of substance abuse treatment services. Some of the information documented includes demographic attributes (e.g. family status and income level), the patient\'s history (e.g. history of abuse and involvement in combat), behavioral and mental diagnoses, interventions prescribed, date of program commencement, referral and follow-up dates, severity of substance dependence, medical updates, and so forth.

The third component of case management involves client participation. This involves ensuring that the client participates in the care delivery process (Woodside & McClam, 2014). This is informed by the need to deliver care that resonates with the individual needs of the patient. The importance of patient participation in substance abuse treatment cannot be overemphasized (Allen, Crawford & Kudler, 2016). This is particularly true because the search for rehabilitation for substance abuse is predominantly initiated by the patient (ACSAP, 2009). Involving the patient throughout the care process, therefore, ensures important aspects are not missed. Patient participation is a crucial element of substance abuse treatment at MCXL-PHS. The process involves not only the patient, but also their significant family members such as spouses. The focus of patient involvement is on familiarizing the patient with the objectives of the care plan and the role of the case manager, getting the perspectives of the patient regarding various aspects of the intervention such as recreational therapy and physical training, and understanding the patient\'s preferences with regard to the timing and structure of the prescribed therapeutic interventions.

Models of Case Management

There are three models that define the process of case management as well as the role of case managers: role-based case management, organization-based case management, and responsibility-based case management (Woodside & McClam, 2014). Role-based case management stipulates the role expected of the case manager. For instance, one case manager may focus on therapy, while another may be expected to ensure cost efficiency. Organization-based case management involves offering a spectrum of services, keen on addressing multiple problems. Responsibility-based case management involves allowing the client, family members, volunteers, and social networks to undertake some case management functions.

As mentioned earlier, the agency provides services aimed at treating not only substance abuse, but also other mental disorders such as depression, anxiety, and PTSD. Focusing on multiple problems is an indication that the agency exemplifies the organization-based case management model. The agency offers a wide range of services in a single location oblivious of the fact that substance abuse often occurs alongside other complications. Though the agency embodies the organization-based case management model, aspects of the other two models are also evident. For role-based case management, case managers often assume diverse roles. There are those concerned with psychiatric therapy, those concerned with physical training, and those concerned with behavioral therapy. Others serve as marriage therapists, recreational therapists, and pain management specialists. Indeed, as put by Mooney et al. (2014), effective treatment of substance abuse in military personnel takes the effort of an interdisciplinary team.

Aspects of responsibility-based case management are also evident. This is particularly evidenced by the involvement of family members in the care process. As narrated by the interviewee, the agency acknowledges family members as crucial players in the case management process. Spouses, partners, and loved ones are often asked to walk with the patient throughout the care process. Family members participate in ways such as providing social support, accompanying patients to the hospital, and helping patients adhere to therapeutic schedules. The interviewee indicated that patients with family support were likely to recover in a shorter duration and less likely to experience a relapse. To enhance responsibility-based case management, it is crucial for the agency to form a peer support network whereby patients with the same problem can meet (within or outside the hospital) to share experiences. This would be useful for patients that may not have family support.

Roles of the Case Manager

The case manager plays different roles at the same time. The case manager is an advocate, a broker, a coordinator, a consultant, a counselor, a planner, a problem solver, and a record keeper (Woodside & McClam, 2014). They plan the continuum of care delivery, coordinate the delivery of care, connect patients with health care services, oversee follow-ups and consultations, and provide patients with education about their condition and self-care techniques. The case manager also facilitates communication and flow of information between members of the multidisciplinary team, solves interpersonal conflicts, monitors and assesses outcomes, documents every aspect of the care process, and advocates for the needs of the patients. The role of the case manager is indeed an involving one, requiring outstanding skills in communication, interpersonal relations, conflict resolution, organization, as well as leadership and management.

As a case manager, the interviewee agreed that the role of the case manager is quite complex. Fulfilling all those roles simultaneously is without a doubt not a straightforward undertaking as one may think. The interviewee intimated that a case manager requires strong leadership and management skills. The role involves interacting with patients, families, and other members of the multidisciplinary team, deciding which interventions to use based on evidence, reporting outcomes, and so on; hence the need for such skills. Recognizing the complex roles of the case manager, the agency has a program for equipping case managers with the various skills expected of them. Case managers participate in education and training initiatives in an attempt to sharpen their case management abilities. This often involves internally or externally organized seminars and workshops. According to the interview, these initiatives have greatly helped case managers to be better advocates, record keepers, planners, problem solvers, consultants, and counselors.

Three Phases of Case Management

The three phases of case management according to Woodside & McClam (2014) include assessment, planning, and implementation. Assessment is the first step of the care process and involves initial contact with the patient, gathering of information, and identification of the problem. This phase is important in substance abuse treatment. It is at this stage that information about the patient is collected (such as demographic characteristics, substance abuse profile, and lifestyle factors) (Mooney et al., 2014; Decker et al., 2017). The interviewee described the assessment phase as the diagnostic stage of the care process. When a patient visits or contacts the hospital seeking to be rehabilitated, focus is first on collecting information relating to aspects such as gender, race, age, branch of service, occupational rank, homelessness, family history and status, type of substance used and frequency of use, combat exposure, previous diagnoses, prior outpatient service or hospitalization, and co-morbidities. Other information that may be collected at this stage includes the impact of substance abuse on the individual\'s physical, psychological, social, and family functioning. This information facilitates the determination of the severity of substance abuse and any underlying complications.