Cuyahoga CSAT provides project participants with comprehensive case management and substance abuse treatment, based on Treatment Improvement Protocol #27 published by the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration.

Two full-time case managers employed by Recovery Resources are the principal service providers for the project. They have offices at the Community Women’s Shelter, and coordinate services with staff members of the Shelter. They've had specialized training in interventions designed for those who have substance-use disorders and the depressive and anxiety disorders that are frequently found among homeless women. The case managers have also been trained to recognize and respond appropriately to the lingering effects of trauma among this population. Each case manager works with about 25 clients in a project year.

Case finding.
MHS conducts an intake assessment with each woman who enters the shelter, and it maintains a database of client information. A client’s homeless status is verified by information from prior service providers, or from friends and relatives. A baseline assessment determines her need for basic services. Through this assessment, MHS identifies potential clients based on preliminary diagnoses, length of time in the shelter, and probability of remaining in Cuyahoga County.

Pretreatment and assessment.
Case management activities may begin during the pretreatment phase. Case managers begin the engagement process by conducting pretreatment groups in the shelter on a daily basis. These pretreatment groups will enable case managers to build rapport with clients, assess their motivational stage, and move them toward readiness for treatment. Case managers discuss with clients basic information about addiction, treatment and recovery, use motivational interviewing techniques, complete a basic screening evaluation, and discuss with clients the likely consequences of continued substance use.

The pretreatment phase will offer the opportunity to assess a client’s level of motivation or "stage of change" during this exploratory period. Structured, motivational interviewing will be used to move a client from the precontemplation phase (or non acknowledgement of a problem), to contemplation of change, determination and action. Case managers educate clients about the structure and steps in treatment, and the internal work and changes that will be necessary for recovery.

When clients indicate a willingness to enter treatment, they will be assessed using the Computerized Intake Assessment Instrument – Cleveland. Completion of the CIAI-C yields a psychosocial summary report. The assessment produces a DSM-IV substance-use diagnosis, and helps clinicians to determine the appropriate level of care for the client. With client consent, the CIAI-C assessment is shared with the treatment agency to which she is referred. At this point, Case managers will explain the procedures for the SAMHSA-required periodic assessments, and obtain the informed consent for these procedures.

Following this assessment phase, Case Managers begin to implement the other four core functions of Comprehensive Case Management: planning, linkage, monitoring and advocacy.

Planning.
Based on assessment results, the case manager and client work in partnership to identify goals that are important to the client and build on her strengths. Goals in the service plan will be structured as measurable, manageable steps and strategies, framed in a positive context, to ensure client success. Case managers will coach clients in identifying their own goals, identifying the steps to their achievement, accessing and accepting assistance in meeting their objectives and learning how to identify and overcome barriers. The client’s acquisition of these skills is as important as the attainment of the goals themselves. As substance abuse and mental health issues are addressed, clients will participate in new and unfamiliar activities, adopt new habits, make new friends and experience both sobriety and periods of relapse. In partnership with her Case Manager, the client will experience growth through the exercise of these skills.

Among the female, homeless population special attention must be paid to planning goals which address the woman’s housing and primary health care needs. Demographic on residents of the Community Women’s Shelter indicate that physical problems and disabilities are a significant concern. Focus group data also indicated that this population identifies a lack of housing as the root cause of many of their problems. Working with clients based on their perceived needs, Case Managers will help them to identify goals for housing and primary health care.

Linkages.
Once goals and steps are identified, Case managers begin the work of linking clients to services. More than just providing a list of possible resources, Case Managers will coach a client to build her skills in resource acquisition. Case managers will reinforce the client’s commitment to contacting a resource, plan the steps of making the contact, brainstorm possible obstacles and solutions and model and role play the steps to acquiring the resource.

For example, perhaps a client wishes to make a medical appointment. The Case manager might provide her with a list of potential providers, taking into consideration her medical condition and insurance status. She will discuss the client’s preference for providers, and reinforce the positive outcome of addressing her medical issue. Together, they will make a list of the steps and sequence necessary to making and keeping the appointment. Barriers, such as transportation, will be considered, and alternatives (using the busline instead of relying on a ride from a friend) will be discussed. Finally the client and Case Manager may develop questions to ask the physician, and role play asking those questions. Such intensive focus on linkage and support in the Comprehensive Case Management Model is especially important to this population.

A vital component of linkage for clients of the Women’s Community Shelter will be ensuring that transportation is not a barrier to accessing services. Case Managers will provide taxi vouchers as needed to ensure women can complete referrals to all services.

Linking treatment
with housing and primary medical care.
Linkage to primary health care services for women enrolled in this project will be provided through Case Managers working closely with the Free Clinic of Greater Cleveland, Neighborhood Family Practice and Care Alliance (Health Care for the Homeless, located next door to the women’s shelter), each a provider of free medical care.

Recovery Resources has a longstanding referral relationships with these providers. Similarly, RR will provide linkages to local transitional housing providers (Women’s Transitional Housing, Hitchcock and Family Transitional Housing). RR also operates a Supportive Housing unit, providing links to a continuum of housing options. It is anticipated that Case Managers will devote a substantial portion of their time advocating for housing options for their clients.

Monitoring.
Once linkages are made, Case Managers will be responsible for monitoring the fit and relationship between the client and the resource. Continuing to meet with clients to verify that goals were met, strategizing ways to overcome obstacles and adjusting service plans are the key activities in this phase.

Advocacy.
In the course of this monitoring, Case managers may note that a client’s needs are not being met, hindering the achievement of that client’s goals. This make take the form of a client being refused resources, discharged from a program without cause, or the need to modify services to address a client’s circumstances. Advocacy may mean direct contact with service providers, landlords or child welfare workers. It may also take the form of educating service providers regarding substance abuse and mental illness or smoothing over a dispute between a client and a provider. It is in this role that Case Managers must exhibit the skills of exemplary "boundary crossers," being able to respect the professional boundaries of agencies and service systems, while remaining client-centered.

Case management in treatment.
The case manager’s first activity in supporting a client in treatment is to appropriately match the client to a level of care and a provider’s culture and philosophy. Sensitivity to a woman’s race, culture, sexual orientation and personal preferences are of paramount importance. At the same time, as the client transitions to treatment, case managers work with the new provider, advocating for a client’s particular needs.

During this primary treatment phase, the case manager coaches and encourages the client to stay with treatment, recognizing that other issues (housing, health care, children) may be the client’s primary focus. Case managers coordinate services to ensure that while treatment goals are met, other needs are also addressed. Case managers provide support during transitions (e.g., from residential treatment to outpatient). Assisting in the development of community based support systems during this phase if the client is to successfully reintegrate into the community following treatment. Case Managers will be expected to be in frequent contact with the treatment program to check on client attendance, to divert a crisis or to intervene in the event of one.

Case management during treatment also serves the function of continually building on the client’s strengths, enhancing skills for functioning at a higher level. Service plans will emphasize a higher level of responsibility, as the client prepares to become more independent and return to the community.

Substance abuse treatment.
As is the case in most publicly funded treatment systems in the country, limited funds for clients with no insurance (i.,e, non Medicaid clients) means that clients needing to access the Board-funded provider network must be placed on a waiting list for treatment services. Funding through this grant will be used to provide immediate access to the treatment network for these clients.

There are potentially 16 alcohol and drug treatment providers which would be eligible to provide services to these clients. The Board will release a Request for proposal, which will stipulate that providers wishing to participate in the project will demonstrate that they are 1) actively implementing the Trauma Recovery and Empowerment Model 2) prepared to interact with Case Managers employing the Comprehensive Case Management Model and 3) prepared to work with a homeless, dually diagnosed client.