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Module 7 - Coordinated CAre Systems

PARTICIPANT HANDOUT

Introduction

Today, individuals with alcohol use problems are identified in a broad array of settings and many are identified at increasingly earlier stages. A growing awareness that most alcohol-related problems are experienced by persons who do not fit the traditional definition of "alcoholic" (Institute of Medicine, 1990) has led to increased case finding of individuals with non-dependent drinking problems. As a result, persons with all levels of alcohol problems are identified in child protection programs, voluntary family support agencies, employee assistance programs, inpatient and outpatient psychiatric facilities, health care settings, public financial support programs, schools, faith-based organizations, vocational rehabilitation settings, and traditional alcohol treatment programs.

A growing body of alcohol treatment research suggests that alcohol dependent persons may require a wide variety of services to achieve sobriety and minimize continuing relapse (Institute of Medicine, 1990; Cummings, 1991). The result is a movement to develop coordinated systems of care that acknowledge: 1) individuals with alcohol use problems are encountered in other than alcohol treatment settings, 2) persons with alcohol-related problems experience a multiplicity of needs, and 3) public and private treatment innovations must be considered.

This module examines issues and examples for social workers engaged with individuals who experience alcohol use problems. It encourages the development of coordinated systems of care-systems that replicate a full array or continuum of options.

Learning Objectives

By the end of this module, learners should be able to:

A. Define and provide rationales for coordinated care systems for individuals with alcohol use problems;
B. Recognize major components of a service system for individuals with alcohol use problems (i.e., child welfare, primary health/mental health, social service, and criminal justice systems);
C. Identify barriers to coordinated care in the AODA service delivery system;
D. Understand the social work role and skills necessary for the management and resource development of coordinated care.

Coordinated Care in the Treatment of Alcohol Use Problems

Recovery from alcohol use problems is currently conceptualized as a multi-dimensional process, requiring levels of care that can accommodate people through various stages of change and a great variety of services (Institute of Medicine, 1990). Coordinated systems of care are typified by the availability of levels of care on a continuum from the least intensive (periodic outpatient contacts) to the most intensive (inpatient hospitalization, residential care), as well as the availability of a variety of types of care within the system (e.g., health, child, and spiritual care).

 

Coordinated systems of care for persons with alcohol-related problems presume that the number and intensity of alcohol problems occur on a continuum, and that they can be pervasive, affecting a person's employment, ability to care for children, medical condition, psychiatric health, spirituality, educational status, and friends and family support networks. Such coordinated systems of care have been recommended for many years (Glaser, 1994), but their development has been hampered by the need to incorporate the aims and technologies of both alcohol-specific and non-alcohol-specific treatment settings. The result of this "mixing of apples and oranges" can be a messy rather than smooth service system.

Specialized
Non-specialized
  • Focus on alcohol use disorders
  • Accept referrals from non-specialized
  • Coordiante services
  • Variety of types and levels of program
  • Focus on other than alcohol problems
  • May make referrals if screening for them
  • Philosophy, goals may be imcompatible
  • Wide variety of settings

Specialized Treatment Programs

Alcohol-specific treatment sites are characterized by their primary focus on alcohol use disorders. These settings maintain a degree of association with other programs, from formalized referral agreements to less formal, but still important coordinating relationships. These specialized systems include many levels and types of alcohol treatment services, such as social and medical detoxification programs, short- and long-term treatment programs, halfway houses, community prevention programs, diversion programs, long-term therapeutic communities, and self-help adjunct programs (CSAT, 1993). Central to the growing treatment system are consumer developed self-help groups such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, Women for Sobriety, and Rational Recovery. While these self-help groups are not universally viewed as helpful, they serve as important adjuncts to professional treatment modalities. They may or may not be responsive to individual differences and the challenges of cultural competence.

These various services often have differences in philosophy, treatment orientation, goals, and in the preference for abstinence as a prerequisite or as a long-term goal of treatment. The role of medication in the treatment of dependent drinking has been changing rapidly and several studies are in progress to investigate combinations of pharmacotherapy with different models of treatment (NIAAA, 2001, Project Combine).

Programs Not Specializing in Alcohol Treatment

Non-alcohol-specific treatment sites encounter a full continuum of drinkers-alcohol abstainers, users, abusers, and dependent drinkers. The programs often have disparate and conflicting goals, methods of screening for alcohol use problems, financial reimbursement systems, cultural and theoretical orientations, and available intervention approaches. These differences among components of a community service network can offer a wealth of resources for maintaining sobriety or non-abusive drinking patterns. Unfortunately, their coordination into a functioning system of services poses unique challenges for the social work professional. Minimally, the development of coordinated systems of care requires an understanding of the goals of each of the components, recognition of the prevalence of alcohol use problems in each of the sites, and analysis of the current methods of identification of alcohol problems used in each. The purpose, incidence, and screening methods used in some of the major components of coordinated care systems of many communities are worth examining.

Components of a Coordinated System of Care

Most communities host a variety of service systems to interact with individuals who experience problems with alcohol use. Typical systems include child welfare, primary health/mental health care, social service, educational, vocational, and legal and criminal justice programming. In a coordinated system of care, these systems would become component sub-systems. It is important to understand the nature of each of these sub-systems with regard to their goals, prevalence, and screening/ identification methods related to individuals with alcohol use problems. A well-developed coordinated care system is characterized by a decentralized referral structure, since the system must be able to "capture" clients from a wide variety of settings. It is also characterized by the availability of multiple levels of care that can address different aspects and steps in the treatment process (e.g., input, throughput, and output).

Component Systems
- Child welfare
- Primary health care and mental health care
- Social service
- Educational & vocational
- Legal & criminal justice


Child Welfare

Goals. Child welfare systems are a mix of public and private programs designed to identify children at risk of maltreatment, and provide for their safety through a continuum of services that include prevention, temporary substitute care, family reunification, permanency planning, and adoption. The need to identify and treat alcohol and substance use problems arises when such problems interfere with the parents' (or other caregivers') ability to care for a child after an initial allegation of maltreatment. In addition, the need to screen for and treat problem substance use is critical when reunification of the family is planned following a child's substitute care placement.

Prevalence. In 85% of the states responding to the 1999 National Committee for Prevention of Child Abuse annual state survey, substance abuse is reported to be one of the top two problems experienced in the families of 3.2 million children reported for child abuse and neglect in the United States (Peddle & Wang, 2001). Among confirmed cases of child maltreatment, 40% involve the use of alcohol or other drugs (Children of Alcoholics Foundation, 1996). Additionally, studies have reported that substance abuse among parental caretakers was the primary cause of the increase in child welfare cases during the 1990's (Reid, Macchetto, & Foster, 1999). Research further suggests that substance abuse among caretakers is a factor in a majority of cases of emotional abuse and neglect, and the resulting neglect is the major reason that children are removed from a home in which parents have alcohol or other drug problems (Prevent Child Abuse America, 2001).

The prevalence of alcohol consumption among pregnant women has increased to 15.3% (Ebrahim et al, 1998), after a decline during the previous 10 years. Estimates of Fetal Alcohol Syndrome in the U.S. vary from 0.5 to 3 per 1000 live births (Stratton, Stratton, Howe, & Battaglia, 1996). In a review of neglect reports nationally, Chasnoff (1998) concluded that substance abuse during pregnancy is a major factor in the presence of neglect among young children.

Screening and Identification. Child welfare workers have limited training in screening for substance abuse problems, in determining the level of risk posed to minor children, or in offering any intervention besides referral to specialized programs (Tracy & Farkas, 1994). Tracy (1994) also reported that child welfare workers even doubt their right to ask parents about substance use, and that the workers lack necessary interviewing and assessment skills in this area.

Primary Health Care Providers/Mental Health Care Providers

Goals. Primary health care providers include both physical and behavioral health (mental health) clinicians whose goals are to cure disease or ameliorate symptoms of chronic disorders. Sites include primary care, acute, subacute, and long-term care settings. In mental health settings, the treatment goals are more often to control the most painful symptoms of mental disorders, rather than to cure them (Austrian, 2000).

Prevalence. Manwell, Fleming, Johnson, and Barry (1997) reported that 15% of males and 5-10% of females seen by primary care clinicians in ambulatory care settings are at-risk for, or are experiencing, problems related to alcohol use, while 5% are alcohol dependent. It is estimated that 100,000 deaths in the United States can be attributed to alcohol use and abuse (Stinson, Dufour, Steffens, & DeBakey, 1993), and approximately 40% of individuals treated for head injuries in emergency room settings have been previously treated for alcohol problems (Cherpitel, 1988). About 50% of those admitted to Level I Trauma centers have been found to be legally intoxicated (Soderstrom & Cowley, 1987) and 20-25% of those being treated for trauma have been found to have alcohol use problems (Waller, 1988).

In the general mental health services population, it is estimated that nearly 50% of those with severe and persistent mental illness also have a co-occurring substance abuse disorder (Mueser et al., 1990; Test, Wallisch, Allness, & Ripp, 1989). The lifetime prevalence for any substance use disorder with any other mental disorder is 13.7% (Kessler et al., 1996), and for alcohol abuse/dependence specifically, is reported to be 37% (Regier et al., 1990). The lifetime prevalence of alcohol abuse/dependence disorder with specific Axis I disorders is presented in Table 1.

Table 1. Lifetime Prevalence of Any Alcohol Diagnosis with Axis I Diagnosis

Any Alcohol Diagnosis
Major Depression
16.5%
Bipolar I Disorder
46.2%
Schizophrenia
33.7%
Anxiety Disorders
17.9%
Panic Disorders
28.7%
Phobias
17.3%
Obsessive-Compulsive Disorder
24.0%

(Regier et al., 1990)

Screening & Identification. Despite the connection between substance use problems and medical disorders, alcohol and drug screening has not been routinely practiced in primary care health settings. Soderstrom and Cowley (1987) reported that only 55% of Level I trauma centers regularly obtain blood alcohol levels in their patients, and only a few centers routinely provide referrals for alcohol problems. Similarly, alcohol use by pregnant women is not routinely identified, despite the harm associated with drinking during this period (Serdula, Williamson, Kendrick, Anda, & Byers, 1991).

A number of studies have developed and investigated the utility of screening instruments in primary health care settings. These include the CAGE (Ewing, 1984), the Michigan Alcoholism Screening Test-MAST (Selzer, 1971), the Alcohol Use Disorders Identification Test-AUDIT (Babor & Grant, 1989), the Health Screening Questionnaire-HSQ (Cutler, Wallace & Haines, 1988), the Health Screening Survey-HSS (Fleming & Barry, 1991), and the Rapid Alcohol Problem Screen-RAPS (Cherpitel, 1995). Currently available laboratory tests to detect alcohol in urine and blood (e.g., gamma-glutamyl transferase-GGT, mean corpuscular volume-MCV, and carbohydrate-deficient transferrin-CDT) are not recommended for routine screening use in primary care settings (Babor, Kranzler, & Lauerman, 1989; NIAAA, 1997), but are recommended to confirm a diagnosis of alcohol dependence or to detect relapse.

Primary Health/Mental Health Alcohol Screening Instruments
CAGE Ewing, 1984
MAST Selzer, 1971
AUDIT Babor & Grant, 1989
HSQ Cutler, et al, 1988
HSS Fleming & Barry, 1991
RAPS Cherpitel, 1995

The difficulty of screening for alcohol use problems in mental health settings has been complicated by the concept of "dual diagnosis." Patients presenting with symptoms of other Axis I disorders rarely offer information about their alcohol use and are rarely queried about problematic use at intake (Rosenthal & Westreich, 1999). If alcohol screening is conducted in mental health settings, it is primarily through structured histories and physical examination.

Social Service System

Goals. The social service system consists of a variety of community-based private, for-profit and not-for-profit social agencies, whose common goals are the resolution of family, marital, or individual problems, or other life adjustment difficulties. These non-medical, non-hospital based systems include crisis lines, outreach units, day treatment programs, intensive outpatient programs, in-home programs, family service centers, community mental health centers, and individual practitioners. The mental health components of the social service system may overlap significantly with primary care systems in dealing with biologically based mental illnesses, but they also address a host of adjustment issues that are distinct.

Prevalence. It has been difficult to determine the prevalence of alcohol use problems among those seen in social service agencies, because persons with alcohol use problems more commonly focus on the issues that initially bring them into the voluntary care setting. These might include such concerns as marital conflict, domestic violence, and employment problems. The individuals tend not to make a connection between these problems and their alcohol use (Zweben & Barrett, 1997; Cooney, Zweben & Fleming, 1995). Shaw. Cartwright, Spratley, and Harwin (1978) reported that only 9% of non-dependent problem drinkers in social service settings were able to acknowledge their drinking as a primary problem. Even dependent drinkers are not easily identified in these settings. In a study of 100 cases from four different agencies, only five cases were identified as involving a substance abuse problem; subsequent interviews revealed that 39 of the cases had some level of substance abuse, including alcohol dependency (Kagle, 1987).

Screening and Identification. Googins (1984) reported that only 40% of social service agencies included questions about an individual's drinking history (or that of family members) in their intake procedures. While a number of screening instruments are available for use among professionals in secondary settings, these professionals are not always knowledgeable or trained in their use (Van Wormer, 1987).

Criminal Justice System

Goals. The criminal justice system is a complex array of levels of retribution and rehabilitation initiatives for alcohol use problems. This includes a continuum from the least restrictive settings (diversion programs for youth and drinking drivers) to more intrusive alternatives (house arrest, halfway houses or work release centers, "boot camps," and incarceration). Although many professionals support the position that adult offenders with alcohol problems have the right to treatment, courts have not consistently endorsed this stance. Instead, in recent years, courts around the country have increasingly reinforced punishment and retribution as the primary goals of the criminal justice system (CSAT, 2000).

Social Services
- Uncertain prevalence
- Non-dependent and dependent drinkers fail to self-identify
- Professionals fail to interview about alcohol

Prevalence. Adults with alcohol use problems interact with the criminal justice system as a result of driving while intoxicated (DWI) or for other illegal activities with alcohol use identified as a complicating factor (e.g., domestic violence, child abuse, disorderly conduct, assault, battery, or weapons offenses). In 1997, 1.4 million people were arrested in the U. S. for DWI, more than all other reported criminal offenses except larceny and theft (National Highway Traffic Safety Administration, 1998). Individuals aged 21-24 years accounted for the largest number of DWI arrests per 100,000 drivers (Greenfeld, 1998). Between 1984 and 1993, arrests of individuals under the age of 18 for drunkenness increased by 43%, while arrests for DWI increased by 50% (FBI, 1995).

Screening & Identification. Screening and identification of a sanctioned individual in the criminal justice system is complicated by the need to screen for security risk first; alcohol use problems are subordinate to this need. In more restrictive settings, the purpose of screening is to determine who can benefit from treatment, due to limited availability of services. In less restrictive settings, the purpose of screening is the early identification of alcohol problems and subsequent matching to the appropriate level of care.

Criminal Justice System Alcohol Screening Instruments

CAGE

Ewing, 1984

Offender Profile Index
Inciardi, 1993
MAST
Selzer, 1971

Screening instruments recommended for use in criminal justice settings include: the CAGE (Ewing, 1984), the Offender Profile Index (Inciardi, 1993), and the MAST (Selzer, 1971). Urine analysis screening is often the first or primary method of identification, as well as a means of providing information about relapses during treatment and continuing care, but they only measure recent use and provide little information about extent, history, or other important assessment and treatment variables.

Barriers to Coordinated Care

The barriers to coordinated care are imbedded in goal inconsistencies among specific settings, varied definitions of alcohol use problems employed by each of the component settings, lack of incentives for coordination, lack of training in screening and early identification of persons with substance abuse problems, lack of common screening and assessment tools used by the settings, and the multiplicity of funding streams available to each of the component parts.

Barriers to Coordinated Care
Among System Components

  • Conflicting, inconsistent goals
  • Incompatible definitions of alcohol use problems
  • Use of disparate interventions
  • Lack of common screening tools
  • Lack of financial incentives for coordination
  • Agency certification conflicts
  • Confidentiality of information

Inconsistent Goals

Conflicting goals among agencies represent a significant barrier to coordinated care for persons with alcohol use problems. For example, the problem of treating alcohol dependent caretakers in child welfare agencies, while protecting dependent children from harm, is problematic for many providers. This conflict can best be demonstrated through varied responses to relapse. While relapse is regarded by many alcohol treatment professionals as an expected part of the recovery process, it raises significant questions for the care and safety of dependent children when a parent returns to destructive, dependent drinking patterns for any period of time. Many social service and criminal justice programs view relapse as a rationale for discontinuation of services (e.g., family support programs, court diversion programs). This stance may bring them into conflict with treatment settings that adopt harm reduction as a treatment goal or view relapse as a "normative" aspect of the recovery process (Austin, Bloom, & Donahue, 1992). In one drinking check-up program, securing referrals from court- ordered DUI programs and employee assistance program were difficult, as the goal of moderate drinking was a planned option for program participants (Zweben & Barrett, 1997).

Incompatible Definitions

Various components of a service system may employ differing definitions of alcohol use problems. Mental health settings rely primarily on DSM-IV dichotomies of "alcohol abuse" and "alcohol dependence" (American Psychiatric Association, 2000) or the International Classification of Disease (ICD-10, World Health Organization, 1992) categorization. These definitions rely heavily on clinician experience, judgment, cultural sensitivity to the client's experiences, and some observational data. They are identified as subscribing to the "disease" concept of alcoholism. Social service agencies often use a definitional perspective traditionally advocated by Alcoholics Anonymous (cf. Miller & Kurtz, 1994) in which the term "alcoholic" is determined by personal history, life course, and the ability to self-identify oneself as having a chronic disease. (Alcoholics Anonymous is more recently identified as recognizing spiritual aspects of alcoholism.) Some self-help organizations (including boot-camps, faith-based groups) and criminal justice settings (courts, probation and parole departments) define alcohol problems as violations of religious, moral or legal strictures and assume that individuals with alcohol problems are suffering from a lack of self-discipline or self-restraint, and deserve punishment (Wilbanks, 1989) and/or incarceration (Thombs, 1994). Medical settings tend to define alcohol use problems from a biochemical perspective, emphasizing genetic factors and neurochemical changes in the brain.

Use of Disparate Interventions

Related to the definitional discrepancies of alcohol use problems, many sites employ widely differing interventions that reflect widely differing theoretical and cultural orientations to treatment that are not easily blended. Service settings which mandate abstinence as a condition for treatment participation (e.g. probation and parole agencies) and request regular AA attendance may be in conflict with referral sources which promote client choice and individualized treatment goals, or for whom AA is not a good cultural fit. For example, some social service agencies require a client to stop drinking before family counseling can begin, and negotiate differences between client and practitioner concerning how the problem behaviors will be addressed in the treatment situation. Clients themselves will be reluctant to participate in treatments where there are serious disparities between the referral source and the specialist practitioner with regard to the above issues.

Lack of Common Screening

As described in the particular components of coordinated care systems, regular screening for alcohol use problems has not been incorporated, mostly due to a lack of agreement on a common set of screening instruments.

Financial incentives

Despite available evidence, insurance companies and health care maintenance organizations (HMOs) are not convinced that providing screening and intervention for substance use problems will reduce health care utilization and related costs (Zweben & Fleming, 1999). Consequently, financial incentives are not offered to providers for undertaking the training in standardized screening and intervention protocols for alcohol and drug problems that are currently available to providers (cf., NIAAA, 1995; 1997). Providers who are familiar with the standardized referral protocols are reluctant to employ these techniques without receiving additional compensation from payees.

Social Worker Role in Resource Management with Coordinated Systems of Care

A mix of traditional and innovative skills are required to manage the multiplicity of resources needed to maintain a coordinated system of care. Social workers have traditionally been educated to practice in a variety of settings. These skills must be merged with newer skills to move toward, and operate within, a coordinated system of care. These skills must be evident in both case and system levels of operation.

Case Level Knowledge and Skills
For Managing Coordinated Care

  • Familiarity with and ability to implement common alcohol screening approaches
  • Knowledge of and ability to implement a wide variety of interventions, including treatment referral & compliance
  • Ability to make early diagnosis of levels of alcohol use problems
  • Case management, consultation & collaboration
  • Identification of alcohol use problems in special populations
  • Cultural competence

Screening

Social workers must be familiar with a number of screening tools, their psychometric properties, their applicability to special populations, and their suitability for specific sites. Other modules describe some useful screening instruments. Instruments are also available from the NIAAA at http://www.niaaa.nih.gov/publications/instable.htm, or in the Treatment Improvement Protocol (TIP) Series, which can be ordered by telephoning SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI; 1-800-729-6686).

Intervention Skills

At minimum, social workers in any setting should be familiar with the transtheoretical model of stages of change (Prochaska & DiClemente, 1983). Another minimum requirement is the ability to implement brief interventions with risky drinkers, and motivational enhancement techniques with both abusive and dependent drinkers in individual and group settings. For information on these methods see Enhancing Motivation for Change in Substance Abuse Treatment available through NCADI (1-800-729-6686), and Increasing Motivation for Change (Miller, 1995). In addition, familiarity with policy approaches to prevention (e.g. impact of increases in alcohol taxes or the impact of advertising) can lead to effective system-level interventions.

Diagnosis

Clinicians should become familiar with the diagnostic system used in their particular setting and the system used within the coordinated service system. In the United States, the Diagnostic and Statistical Manual of Mental Disorders is commonly used to diagnose alcohol dependence, abuse, and other conditions resulting from alcohol use (American Psychiatric Association, 2000). For a review of the principles of diagnosing alcohol use problems and specific case examples, see Morrison's (1995) DSM-IV Made Easy.

Case Management

Social workers receive training in case management techniques, consultation, and collaboration, however their functioning could be enhanced by specific knowledge of the multiple systems that are commonly encountered by persons with alcohol use problems. Sources for information include the Journal of Case Management and the NASW Standards for Social Work Case Management (1992).

Special Populations

While social workers must possess knowledge of alcohol abuse and dependency patterns, as well as help-seeking methods in specific cultures, they should receive specific training to handle ethnic, social class, age, national origin, gender, and sexual orientation bias in screening and coordination. In addition to recognizing the interplay of alcohol use problems with specific population characteristics, cultural and linguistic sensitivity and competency is also important. For a discussion of these issues see Special Populations in Treatment (pp. 345 - 405), in Institute of Medicine, 1990, Broadening the Base of Alcohol Problems.

System Level Knowledge and Skills
for Managing Coordinated Care

  • Knowledge of purpose and practices of components of service system (cross training)
  • Knowledge of systems barriers to coordination
  • Case & system level advocacy


Interdisciplinary Training

Social work practice is interdisciplinary in nature and social workers should receive specific training at sites with which individuals experiencing alcohol use problems might come in contact. Social workers must learn the terminology, procedures, and roles of other disciplines in relation to the treatment of alcohol use problems, preferably including internships at sites that are a component of a coordinated system of care for alcohol problems.

Advocacy

As more coordinated systems of care emerge, obvious deficiencies and inequities will become apparent. It is the role of social work professionals to identify and actively work toward the development of new resources and the equitable distribution of existing resources. This advocacy must exist for the specific client, as well as for groups of clients who are not well served by the existing system. Advocacy might also include political action in service of resource development.

Practice Interventions Summarized

A set of important practice interventions relate to the management and coordination of a system of care:
1. Conduct assessments for alcohol use problems that include standardized measures.
2. Formulate an appropriate care plan, based on the assessment process results.
3. Identify the services and supports that are already being received and explore their efficacy for the client.
4. Include services that are needed but not being received.
5. Identify the correct contact person/agent/agency for each of the needed services and making a referral.
6. Implement a case planning group and define the appropriate roles for the "players,"
7. Monitor implementation of the plan and conduct valid periodic evaluations.

Example

"In December 1999, a consortium responded to a request for proposals, released by the State of Wisconsin, to coordinate care and expand substance abuse treatment capacity for TANF-eligible families (Temporary Assistance to Needy Families). The consortium was awarded a grant from the Bureau of Substance Abuse Services … to develop, implement, and evaluate an innovative coordinated system of care for persons in Milwaukee County who are experiencing a wide variety of problems resulting from their use of alcohol or other drugs.
Since December 1999 the consortium has maintained the support and commitment from Community Service Providers, Central Intake Units and AODA Treatment Agencies." (Center for Addiction and Behavioral Health Research, 2001).

The Milwaukee County AODA/TANF Coordinated Service System demonstrates many of the concepts and practices discussed in this module. It serves women who receive TANF support and have alcohol and other drug abuse problems. An evaluation of this project was undertaken to describe the process by which the existing system of services evolved into a managed, coordinated care system. Outcome measures determined how well the service users fared under the coordinated system of care. The State of Wisconsin mandated that such an evaluation be conducted and the project team was committed to providing the social work community with empirically-based, "best practices" related to serving this population.

Data were collected using the following instruments: Rapid Alcohol Problem Screen was used with modification to include other drugs (RAPS-D) in prescreening activities; Multiproblem Screening Instrument (MPSI) and the Alcohol Use Disorders Identification Test (AUDIT-13) were used in screening; and the Addiction Severity Index tailored for use with women (ASI-F) was used in assessment (http://www.uwm.edu).

The evaluation measures were placed into use in the community programs that were involved with the collaborative project. This included use of the RAPS-D by 17 programs acting as community-based service providers; the AUDIT-13 and MPSI-A being used by the 3 agencies providing central intake functions and the 3 agencies acting as free-standing central intake units; and the ASI-F being used by all 15 programs acting as treatment providers.

The entire AODA/TANF Service System can be conceptualized as a wheel. However, it is important to recognize that this system exists within a context of community supports (e.g., churches and other supports). Some of the most important concerns that arose involved housing and transportation. It was also important that there existed a wide variety of substance abuse treatment opportunities, each with a different domain of service (e.g., women-only programming, program for Hispanic persons, inpatient program, etc.).

Several notable system outcomes were detected during the initial evaluation phase (end of year 1). Furthermore, outcomes were detected at the individual case level, but these are tentative since there were still very few individuals who had completed the process and the follow-up evaluation at the time of this report. To date, data are available for 71 clients at the 3-month follow-up and only 9 individuals at the 1-year follow-up.

CONCLUSIONS

The social work practice environment as related to alcohol treatment is quickly moving beyond individual systems of care. The establishment of coordinated care systems is encouraged by notions of "best practice," as well as by incentives for coordination offered through managed care organizations. In response, multiple providers with diverse roles are developing ways to coordinate disparate types of care.

To operate effectively in this environment, social workers must become knowledgeable in managing a significantly more complicated system of care in which persons with alcohol use problems of varying intensity are moved quickly through levels of care that are matched to their problem level and empirically demonstrated to be effective.

RECOMMENDED CLASSROOM EXERCISES

  1. First, have students develop a compilation of brief descriptions of the philosophy, goals, problem prevalence, screening and identification, referral and possible treatment approaches used in their field placement agencies with respect to alcohol use problems. Then, as a group, analyze discrepancies and compatibilities that would foster or impede the development of a coordinated system of care in this community.
  2. Brainstorm a means of ensuring that all of the significant players in your community's service delivery systems obtain at least a minimum level of training in the identification and referral of alcohol use problems. Explore mechanisms that would overcome interdisciplinary, inter-institutional, and economic cost barriers to implementing the plans.
  3. Develop and share eco-maps of several clients (or family systems) that experience alcohol use problems. Discuss the implications of their involvement with multiple coordinated and uncoordinated systems of care.
DISCUSSION ISSUES
  1. Discuss how "turf" concerns manifest themselves in efforts to develop coordinated systems of care. What do they look like, how are they expressed? What factors exacerbate them and what factors might ameliorate them?
  2. Discuss the social work ethics concerns that might arise in an effort to coordinate care across programs.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition text revision (DSM-IV-TR™). Washington, D.C.: APA.

Austin, J., Bloom, B., & Donahue, T. (1992). Female offenders in the community: an analysis of innovative strategies and programs. San Francisco: National Council on Crime and Delinquency.

Austrian, S.G. (2000). Mental disorders, medications, and clinical social work, second edition. New York: Columbia University Press.

Babor, T. F. and Grant, M. (1989). From clinical research to secondary prevention: international collaboration in the development of the Alcohol Use Disorders Identification Test (AUDIT). Alcohol Health and Research World, 13, 371-374.

Babor, T. F., Kranzler, H. R., & Lauerman, R. J. (1989). Early detection of harmful alcohol consumption: comparison of clinical, laboratory, and self-report screening procedures. Addictive Behaviors, 14, 139-157.

Center for Addiction and Behavioral Health Research. (2001). Milwaukee AODA/TANF Coordinated Service System. Milwaukee, WI: University of Wisconsin-Milwaukee, CABHR. http://www.uwm.edu/Dept/CABHR/MATE/

Center for Substance Abuse Treatment. (1999). Enhancing motivation for change in substance abuse treatment, treatment improvement protocol (TIP) series 35. Rockville, M.D.: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, CSAT.

Center for Substance Abuse Treatment. Kandall S. R., Consensus Panel Chair. (1993). Improving treatment for drug-exposed infants, treatment improvement protocol (TIP) series 5. Rockville, M.D.: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, CSAT. DHHS publn no. (SMA) 93-2011.

Center for Substance Abuse Treatment. Inciardi, J. A., Consensus Panel Chair. (2000). Screening and assessment for alcohol and other drug abuse among adults in the criminal justice system, treatment improvement protocol (TIP) series 7. Rockville, M.D.: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, CSAT.

Chasnoff, I. J. (Ed.). (1988). Drugs, alcohol, pregnancy and parenting. Hingham, M.A.: Kluwer Academic Publishers.

Cherpitel, C. J. (1988). Drinking patterns and problems associated with injury status in emergency room admissions. Alcoholism: Clinical and Experimental Research, 12, 105-110.

Cherpitel, C. J. (1995). Screening for alcohol problems in the emergency room: A rapid alcohol problems screen. Drug and Alcohol Dependence, 40, 133-137.

Children of Alcoholics Foundation, Inc. (1996). Collaboration, coordination and cooperation: helping children affected by parental addiction and family violence. New York: Children of Alcoholics Foundation.

Cooney, N.L., Zweben, A., & Fleming, M.F. (1995). Screening for alcohol problems and at-risk drinking in healthcare settings. In R..K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: effective alternatives (2nd edition), (pp. 45-60). Boston: Allyn and Bacon.

Cummings, N. A. (1991). Inpatient versus outpatient treatment of substance abuse: recent developments in the controversy. Contemporary Family Therapy, 13: 507-521.

Cutler, S. F., Wallace, P.G., & Haines, A. P. (1988). Assessing alcohol consumption in general practice patients-a comparison between questionnaire and interview. Findings of the Medical Research Council's general practice research framework study on lifestyle and health. Alcohol and Alcoholism, 23, 441-450.

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