Improved Outcome And Quality of Life in dual recovery patients receiving case management

Patients with co-occurring substance abuse and mental illness present significant challenges to their counselors and doctors. The Harris County Dual Disorders Project has shown that case managers can add to the effectiveness of the treatment team. In this study, patients who were followed by case managers significantly reduced their utilization of expensive psychiatric resources; the savings to the public agency more than made up the salaries of the case managers, and freed up these psychiatric resources for other patients in need.

The Harris County Dual Disorders Project began in 1998 in response to a funding opportunity from the Texas Commission on Alcohol and Drug Abuse and the Texas Department of Mental Health and Mental Retardation to expand and enhance services for persons with co-occurring substance abuse and mental illness in Harris County. We designed a collaborative project which used existing community resources for addiction treatment and mental health care. The project funds were primarily designated for a mobile mental health team, with LPCs and doctors that assess and treat mental illness in clients at several addiction treatment centers, addiction counselors who are cross-trained in mental health issues and placed at addiction treatment centers and at MHMRA clinics, education and supervision for addiction counselors in mental health issues and for mental health specialists in addiction treatment issues, case management for patients with the greatest needs.

Preliminary data in our agency (MHMRA of Harris County, Texas) showed that patients with co-occurring substance abuse and mental illness had more frequent hospitalizations, crisis center visits, incarcerations, suicide attempts than other patients; had poor compliance with medication and office visits; and had poor stability at work and in relationships. The cost to the system of providing care to these patients was about twice that of caring for other patients.

Although mental health agencies are expected to assess patients for chemical dependency, and chemical dependency programs are expected to assess clients for mental illness, these assessments are not always done, or done well, and mental health agencies and chemical dependency treatment agencies do not always communicate well. Our program has been designed to address these issues. We have provided training to staff in the mental health systems and in the chemical dependency treatment system in assessment and referral, a total of some 300 professionals. Screening tests improve our ability to assess a large number of patients; we prefer the modified Self-Administered Alcoholism Screening Test (SAAST) to screen patients in the mental health system for addiction, and the Brief Psychiatric Rating Scale (BPRS) to screen clients in chemical dependency settings for mental illness. Patients and clients who meet the screening criteria have a face-to-face assessment by a staff professional.

An important element of our program is the use of case managers to coordinate and care for the most difficult patients with the most serious problems. Some of the services the case managers provide are:

  • Assessment
  • Referral to community resources
  • Assistance in navigating unfamiliar systems
  • Housing and employment referrals
  • Interfacing with criminal justice
  • Individual supportive counseling and motivation enhancement strategies

In order to be included in case management, patients have to meet the following criteria:

  • Any substance dependence diagnosis
  • Substance use in the last 30 days (or before prior treatment or incarceration)
  • Any DSM-IV Axis I diagnosis > 2 years
  • BPRS total score > 39
  • GAF score < 40
  • Multiple chemical dependency and mental health treatment episodes

In the first phase of case management (while in active treatment), case managers see their clients at least once a week, and usually several times a week. This drops down to twice a month in the moderate intensity phase, and once a month in the maintenance phase. Case managers also contact their clients by telephone, reducing the frequency of these contacts over time as well.

We have had over 400 clients in case management, and have compiled data on the first 79 patients to complete at least 6 months of case management services. The majority had major depressive disorder or bipolar disorder, and were alcoholic or cocaine addicts.

While under case management, these clients significantly reduced their utilization of the hospital and the crisis emergency center. In addition, the rate of arrest and incarceration fell nearly to zero. The rate of admission to public psychiatric hospitals dropped from 0.5 admissions per patient per year to 0.15, and the number of bed-days used per patient per year in psychiatric hospitals dropped from 8.5 to 2.0. Crisis center visits dropped from about one visit per patient per year to nearly zero, and admissions to the psychiatric unit at the Harris County Jail dropped from 0.4 per patient per year to 0.1. We calculated an average cost of intensive psychiatric services which includes the cost of hospitalization, crisis center visits, and jail admissions; this index dropped from $9500 per patient per year to $1500.

The annual cost of providing case management in our program is $374,000; this covers services to about 236 clients a year, making the annual cost per patient per year $1,585. The adjusted cost savings to the agency due to reduced utilization of high-intensity services averaged $7,100, yielding an overall savings of $5515 per patient per year.

Conclusion Case management has proven to be a cost-effective addition to the treatment regimen for dual recovery patients, and the case managers have proven to be important members of the treatment team.

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