By Melinda Young
EXECUTIVE SUMMARY
Case management can help some of the most challenging clients, such as people who are returning from jail and who are struggling with opioid use disorder.
- A study of people with opioid use issues in rural Kentucky revealed a case management program could help them improve their lives, help them remain substance-free, and stay out of jail.
- The case managers recruited for the program were well acquainted with the region and quickly built trust with their clients.
- Case managers used creative techniques to help clients with social determinants of health, including asking for donations on social media for items clients needed.
A three-year grant program using case management was designed to improve the lives of people with opioid use disorder. The results of a new study reveal positive results in helping people gain independence and improve their lives.
The case management-style program targeted people with multiple social determinants of health issues, including a large proportion who had been in jail or prison.1
“This part of Kentucky is in the Appalachian region, which has a high opium issue,” says Patrick Hardesty, PhD, professor and director of counselor education and supervision at Lindsey Wilson College in Columbia, KY. “Now, it’s more fentanyl, so the drugs keep changing. But drug issues in Appalachia are well known; we’re part of the highway for opium.”
Along with opioid use, there are public health issues involving hepatitis and HIV. Also, many people who use opioids have been to jail.
To recruit people to the program, researchers visited jails, gave presentations, and handed out educational surveys. They invited people to join the program after they were released from jail.
“We expanded it to be at county fairs to do a presentation and have people complete the education survey,” Hardesty says. “Many of our clients were prisoners, and many were not.”
Originally, the program grant was for 500 people. But when the COVID-19 pandemic hit in the last year of the grant, recruitment became challenging. Researchers were not allowed to enter jails, and no large public venues were available.
“We bought billboard space, put ads in newspapers and newsletters, and tried to get the word out about the program,” Hardesty says. “We were able to sign up 480 people and were happy with it.”
Aiding the Transition
The goal was to alter the trend of people leaving jail with substance use problems that deteriorate and lead to poor health outcomes — and sometimes lead to people returning to jail.
“Many of our sample of 480 were lost due to going back into jail or not being released from jail when they said they would be released,” Hardesty says. “We’d sign them up, anticipating their release, and they would not be discharged. This is not uncommon.”
It is common for people to experience difficulties transitioning out of jail. This was something Hardesty and colleagues wanted to improve.
“There were gains,” Hardesty says. “Breaking even is a win if you don’t go back into jail and deteriorate.”
Building Community Trust
Case managers knew the targeted communities well. They easily formed relationships with clients and often knew their family members or shared other connections.
“Our case managers are excellent,” Hardesty adds.
The case managers were recruited from their paraprofessional counseling roles with the Lake Cumberland District Health Department. They worked in a 10-county area where people know each other. The case managers often learned they had gone to school with clients or their family members. They could communicate with family members based on these community connections.
“That’s an interesting part I wasn’t aware of until it was happening,” Hardesty notes. “One case manager could tell me the whole story of each person that was in the program — they grew up with them.”
After completing a college practicum at a county drug court, watching people with few skills and resources try to navigate sobriety and stay out of jail, a case manager says she was ready to work for the intervention project and help people with opioid use disorder.
“It was a major eye-opener for me,” says Susan Adams, TCADC, TCM, public health services supervisor at the Lake Cumberland District Health Department and program director of Comprehensive Addiction Referral Education in Somerset, KY.
Knowing the community helped build connections and trust. “‘Our family knows your family’ or those kinds of things are always helpful when you are trying to build a relationship with people,” Adams explains. “I just let people know that I don’t want them to think of me as somebody different — I’m here because I care, and I want to help them.”
This built-in trust and connection also made it easier for case managers to track down clients when they no longer responded to calls or messages.
“They’d hound these people, if necessary,” Hardesty says. “They’d send letters and contact them, and they could check the criminal justice records to see if any were put back into jail and find them that way.”
Hardesty trained the case managers in data collection but let them handle their cases based on their previous experience and knowledge. Their goal was to prevent people from returning to jail and drug use. But the specific steps they could take evolved as the program progressed. “We were throwing parts of the airplane over the cliff and trying to build it as we were falling,” he says.
Addressing Social Determinants of Health
One of the biggest issues involved transportation to work, to health appointments, and to substance use programs. “We did a wraparound package that included transportation and housing assistance,” Hardesty says. “In these rural Appalachian areas, transportation is a big deal.”
Driving often was not an option, and public transportation was scarcer in these rural areas than they were in the city.
Adams could not help a client find public transportation to work, so she used her personal Facebook page to ask for help in giving him a bicycle. Her friends came through, and the client maintained steady employment by cycling to work.
“When we first started the program, there was no extra funding for housing, transportation, or doing simple things like going to the dentist or getting food and clothing,” Adams explains. “If community resources could not help, we went to social media to find someone furniture, clothing, or food.”
Case managers were creative in connecting clients to resources. They used the traditional sources, such as food banks, Goodwill, and other nonprofit organizations, but they also looked for every opportunity to connect their clients with resources that would help them maintain their recovery and not worry as much about their day-to-day food and shelter needs.
“We wanted them to focus on staying in recovery and staying out of incarceration,” Adams says. “We’ve been blessed and fortunate that when we had a need, someone was there to meet that need.”
It also was difficult to connect clients to vocational assistance to find work opportunities. The local healthcare system was lacking, with too few inpatient beds for people with substance use disorder.
“It reminded me of when I worked in Belize — the same level of care,” Hardesty adds. “But that’s the way it is in some of these parts.”
The program’s outcomes showed a little improvement, with 119 people who remained at the same level as baseline, and 63 people moving one level up. The overall group’s health status improved slightly.
Reincarceration Is a Challenge
It was difficult to keep people from returning to jail. The lack of resources and social support often led to reincarceration for minor reasons, such as parole violations related to failing to pay child support, Hardesty says. The case management program was more successful with improving people’s job status and finding housing.
Although the program’s findings were modest, any positive trend was encouraging because the target population is particularly vulnerable and difficult to reach.
The case managers took pride in success stories. For example, Adams recalls a middle-aged client who spent years in and out of incarceration due to what she calls his “substance use disorder madness.”
“I met him at the health department, and we just kind of had a great friendship and relationship from day one,” Adams says. “He had no one to encourage him [or] to help him, so we took tiny steps to be able to assist him.”
The man found a job where he has remained for several years. “He’s remained substance-free and has a relationship with his adult children. He is married, and has another child,” Adams notes.
When the initial grant ended, the program obtained a federal grant. Adams is hopeful they will receive future grants, allowing case managers to help people with little family and social support.
“This is a wraparound program for adults in trouble, and I think it’s the only way,” Hardesty says. “Traditional methods don’t work.”
Harm reduction, drug rehabilitation, and other tactics aimed at people with opioid use disorder are important, but not enough to maintain positive changes.
“I don’t think the program would work without case managers waking up every morning and saying, ‘Where are my clients today?’” Hardesty says. “That’s the attitude they had — they were involved in the care and put energy into it. They were phenomenal people.”
REFERENCE
- Hardesty PH, Wooldridge M, Thompson KJ. Utilizing case management to address the opioid crisis in Central Kentucky. Prof Case Manag 2022;27:256-259.
Case management can help some of the most challenging clients, such as people who are returning from jail and who are struggling with opioid use disorder. A study of people with opioid use issues in rural Kentucky revealed a case management program could help them improve their lives, help them remain substance-free, and stay out of jail.
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