This study compared three- and nine-month outcomes of substance-abusing offenders (recruited in prison treatment programs) who were randomly assigned either to strengths-based case management or to referral and supervision as usual. Contrary to expectations, the groups did not show statistically significant differences at the two follow-up points with respect to receipt of substance abuse services or to behavioral outcomes related to drug use, arrest, and HIV risk behavior. Those in the TCM group who attended residential treatment report significantly more days in treatment than did those in the SR group, but the number of parolees who participated in residential treatment was small. The TCM group also reported receiving a higher number of employment and educational services and financial services, while those in the SR group received a higher number of mental health services. Overall, the findings suggest that strengths-based case management, as implemented in the TCM protocol, had limited positive impact on the outcomes of substance-abusing parolees compared with those who received standard parole supervision and referral services.
Thus, the results of this study do not support the positive findings from the previous studies of case management in general (Coviello et al. 2006
; Rapp et al. 2008
; Siegal et al. 1996
; Sorensen et al. 2005
) and of strengths-based case management in particular (Hall et al. 1999
; Siegal et al. 2002
; Strathdee et al. 2006
; Vaughan-Sarrazin et al. 2000
). It should be noted, however, that earlier studies recruited their participants from a general substance-abusing population (although many clients did have a history of criminal justice involvement). The TCM study was the first (to our knowledge) to test the effectiveness of strengths-based case management with an exclusively parolee population recruited in prison.
The case managers in this study made direct referrals to treatment programs and service agencies and assisted clients in overcoming barriers to accessing such services. Although the case managers did provide some support and counseling to help clients deal with personal or interpersonal problems, it was expected that such problems would primarily be addressed when clients sought services in treatment or other agencies. In other words, services were not directly provided by or through the TCM study; it was up to the client, often with the assistance of the case manager, to go to a specific agency if he or she thought that a service would be helpful for a particular need. For this reason, the case managers had an indirect effect on longer-term behavioral outcomes such as drug use, crime, and employment since these outcomes primarily depended on whether clients sought out services and on the nature, quality, and intensity of the services provided by community treatment programs and other service agencies. We did not collect comprehensive data on the service ecology of cities or counties where TCM case management was provided.
Although 69% of clients in the TCM group attended four or more community sessions, attendance could have been better. Early in the study, it became evident that there was a problem with attendance at case management session. To attempt to correct this, the participating research centers identified specific activities that might increase attendance. Case managers were expected to undertake and document the following activities to re-engage clients who missed two consecutive sessions: write letters; make telephone calls during work hours, evenings, and weekends; attempt to locate clients in the community (home, parole office, etc.); and conduct database searches for contact information. The case managers documented each activity for each client and reported aggregate results monthly to the lead center of the TCM study. How effective were these efforts to re-engage clients? When this heightened activity began, 67% of TCM clients to that point had attended four or more sessions. At the end of the intervention 18 months later, the percentage was 69%, with the percentage for the intervening months never exceeding 70%. It appears that the activities undertaken to improve session attendance had little effect, although they may have prevented a decline in attendance over time. In assessing the success of these efforts, it should be noted that participation in case management was voluntary and that 24% of the clients were reincarcerated before the end of the 12-week intervention.
The study was designed to determine whether the TCM intervention improved parolee outcomes compared with standard parole supervision. But various considerations need to be addressed before it can be concluded that this study was a fair test of strengths case management with this population. These considerations fall under three categories: theory, design, and implementation.
With respect to theory, strengths-case management is not a new or an untested intervention. It has a theoretical and empirical history extending back at least 20 years, and case management generally has an even longer history. Principles, techniques, and procedures are documented in research and clinical literature (e.g., Rapp and Wintersteen 1989
; Saleebey 2002
) and are included in the professional training of case managers. The TCM intervention included the main activities included in all case management models as well as those elements that are unique to the strengths approach to case management. The intervention manual for TCM was adapted from previous manuals on strengths case management developed in NIDA-funded studies.
What was new about the TCM study was its use with a prisoner/parole population that was classified institutionally as low or medium risk. This population presents conditions and circumstances that are not usually faced by case managers who work with a general population of clients with substance use problems and whose criminal justice status is typically probation or drug court. The transition period from prison to the community is extremely stressful for parolees, who have many needs associated with re-entry after several years of incarceration and who may have difficulty addressing them. In addition, since family and other social bonds have often been strained or broken, there may be limited support for recovery and pro-social behaviors. Parole agents, whose primary responsibility is supervision and public safety, may not have the resources or the time to assist with these needs. Under these circumstances, case management principles and practices developed for other populations may need to be adapted to the needs of parolees.
For this population, the main addition of the TCM intervention to the strengths case management approach was scheduling a conference call with the parolee, counselor, parole officer, and family members prior to release. Less than 75% of these calls took place, and in any case, the calls may have been a weak addition to the standard strengths case management model.
With respect to design, the TCM study had a rigorous design that was well executed. The target sample was 800, the final sample was 812. Eligible subjects were consented and randomized (by computer at a central location) to one or the other of the study groups. Compliance with assignment was very good. The interview forms included either standardized instruments or instruments used in previous studies with an offender population. Objective measures (i.e., urine tests, official records) were collected. Follow-up rates were high (91% at three months, 90% at nine months). The follow-up points were designed to assess shorter-term (three months) and longer-term (nine months) outcomes. Although researchers often prefer a longer assessment period (12 months or more), it is usually to see whether the early group differences hold up over a longer period (they seldom do, at least for offender populations). The major problem in study design was that 52 inmates who entered the study had their release date extended beyond the point where they could participate in community case management services or were released to counties or states without TCM services. These subjects were not included in follow-up. The number of subjects who did not parole in time was similar in the two study conditions (29 in TCM, 23 in SR) and did not differ from those who were released to parole. Since many of those whose prison stay was extended had violated some rule, the practical effect of not including those not released is that the overall evaluated sample was at somewhat lower risk for recidivism than otherwise.
The eligibility criteria of this study placed few restrictions on who could participate. The main exclusion criteria were whether the person was a sex offender, had an immigration hold, was too cognitively impaired to provide informed consent, or already had a referral to case management following release to parole (which would most likely be indicative of a mental health problem). The fact that only 39 of the 909 prisoners who were formally screened for eligibility were excluded (see Fig. ) suggests that the individuals who were recruited into the study constituted a heterogeneous sample. It is possible, however, that selecting offenders on the basis of need (using a formal needs assessment procedure) would have resulted in a more appropriate population to receive case management.
Another consideration in assessing influences on study findings is how well the intervention was implemented. Each of the participating research organizations hired (either directly or through subcontract) staff with experience in counseling or case management and in working with clients who were drug users and/or offenders. All case managers received initial and refresher training in the principles and practices of strengths case management and in the procedures of the study. Supervision at each center and monthly conference calls addressed problems and helped promote adherence to the study protocol. Case managers completed forms at each session that indicated whether the expected activities for a given session were completed, partially completed, or not completed. Another form documented non-scheduled contacts with clients or with other persons (e.g., parole agents, service providers, family members). The participating centers received regular quality assurance reports from the lead center that listed missing forms or missing responses that the case manager were expected to correct. These forms continually reminded the case managers of the elements of the study protocol that they needed to comply with. The turnover in case managers at three of the four sites may have had an effect on outcomes, despite efforts to provide training in the model to the new case managers. Although all studies experience problems in implementation, the TCM study was carried out with a high degree of fidelity to its original protocol.
Client attendance at case management sessions is likely to have affected outcomes, although it is unclear what an adequate ‘dose’ of case management would be. Nearly 70% of TCM clients attended four or more case management sessions. This is comparable to the actual number of sessions that clients have attended in other intervention studies, including those of case management (see Prendergast et al. 2009
for an analysis of compliance in the TCM study). As noted above, the TCM case managers took active measures (e.g., telephone calls, letters) to engage clients who missed sessions, but clients ultimately decided how many sessions they wanted to attend—or they were reincarcerated and could not attend any more sessions. With respect to the strengths model itself, compared with SR clients who received other case management services, TCM clients were more likely to agree that they received services in accordance with the principles and practices of strengths case management. One factor that might have affected the outcomes is travel. Although this was not measured, case managers in all participating sites traveled considerable distances to one or more prisons on numerous occasions, and in two of the sites, case managers traveled to other cities to meet with clients away from the central office. Such travel time may have reduced the time that case managers had to spend with clients.
Determining whether adding case management to standard parole services would improve outcomes depends, in part, on whether the TCM group and the SR group received similar parole services (independently of case management). If not, differences (or lack thereof) between the groups may not be directly attributable to case management. Since detailed information on parole services was not collected, a strong test of this factor is not possible. However, a proxy measure of the level of parole services between groups is the response from clients as to who referred them to various services. At the three-month interview, clients in the TCM group reported that 40% of referrals to services were from their parole officer, compared with 39% of referrals from parole officers in the SR group, suggesting that parole officers were equally as likely to refer parolees in both groups to services. A related issue is whether clients lacked trust in their case manager over concerns that information provided in sessions would be shared with the parole officer. Case managers made it clear to clients (and to parole officers if the issue arose) that any information that clients provided to the case manager would not be shared with their parole officer without the client’s permission.
Although the strengths model of case management used in this study did not improve outcomes overall, modifications to the model might prove beneficial. First, case managers might have contacted inmates earlier and more frequently in prison to establish a stronger relationship and reinforce plans for re-entering the community, although this would add to the cost of the intervention. Second, the physical location of the case manager might be important. In this study, case managers were usually located in stand-alone offices separate from parole, treatment, and other services. Client attendance and services coordination might be improved if case managers were hired by and located at a parole or social services agency. The case managers in all of the sites were located in metropolitan areas; their active assistance in locating and coordinating services with clients might have had greater impact in rural areas, where services are more limited. Third, the ‘dose’ of the intervention could be increased by lengthening the time that case management is provided (e.g., six months) in order to give the case manager and the client more time to address different needs over a more extended period. But given the high early dropout rate observed in this study (and in most others), it is not clear how many clients would take advantage of the additional time. Fourth, greater participation might be encouraged by providing incentives for attendance in accordance with contingency management principles (e.g., Carroll et al. 2006
; Helmus et al. 2003
). Although incentives need not be costly, they would add somewhat to the cost of a case management intervention. Fifth, case management services could be targeted to a more homogeneous population of parolees with high need (relative to other parolees). Finally, rather than providing case management to parolees who have participated in prison drug treatment programs and who already have a referral to treatment, case management might be more effective with parolees who did not receive prison treatment and who lack connections to community treatment. One or more of these modifications could be tested in a randomized trial to determine whether they have a positive impact on parolee outcomes.
Findings should be considered in light of several limitations. Given the characteristics and circumstances of parolees, the results of the study should not be generalized to other populations with substance abuse problems. Although case managers were provided training, supervision, and feedback on their adherence to the protocol, the study did not use clinical trial methods of fidelity monitoring such as recording and rating case management sessions. The expected and actual dosage of treatment may not have been strong enough to affect outcomes, but it is not clear how much attendance could have been increased given the voluntary nature of the intervention. Measures of services received and behavioral outcomes were based on self-report, except for drug use, where comparison of self-report with urine test results indicated a high degree of concordance.