Case Management and Referral

Required material: There are two required texts for this course.

Please let me know if you cannot access these.

Study Guide for the Florida MCAP, CAP, Certification Exam (2016)

This comprehensive review is published by the Florida Certification Board (FCB)

Comprehensive Education Services. It should be available from the St.

Petersburg College Health Education Campus (HEC) bookstore. But it may also

be ordered directly from FCB. ( )

CSAT Technical Assistance Publication (TAP) 21 – Addiction Counseling

Competencies: The Knowledge, Skills, and Attitudes of Professional Practice

The TAP-21 can be viewed online at

or a hard-copy can be ordered free of charge from the US Dept. of Health and Human

Services and SAMHSA’s National Clearinghouse for Alcohol & Drug Information

Case Management and Referral

Read Chapter 5 in the FCB text

Case Management Resource:

2-1-1 Tampa Bay Cares – Online database of social services resources in Pinellas County.
Case Management

Persons who are substance dependent often have problems in many of the biopsychosocial spheres of their lives. Common problems include poor health, financial problems, relationship problems, employment/education problems, homelessness, legal problems and mental health issues. Often, these problems need to be addressed, if the person is going to maintain sobriety. This is where effective case management plays a key role. A good case manager will link together different service resources to provide a comprehensive plan specific for the needs of their client.

Case management is a set of social service functions that help clients access the resources they need to recover from substance abuse. These functions include:
The difference between a case manager and a counselor?

Case Manager – Links client to services (resource acquisition).
Counselor – Facilitates intra and interpersonal change.
4 major objectives of case management:

Continuity of care
Case management principles:

Case management offers the client a single point of contact with health/social services.
Case management is client-driven and driven by client need.
Case management involves advocacy.
Case management is community-based.
Case management is pragmatic.
Case management is anticipatory.
Case management is flexible.
Case management is culturally sensitive.
Service Planning

Case managers assist their clients in developing a personal plan to meet their varied needs.

The service plan contains:

Long term goals
Current status narrative
Required services, supports and resources
Service plan goals (things that are to be achieved) need to be:

Behaviorally specific
Making Referrals

Reasons to refer a client:

When a client is in need of a service that you or your agency cannot provide.
When the counselor believes s/he is not the best person to provide a particular service.
When the counselor feels there may be a conflict of interest in providing the service.
When the counselor recognizes that the client needs a different level of care.

Progress Notes

Read pages 126-129 in the FCB text.

Progress notes are written entries in the client file that document events throughout treatment.

Progress notes:

Assess client progress or lack of progress in treatment
They reference the goals and objectives of the treatment plan
They act as the basis of treatment plan reviews and updates
They document referrals, appointments, follow-up attempts
They identify billable services (e.g., Individual or group sessions)
They are done by the clinical staff
They are signed/credentialed/dated by the staff
They link services provided to the progress made
They justify continued stay, or graduation to another level of care
They document the client’s present condition
They document treatment plan reviews or any changes to the treatment plan
Components of a progress note:

Amount of time spent
Treatment problems or goals to which the note relates
Description of what happened, who was involved and outcome
Description of further treatment or recommendations
Signature of counselor with credentials
SOAP method of progress notes

(This info is not in the text)

The SOAP method is a commonly used structural model for writing progress notes. SOAP is an acronym:

S = Subjective Data
O = Objective Data
A = Assessment
P = Plan
Sometimes Intervention and Evaluation are also added at the end of the soap note.

Sample SOAP Note:

S = Client reports, “I had an awful urge to drink, so I pawned my walkman, bought a 12-pack of beer and got trashed. It was like I couldn’t fight it anymore.”

O = Client had recently complained of frequent relapse urges. A breathalyzer test indicates he has a current blood alcohol level (BAL) of 0.161, indicating intoxication. A urine drug screen was negative for drugs of abuse. Client has not attended an AA meeting in two weeks.

A = Client recently stopped attending AA meetings, experienced an urge to drink and relapsed on alcohol.

P = Will monitor client for symptoms of alcohol withdrawal requiring referral to detox. Will recommend he begin attending AA again and call his sponsor next time he has urges to drink. Will recommend that he read the NA pamphlet “Recovery and Relapse” and complete a relapse prevention workbook. Continue treatment.

Lesson 9 Discussion Question

Case Management

Why is case management important? How do non-substance-related issues such as homelessness, unemployment, health, relationships, etc. impact a person’s addiction and recovery? Please answer this question and respond to two other students’ posts.

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