Module 4: Coordinating and Integrating Systems

1F. Coordinated Case Management

Coordinated case management is at the core of any successful transition and positive treatment outcome. Case management links the youth with appropriate resources in the community, keeps track of the youth's progress, and monitors their compliance with any conditions imposed by the court or substance abuse or mental health agency.

Case Managers

The case manager typically serves as a broker of services, an advocate, occasionally as a therapist, and as the individual who ensures all the systems with which the youth is involved are "on the same track" and communicating with each other. The casemanager needs to manage:

• Treatment needs
• Treatment readiness
• Treatment planning
• Treatment progress
• Treatment outcomes

Resolving the sometimes-conflicting interests of youth, their families, the justice system, and mental health and substance abuse providers is a challenging task. The most effective case managers are those who are comfortable with and knowledgeable about the cultures, families, and systems with which the youth engage. A single, full-time case manager working collaboratively with a transition team is the ideal situation. A case manager in this role is often called a "Boundary Spanner," because of his or her ability to manage interactions in multiple settings (Steadman, 1992). Because resources are often limited, this ideal situation is not always possible; in this case the primary counselor should take the lead in providing care to the youth. Ordinarily this role is filled by the mental health or substance abuse counselor, who can make appropriate referrals to other agencies and services.

Functions of Case Management

Specific functions include:

• Assessing the youth's needs and abilities
• Planning for treatment services
• Maintaining contact with the youth's probation officer
• Brokering treatment and other services for the youth
• Monitoring and reporting progress to other transition team members
• Providing support and helping youth with all treatment areas (substance abuse, mental health, juvenile justice)
• Monitoring drug screening
• Protecting the youth's confidentiality

Goals of Case Management

The first goal of effective case management is continuity of treatment, providing ongoing assessment to youth, as well as identifying their needs and ensuring provision of care (TIP 30, 1998). Case management works best when it begins in a juvenile detention facility and follows the youth without interruption through the transition period. Planning should begin early, and is most effective when all aspects of the youth's care and needs are addressed (e.g., family, medications, school).

A second goal of case management is empowering families and developing their mastery in navigating through the multiple systems in which youth with co-occurring disorders are involved. Improving family mastery of systems as well as enhancing their skill in effective parenting strategies is at the core of the most effective emerging integrated multisystemic interventions. For more information on how to involve families, see Importance of Families in Module 1.