Case management applied to the treatment of alcohol dependence

Abstracts

Este artigo visa conceituar e descrever o conceito de gerenciamento de caso clínico inicial aplicado ao tratamento de dependentes do álcool e suas principais etapas, bem como ressaltar as funções do gerente de caso, a importância do primeiro contato, averiguar a motivação para tratamento e algumas sugestões de metas e atividades para incentivar a aderência ao tratamento.

Bebidas alcoólicas; Terapia; Reabilitação; Aconselhamento; Gerenciamento clínico

Case management applied to the treatment of alcohol dependence

Neliana Buzi Figlie^I; Ronaldo Laranjeira^II

^IAmbulatório de Dependência do Álcool da UNIAD (Unidade de Pesquisa em Álcool e Drogas) – Departamento de Psiquiatria – UNIFESP

^IIUnidade de Pesquisa em Álcool e Drogas (UNIAD) – Departamento de Psiquiatria – UNIFESP

^{Correspondence}

ABSTRACT

This article aims is to conceptualize and describe the main steps in case management applied to the treatment of alcohol dependence. It is important to note the case manager functions, the importance of the first appointment, check the motivation to the treatment, some goals and activities suggestions for adherence reinforcement.

Keywords: Alcoholic beverages. Treatment. Therapy. Counseling. Disease management.

Introduction

Evidence suggests that case management has been a powerful intervention to assist people with psychosocial problems, including chronic mental diseases, old age and child emotional disturbances.^{1 2 3} More recently, this type of approach has been adapted for the work with chemical dependence.^{4 5}

Generally, case management may be defined as a set of interventions aiming to facilitate the treatment outcome. Some of the relevant functions within this context are to: 1) identify the specific needs, determining strong and weak points, as well as the patient's needs; 2) plan, developing a specific proposal for each patient; 3) establish a connection with other services, be they in formal or informal health service network; 4) monitor and assess the case, visualizing the progress obtained; 5) facilitate the legal support if needed.^{6 7 8} Although widely accepted in health services, there is not yet an operational consensus about the definitions of these functions.⁹ They describe what case managers do, but not how they do, as we cannot rule out the influence of variables such as: service's goals, type of service, target population, socio-demographic characteristics, among others which would hamper the standardization of a consensus about 'how to do'.

Case management has become popular without a specific protocol, as it depends on the diversity of adaptations to the local and cultural circumstances. However, this article aims to discuss the practical challenges of implementing case management applied to the treatment of alcohol-dependent subjects.

Case management in the treatment of chemical dependence

Marshman ¹⁰ has described the functions of case management specifically in the context of chemical dependence:

1) Providing individualized support for patients and their family members;

2) Helping patients to solve problems;

3) Helping the patients' family and employability;

4) Facilitating the access between patients and treatment;

5) Facilitating the access of patients to consultation psychiatry for specific treatments if needed;

6) Keeping aware of the changes in the patients' needs and problems during the treatment;

7) Assuring patients that they could be reached and encouraged to return to the treatment in case of dropout;

8) Reinforcing and continuing the treatment process, in a less invasive way, proceeding the treatment in order to support the rehabilitation of patients in the community, early identifying future difficulties.

In the planning of case management it is important to take into account the duration, intensity, assessment and type of service, keeping in mind:

1) Target population: The characteristics of the target population may be determinant in the type of case management program. Characteristics such as gender, age, race, severity and chronicity of the problems are important considerations in the definition of the program. For example: when a high proportion of patients is part of an ethnic minority, an important consideration in the planning of case management is what the program may perform in ethical and cultural terms in order to enable the patients' rehabilitation.

2) Objectives: The program's objectives are important to prevent misunderstandings in the implementation. The objectives depend on the target population and on the problem's definition. For example: distinguishing a harmful alcohol consumption from alcohol dependence is fundamental to define the treatment's objectives which are pertinent to patients; the definition of the treatment's success is different for a homeless when compared to a middle-class patient.

There are determined fields which suffer a direct impact from the consequences of alcohol consumption. Among them stand out: alcohol consumption pattern, work, physical and emotional health, legal problems, dwelling stability and patients' satisfaction. When identifying which of these fields is the most problematic for patients, the professional establishes as the focus the solving of the problems in the specific field, besides the issue of alcohol consumption, aiming to succeed in the treatment.

3) Setting: The setting may be determinant for the treatment's outcome. Studies have shown¹¹ that the effectiveness of case management is more related to the involvement of the service in the patient's environment than the case management per se. The higher the connections of the professional with other services, be they formal or informal, the higher will be the quality of the treatment.

4) Administrative model: There is a consensus that an interactive and multidisciplinary team is beneficial for case management, as it allows the exchange of different points of view to manage problems, increasing the creativeness and energy, preventing therefore isolated actions.

5) Case manager: the profile of a case manager includes academic formation, professional identity, commitment with the philosophy of the treatment setting, knowledge and experience on chemical dependence, readiness to research the several areas of the patients' lives, knowledge of the characteristics of the population, as well as the service's system.

Alcohol dependence

Although the treatment field for alcohol dependence syndrome has developed in the last years, it is undeniable that there is part of society that does not respond to treatment. This absence of response, combined with case management aimed at the social well-being and medical programs, have arisen questions about how it would be appropriate treating or facilitating the treatment for this demand. Among the characteristic of patients dependent on alcohol and other drugs, stand out: ⁹

1) Severest forms of chemical dependence;

2) Coexistence of medical and psychiatric conditions;

3) Severe incapacitation in several areas of life;

4) Socioeconomic challenge;

5) Lack of formal education;

6) Unemployment and poverty

7) Social stigma;

8) Extensive use of public services;

9) Problems present for long periods (chronicity);

Unfortunately the traditional treatments are not always conceived to deal with these problems. This type of patients needs continuous and intermittent professional support for months and/or years, and most of conventional treatments provide episodic interventions. The recent model and the implementation of specialized treatment programs for specific substance-related problems in sub-populations has currently improved the fragmentation of care. Structured programs impose barriers for the treatment such as admission criteria and procedures, distinct treatment model and lack of integration with other services. Case management arises as an alternative to circumvent these difficulties and the fragmentation of health services.¹¹ Case management is aimed at problems of accessibility, efficacy, treatment continuity, its format and implementation. A clear conception of what will be performed in the case management is needed, by whom, with whom and which will be the aimed benefits. Below the main goals of case management in a particular setting are described.⁶

1) Increasing the treatment's continuity (fundamental): Cross-sectional (researching individual and comprehensive evidence of the treatment in a determined period of time) and longitudinal studies (with the continuing of the intervention, collecting evidence about the response to the intervention provided).

2) Increasing the accessibility: overcoming administrative barrier

3) Increasing the assessment: assign an effect point for the treatment's outcome whenever multiple services are involved to meet the patients' needs.

4) Increasing the effectiveness: rising the probability of patients receiving services adequate to their needs, decreasing the duplication of services. Cost analysis may or not be performed.

Summing up, the professional acts as an agent responsible for the coordination of the case as to enable the patient's individual needs, and the latter may keep receiving several other types of interventions in varied services. In this context, the professional or manager is not seen as a care provider, but as someone who visualizes, comprehensively, the patient's needs and acts as a facilitator to supply these needs.

What is needed in alcohol dependence treatments: Practical clues

1. Functions of the case manager

Professionals called case managers may be engaged in additional and alternative functions aiming at the treatment's success. This is a fundamental aspect for the applicability of case management with alcohol-dependent subjects, as much of the work, such as establishing connections with other services or coordinating any specific situation of the patient, may demand from professionals a whole adaptation in their professional life.

If the treatment proposal is developed in a team, it is important to verify which professional will be the case manager. The idea is that this professional would be the reference for the patient in the service, being very integrated to the team as he/she will act as an interlocutor between the treatment proposal and the patient's needs, in order to enable them. Not necessarily case managers should have finished college. Many times community agents, provided they have the adequate training, may be case managers. Most importantly, these professionals should be available and sensitive regarding patients and should keep in continuous contact with them.

2. The first contact: the clinical history

The collection of information to obtain the clinical history should be performed through the analysis of situations of use, risk of use, social and health consequences of chemical dependence, but also must^*: 1) create a therapeutical alliance and favor the engagement of patients in the treatments; 2) understand the context in which the dependence has developed; 3) identify the factors which favored the installation of dependence; 4) identify the factors which maintain the dependence; 5) identify the factors which favor abstinence; 6) gather conditions to establish the diagnostic hypothesis.

Professionals have to be sensitive to verify at which point all information needed for the clinical history could be assessed in one or two sessions; if patients are not intoxicated up to the point of compromising the trueness of their answers; if, in that moment, it would be more productive to assure the therapeutical link and alliance as to make patients return in the next consultation; as well as the capability of performing a sympathetic listening and the capability of being in the relationship in order to help, and the concept of help should be established by the patients and not only by the professional or the treatment's requisitioner, assigning the self-efficacy to the patients as to prevent the arguing and break the resistance. But, more important than collecting information is to be with patients, being able to listen to them, situating oneself in the patients' place as to not judge, but understand their fears, desires, anguishes and attitudes to understand and receive them without being judgmental, aiming to assure the continuity of the treatment in the future.

3. Checking the motivation for treatment

In the treatment setting it is essential a careful assessment to identify the nature, problems, adequacy and possible objectives of the treatment. Similarly, the treatment process should identify the specific factors which will help or hamper the objectives to the reached. In this context, the motivation is useful to identify the different factors which may be appropriate for the different motivation stages, being an important orientation for the case manager. For example, patients in the pre-contemplation stage should be helped to recognize and develop awareness about their problems rather than being directly guided towards abstinence. Patients in the contemplation stage are open to interventions which increase the awareness (educational and self-monitoring methods), but are resistant to orientations directed towards action. In the action stage, patients need practical help with procedures for behavioral change¹². Table 1 displays a definition of the stages of change, with suggestions of interventions for the case manager.¹³

Some scales may help in the identification of the patients' motivation. The University of Rhode Island Change Assessment Scale (URICA) investigates the stages of change: contemplation; pre-contemplation; action; maintenance.¹⁴ This scale has been translated and culturally adapted into Portuguese.¹⁵ Other scale used to measure the readiness to change the drinking behavior is the The Stages Readiness and Treatment Eagerness Scale (SOCRATES) ¹⁶, which has been also validated and adapted.^**

Goals and activities to incentive compliance

Considering the objectives, target-population, the setting and the administrative model of the intervention, table 2¹⁷ displays some of the specific goals, related activities and methods of verification aimed to increase the treatment's adherence and retention.

Final Considerations

Summing up, studies on mental health and substance dependence⁹ indicate that case management may be a useful tool especially in the treatment of patients with multiple problems, being fundamental the establishment of a point of responsibility for each patient. The case management program works with realistic and feasible goals, both for patients and the treatment, as to avoid false promises. The implementation of the program may require months until all the team be integrated into the proposal, as to the point of being acquainted with the target population and the specific community. In this procedure, many problems may arise and they may not always be predicted, but it is possible to act helping to solve problems and, for that, the communication between the case manager, the treatment program and the patients is essential.

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*

Note: Figlie NB, Laranjeira R, Bordin S. Aconselhamento em Dependência Química. São Paulo: Roca (in press 2004).

**

Note: Figlie, NB, Dunn J, Laranjeira, R. "Motivation for Change in Alcohol Dependent Outpatients from Brazil". Addictive Behaviors (in press 2004).

Publication Dates

• Publication in this collection
  04 Jan 2005
• Date of issue
  May 2004