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Learner Guide

CHCCSM005

Develop, facilitate and review all aspects of case management

CHCCCS004

Assess co-existing needs

CHCCSM004

Coordinate complex case requirements

Learner Guide

CHCCSM005 Develop, facilitate and review all aspects of case management

CHCCCS004 Assess co-existing needs

CHCCSM004 Coordinate complex case requirements Page 2

This learner guide is copyright protected by:

Compliant Learning Group (Australia)

Level 13, 269 Wickham St, Fortitude Valley 4006

Email: [email protected]

Website: http://compliantlearningresources.com.au/

Learner Guide

CHCCSM005 Develop, facilitate and review all aspects of case management

CHCCCS004 Assess co-existing needs

CHCCSM004 Coordinate complex case requirements Page 3

TABLE OF CONTENTS

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LEARNER GUIDE CLUSTER ...................................................................................................... 6

I. DEVELOP, FACILITATE AND REVIEW ALL ASPECTS OF CASE MANAGEMENT . 14

1. Determine the appropriate response to case management in accordance with organisation and legislative requirements ........................................................................................................................................ 14

1.1 Develop and utilise case management processes in accordance with statutory requirements ........................................................................................................................... 14

1.2 Implement appropriate processes to enable the client to set goals and participate in case management processes .............................................................................................. 30

1.3 Integrate appropriate cultural considerations into all aspects of case management planning ................................................................................................................................. 39

1.4 Provide information on rights of appeal and avenues of complaint so the client understands rights and responsibilities ................................................................................. 53

2. Conduct case management meetings.................................................................................................... 56

2.1 Facilitate information sharing with the client and establish an appropriate rapport . 57

2.2 Identify and agree on client and worker roles, responsibilities, boundaries, and processes of service delivery ................................................................................................... 60

2.3 Determine and agree organisation, family and community needs, responsibilities and rights ...................................................................................................... 64

3. Develop an appropriate case management plan ................................................................................. 69

3.1 Collaborate with the client to identify strengths, abilities and goals and develop an agreed approach to case management ................................................................................... 70

3.2 Develop a case management plan to reflect initial assessment of needs ............... 72

3.3 Work with the client to identify the full range of immediate, short and long-term needs of the client and other relevant parties......................................................................... 73

3.4 Establish and agree on processes to monitor and change case plan ..................... 75

3.5 Identify strategies to deal with complex or high-risk situations ................................ 78

3.6 Match requirements of case plan to experience, workload and geographical location of worker or service provider .................................................................................... 80

3.7 Assist clients to set and achieve realistic targets for change or action and to take personal responsibility ............................................................................................................ 81

4. Monitor and review casework activities and processes ..................................................................... 83

4.1 Implement strategies to regularly monitor the effectiveness of case management processes against agreed goals, service provision and client and stakeholder satisfaction .. 84

4.2 Assess the need for changes in case plan and develop strategies for appropriate alternatives and/or ongoing interventions ............................................................................. 85

4.3 Negotiate with relevant parties any proposed changes arising from case review .. 86

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4.4 Document all casework interventions in compliance with evidence-based practice and confidentiality requirements ............................................................................. 87

4.5 Implement case closure in accordance with organisation procedures .................... 91

II. ASSESS CO-EXISTING NEEDS ...................................................................................... 93

1. Prepare for assessment ................................................................................................................................ 93

1.1 Identify and prepare assessment tools and processes according to organisation policy and procedures ............................................................................................................ 94

1.2 Gather existing information about the person........................................................... 100

1.3 Seek additional information from specialists and other sources as required to determine the range of issues that may be affecting the person ........................................... 102

1.4 Organise practical aspects of assessment in consultation with the person being assessed ................................................................................................................................. 103

1.5 Provide information about the assessment process to the person and obtain consent .................................................................................................................................. 105

2. Analyse the person’s needs using a collaborative approach ........................................................... 107

2.1 Work within scope of own role and seek assistance from colleagues and experts as required ................................................................................................................................. 108

2.2 Empower the person to identify and prioritise their own needs ........................... 109

2.3 Evaluate needs based on full range of relevant information.................................. 110

2.4 Identify and analyse complex, multiple and interrelated issues ............................ 111

2.5 Evaluate issues of urgency and eligibility ................................................................. 121

2.6 Assess potential risk factors for service delivery .................................................... 122

3. Determine appropriate services ........................................................................................................... 123

3.1 Consider service delivery and referral options from strengths-based perspective .... 123

3.2 Evaluate internal capability and other service networks to determine best fit for the person .............................................................................................................................. 125

3.3 Provide the person with service information and support their decision-making process 126

3.4 Encourage the person to advocate on their own behalf to access services ........... 127

4. Complete reporting ............................................................................................................................... 129

4.1 Document the outcomes of the assessment process according to organisation procedures ............................................................................................................................. 129

4.2 Maintain and store the person’s information according to confidentiality requirements ......................................................................................................................... 131

4.3 Provide the person’s information to other services according to consent and confidentiality requirements ................................................................................................. 133

5. Evaluate assessment and referral processes ...................................................................................... 134

5.1 Seek feedback about assessment processes from the person and other networks .... 134

5.2 Monitor processes and their outcomes in terms of success in meeting the person’s needs 135

5.3 Routinely seek feedback and reflect on own performance ........................................ 136

5.4 Use feedback and own evaluation as a basis for improving processes ................. 137

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III. COORDINATE COMPLEX CASE REQUIREMENTS ............................................ 138

1. Establish coordination function .............................................................................................................. 138

1.1 Work with the client and other services to determine the service provision requirements ......................................................................................................................... 138

1.2 Negotiate collaborative working arrangements for all services involved .................. 141

1.3 Develop a plan to identify all available services, their appropriateness, timeframes and expected outcomes ......................................................................................................... 143

1.4 Work with the services to agree on coordination requirements and boundaries ...... 145

2. Support the client to access multiple services ................................................................................... 146

2.1 Identify, implement and maintain duty of care responsibilities ............................... 146

2.2 Provide information to the client about the coordination role .............................. 149

2.3 Work with the client to establish communication requirements ........................... 150

2.4 Assess need and arrange interpreter, according to client’s needs ......................... 151

2.5 Work with the client and other services to identify barriers to attaining outcomes .. 153

2.6 Work with the client to prioritise needs and communicate these with service providers 154

2.7 Facilitate case conference and meetings to coordinate responsibilities and roles .... 154

2.8 Work with other services to minimise client confusion and concerns in a coordinated manner .............................................................................................................. 155

3. Monitor client progress ........................................................................................................................ 159

3.1 Facilitate communication between service providers to identify and manage service duplication ................................................................................................................ 159

3.2 Work with the client and services to monitor progress toward outcomes ............. 160

3.3 Obtain client feedback about services ................................................................... 160

3.4 Identify and implement further support required to meet changing needs and progress towards outcomes ................................................................................................... 162

REFERENCES ............................................................................................................................ 163

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LEARNER GUIDE CLUSTER

Description

CHCCSM005 – Develop, facilitate and review all aspects of case management

▪ This unit describes the skills and knowledge required to undertake case management meetings

to plan, monitor, and review service provision.

▪ Workers at this level work autonomously and are responsible for own outputs within

organisational guidelines.

▪ This unit applies to work in a range of health and community services contexts.

CHCCCS004 – Assess co-existing needs

▪ This unit describes the skills and knowledge required to assess the diverse and multi-faceted

needs of people and determine both internal and external services required to meet those

needs.

▪ This unit applies to a range of community service contexts.

CHCCSM004 - Coordinate complex case requirements

▪ This unit describes the skills and knowledge required to coordinate multiple service

requirements for clients with complex needs within a case management framework.

▪ Workers at this level work under supervision within established guidelines but take on a team

leadership role in the coordination of services and service providers.

▪ This unit applies to work in a range of health and community services contexts.

Click here for more details

https://training.gov.au/Training/Details/CHC52015

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About this Unit of Study Introduction

As a worker, a trainee, or a future worker you want to enjoy your work and become known as a

valuable team member. These units of competency will help you acquire the knowledge and skills to

work effectively as an individual and in groups. They will give you the basis to contribute to the goals

of the organisation which employs you.

It is essential that you begin your training by becoming familiar with the industry standards to which

organisations must conform.

These units of competency introduce you to some of the key issues and responsibilities of workers

and organisations in this area. The units also provide you with opportunities to develop the

competencies necessary for employees to operate as team members.

This Learner Guide Covers

Develop, facilitate and review all aspects of case management

A. Determine appropriate response to case management in accordance with organisation and

legislative requirements

B. Conduct case management meetings

C. Develop an appropriate case management plan

D. Monitor and review case work activities and processes

Assess co-existing needs

A. Prepare for assessment

B. Analyse the person’s needs using a collaborative approach

C. Determine appropriate services

D. Complete reporting

E. Evaluate assessment and referral processes

Coordinate complex case requirements

A. Establish coordination function

B. Support the client to access multiple services

C. Monitor client progress

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Learning Program

As you progress through this unit of study, you will develop skills in locating and understanding an

organisation’s policies and procedures. You will build up a sound knowledge of the industry standards

within which organisations must operate. You will become more aware of the effect that your own

skills in dealing with people have on your success or otherwise in the workplace. Knowledge of your

skills and capabilities will help you make informed choices about your further study and career

options.

Additional Learning Support

To obtain additional support, you may:

Search for other resources. You may find books, journals, videos and other materials which

provide additional information about topics in this unit.

Search for other resources in your local library. Most libraries keep information about

government departments and other organisations, services and programs. The librarian should

be able to help you locate such resources.

Contact information services such as Infolink, Equal Opportunity Commission,

Commissioner of Workplace Agreements, Union organisations, and public relations and

information services provided by various government departments. Many of these services

are listed in the telephone directory.

Contact your facilitator.

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Facilitation

Your training organisation will provide you with a facilitator. Your facilitator will play an active role

in supporting your learning. Your facilitator will help you anytime during working hours to assist with:

How and when to make contact,

what you need to do to complete this unit of study, and

what support will be provided.

Here are some of the things your facilitator may do to make your study easier:

Give you a clear visual timetable of events for the semester or term in which you are enrolled,

including any deadlines for assessments.

Provide you with online webinar times and availability.

Use ‘action sheets’ to remind you about tasks you need to complete, and updates on websites.

Make themselves available by telephone for support discussion and provide you with industry

updates by email where applicable.

Keep in touch with you during your studies.

Flexible Learning

Studying to become a competent worker is an interesting and exciting thing to do. You will learn

about current issues in this area. You will establish relationships with other students, fellow workers,

and clients. You will learn about your own ideas, attitudes and values. You will also have fun. (Most

of the time!)

At other times, study can seem overwhelming and impossibly demanding, particularly when you have

an assignment to do and you aren’t sure how to tackle it, your family and friends want you to spend

time with them, or a movie you want to see is on television.

Sometimes being a student can be hard.

Here are some ideas to help you through the hard times. To study effectively, you need space,

resources, and time.

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Space

Try to set up a place at home or at work where:

You can keep your study materials,

you can be reasonably quiet and free from interruptions, and

you can be reasonably comfortable, with good lighting, seating and a flat surface for writing.

If it is impossible for you to set up a study space, perhaps you could use your local library. You will

not be able to store your study materials there, but you will have quiet, a desk and chair, and easy

access to the other facilities.

Study Resources

The most basic resources you will need are:

1. A chair

2. A desk or table

3. A computer with internet access

4. A reading lamp or good light

5. A folder or file to keep your notes and study materials together

6. Materials to record information (pen and paper or notebooks, or a computer and printer)

7. Reference materials, including a dictionary

Do not forget that other people can be valuable study resources. Your fellow workers, work supervisor, other students, your flexible learning facilitator, your local librarian, and workers in this area can also help you.

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Time

It is important to plan your study time. Work out a time that suits you and plan around it. Most people

find that studying, in short, concentrated blocks of time (an hour or two) at regular intervals (daily,

every second day, once a week) is more effective than trying to cram a lot of learning into a whole

day. You need time to ‘digest’ the information in one section before you move on to the next, and

everyone needs regular breaks from study to avoid overload. Be realistic in allocating time for study.

Look at what is required for the unit and look at your other commitments.

Make up a study timetable and stick to it. Build in ‘deadlines’ and set yourself goals for completing

study tasks. Allow time for reading and completing activities. Remember that it is the quality of the

time you spend studying rather than the quantity that is important.

Study Strategies

Different people have different learning ‘styles’. Some people learn best by listening or repeating

things out loud. Some learn best by ‘doing’, some by reading and making notes. Assess your own

learning style, and try to identify any barriers to

learning which might affect you. Are you easily

distracted? Are you afraid you will fail? Are you

taking study too seriously? Not seriously enough?

Do you have supportive friends and family? Here are

some ideas for effective study strategies:

Make notes. This often helps you to remember new

or unfamiliar information. Do not worry about

spelling or neatness, as long as you can read your

own notes. Keep your notes with the rest of your

study materials and add to them as you go. Use pictures and diagrams if this helps.

Underline keywords when you are reading the materials in this Learner Guide. (Do not underline

things in other people’s books.) This also helps you to remember important points.

Talk to other people (fellow workers, fellow students, friends, family, and your facilitator) about what

you are learning. As well as helping you to clarify and understand new ideas, talking also gives you a

chance to find out extra information and to get fresh ideas and different points of view.

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Using This Learner Guide

A Learner Guide is just that, a guide to help you learn. A Learner Guide is not a textbook. Your

Learner Guide will:

Describe the skills you need to demonstrate to achieve competency for this unit.

Provide information and knowledge to help you develop your skills.

Provide you with structured learning activities to help you absorb knowledge and information

and practice your skills.

Direct you to other sources of additional knowledge and information about topics for this

unit.

How to Get the Most out of Your Learner Guide

Read through the information in the Learner Guide carefully. Make sure you understand the material.

Some sections are quite long and cover complex ideas and information. If you come across anything

you do not understand:

Talk to your facilitator.

Research the area using the books and materials listed under Resources.

Discuss the issue with other people (your workplace supervisor, fellow workers, fellow

students).

Try to relate the information presented in this Learner Guide to your own experience and to

what you already know.

Ask yourself questions as you go. For example, ‘Have I seen this happening anywhere?’ ‘Could

this apply to me?’ ‘What if...’. This will help you ‘make sense’ of new material and build on

your existing knowledge.

Talk to people about your study. Talking is a great way to reinforce what you are learning.

Make notes.

Work through the activities.

Even if you are tempted to skip some activities, do them anyway. They are there for a reason, and

even if you already have the knowledge or skills relating to a particular activity, doing them will help

to reinforce what you already know. If you do not understand an activity, think carefully about the

way the questions or instructions are phrased. Read the section again to see if you can make sense of

it. If you are still confused, contact your facilitator or discuss the activity with other students, fellow

workers or with your workplace supervisor.

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Learning Checkpoints

This learner guide contains learning checkpoints which are represented by the following icons:

Checkpoint! Let’s

Review

Further Reading

Further Reading directs you to external resources that are highly recommended for you to read.

They also contain additional questions to facilitate supplementary learning and to guide you relate

what you have read in real life.

Checkpoint! Let’s Review contain review questions for you to answer on your own to ensure that

you have learned key points from the relevant section. If you have a hard time answering these

questions, worry not. You can always revisit chapters and take another shot at these review questions.

Additional Research, Reading and Note Taking

If you are using the additional references and resources suggested in the Learner Guide to take your

knowledge a step further, there are a few simple things to keep in mind to make this kind of research

easier.

Always make a note of the author’s name, the title of the book or article, the edition, when it was

published, where it was published, and the name of the publisher. This includes online articles. If you

are taking notes about specific ideas or information, you will need to note down the page number as

well. This is called the reference information. You will need this for some assessment tasks, and it will

help you to find the book again if you need to.

Keep your notes short and to the point. Relate your notes to the material in your Learner Guide. Put

things into your own words. This will give you a better understanding of the material.

Start off with a question you want answered when you are exploring additional resource materials.

This will structure your reading and save you time.

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I. DEVELOP, FACILITATE AND REVIEW ALL ASPECTS OF

CASE MANAGEMENT

1. Determine the Appropriate Response to Case Management in Accordance with

Organisation and Legislative Requirements

1.1 Develop and Utilise Case Management Processes in Accordance with Statutory

Requirements

Case management, according to the Case Management Society of Australia and New Zealand

(CMSA):

‘is a process encompassing a culmination of consecutive collaborative phases that assist clients to access available

and relevant resources necessary for the client to attain their identified goals. Key phases of the case management

process include client identification (screening), assessment, stratifying risk, planning, implementation (care

coordination), monitoring, transitioning, and evaluation.’

Case management is one of the primary places

in human service systems where the whole

person is taken into account. Unlike specific

services, case management does not focus on

just one problem but rather on the strengths,

needs, and personal concerns a person has.

Case management serves two (2) purposes:

It is a method for determining an

individualised service plan for each

person and monitoring the plan to use it is effective.

It is a process used to ensure that the money being spent for the person’s services is being

spent wisely and in the most efficient manner.

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Models of Case Management

Generally, models of case management practice lie on a continuum, from ‘brokerage’ at one end,

through models that are based on ‘relationship’ and ‘continuity of care’ to ‘clinical case

management’, including specialist interventions and rehabilitation, and ‘intensive case

management’ at the other end.

There are many different models of case management, but the major approaches are the following:

Standard Community Care Models

▪ Brokerage case management

o This is a very brief approach to case management in which case workers attempt to

help clients identify their needs and broker support services.

o The focus of this model is on assessing needs, referring to services and coordinating,

and monitoring on-going treatment.

o The case manager coordinates services provided by a variety of agencies and

professionals. Services are mainly office-based.

▪ Clinical case management

o This model combines case management and clinical or rehabilitation activities.

o Clinical case management emerged out of a need for case managers to provide some

therapeutic services.

o Many functions are similar to the brokerage model, including engagement, assessment

and planning, and community linking but with the added component of therapeutic

interventions such as psychotherapy, psychoeducation, and crisis intervention.

o Work is mainly office-based, and case managers are clinicians.

▪ Generalist case management

o This model utilises the commonly accepted functions of case management and is

characterised by a closer involvement between case manager and client.

o This approach is appropriate in instances where treatment and social services in a

particular area are relatively integrated, and the need for monitoring and advocacy is

minimal.

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Intensive Comprehensive Care Models

▪ Assertive community treatment (ACT) case management

o The services are usually provided by a community team on an ongoing and intensive

basis.

o This model of case management assumes a comprehensive role for a team of workers

by providing services such as skills-building, family consultations, and crisis

intervention.

o This approach is defined by:

▪ smaller caseloads,

▪ a multi-disciplinary team approach (usually at least two case managers, a nurse, and

a psychiatrist),

▪ shared caseloads,

▪ services delivered by the team in the person’s natural environment versus making

referrals outside of the team, and

▪ unlimited time frame and 24-hour coverage.

o A range of services is provided including but not limited to, mental health, housing,

daily living skills, socialisation, employment, crisis intervention, and/or substance

abuse treatment.

▪ Intensive case management

o This model provides outreach and direct counselling services with a smaller caseload

and without a team approach.

o Intensive case management is developed to meet the complex needs of high service

users and defined by low staff to client ratio, outreach, services brought to the client,

and practical assistance in a variety of areas.

o The main distinction from the ACT model is that caseloads are not shared.

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Rehabilitation-Oriented Community Care Models

▪ Strengths-based case management

o This model focused on client’s strengths, self-direction, and the use of informal help

networks.

o Strengths-based case management model provides clients support for asserting direct

control over their search for resources (e.g., housing and employment), and it

examines the client’s own strengths and capabilities as the means for resource

acquisition.

o To help clients take control and find their strengths, this model of case management:

▪ encourages the use of informal helping networks,

▪ promotes client-case manager relationship, and

▪ provides an active form of outreach to clients.

Case Management Approach

To identify, analyse and address individual needs, case management takes on a ‘systems approach’.

Case Management

Approach

Client centred

Evidence based

HolisticInclusive

Strengths based

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Client-centred

There is a partnership between the case manager and the client in which the client’s goals are given

priority during assessment and involvement. The client’s aspirations, choice, expectations, needs,

preferences and values are respected, and interventions are adapted according to these.

A client-centred case management approach ensures that the person has a major role in identifying

goals and service needs and that there is shared accountability. This approach is utilised to

empower people, draw on their strengths and capabilities, and promote an improved quality of

life by facilitating timely access to the necessary supports.

Evidenced-based

According to David Sackett, a medical doctor and a pioneer in evidence-based medicine:

‘evidence-based practice is the conscientious, explicit and judicious use of current best evidence in making

decisions about the care of the individual patient. It means integrating individual clinical expertise with the best

available clinical evidence from systematic research.’

In case management, the case manager works within a framework that uses that most

contemporary, relevant, and reliable evidence to provide effective and innovative case

management of the highest quality.

Evidence may come from a number of different sources such as:

Contemporary research and theoretical knowledge.

Data and statistical information.

Information from evaluation and reflective processes.

Existing professional practice standards, values, ethical practice and professional conduct.

The requirements of evidence-based practice are:

▪ Best researched evidence – Usually found in clinically relevant research that has been

conducted using sound methodology.

▪ Clinical experience and ethics – Refers to the clinician’s cumulated experience,

education, and clinical skills.

▪ Client preferences and culture - Personal preferences and unique concerns,

expectations, and values brought by the client.

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Holistic

The case manager uses a framework that comprehensively considers the general socioeconomic,

cultural, and environmental conditions of the client.

Working with clients in a holistic approach requires the case manager to look at the person from

a whole-of-life- perspective including:

Accommodation/housing

Culture/religion

Education

Emotional support

Finances

Health and mental health

Legal issues

Networks/community family

Recreation

Work

Inclusive

The case manager recognises and demonstrates compliance with enabling legislation and

standards pursuant to the terms and conditions of employment and registration with a

professional body.

Strengths-based

The client and the case manager acknowledge and concentrate on the strengths, skills, and

aptitudes of the client, in contrast to their deficits, to promote self-efficacy and self-esteem.

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Case Management Standards of Practice

Standards of practice are designed to specify the minimum level of practice or benchmark to be

attained by a case manager throughout the case management process. It also provides the

foundation for a best practice framework and uniform approach for practitioners.

Standards of practice are designed to enhance case management practice.

These standards provide a basis for quality guarantee, expectations and accountability for

clients, employers and other professionals.

Such standards also reinforce current practices and are designed to provided objectives and

guidelines to assist the case manager in competently practising case management.

Bear in mind that these standards are not intended to detract from any responsibilities which may

be imposed by law or regulation.

According to the Australian Association of Social Workers (AASW), the aim of practice standards

is to provide a:

✓ Guide to practice.

✓ Measure of accountability for members.

✓ Basis for standardisation of practice across Australia.

✓ Basis for quality guarantee, expectations and accountability for clients, employers and

other professionals.

✓ Benchmark for the assessment practice.

✓ Guide for planning ongoing professional development.

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STANDARDS OF PRACTICE FOR CASE MANAGEMENT

Standard 1: Case Identification (screening) and Assessment

Clients who meet the eligibility criteria for case management are identified and an assessment is completed.

Rationale: An element of screening occurs to determine the initial needs of the client. These needs and risk stratification are matched against the eligibility criteria of the program providing case management, and the case manager then completes an assessment.

Standard 2: Planning

Agreed goals between the client and case manager are documented based on the client’s identified needs, including the client’s aspirations, choices, expectations, motivations, preferences and values. Actions are planned and a timeline for review is set.

Rationale: Client needs will form the basis of intervention planning by the case manager. This planning will include:

• Determining the match between client’s needs and resources, services and supports available to meet these needs.

• Discussion with the client, key stakeholders (both formal and informal) regarding their ability to meet these needs.

• Advocating for the development of resources, services and supports to meet client needs where no solutions exist.

Documented goals reflect the process of assessing client needs and the actions towards addressing these needs. In addition, client goals include the establishment of criteria to support an evaluation of the effectiveness of interventions facilitated through case management.

The level of need will also have implications for the caseload of the case manager who must recognise their own abilities and limitations to be able to work effectively with the client.

Standard 3: Monitoring

Planned resources, services and supports are monitored against the agreed goals documented in the client’s individualised care plan.

Rationale: Case managers ensure that clients receive the resources, services and supports that have been arranged in order to meet client goals. Case managers advocate for client-oriented solutions at the service delivery level and at the policy-making level. Case managers also make adjustments to the agreed care plan to reflect the level of required resources, services and supports.

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Standard 4: Evaluation and Outcomes

Case management actions are outcome oriented. Periodic reassessment and evaluation of client outcomes are conducted against the expected outcomes and available evidence.

Rationale: The purpose of case management actions is to support clients to achieve desired goals/outcomes. The outcome is based on available evidence which demonstrates effectiveness. Evaluation activities measure the effectiveness and efficiency of the case management interventions that were planned to meet client goals. The case manager must undertake periodic evaluation as stipulated by the agency, program and/or funding body guidelines and/or policies and procedures are the request of the client.

(Source: National Standards of Practice for Case Management (CMSA), 2013)

Organisation and Legislative Requirements

Case managers have a legal obligation to follow statutory and regulatory requirements when

providing case management services. You, as the case manager, have a responsibility to keep

clients safe and to protect their safety if you believe they are at risk of harm. The statutory and

regulatory requirements contained in Acts and Regulations must guide your decisions about what

is right in relation to your clients.

Relevant/current legislation includes:

Child protection

Health and safety

Privacy

Freedom of information

Statutory and policy requirements include:

Child protection and guardianship legislation

Codes of practice

Freedom of information

Privacy and confidentiality

Health records legislation

Privacy legislation

Public health

Workplace health and safety

Access and equity

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Case management processes must also meet relevant service standards, and workers must adhere

to relevant codes of practice and organisation requirements. These can vary depending on the

nature of the service being provided. However, there are many that are common to all services

including:

Assessment

Codes of conduct

Communication

Complaints, conflict resolution, and procedures

Confidentiality

Consent

Coordination and networking with external agencies

Critical incidents procedures

Delegations (who has the authority to make decisions)

Duty of care

Mandatory notification

Workplace health and safety procedures

Recruitment and retainment of staff

Referral

Service provision and practice

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MANDATORY REPORTING OF CHILD ABUSE AND NEGLECT

According to Australian Institute of Family Studies: ‘mandatory reporting is a term used to describe the legislative requirement imposed on selected classes of people to report suspected cases of child abuse and neglect to government authorities’.

Who is mandated to report? What must be reported? Abuse and neglect types which must be reported

State/Territory: Queensland

Legislation: Child Protection Act 1999 (Qld)

Relevant persons: doctors, registered nurses, teachers, a police officer who, under a direction given by the commissioner of the police service under the Police Service Administration Act 1990, is responsible for reporting under this section, a person engaged to perform a child advocate function under the Public Guardian Act 2014.

Has a reasonable suspicion that a child has suffered, is suffering or is at an unacceptable risk of suffering significant harm caused by physical or sexual abuse and may not have a parent able and willing to protect the child from the harm.

Physical abuse

Sexual abuse

https://aifs.gov.au/cfca/publications/mandatory-reporting-child-abuse-and-neglect

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State/Territory: Australian Capital Territory

Legislation: Children and Young People Act 2008 (ACT)

A person who is: a doctor, a dentist, a nurse, an enrolled nurse, a midwife, a psychologist, a teacher at a school, a person authorised to inspect education programs, materials or other records used for home education of a child or young person under the Education Act 2004, a police officer, a person employed to counsel children or young people at a school, a person caring for a child at a child care centre; a person coordinating or monitoring home-based care for a family day care scheme proprietor, a public servant who, in the course of employment as a public servant, works with, or provides services personally to, children and young people or families, the public advocate, an official visitor, a person who, in the course of the person’s employment, has contact with or provides services to children, young people and their families and is prescribed by regulation.

A belief, on reasonable grounds, that a child or young person has experienced or is experiencing sexual abuse or non-accidental physical injury; and the belief arises from information obtained by the person during the course of, or because of, the person’s work (whether paid or unpaid).

Physical abuse

Sexual abuse

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State/Territory: New South Wales

Legislation: Children and Young Persons (Care and Protection) Act 1998 (NSW)

A person who, in the course of his or her professional work or other paid employment delivers health care, welfare, education, children’s services, residential services or law enforcement, wholly or partly, to children.

A person who holds a management position in an organisation, the duties of which include direct responsibility for, or direct supervision of, the provision of health care, welfare, education, children’s services, residential services or law enforcement, wholly or partly, to children.

Reasonable grounds to suspect that a child is at risk of significant harm and those grounds arise during the course of or from the person’s work.

Physical abuse

Sexual abuse

Emotional/ psychological abuse

Neglect

Exposure to domestic violence

State/Territory: Northern Territory

Legislation: Care and Protection of Children Act 2007 (NT)

Any person.

A health practitioner or someone who performs work of a kind that is prescribed by regulation.

A belief on reasonable grounds that a child has suffered or is likely to suffer harm or exploitation.

Reasonable grounds to believe a child aged 14 or 15 years has been or is likely to be a victim of a sexual offence and the age difference between the child and offender is greater than 2 years.

Physical abuse

Sexual abuse or other exploitation of the child

Emotional/ psychological abuse

Neglect

Exposure to physical violence (e.g., a child witnessing violence between parents at home)

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State/Territory: South Australia

Legislation: Children’s Protection Act 1993 (SA)

Medical practitioners, pharmacists, registered or enrolled nurses, dentists, psychologists, police officers, community corrections officers, social workers, a minister of religion, a person who is an employee of, or volunteer in, an organisation formed for religious or spiritual purposes, (with the exception of disclosures made in the confessional), teachers in educational institutions including kindergartens, approved family day care providers, any other person who is an employee/volunteer in a government or non-government organisation that provides health, welfare, education, sporting or recreational, child care or residential services wholly or partly for children, being a person who is actively engaged in the delivery of those services to children or who holds a management position in the relevant organisation, the duties of which include direct responsibility for, or direct supervision of, the provision of those services to children.

Reasonable grounds to suspect that a child has been or is being abused or neglected; and the suspicion is formed in the course of the person’s work (whether paid or voluntary) or carrying out official duties.

Physical abuse

Sexual abuse

Emotional/ psychological abuse

Neglect

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State/Territory: Tasmania

Legislation: Children, Young Persons and Their Families Act 1997 (Tas.)

Registered medical practitioners, nurses, midwives, dentists, dental therapists, dental hygienists or oral health therapist, registered psychologists, police officers, probation officers, principals and teachers in any educational institution including kindergartens, persons who provide child care or a child care service for fee or reward; persons concerned in the management of a child care service licensed under the Child Care Act 2001, any other person who is employed or engaged as an employee for, of, or in, or who is a volunteer in, a government agency that provides health, welfare, education, child care or residential services wholly or partly for children, and an organisation that receives any funding from the Crown for the provision of such services; and any other person of a class determined by the Minister by notice in the Gazette to be prescribed persons.

A belief, or suspicion on reasonable grounds, or knowledge that: a child has been or is being abused or neglected or is an affected child within the meaning of the Family Violence Act 2004, there is a reasonable likelihood of a child being killed or abused or neglected by a person with whom the child resides, or while a woman is pregnant that there is reasonable likelihood that after the birth of the child the child will suffer abuse or neglect, or may be killed by a person with whom the child is likely to reside, or that the child will require medical treatment or other intervention as a result of the behaviour of the woman or another person with whom the woman resides or is likely to reside, before the birth of the child.

Physical abuse

Sexual abuse

Emotional/ psychological abuse

Neglect

Exposure to family violence

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State/Territory: Victoria

Legislation: Children, Youth and Families Act 2005 (Vic.)

Registered medical practitioners, nurses, midwives, a person registered as a teacher or an early childhood teacher under the Education and Training and Reform Act 2006 or teachers granted permission to teach under that Act, principals of government or non- government schools within the meaning of the Education and Training Reform Act 2006, and police officers.

Belief on reasonable grounds that a child is in need of protection on a ground referred to in Section 162(1)(c) or 162(1)(d), formed in the course of practising his or her office, position or employment as soon as practicable after forming the belief and after each occasion on which he or she becomes aware of any further reasonable grounds for the belief.

Physical abuse

Sexual abuse

State/Territory: Western Australia Legislation: Children and Community Services Act 2004

Doctors, nurses and midwives, teachers or boarding supervisor, and police officers.

Belief on reasonable grounds that child sexual abuse has occurred or is occurring and forms this belief in the course of the person’s work, whether paid or unpaid.

Sexual abuse

(Source: Australian Institute of Family Studies)

https://aifs.gov.au/cfca/publications/mandatory-reporting-child-abuse-and-neglect

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1.2 Implement Appropriate Processes to Enable the Client to Set Goals and

Participate in Case Management Processes

The development of clear goals is a very important phase of the case management process. A goal

is a statement defining the expected outcome for each client by the time case management services

are terminated. Goal statements should include a time frame and a date by which the goal will be

reached. A goal without a date opens the possibility for an endless service delivery process.

Goals for case management services should be established with, not for, each client. Clients need

to be involved in the work of figuring out where they want to be at a given time. You, as the case

manager, is an important resource in this process, suggesting options, offering opinions,

discussing what might be reasonable and possible given the known resources, helping people

focus, and when appropriate, supporting clients who want to explore the development of new

resources as one of their goals. Case management works much more effectively when clients are

intensively involved in all stages of the process to the extent possible.

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Behaviour Change Models

There are a number of behaviour change models that can be integrated into the goal-setting

process. These models help explain specific behaviours by identifying the underlying factors that

influence them. It also illustrates the stages through which an individual will progress during a

change in his/her behaviour.

Transtheoretical Model

Useful for selecting appropriate interventions by identifying the client’s position in the

change processes (Precontemplation, Contemplation, Preparation, Action, Maintenance,

and Termination) so that the interventions can be tailored according to the skills the client

already possesses.

o Precontemplation is the stage in which people do not intend to make a change

in the near future (often defined as the next 6 months).

o Contemplation is the stage where people intend to change (within the next 6

months). People in this stage are aware of the pros of changing but can also

identify the cons.

o Preparation represents the stage where people have a plan of action and intend

to take action in the immediate future (within a month).

o Action is the stage in which people make the behaviour change.

o Maintenance represents the state where people work to prevent relapse.

o Termination represents that the stage where individuals have 100 percent efficacy

and will maintain their behaviour. This is the most difficult to maintain, so many

people remain a lifetime in maintenance.

Precontemplation

Contemplation

Preparation

Action

Maintenance

Termination

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How can you apply this model in practice?

It is essential that you match behaviour change interventions to people’s stages. For example:

1. When working with clients in the pre-contemplation stage, encourage them to start thinking

about change and the benefits that come with it.

2. If the client is in the contemplation stage, it is important to encourage the client to weigh up

the pros and cons of the change/modification.

3. Clients in the preparation stage can now be engaged, and you can now work with him/her

to create a plan for adopting changes and overcoming challenges.

Action is the stage where the client carries out the prepared plan. During this stage, it is

important to offer continuous support and encouragement, while helping the client focus

on the long-term advantages of making behaviour changes. It is at this stage where goal-

setting (using SMART goals) is particularly useful. It is also important to teach the client

how to anticipate and overcome obstacles that might deter his/her motivation or

adherence.

The client has progressed in the maintenance stage when he/she is maintaining new

behaviour changes. It is important to offer continued encouragement so that the client

maintains the changed behaviour, and to identify those things that might cause a relapse.

Take time to work with the client to identify things that might tempt or undermine the

positive changes he/she has made. Help the client strategise how to prevent these newly

identified triggers for relapse.

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Relapse Prevention Model

Original cognitive-behavioural model of relapse (Marlatt & Gordon, 1985)

According to the model, people with effective coping responses have confidence that they

can cope with the situation (i.e. increased self-efficacy, thereby reducing the probability of

a relapse. Conversely, people with ineffective coping responses will experience decreased

self-efficacy, which, together with the expectation that a certain behaviour will have a

positive effect (i.e. positive outcome expectancies), can result in an initial lapse. This lapse,

in turn, can result in feelings of guilt and failure (i.e. an abstinence violation effect). The

abstinence violation effect, along with positive outcome expectancies, can increase the

probability of a relapse.

This model is useful in designing maintenance, stand-alone treatment, and behaviour self-

control programs to teach individuals who are trying to maintain changes in their

behaviour how to anticipate and cope with the problem of relapse.

This model provides a strategy for anticipating barriers and other factors contributing to

participant relapse. This model has two (2) main goals:

1. To prevent the occurrence of initial lapses after a commitment to change has been

made.

2. To prevent any lapse that does occur from escalating into a full-blown relapse.

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How can you apply this model in practice?

Use this model as a behavioural self-control program that teaches individuals with

substance addiction how to anticipate and cope with the potential for relapse.

Use this as a stand-alone substance abuse treatment program or as an aftercare program

to sustain gains achieved during initial substance use treatment.

Use this in coping skills training, teaching clients strategies to:

✓ Understand relapse as a process.

✓ Identify and cope effectively with high-risk situations such as negative emotional

states, interpersonal conflict, and social pressure.

✓ Cope with urges and cravings.

✓ Implement damage control procedures during a lapse to minimise negative

consequences.

✓ Stay engaged in treatment even after a relapse.

✓ Learn how to create a more balanced lifestyle.

✓ Acknowledge that a lapse is a normal experience and should not be viewed

negatively.

Coping skills training strategies include both cognitive and behavioural techniques.

▪ Cognitive techniques provide clients with ways to reframe the habit change

process as a learning experience with errors and setbacks expected as mastery

develops.

▪ Behavioural techniques include the use of lifestyle modifications such as

meditation, exercise, and spiritual practices to strengthen a client’s overall coping

capacity.

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Ecological Approaches

Provides a framework used to develop comprehensive intervention approaches that

systematically target mechanisms of change at each level of influence (intrapersonal,

interpersonal, institutional, community, and public).

o Intrapersonal factors – Characteristics of the individual such as knowledge, attitudes,

behaviour, self-concept, skills, and development history.

o Interpersonal processes and primary groups – Formal and informal social

networks and social support systems, including family, workgroup, and friendship

networks.

o Institutional factors – Social institutions with organisational characteristics and

formal (and informal) rules and regulations for operations.

o Community – Relationships among organisations, institutions, and informational

networks within defined boundaries.

o Public policy – Local, state, national, and global laws and policies.

The core concept of an ecological approach is that behaviour has multiple levels of

influences. This approach is believed to provide comprehensive frameworks for

understanding the multiple and interacting determinants of health behaviours.

Public

Community

Insitutional

Interpersonal

Intrapersonal

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This approach is based on four core principles:

o Multiple factors influence behaviours.

o Environments are multidimensional and complex.

o Human-environment interactions can be described at varying levels of the

organisation.

o The interrelationships between people and their environment are dynamic.

How can you apply this model in practice?

Each level in the ecological model can be thought of as a level of influence and also as a

key point for prevention.

This approach offers a framework for program planners to determine how to focus

prevention activities, specifically what programs and policies to implement, to reduce risk

factors and increase protective factors at each of the different levels in the model.

This framework can be used to answer the following questions in relation to behaviour

change:

1. Where do you want to make the most impact?

2. Where are the gaps?

3. What activities can fill those gaps?

An ecological approach to behaviour enables Case Managers to:

✓ Offer support and facilitate continuing change efforts across the levels.

✓ Coordinate and communicate with those in the client’s system about the agreed

change efforts.

✓ Identify opportunities to promote participation by recognising the multiple factors

that influence an individual’s behaviour.

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This model enables workers to identify and implement appropriate strategies at each level:

✓ Strategies which bring change at the intrapersonal level tend to focus on changing

an individual’s knowledge, attitudes, behaviour, and skills (e.g. education and

mentoring programs).

✓ Strategies which bring change at the interpersonal level include community

education, support groups, peer programs, workplace incentives, and social

marketing campaigns.

✓ Strategies focusing on institution and community levels including the development

of the community, education, and awareness programs.

✓ Strategies on the public level must focus on developing the political will to

implement laws and policies that are already in place and encouraging all sectors

of the community to comply with such laws and policies.

Guidelines in Setting Goals

Goals should be clear plans for concrete actions – Goals should be expressed as

behaviour/s the client intends to do, which will distinguish them from wishful thinking,

good intentions or desirable outcomes.

Goals should be realistically challenging – If goals are too hard; the sense of self-

efficacy will be lost; if they are they are too easy, they won’t inspire much effort.

Goals should incorporate the client’s interests – It is difficult to be motivated to work

on something that is not genuinely interesting, and this is why the interest of the client

should be considered.

Goals should conform to the client’s values – Some of our important basic ideas about

ourselves involve a sense of personal integrity, different people have different values, and

goals should align with values inherent to a person.

Goals should have verifiable outcomes – Verifiable outcomes will allow clients to see

themselves being successful in achieving the goals they have set. This, in turn, will build

self-efficacy so that they will be more likely to keep achieving the goals.

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Goals should depend on the client’s own efforts – It is important that achieving goals

does not depend on the actions or reactions of things outside of the client’s control.

Goals should be achieved reasonably soon – Distant goals tend to be weaker

motivators, while closer goals tend to be stronger motivators. Daunting goals can be

broken into manageable steps so that they are seen as a series of sub-goals.

Goals should be set with the involvement of the client – collaborative goal-setting is

the beginning of all successful behaviour change programs and workers showing practical

respect for the client’s autonomy.

(Source: The keys to successful behaviour change, Australia Psychological Society, 2017)

https://www.psychology.org.au/publications/inpsych/behaviour/

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1.3 Integrate Appropriate Cultural Considerations into All Aspects of Case

Management Planning

Cultural considerations are crucial to the effectiveness of any case management approach. Culture

refers to everything that defines and distinguishes a person including ethnicity, gender, age, sexual

orientation, language, values, goals, and life experiences.

Case managers need to be aware of and be sensitive to cultural diversity, life situations, and other

various factors that shape a person’s identity. The case manager shall provide and facilitate access

to culturally and linguistically appropriate services. He or she must practice cultural competence

in all aspects of case management planning by:

Treating every client as an individual with a unique frame of reference.

Collaborating on the goals and content of the plan.

Tailoring services to clients instead of expecting them to conform to the service’s

preference.

Obtaining ongoing feedback from clients on the usefulness of the service and adjusting

the approach accordingly.

Community services and organisations have an obligation to develop policies, procedures and

standards of practice that aim to integrate

appropriate cultural considerations into all

aspects of case management planning.

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Working with Culturally Diverse Clients

Service organisations and service workers need to consider the diversity of their client’s values,

beliefs, and cultural expectations. To work effectively with culturally diverse clients, you will need

to be culturally responsive and commit to an inclusive approach that is respectful and relevant to

the client and their cultural identity. Specifically, you will need to:

Be aware of your own cultural background/experiences, attitudes, values and biases that

might influence your ability to assist clients from diverse cultural populations. It is essential

that you correct any prejudices and biases you may have regarding different cultural

groups.

Educate yourself wherever possible to enhance your understanding and to address the

needs of culturally diverse clients. This may involve learning about cultural, social,

psychological, political, economic, and historical material specific to the particular ethnic

group being served.

Recognise that ethnicity and culture may have an impact on a client’s behaviour.

Assist clients to become aware of their own cultural values and norms, and facilitate

discovery of ways clients can apply this awareness to their own lives to society at large, as

well as within the organisation.

Respect the client’s religious and/or spiritual beliefs and values.

Work to eliminate biases, prejudices, and discriminatory practices.

Provide information in a language that the client can understand.

Provide information in writing, along with verbal explanations.

(Source: The needs of culturally diverse clients, Community Door, 2016)

Special Needs of Diverse Client/Population

Aboriginal and/or Torres Strait Islander people

Aboriginal peoples are the oldest surviving culture in the world, having established ways of

managing their land and society that were sustainable and ensured good health. They have

occupied Australia for at least 60,000 years.

There were many different Aboriginal and Torres Strait Islander groups and hundreds of

languages. However, the population declined rapidly after colonisation.

To meet their cultural needs, services to ATSI people must be culturally appropriate, culturally

responsive, and holistic. Also, they must be provided with access to workers from within their

own community.

http://etraining.communitydoor.org.au/mod/page/view.php?id=286

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Cultural protocols and systems that may apply when working with ATSI people may include the

following:

A ‘Welcome to Country’ is where an Aboriginal or Torres Strait Islander Traditional

Custodian or Traditional Owner (in most cases an Elder), or a senior representative,

welcomes people to their land.

An ‘Acknowledgment of Country’ is traditionally performed in public events and meetings

when a person is about to address the audience. It is an acknowledgement of the

Aboriginal or Torres Strait Islander community as the traditional owners of the land, and

the special respect held for their Elders.

Smoking ceremonies are undertaken in Aboriginal communities in order to cleanse the

space in which a ceremony is taking place. They are also used in the context of healing,

spiritual renewal and strengthening by some Aboriginal healing practitioners.

Things workers need to consider when working with this group may include the following:

Respect, acknowledge, actively listen and respond to the needs of Aboriginal peoples and

communities in a culturally appropriate manner.

Don’t mimic Aboriginal speech patterns or attempt to speak Aboriginal English as a way

of encouraging an Aboriginal person to be more open.

Be aware and respectful of relevant extended family and kinship structures when working

with Aboriginal people. Ensure that extended family is included in

important meetings and in making important decisions.

Further Reading

The following are additional resources for further reading:

▪ Working and Walking Together: Supporting Family Relationship Services to Work with Aboriginal and Torres Strait Islander Families and Organisations

▪ Working with Aboriginal People and Communities: A Practice Resource

▪ Engaging with Aboriginal and Torres Strait Islander Communities

http://www.supportingcarers.snaicc.org.au/wp-content/uploads/2015/03/02497.pdf

http://www.carersaustralia.com.au/storage/2011Working%20with%20Aboriginal%20People%20and%20Communities.pdf

https://www.kidsmatter.edu.au/sites/default/files/public/Handbook_engaging_with_web.pdf

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Children and Young People

Case managers and workers must bear in mind the following agreed protocols for collaborative

practice in child protection when working with children and young people:

▪ UN Convention on the Rights of the Child 1989, a human rights treaty which sets out the

civil, political, economic, social, health, and cultural rights of children.

▪ Child protection legislation

Principal acts across Australian states and territories:

o Australian Capital Territory - Children and Young People Act 2008

o New South Wales - Children and Young Persons (Care and Protection) Act 1998

o Northern Territory - Care and Protection of Children Act 2007

o Queensland - Child Protection Act 1999

o South Australia - Children’s Protection Act 1993

o Tasmania - Children, Young Persons and their Families Act 1997

o Victoria - Children, Youth and Families Act 2005

o Western Australia – Children and Community Services Act 2004

▪ National Framework for Protecting Australia’s Children

▪ Relevant interagency guidelines – these are guidelines provided by states/territories that

cover the purpose, legislative and operational basis, roles, responsibilities, and practice

principles for protection of children (e.g., Guidelines for Protecting Children, WA; NSW

Interagency Guidelines for Children Protection Intervention)

▪ Codes of practice in child protection network (e.g., NSW – Office of the Children’s

Guardian; SA – Interagency Code of Practice)

https://www.unicef.org/crc/files/Rights_overview.pdf

https://aifs.gov.au/cfca/publications/australian-child-protection-legislation

https://www.dss.gov.au/our-responsibilities/families-and-children/publications-articles/protecting-children-is-everyones-business?HTML

http://www.health.wa.gov.au/circularsnew/attachments/1052.pdf

http://www.victimsservices.justice.nsw.gov.au/sexualassault/Documents/Child-Protection-Interagency-Guidelines.pdf

http://www.kidsguardian.nsw.gov.au/children-s-employment/information-for-employers/code-of-practice

https://www.childprotection.sa.gov.au/child-protection-initiatives/interagency-code-practice

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The following are the things that workers need to consider when working with children and young

people:

Safety, welfare and well-being of a child or young person are the paramount consideration.

The child’s or young person’s sense of racial, ethnic, religious, individual or cultural

identity should be preserved and enhanced.

The child’s or young person’s education, training or lawful employment should be

encouraged and continued without unnecessary interruption.

The child’s or young person’s age, maturity, developmental capacity, sex, background and

other relevant characteristics should be considered.

Delay in decision-making processes under the Act should be avoided because the delay is

likely to prejudice the child’s or young person’s well-being.

Special needs that are related, specifically to children and young people, may include the following:

Safety and physical and emotional security

Accommodation

Access to services/information

Counselling

Ongoing assessment

Referrals to specialist services

Referrals to community support and/or education groups

Information provided to caregivers, such as parenting information

Safety plans including protective behaviour techniques

Culturally and linguistically diverse (CALD)

Culturally and linguistically diverse (CALD) clients are those who may identify as being from a

culturally and linguistically diverse background including recently arrived migrants and refugees,

migrants and refugees who have lived in Australia for some time, as well as people whose parents

or earlier ancestors migrated to Australia.

Culturally and linguistically diverse client groups often have complex needs related to their

particular life situation or history.

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Protocols and systems that may apply when working with CALD individuals include:

Using appropriate terminology and avoid stereotyping.

Developing cross-cultural competence.

Collecting and recording accurate information about cultural, linguistic and religious

identity.

Developing effective cross-cultural communication skills.

Utilising interpreters.

Establishing links with service providers and ethnic community organisations.

Utilising culturally appropriate placements.

Ensuring a culturally appropriate response.

Things that workers need to consider when working with CALD individuals may include:

People from CALD backgrounds are not homogenous.

Develop a working knowledge of the migration experience.

Develop an understanding of the refugee experience.

Develop a working knowledge of differences in child-rearing practices.

Find out about traditional cultural practices.

Consider intergenerational issues and their impacts.

Be aware of barriers to identifying and reporting child abuse.

Understand the impacts of racism and discrimination.

Recognise stressors potentially contributing to domestic and family violence.

Further Reading

The following are additional resources for further reading:

▪ People from culturally and linguistically diverse backgrounds (Department of Health)

▪ Working with people from culturally and linguistically diverse background

http://health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-p-mono-toc~mental-pubs-p-mono-pop~mental-pubs-p-mono-pop-cul

https://www.communities.qld.gov.au/resources/childsafety/practice-manual/prac-paper-working-cald.pdf

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Lesbian, gay, bi-sexual, transgender, intersex (LGBTI)

LGBTI people have lived through a time in the nation’s history when they suffered stigma,

discrimination, criminalisation, family rejection, and social isolation.

Their special needs include:

Groups within LGBTI communities have specific social, cultural, psychological, medical,

and care needs.

Core relationship links with non-biological family or the ‘family of choice’ may be more

important to LGBTI people than their biological family and should be included in care

planning in the same way family members generally are.

LGBTI people also have other diverse characteristics that overlap and influence their

specific needs and how they access services, e.g. people from culturally and linguistically

diverse backgrounds, Aboriginal and Torres Strait Islander people, those suffering

financial disadvantage, etc.

Protocols and systems that may apply when working with LGBTI individuals include:

Recognition and affirmation of sexuality, sex, or gender diversity.

Recognition of the negative impact of discrimination, stigma, homophobia and

heterosexism on a person’s well-being.

Critical analysis of the assumption that all consumer or staff are heterosexual and not

diverse in terms of sex or gender.

A client-centred approach that takes into account the broader social determinants that

impact on the well-being of LGBTI persons.

A culturally competent and safe workforce that is knowledgeable and responds to the lived

experience of LGBTI persons.

Safe and welcoming environment and services free from discrimination based on

sexuality, sex, or gender diversity.

The following are the considerations that workers must bear in mind when working with LGBTI

individuals:

A large number of LGBTI people hide their sexuality or gender identity when accessing

services, at social and community events, and at work.

Young people aged 16 to 24 years are most likely to hide their sexuality or gender identity.

LGBTI young people report experiencing verbal homophobic abuse, physical

homophobic abuse and other types of homophobia, including cyberbullying, graffiti,

social exclusion, and humiliation.

80% of homophobic bullying involving LGBTI young people, occurs at school and has a

profound impact on their well-being and education.

Transgender males and females experience significantly higher rates of non-physical and

physical abuse compared with lesbians and gay men.

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Gay, lesbian, bisexual, and transgender people are three times more likely to experience

depression compared to the broader population.

Around 61% of same-sex attracted and gender-questioning young people said they

experienced verbal abuse because of their sexuality, while 18% reported experiencing

sexual abuse.

Young men and gender-questioning young people were more likely than young women to

experience verbal abuse.

Further Reading

The following are additional resources for further reading:

▪ Face the facts: Lesbian, Gay, Bisexual, Trans and Intersex People (Australian Human Rights Commission)

▪ LGBTI Cultural Competency Framework (National LGBTI Health Alliance)

▪ National Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI): Ageing and Aged Care Strategy (Department of Health and Ageing)

Older people

Older people need support for their physical, emotional, and social needs. In cases where nursing

homes and other institutional settings are inappropriate, case management serves, as an effective

means of fostering an older adult’s autonomy, establish safe living arrangements in the privacy

and comfort of their own home. Appropriate case management planning can assist older people

in remaining connected to their families, friends, neighbours, pets, and community. The goal

should be to maximise the client’s health, self-esteem, quality of life and right to self-

determination.

https://www.humanrights.gov.au/face-facts-lesbian-gay-bisexual-trans-and-intersex-people

http://www.lgbtihealth.org.au/sites/default/files/Cultural%20Competancy%20Framework.pdf

https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/08_2014/national_ageing_and_aged_care_strategy_lgbti_print_version.pdf

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Special needs of older people may include:

Material well-being

Emotional well-being

Social inclusion

Physical well-being

Interpersonal relationships

Self-determination

Each State/Territory has its own prevailing protocols and systems that respond to the service

needs of older people, for example:

▪ Australian Capital Territory – Elder Abuse Prevention Program Policy

▪ New South Wales – Interagency Policy for Preventing and Responding to Abuse of Older

People

▪ Northern Territory – The Health and Well-being of Older Territorians

▪ Queensland – A Guide for Elder Abuse Protocols

▪ South Australia – Protocol for Responding to Abuse of Older People Living at Home in

the Community

▪ Tasmania – Protecting Older Tasmanians from Abuse

▪ Victoria - Improving Care for Older People

▪ Western Australia – Elder Abuse Protocol: Guidelines for Action

The following are things that workers need to consider when working with older people:

▪ Changes that ageing may bring to:

o Physical processes

o Cognitive function (including dementia)

o Social interaction

o Role and family relationships

o Living arrangement

o Level of independence (financial, community access, self-care)

▪ Loss and grief

▪ Family carer issues

▪ Societal attitudes and expectations

http://www.communityservices.act.gov.au/__data/assets/pdf_file/0004/317605/Elder_Abuse_Prevention_Program_Policy_2012_FINAL_2.pdf

http://www.elderabusehelpline.com.au/uploads/pdf/FACS-NSW-Interagency-Policy-updated-November-2015.pdf

https://www.google.com.ph/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&cad=rja&uact=8&ved=0ahUKEwie1Pe7puvRAhVQObwKHfvlDn8QFgg2MAU&url=http%3A%2F%2Fdigitallibrary.health.nt.gov.au%2Fprodjspui%2Fbitstream%2F10137%2F577%2F1%2FThe%2520Health%2520and%2520Wellbeing%2520of%2520Older%2520Territorians.pdf&usg=AFQjCNFKvUsXG70mcWHeffkpUfSXkBMKHA&sig2=5eVbHBDecv_zvF_gq2rq0Q&bvm=bv.145822982,d.dGo

https://www.eapu.com.au/uploads/EAPU_general_resources/EA_Protocols_FEB_2012-EAPU.pdf

http://www.sa.agedrights.asn.au/files/49_1095_aras_abuseprotocols_final3.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0017/231812/Protecting_Older_Tasmanians_from_Abuse.pdf

https://www.google.com.ph/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiu6Ouxs-vRAhVDVZQKHTVGA78QFggZMAA&url=https%3A%2F%2Fwww2.health.vic.gov.au%2FApi%2Fdownloadmedia%2F%257B8DF949D8-2851-4DFC-8B57-57A7E1C24E95%257D&usg=AFQjCNF69JnLhgTVY76BzbG6mpccz_srcA&sig2=jFdz_D286K6y6ELHQJBlYg&bvm=bv.145822982,d.dGo

http://www.advocare.org.au/uploaded/files/client_added/SO103%20Elder%20Abuse%20Protocol%20v2.pdf

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People experiencing or at risk of homelessness

Homelessness is defined under Australian federal law as inadequate access to safe and secure housing.

This exists where the only housing to which a person has access:

▪ is likely to damage the person’s health,

▪ threatens the person’s safety,

▪ marginalises the person by failing to provide access to adequate personal amenities or the

normal economic and social support of a home, or

▪ places the person in circumstances that threaten or adversely affect the adequacy, safety,

security and affordability of that housing.

For some people, being homeless means being ‘roofless’—living on the streets, in parks or in

deserted buildings—this is the most visible kind of homelessness. For other people, being

homeless means moving between various types of temporary shelters, such as the homes of

friends and relatives, refuges and hostels, or living in boarding houses on a long-term basis, with

shared amenities and without security of tenure.

(Source: Homeless is a Human Rights Issue, Australian Human Rights Commission, 2008)

Special needs of people experiencing or at risk of homeless include but are not limited to the

following:

▪ Accommodation, that is, supported accommodation and/or assistance to obtain short-

term accommodation and independent housing.

▪ Financial or employment assistance.

▪ Counselling/personal support in living skills and relationships.

▪ General support and advocacy, including legal aid.

▪ Specific services, including drug rehabilitation, disability services, health and medical

services and culturally appropriate support.

▪ Assistance with basic needs such as meals and transport.

https://www.humanrights.gov.au/publications/homelessness-human-rights-issue#2

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Each State/Territory has its own prevailing protocols and systems that respond to the service

needs of people experiencing or at risk of homelessness:

▪ Australian Capital Territory – Social Housing and Homelessness Services

▪ New South Wales – Protocol for People in Public Places

▪ Northern Territory – Housing the Territory

▪ Queensland – Queensland Homelessness Information Platform

▪ South Australia – Homeless to Home

▪ Tasmania – Tasmania’s Affordable Housing Action Plan

▪ Victoria - Protocol for Assisting People Who Sleep Rough

▪ Western Australia – Forging Stronger Partnerships to Address Homelessness

The following are things that workers need to consider:

▪ Indigenous people are disproportionately affected by homelessness as they face greater

social and economic disadvantage than other sectors of the population.

▪ Women are significantly affected by homelessness, and the major causes include domestic

violence, sexual assault, and family breakdown.

▪ Children and young people are disproportionately affected by homelessness, and this is

strongly linked to relationship and family breakdown, domestic violence, physical and

emotional abuse, anxiety and depression, unemployment, and substance abuse.

▪ People with mental illness are disproportionately affected by homelessness.

▪ People coming to Australia as asylum-seekers or refugees are particularly vulnerable to

homelessness due to poverty and social isolation.

http://www.communityservices.act.gov.au/hcs/services/social_housing/social_housing_and_homelessness_services

http://www.housing.nsw.gov.au/__data/assets/pdf_file/0003/326046/ImplementationGuidelines.pdf

https://housing.nt.gov.au/__data/assets/pdf_file/0010/117694/Homelessness_fact_sheetv3.pdf

http://www.hpw.qld.gov.au/Housing/Homelessness/QldHomelessnessInformationPlatform/Pages/default.aspx

https://www.sa.gov.au/__data/assets/pdf_file/0013/13216/Homeless_to_Home_Publication.pdf

https://www.dhhs.tas.gov.au/__data/assets/pdf_file/0003/203691/150596_TAH_Action_Plan_WCAG_d1.pdf

https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwj1uri6xOvRAhVHXbwKHQOkDFcQFggeMAE&url=http%3A%2F%2Fwww.portphillip.vic.gov.au%2FProtocol_for_Assisting_People_who_sleep_rough.doc&usg=AFQjCNEImPt19nlgaxu0Nrh_YhZR2cqi7w&bvm=bv.145822982,d.dGc

https://www.dcp.wa.gov.au/servicescommunity/information/Documents/Service%20Excellence/Protocols/WAPoliceProtocols.pdf

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People with a disability

One in five people in Australia have a disability, and this proportion is increasing with an ageing

population. There are many different kinds of disability, and they can result from accidents, illness,

or genetic disorders. A disability may be:

▪ Physical – affects a person’s mobility or dexterity

▪ Intellectual – affects a person’s abilities to learn

▪ Mental illness – affects a person’s thinking processes

▪ Sensory – affects a person’s ability to hear or see

▪ Neurological – affects the person’s brain and central nervous system

▪ Learning disability

▪ Physical disfigurement

▪ Immunological – the presence of organisms causing disease in the body

Some people may have more than one disability; it may be visible or hidden, may be permanent

or temporary and may have minimal or substantial impact on a person’s abilities.

Although some people are born with disability, many people acquire disability. For example, a

person may acquire a disability through a workplace incident or car accident or may develop a

disability as they age. There is a strong relationship between age and disability; as people grow

older, there is a greater tendency to develop conditions which cause disability.

(Source: What is a Disability?, Australian Network on Disability, 2017)

Special needs of people with disability include, but are not limited to the following:

▪ Home and maintenance modifications

▪ Goods and equipment/assistive technology

▪ Allied health (e.g. occupational therapy, physiotherapy, etc.)

▪ Respite care

▪ Independent living centres/services

http://www.and.org.au/pages/what-is-a-disability.html

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Each State/Territory may have its own prevailing protocols and systems that respond to the

service needs of people with a disability, examples are:

▪ South Australia – Protocol about Young People with Disability in, or at Risk of Entering,

Residential Aged Care

▪ Victoria – Disability Services – Aged Care Assessment Services Protocol

▪ Western Australia – Joint protocol to guide the assessment and support of younger people

with disability

▪ The Department of Human Services also provides a Protocol for engaging people with disability.

The following are things that workers need to consider when working with older people:

▪ Access to services for people with disabilities and their carers

▪ Family and carer issues

▪ Grief and loss

▪ Support in meeting individual needs and personal goals of people with disabilities

http://www.dcsi.sa.gov.au/services/disability-sa/disability-sa-policies-and-guidelines/ypirac

http://www.dhs.vic.gov.au/__data/assets/pdf_file/0009/595296/cis_acasprotocolyoungpeople_pdf_0509.pdf

http://www.disability.wa.gov.au/Global/Publications/About%20us/Policies/protocol_for_younger_people_with_disabilties.pdf

https://www.humanservices.gov.au/corporate/publications-and-resources/protocol-engaging-people-disability

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STRATEGIES FOR INTEGRATING CULTURAL CONSIDERATIONS INTO ALL ASPECTS OF CASE MANAGEMENT PLANNING

✓ Find out the individuals preferred language and engaging an interpreter if required.

✓ Develop a cultural understanding by acknowledging all three layers of cultural factors and individual culture.

✓ Be sensitive to the individual’s gender preferences.

✓ Be conscious of physical contact, especially with those of the opposite sex.

✓ Be aware of differences in eye contact or handling belongings.

✓ Consult the person regarding their religious practice and make appropriate arrangements for them.

✓ Be aware of differences in communication styles.

✓ Be aware of differences in interpretation of meanings.

✓ Clarify the similarity of and differences between the provisions of services in the person’s country of origin and Australia.

✓ Seek the commitment of those involved in the planning to nurture cultural diversity.

✓ Learn to listen—listen to what is really said, not what you want to hear.

✓ Test for understanding—ask questions to be certain you know what is being said.

✓ Adapt your communication style to fit the situation—individuals from different cultures may react differently that is why you must know who you are communicating with.

✓ Use language that fosters trust and alliance.

✓ Understand the dimensions of diversity, use inclusive and valuing language, use diverse resources, readily adapt to differences in communication styles of diverse people, display respect for human differences and be aware if and comfortable about dealing with diverse issues.

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1.4 Provide Information on Rights of Appeal and Avenues of Complaint so the Client

Understands Rights and Responsibilities

Client rights are protected by legislation, codes of ethics, and standards. From there, the service

develops policies and procedures which are the guidelines that operate in the workplace.

The rights of the client include:

•Clients must be treated with dignitiy and respect by workers while being responsive to social, cultural and physical needs of clients.

The right to be treated with respect and courtesy

•Informed choice—if a client is referred to another service, they need to understand what is involved and give their consent.

The right to be informed and to give his/her views

•Clients have access to all information held about them by the service.

•Clients’ views should be taken into account in the planning and evaluation of the service.

•Clients should be involved in discussions about their assessment and support plan.

The right to be part of decisions about his/her care and/or case

•Clients should be made aware of the standard of service which they can expect.

•Clients have the right to be informed about the service, policy and procedures, expectations and rules of the service.

The right to receive quality services

•Client privacy should be protected.

•Confidentiality—client information is not shared without the client’s approval and that files containing personal information are kept secure.

The right to privacy and confidentiality

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Vis-à-vis the concept of rights is the concept of responsibilities; rights cannot be viewed in

isolation of responsibilities. While clients have the right to expect organisations to uphold all their

rights, they also have responsibilities to fulfil as a client of the service.

The client’s role is to collaborate with the case manager, agency and other key stakeholders in

determining his/her individual, diverse and special needs, including aspirations choices,

expectations, motivations, preferences, and values.

His or her responsibilities include the following:

As a case manager, you need to be aware of the rights, as well as the responsibilities of your client.

You also have an obligation to uphold and support your client’s rights. One of the ways of

upholding your client’s rights is to make sure that the clients know how to complain.

Informing the service if they will not be available to attend an appointment

Respecting the rights of the case manager, staff, management, volunteers, and other clients

Taking responsibility for the decisions that they make

Providing accurate and complete information that enables the case manager/staff to provide appropriate service

Following through on tasks that have been agreed to

Respecting and abiding by the rules of the services (as long as these are reasonable and have been agreed to in the first place)

•Clients have access to a person who will defend and safeguard their rights and have their views and wishes genuinely considered when decisions are being made about their situation

The right to an advocate

•Clients have the right to complain about the service they are receiving.

The right to make a complaint

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There is always the potential that the services received by the client may not be perceived by the

client as fair or appropriate. To enable the client to take action to recover any lost rights or even

seek compensation, the service must have a policy that will guide its staff on how to manage

complaints and ensure that the client’s right to have complaints and to appeal are fairly assessed.

The service must provide information to clients about internal and external mechanisms for

making a complaint. It must also act fairly and appropriately when a complaint is received.

As the case manager, you may be tasked, in accordance with the organisation policy and

procedures to:

Inform the clients about their right to make a complaint and to appeal a decision.

Inform clients about how to make a complaint and to appeal a decision, using either the

internal or external mechanisms available to them.

Inform clients about the support and advocacy available to assist them if they make a

complaint or appeal a decision.

Describe how complaints and appeals are raised, considered, decided upon and actioned

in a timely and culturally appropriate manner.

Explain procedural fairness and steps to make sure a client will not be disadvantaged by

making a complaint or appealing a decision.

Discuss how clients will be told of the outcomes of their complaint or appeal.

Discuss how the outcomes of complaints and appeals will be used for continuous

improvement.

Clarify procedures and actions.

Clarify the timing of any actions.

Show the client when the complaint/appeal is approved and when it was last reviewed.

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2. Conduct Case Management Meetings

One of your responsibilities as a case manager is to organise and oversee the delivery of services to

clients. You connect the clients to the community and other relevant resources, and you work to

protect the rights and well-being of the client.

When working with clients to meet their needs, different parties are often involved including family

members and health professionals. It may be necessary to organise meetings with these parties to plan

and regularly review the delivery of a service and/or if a particular issue arises.

It is also important to facilitate sharing of information and to establish rapport between parties.

Information sharing may occur in the following formal processes:

Case conferences – Provide holistic, coordinated, and integrated services across providers

and to reduce duplication.

Case conferences are usually

interdisciplinary and include

one or multiple internal and

external providers, and if

possible and appropriate, the

client and family

members/support system.

Case review meetings –

Used for information

gathering to assist assessment

and planning and interagency

planning and coordination, review, and monitoring of the plan.

Formal briefings on client progress – Include communication, information sharing and

collaboration occur regularly with the case manager and other staff serving the client within

and between agencies. These briefings may include activities such as directly arranging access,

reducing barriers to obtaining services, establishing linkages, and other activities recorded in

progress notes.

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2.1 Facilitate Information Sharing with the Client and Establish an Appropriate

Rapport

Case management generally involves a number of people, all of whom should be actively involved

in assisting the client. Meetings are a good forum for all stakeholders to:

Share insights about what is and is not working.

Develop a shared sense of purpose.

Find out how each of the stakeholders is feeling about the process.

Develop better ways of working together to improve care.

When a number of other services are involved, organisations may need to negotiate which service

will take a lead role in coordination, and this role is usually taken up by the case manager of the

service that has the most contact with the client. As part of their coordination responsibilities, this

service takes on the duty of calling case conferences and chairing the meetings.

Role of the Case Conference and Meeting Chairperson

The role of the chairperson is to:

Facilitate participation of all members.

If necessary, to assist the client to put forward their views.

Summarise the agreed outcomes.

Check with everyone that they agree with the outcome and understand and understand

what their role is.

Make sure that the plan is written down.

Arrange further meeting as required.

Follow-up with participants to make sure they undertake the tasks they have agreed to.

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Information Sharing with the Client

The key person in the meeting is the person receiving support. Information must be shared with

the person regarding the purpose of the meeting and why certain people have been asked to

attend. The case manager must have consent from the person. If the person is unable to give

consent, an advocate, interpreter, or guardian must be included.

In the case of unaccompanied young people in case management services, the service with

statutory responsibility for the young person would be responsible for providing the consent and

attending the case conferences/meetings.

Case meetings should always aim to include the attendance of the person receiving support. The

tone and context of the meeting should encourage service user participation.

A case meeting should only be called in the absence of the person receiving support in the

following circumstances:

The person cannot be located, and there are concerns regarding their welfare.

The person is in an institution (e.g. prison, hospital, etc.) and gives permission for the

meeting to be convened.

The person is incapable of giving permission (e.g. mental health concerns) and there is a

clear need for the meeting to take place.

The person is too intoxicated to participate but has given permission for the meeting to

be held.

There is an identified risk of violent behaviour at the meeting on the part of the person,

but it is absolutely necessary to hold the meeting in order to progress the support plan.

To inform the service providers of specific clinical information or behavioural traits for

the purposes of ensuring a cohesive meeting with the service user. In such circumstances,

a pre-case meeting may be convened with relevant service providers prior to the actual

case meeting.

There have been difficulties in interagency service communications which are related to

process rather than the case itself, and these difficulties need to be resolved before the

case meeting.

Circumstances which may justify exceptions to the involvement of parents/carers (or their

limited exclusions) according to statutory/legislative requirements.

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Establish Appropriate Rapport

Rapport describes a positive relationship that forms between two or more persons. Once you

have identified the possible barriers to effective communication and considered some strategies

to overcome these, you can then look at how to build rapport with the client.

Establishing appropriate rapport is an essential skill of a case manager. It is particularly important

when you are interviewing clients, as it allows free and open discussion and provides better

outcomes.

Strategies for Building Rapport

• Being clear about your role and the purpose of the interaction.

• Using a person’s preferred name when speaking with them.

• Paying attention to making them comfortable.

• Using a pleasant tone that is clear and precise.

• Explaining words and expressions that may be unfamiliar and not using jargon.

• Asking simple and clear questions.

• Explaining what you already know.

• Explaining clearly any mandated position you have (e.g. You may have to report to other authorities any disclosure of abuse).

• Explaining the actions that are undertaken both during the interview and as a result of the interview.

• Using age-appropriate language; using words familiar to the other person.

• Conveying acceptance by showing interest and concern.

• Being sincere and realistic in goal-setting.

• Not promising anything that cannot be delivered when the meeting is over .

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2.2 Identify and Agree on Client and Worker Roles, Responsibilities, Boundaries, and

Processes of Service Delivery

It is very important that you and your client are clear about your role and responsibilities, as well

as the service’s involvement in his or her care.

Having a clear understanding of what you and the service can do and cannot do, enables you to

communicate this clearly to your client and significant others. It helps to avoid misunderstandings,

breakdowns in communication and unreal expectations being placed on you and the client.

As a case manager, you are likely to be spending a lot of time with your clients, so you need to

remember that, whilst you are part of the client’s support network and probably a very important

part, you are not a friend.

Boundaries in Working Relationships

One of the more difficult ethical dilemmas with which you may be confronted relates to boundary

violations in working relationships. This occurs when a professional worker or employee forgets

that they are in a professional relationship and not a friendship. Once this professional relationship

has been lost, there is then potential for the worker to become over-involved with the client and

potentially violate the client’s rights.

Professional boundaries need to be observed to ensure that professional standards are followed.

Professional boundaries do not mean the avoidance of another person and their problems.

To be effective in your work, you need to be clear about your role and boundaries, and be able to

get this across to the client. The following considerations are useful in communicating the

boundaries of your working relationship with the client:

Identify the information you need to know.

Only seek the information you need, not what you would like to know.

Be clear with them about why you need the information.

Be clear about the system you are part of. Let the client know what you can, and you

cannot offer.

Be aware of your own limitations as a person and a worker.

Establish ground rules about your working relationship with the client from the outset,

depending on the culture of your organisation.

Be aware of your own feelings about the client and how those feelings may affect your

working relationship with them.

Be consistent with ground rules and applying boundaries.

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The issue of boundaries may be clarified through the development of guidelines provided for in

contracts, codes of ethics, and manuals of practice. Also, provide clients with information on what

they need to do or how they can participate in any planning, and empower them in the process.

Processes of Service Delivery

The social service sector provides the community with services that meet a broad range of needs.

The delivery of services aims to promote physical, social, emotional, mental, and spiritual well-

being. Service delivery has the following main functions:

To provide service to the users.

To provide the resources (staff, volunteers, facilities, equipment, skills, knowledge, etc.)

necessary for the service.

To maintain the service to a standard that can be used by all members.

To balance the needs of the service users with the needs of the service and the needs of

the community.

To share and draw on skills/resources where needed.

Service providers are workers in agencies who can offer your clients a service, resource or program

to meet their needs. They could be government, private or community-based agencies. They could

specialise in meeting particular needs, such as drug and alcohol support services, or they could

offer general support to your client, such as counsellors or foster and respite care.

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Clarifying the process of service delivery enables the client to understand service offerings,

including what the service does and does not include, eligibility, service limitations, cost, how to

request services, and how to get help.

Sp ec

ia lis

t se

rv ic

es a

n d

s u

p p

o rt • Income, financial and

community support services

• Employment services

• Housing services

• Access to recreation services

• Care and support services

• Transport and communication services

• Family support services

• Mediation

• Counselling

• Drug and alcohol services

• Intervention and behaviour management

• Specialist cultural liaison and support

N et

w o

rk s • Specialist providers in the

community services and health areas including health and cognitive assessments

• Specialist services to assist communication with client and identification of their needs

• Providers of any of the identified client services required by clients of the organisation

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How are the services provided?

The effectiveness of service delivery is determined by the service’s ability to best meet the needs

of the client and their community. The integration of service delivery is deemed as one of the

most efficient and most effective ways of using resources.

Integrated service delivery refers to a number of service agencies working together to collaborate

and coordinate their support, services, and interventions to clients. The focus is generally on

clients or client target groups who have complex needs that require services for a number of

agencies. Some efforts may be one-off, but more typically, there will be a system developed that

enables services to meet or communicate and possible streamline processes, to provide ongoing

coordination.

The primary purpose of integrated service delivery approaches is to improve outcomes for clients.

How this is achieved, and the factors that are important, will vary according to service settings,

agency capabilities, and specific needs of the clients. They may include:

▪ Improving communication between agencies to monitor client progress and changes, and

be more responsive to these.

▪ Identifying areas of duplication, working at cross-purposes, or what is creating confusion

for clients about who is doing what.

▪ Developing one plan for the client which includes the work being done by/for all agencies.

This plan may include actions and responsibilities the client agrees to do.

▪ Building understanding and capacity between the agencies, such as sharing practice

frameworks and legal and funding limitations, so they can work together more effectively

and generally support each other in their service delivery.

▪ Identifying systematic issues that create problems for clients and for services in their

efforts to meet client needs. This may include identification of client groups or needs that

‘fall between the gaps’. Ideally, there will be a process whereby these issues can be brought

to the attention of decision-makers.

▪ Development of streamlined processes which can provide more seamless services to

clients, such as a common referral or assessment processes.

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How do agencies keep the integrated service process going?

The following are tasks to be undertaken by agencies to keep the integrated service process going:

▪ Organise meetings

▪ Identify team member roles

▪ Develop a case plan

▪ Review the plan regularly

▪ Maintain contact between the team and external referrals

▪ Determine a process for conflict resolution or mediation when necessary

▪ Compile, distribute and maintain meeting records

▪ Close or transfer the case

▪ Evaluate the assistance provided

(Source: A Guide to Integrated Service Delivery to Clients, QCOSS, 2013)

2.3 Determine and Agree Organisation, Family and Community Needs,

Responsibilities and Rights

The parties to a case management process include the organisation(s) providing services, the

person receiving services, the family of the person receiving services, and the community.

Organisation needs, responsibilities and rights

Responsibilities of the organisation include the following:

Provide services that:

o Addresses the needs and the rights of the client

o Meets ethical and legislative requirements

o Meets service standards

Ensure that the case manager and the workers have the required skills and knowledge to

work effectively in their roles.

Ensure that resources needed to implement the case plan are available for case managers

and workers.

http://communitydoor.org.au/sites/default/files/A_GUIDE_TO_INTEGRATED_SERVICE_DELIVERY_TO_CLIENTS.pdf

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Rights of the organisation providing services include:

The right to receive whatever resources have been agreed to with their funding body.

The right to expect people who receive services to keep their arrangements and to work

with staff members respectfully.

The right to expect workers to follow organisational policies and procedures and to work

within their job role descriptions, meet service standards and follow ethical principles.

The organisation also needs resources relevant to its work. It also needs information from the

person receiving services about the person’s situation, needs, goals and other factors affecting the

case.

Funding for organisations can be accessed in a number of ways, such as:

➢ Commonwealth-direct funding

For certain areas of community services, the Commonwealth Government provides funding for organisations that are identified as eligible for supplementary funding. Organisations or services can only use this funding to cover costs arising from the Equal Remuneration Order (ERO). These costs include staff wages and staff on-costs.

➢ Commonwealth-state agreements

For specific States’ efforts in delivering services in key sector, the Commonwealth provides funding mechanisms. The Australian Government is currently providing supplementary funding for the following programs of States/Territories: - National Affordable Housing Specific Purpose Payment - National Disability Services National Specific Purpose Payment - Transitioning Responsibilities for Aged Care and Disability Services, and Home and

Community Care Programme Review Agreement - National Partnership Agreement Supporting National Mental Health Reform

➢ State/Territory-direct funding

State or Territory government also directly funds services/organisations through different departments. The eligibility and funding requirements are provided in the State’s or Territory’s funding agreement which outline the terms, conditions and obligations of funding, service delivery, accountability for both the department and the funded agency.

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Family needs, responsibilities and rights

Different cultures and different families will see rights and responsibilities differently. These

variations may be culturally based and related to how different roles are constructed. While the

family is not the primary focus of the support plan, families can provide support and insights into

the client’s history and needs.

Involving families must be done sensitively

and carefully. Their right to seek legal advice

at any stage of an intervention and the right

to participate and be involved in what care

will meet the needs of the client must be

taken into consideration.

Families who will be part of the support for

the client should be informed that they have

the responsibility to give enough

information to the service provider so that the care plan can be developed and delivered. In cases

where the client’s family might not be present or involved in the client’s life, understanding his or

her family structure and dynamics is still necessary as these influence a person’s values and beliefs.

It is also helpful for the case manager to recognise a family’s communication pattern and decision-

making processes, as this will help establish a good working relationship with the family members

involved in the care of the client.

Family structure and dynamics

Family structure can be defined in terms of parents’ relationships to children in the household

(e.g. biological or nonbiological), parents’ marital status and relationship history (e.g. divorced,

separated, remarried), the number of parents in the family, and the parents’ sexual orientation.

Family dynamics are the patterns of relating, or interactions, between family members. Each

family has a unique set of dynamics, which will impact the members’ development, ideas, and

ways of behaving as well as how we interact with others.

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Communication patterns followed by families

▪ Consensual – Family members communicate freely about thoughts, feelings and

activities, but at the same time, parents are the final decision-makers about important

issues.

▪ Pluralistic – Family members believe in the value of ‘life lessons’ and expect their children

to develop through their interactions with people outside the family unit. Decisions are

made as a family with everyone having equal input.

▪ Protective - Family members do not value open conversation and children are expected

to obey their parents and parents do not usually share the reasoning for their decisions.

▪ Laissez-Faire – Family members are often described as ‘emotionally divorced’ from one

another. Not much is discussed among members of the family and parents often don’t

have an interest or investment in the decisions made by their children.

Decision-making processes utilised by families

▪ Consensus – A particular course of action is mutually agreed on by all involved. There is

equal commitment to the decision, as well as satisfaction with the decision by family

members. Consensus decisions are agreed on through discussion and negotiation.

▪ Accommodation – The family

members’ initial feelings about an

issue are conflicting. This type of

decision making may involve a

voluntary compromise in which

approval is made by all persons

concerned, or a sacrifice, made by

one family member so that others

may have their own way.

▪ De facto – Decision-making occurs when things are allowed to ‘just happen’ without

planning. May also be made when arguments occur to which there was no obvious

resolution or when issues were not brought up and discussed.

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Community needs, responsibilities and rights

The community and its resources are the primary partners which may assist you, as the case

manager, to deliver as much of the ‘help’ or service needed by the client as possible. With this in

mind, the needs, responsibilities and rights of the community must be considered in creating the

case management plan. While the community has a right to a safe and secure environment, it also

has the responsibility to ensure it does not disadvantage those within the community or restrict

the rights of its members in any way.

As a case manager, make sure that the needs, responsibilities and rights of the community are

balanced with the rights of the client receiving support. To do this, it may be beneficial to involve

a community member in the case management meeting to ensure all responsibilities and

boundaries are clearly defined.

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3. Develop an Appropriate Case Management Plan

A case management plan is formulated on information gained in the client’s initial assessment. It

documents the client’s priorities, short- and long-term goals, and identifies actions and required

support resources. To be effective, the plan needs to be client-focused, client-directed and based on

a holistic approach to assessment.

The case management plan provides

structure for the client, service providers

and stakeholders. For service providers

and stakeholders, it can be used as a key

source of information about the client’s

needs, goals and intended actions.

It is a tool that creates focus and sets

some realistic boundaries around the

work you, as the case manager, and the

client can do together.

What does the client want

That fits with resouces in the service system

Within the time available

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3.1 Collaborate with the Client to Identify Strengths, Abilities and Goals and Develop

an Agreed Approach to Case Management

Case management plans are developed in collaboration with the person receiving services and

other stakeholders. The person receiving services is the primary stakeholder and has the primary

responsibility for making decisions about their goals and needs. Developing a case management

plan is a chance for you and your client to step back, work out what the end goal is for you to

work together and think through the steps that are needed to achieve these goals.

Collaborative planning

Collaboration recognises that each party in a case management plan has something to contribute

and that each part is equally valued. As an agreed approach to case management, collaboration is

used to ensure that the person is empowered to develop and retain as much autonomy and control

over their life as possible. Collaborative planning with the client helps them build self-reliance and

play an active role in achieving the results they want.

Collaborative planning is partly to increase the client’s engagement with the plan, but it is also a key

tool in building trust by showing competence (Ballew and Mink, 1996).

It also acknowledges the fact that client’s needs are often best served via collaboration between

specialised services.

Identify client strengths, abilities, and goals

Strengths-based case management focuses on the inherent strengths and skills that people already

have, and can be used as building blocks. This approach accepts that people aren’t defined by

their problem, diagnosis or illness. Instead, they are defined by their capacity for growth and

change.

A strengths-based approach is a specific method of working with and resolving challenges

experienced by the engaged person. It does not attempt to ignore the problems and difficulties.

Rather, it attempts to identify the positive basis of the person’s resources (or what may need to be

added) and strengths that will lay the basis to address the challenges resulting from the problems.

The strengths of a person give one a sense of how things might be and ideas about how to bring

about the desired changes.

(Source: A Strengths-Based Perspective, Resiliencyravb xc Initiatives)

https://www.esd.ca/Programs/Resiliency/Documents/RSL_STRENGTH_BASED_PERSPECTIVE.pdf

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Assisting the client in identifying and recognising their own strengths forms an essential part of

the assessment process. This information can be used to inform the case management approach

that will be used.

Explore the client’s strengths, abilities, and goals by asking questions that:

Invite him or her to share his/her stories and enable them to clarify the challenges:

o What’s happening? How do you feel about this? How long has this been a concern?

o How is it affecting you and others?

Help him or her explore his/her aspirations, dreams, interests, and goals

o What do you want to be happening instead?

o What will it look like when this concern is addressed?

Help him or her explore his/her strengths and the exception to the concern

o What strengths do you have that might be helpful? What do you do well?

o What is happening when the concern is not present?

Help him or her identify resources that might help him/her reach their goals

o Who else might be able to help?

o What other skills and resources might be helpful?

Enable his or her to specify concrete steps towards his/her goals

o What steps can be taken given your picture of the future, strengths and resources?

o Who will do what? When? How? By when?

Best practice in identifying client strengths, abilities, and goals

✓ Work on strengths assessment to identify what client wants/desires in various life

domains

✓ Identify client’s talents, skills, and environmental resources that are currently

available to assist in setting goals

✓ Explore talents, skills, and environmental resources that client has used in the past

that could potentially be accessed and used in setting goals

✓ Prioritise wants/desires held by client in order to identify potential goals for the

case management plan

✓ Use strengths-assessment to identify specific strategies for goal setting

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3.2 Develop a Case Management Plan to Reflect Initial Assessment of Needs

The case management plan is developed from the assessment information and lists the goals

which the client wishes to work on. Each goal is broken down into actions or tasks which are

allocated to the worker or client to do within a time frame.

During the initial needs assessment, the case manager and the client identify:

Immediate actions that need to be taken

The client’s interests and preferences

The client’s current circumstance

The client’s strengths and abilities

The various domains of the client’s life must be taken into consideration when developing the

plan. These areas; social, cognitive, spiritual/cultural, physical/medical, and

psychological/emotional, can impact one another. Thus it is important to consider the person’s

needs collectively rather than individually when developing the case management plan.

In developing the case management plan, the case manager needs to give priority to factors that

will be easily accomplished. Questions to be considered include:

Can the client accomplish the goal/s alone?

Can the goal be broken down into smaller tasks?

What resources are available to assist the client?

Is there someone who can help the client to implement the goal/s?

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3.3 Work with the Client to Identify the Full Range of Immediate, Short and Long-

Term Needs of the Client and Other Relevant Parties

A client’s needs may range from immediate safety issues, such as the risk of harm to self or to

others, to medical requirements relating to acute illnesses, and longer-term needs regarding

recovery and life management.

After the assessment, immediate needs are identified, and the case manager must ensure that these

needs are met. At the same time, short-term and long-term needs are recognised and included in

the plan to guarantee that these will be met in the longer term.

A useful roadmap for identifying needs is Maslow’s hierarchy of needs.

The hierarchy starts with the basic physical needs such as the need for food and shelter. The

second level of needs involves safety. Satisfying these needs involves protection from physical

harm, including living in a safe neighbourhood. The third level includes needs related to belonging.

Belonging needs are met when one is accepted and valued by a group, the family being the first

social grouping. The next tier involves self-esteem needs, and the final level is the need for self-

actualisation. The case manager first ensures that the client’s basic physical and safety needs are

met, and then works with him or her on meeting its other needs.

(Source: Maslow’s Hierarchy of Needs, Simply Psychology, 2016)

http://www.simplypsychology.org/maslow.html

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Identified immediate needs require an immediate response from the case manager, client or both.

You must work with the client to determine an immediate action plan, with clear time frames.

Ensure that it is clear to the client that immediate action and support is only to address immediate

concerns and that through the development of the case management plan, less urgent and longer-

term action planning can take place.

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3.4 Establish and Agree On Processes to Monitor and Change Case Plan

Monitoring of the case plan with the client helps to identify progress, prioritise next steps and

ensure efficiency in achieving goals. Monitoring occurs as an ongoing and proactive process to

constantly inform the client, case manager, agency, and other providers with progress, gaps and

areas of change.

A formal case plan review should be conducted every three to six months by the case manager

and client. A review will determine:

The frequency and depth of any reassessments needed.

Whether identified goals remain current.

If the plan is satisfactory to the client and service providers.

Any changes to the client, their situation or their environment.

If decision-making has helped towards identified goals and the impact of goal

achievements.

Whether all strategies are adequately resourced, and all partners are contributing towards

goal achievement.

Ensure that monitoring and review include accurate and timely case notes on all activities

undertaken and client responses to them. Organisations will benefit from conducting internal

audits of client files to ensure agency case management standards are maintained consistently.

Process to monitor and change case plan

Review progress and re-strategise

Identify barriers and respond to

change

Celebrate milestones

Review agency/service

involvement and possible transition or exit strategy

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Review progress and re-strategise

▪ Engage and support the client with acknowledgement of their capacity, growth, insight,

and motivation.

▪ Review the progress of the client towards planned outcomes, service and support activities

against the case plan.

▪ Update and/or refine case goals, strategies and objectives to meet client needs and ensure

goals are realistic and achievable. Consider the involvement of additional agencies or

supports if necessary.

▪ Document and acknowledge progress.

Identify barriers and respond to change

The monitoring process is likely to identify gaps or barriers to progressing objectives of the case

management plan. Work with the client and other service providers to identify the

challenges/barriers and openly problem-solve:

▪ Is the goal still relevant?

▪ Has the situation changed?

▪ Is there new information that needs to be considered?

Consideration of the client’s environment is critical to understanding barriers and developing best

responses.

Case managers will need to be creative and persistent, and provide an individualised response to

difficulties arising, working within the client’s capacity and service’s resources.

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Celebrate milestones

▪ Ensure recognition is given at any level of achievements toward goals.

▪ Celebrate the successes and acknowledge the efforts of all involved in helping to achieve

this. Ensure the client is acknowledged for their role and contribution.

Review agency/service involvement and possible transition or exit strategy

▪ Determine whether or not the client still requires agency/service involvement.

▪ Review if your service is still the most suitable/appropriate service to be providing the

lead case management role or if another service may now be more suited.

▪ If another service is identified as the preferred lead agency, take a proactive role in

respectfully integrating a transition to a new service. This is discussed further in the

evaluation, transition, or exit stage and should be planned well in advance to reduce any

potential client anxiety relating to this change.

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3.5 Identify Strategies to Deal with Complex or High-Risk Situations

Complex or high-risk situations that can be identified during case management planning include:

▪ Life-threatening/high-risk situations (thoughts of suicide/self-harm, violence/harm to

others, drug overdose, refusal of help/medication, etc.)

▪ Cases where at least three (3) of the following factors are combined:

o Serious/sustained abuse

o Multiple difficulties present in family

o Intellectual or psychiatric disability

o Chronic and serious drug addiction affecting individual’s capacity to participate in

their own care

▪ Where a wide range of other agencies are involved, for example, community services, legal,

medical and police agencies.

▪ Where involvement of protective and custodial agencies with the family has been over a

lengthy and sustained period.

▪ When the age of the client creates special considerations.

▪ Cases with high public/political sensitivity requiring sensitive and experienced case

investigation and management.

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Strategies to deal with complex or high-risk situations

Categorise risks and prioritise them to ensure that you can respond to the most urgent

situation(s) appropriately and immediately.

Assist the client in determining the urgency of need, and to recognise when personal

safety, or the safety of others, is at risk and take action to avoid harm.

Familiarise yourself with the service’s policy and procedure, protocol or process on dealing

with complex or high-risk situations.

Document information provided by the client very carefully.

Make a judgment whether the situation at hand is a crisis and requires a formal crisis

response.

In working with clients in a crisis, you are aiming to:

o Support the client to move out of the crisis phase as soon as possible

o Provide individual and agency support

o Mobilise the client’s own support system

o Use outside supports as required

Depending on the crisis, you may have a legal responsibility to notify authorities or

emergency services if needed. Even if it is not an emergency, your service may require you

to inform your supervisor when a crisis arises.

A major priority in crisis is to make sure people involved, including you, are safe and

secured from any immediate physical danger.

Arrange for immediate support for key people involved in the crisis. This includes

significant others and/or people who have involvement with the client now or in the past.

o Support can also be moral and/or emotional, such as arranging for debriefing for

people directly involved or for a friend/relative to be with your client during the time

of crisis.

Use crisis services or agencies as appropriate. Crisis services offer short-term assistance

and support. Many are specialist services which deal with people experiencing a particular

kind of crisis, such as:

o Emergency accommodation

o Material/financial aid

o Respite care

o Domestic violence outreach/refuge

o Sexual assault counselling/advocacy

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3.6 Match Requirements of Case Plan to Experience, Workload and Geographical

Location of Worker or Service Provider

Match requirements to experience, workload, and geographical location of worker

The practice of case management is complex, involving multiple roles and skills. The case

manager’s qualification and experience should be congruent with the skills required to fulfil his or

her case management responsibilities. Case managers should accept cases and duties only on the

basis of existing competence. Should the case manager need additional knowledge or skill to

perform case management responsibilities, he or she should pursue professional development

activities (including supervision and other activities) to acquire the necessary competence.

Workload is the amount of work required to successfully manage assigned cases and bring them

to resolution. Workload reflects the average time it takes a worker (1) to do the work required for

each assigned case and (2) complete other non-casework responsibilities.

The workload of the case manager must be considered

during case management planning as the complexity of cases

varies from one client to another. The complexity of the case

also dictates the involvement and the tasks that the case

manager will be responsible for.

The location of both the client and the case manager must

also match because additional time must be factored in for

planning, travelling, and post-visit activities. Contact

frequency must be included in the plan; specific types of

clients or intervention may require a high contact frequency at specific points of the case

management process.

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Match requirements to service providers

If the client requires support that does not fall within the scope of your agency, you may need to

investigate other options and refer them to another service provider. The following are the things

you need to consider to match the requirements of the case management plan to the service

providers available:

Is this the best possible service provider to refer to this client to?

Will they be able to adequately meet the needs of the client?

Are there specific protocols (cultural and/or otherwise) that must be followed to ensure

effective referral processes?

Understanding the services and requirements of the agencies that are going to be included in the

case management plan will enable you to provide best possible support to the client.

3.7 Assist Clients to Set and Achieve Realistic Targets for Change or Action and to

Take Personal Responsibility

Once the immediate, short- and long-term needs are identified, related strategies and specific goals

are developed to address these needs. Ensure goals are SMART.

Work with the client to identify their primary goal with you; this goal should be measurable, so

the client knows when it has been achieved.

Maximise the strengths of the client and their networks when determining actions and be

confident about client and agency resources and capacities.

Develop a plan of action for achieving goals with the client and include any other services to be

involved. Develop goals and strategies that are specific to achieving the desired outcomes.

SMART Goals

Specific

Measurable

Attainable

Realistic

Timely/Time-bound

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Strategies for motivating, supporting and encouraging the client to take personal

responsibility

Employing strategies to motivate, support, and encourage clients is one of the responsibilities of

case managers. There are a number of ways to support clients who need to be motivated, to make

decisions for themselves, to have the confidence to act on those decisions, and take responsibility.

You can encourage clients to take personal responsibility by:

Asking them how they think a situation should be handled, rather than telling them how

to handle it.

Assisting them to think of options based on prior success in their individual situation,

rather than options based on theory.

Assisting them to select an option rather than telling them which one to choose.

You can support clients to take personal responsibility by:

Encouraging them to reach a decision.

Emphasising that they have reached a decision and now they need to act on it.

Affirming their ability to make decisions and develop steps to reach their goals.

Also, offering or arranging practical help can support clients to take on personal responsibility. It

is important not to overlook practical matters, for example, those associated with a client’s

capacity to accept and access programs they are referred to. Attention to practical matters, such

as the cost of equipment or transport, can ensure that they are able to access programs and

resources more easily and increase the chance of their success.

However, it is important in this process to refrain from doing things for clients that they can do

for themselves. Encouraging dependency can disempower people, prolong intervention and set

up failure.

Focusing on the client’s strengths and what is working in their situation motivates them to take

on responsibility and move towards change.

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4. Monitor and Review Casework Activities and Processes

The case management plan needs to be treated as a dynamic document that can be updated in

response to the client’s changing needs. Not only many client’s needs change, but goals may no longer

be relevant or may have been achieved ahead of schedule. Case managers need to have formal

processes in place to regularly monitor and change the plan as required.

Monitoring and review mean evaluating progress on the case management plan to determine whether

it is effectively meeting goals or whether the plan needs to change. A plan will usually include review

dates to ensure this happens regularly.

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4.1 Implement Strategies to Regularly Monitor the Effectiveness of Case Management

Processes Against Agreed Goals, Service Provision and Client and Stakeholder

Satisfaction

When actions have been planned, work with the client to establish how the plan will be maintained

and reviewed. Together you need to decide how, and how often, the plan will be reviewed. If, as

part of the monitoring process, a client’s personal information is to be shared with another service,

written permission must be provided by the client.

The agreed monitoring and review activities and processes generally include:

Monitoring case plan implementation.

Facilitating review activities and feedback from workers on the progress of intervention.

Liaising with service providers and significant others.

Advising on how case plans can be modified, ensuring that changes are communicated

appropriately.

Regular meetings with client/families/significant others.

Referring to goal plans developed and individual’s progress towards these goals.

Strategies to regularly monitor the effectiveness of case management processes include:

Scheduling meetings at regular intervals

Preparing and distributing referral forms

Preparing and distributing feedback forms

Preparing and distributing client consent forms

Developing a directory of services

Developing methods of communication between services (phone, face-to-face meeting,

email)

Accompanying the client to a service

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4.2 Assess the Need for Changes in Case Plan and Develop Strategies for Appropriate

Alternatives and/or Ongoing Interventions

Regular and scheduled monitoring allows you and the client to celebrate achievements, review

progress and plan the next steps. It is also a chance to begin to work towards exit planning once

the client has made significant progress.

Monitoring is also a chance to check that the service system is working as it should. If a need is

not being met because a service is unavailable or unwilling to help, then advocacy or a change of

plans may be needed.

Review can take place one on one with the client or in a case management meeting

including workers from other services that are working with the person.

Work with the client through a review of achievement against the plan.

You may also work with the client through an analysis of change compared with the

original assessment tool.

Reviews can be scheduled regularly or triggered by a change in circumstance.

Case management plans are adjusted regularly to fit with changing priorities and goals. Some

considerations assist in assessing the need for changes include:

Has the identified problem changed or what is different?

Were the desired outcomes achieved?

What was not achieved?

What were the barriers that prevented goals being achieved?

To be able to develop strategies for appropriate alternatives and/or ongoing interventions, each

client is provided with opportunities for ongoing assessment and reassessment of their needs. Re-

assessment to be able to develop appropriate alternatives or to determine whether there is a need

to modify the case management plan may be necessary if there is:

Change in the client’s medical condition

Change in the client’s social stability and network

Quality care issue

Risk management issue

Concern regarding the transition/exit plan

Change in the client’s functional capacity and mobility

Evolving needs apart from those identified during assessment

Issues in the availability of community resources/services

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4.3 Negotiate with Relevant Parties any Proposed Changes Arising from Case Review

A schedule of regular meetings should be set up with the client. During these meetings, the plan

can be reviewed, and indicators of success examined. If it appears that targets are not being met,

the plan may need to be revised.

If agreed to by the client, the case manager should communicate with the service providers to gain

an insight into the client’s progress. Communication may occur through a formal meeting or

conference session, via telephone or in writing via email or letter.

Negotiating the revision of the case management plan and goals should always be in collaboration

with the client. Some clients are able to carry on with the work that needs to be done, while others

may remain ambivalent and hesitant.

The case manager must be flexible

enough to allow goals to be changed

or revised and to help clients explore

the possible barriers that will impact

on the client’s capacity to carry these

out. Negotiation with the clients is

easier if the evaluation process is

explained during initial interviews.

Apart from the clients, the case

manager must also negotiate with

other relevant parties especially

when there are changes arising from the case review. All relevant parties must be informed of the

proposed changes and must be provided with the opportunity to discuss the changes and reach

an agreement that will benefit the client.

Negotiation is an ongoing part of a collaboration with the client, support system or caregiver,

providers, and other pertinent stakeholders. The following steps may be used in negotiating with

them:

1. Identify the proposed changes from the case review.

2. Understand and explore the proposed changes. Identify whether these changes will pose

an issue or conflict with relevant stakeholders.

3. Identify the actual conflict and decide what must be achieved to resolve it.

4. Identify and explore alternatives by listing all the possible solutions—brainstorm if

necessary.

5. Choose a course of action and agree on it.

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4.4 Document All Casework Interventions in Compliance with Evidence-Based

Practice and Confidentiality Requirements

Case notes are an integral and important part of practice for case managers. Record-keeping

practices have an impact on client outcomes such that poor case notes can result in poor decision-

making and adverse client outcomes.

A case note is the term applied to a chronological record of interactions, observations and actions

relating to a particular client. It is also used to record details of the interaction of other services

regarding a client issue.

Information that should be included in a case note

The guiding principle for deciding what information should be included in a case note is whether

it is relevant to the service or support being provided. According to the Australian Association of

Social Workers (2016), the type of information that is considered relevant will depend on the

context of practice, however, below are some broad guidance:

A range of biopsychosocial, environmental and systemic factors impacting on the client.

This includes consideration of an individual’s culture, religion and spirituality.

Risk and resilience factors.

Facts, theory or research underpinning an assessment.

A record of all discussions and interactions with the client and persons/services involved

in the provision of support including referral information, telephone and email

correspondence.

A record of non-attendance, either by the case manager or the client, at scheduled and

agreed meetings or activities.

Evidence that the case manager and the client have discussed their respective legal and

ethical responsibilities, that may include:

o Client rights, responsibilities and complaints processes.

o The parameters of the service and support being offered and agreed to.

o Issues relating to informed consent, information sharing, confidentiality and privacy.

o Efforts to promote and support client self-determination and autonomy.

o Specific responsibilities to clients in particular settings (e.g. private practice or rural

settings).

o Professional boundaries and how dual relationships may be managed.

o Record-keeping and freedom of information.

o Discharge planning.

o Relevant legislative requirements and their possible implications for practice.

Details of reasons and any related actions or outcomes leading up to, or following, the

termination or interruption of a service or support.

https://www.aasw.asn.au/

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General principles for good record keeping

Information about a client should be impartial, accurate and complete with care taken to ensure

that:

Only details relevant to the provision of a support or service to which the client has

consented are recorded.

Information recorded is relevant to statutory practice, especially when working with

involuntary clients.

Notes are free from derogatory or emotive language.

Subjective opinions are qualified with relevant background information, theory or

research.

Relevant information is not omitted.

When recording information about third-parties, such as information about a client’s relationship

with significant others, it is equally important to separate fact from opinion.

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How and when should case notes be recorded

Case notes can be recorded manually or electronically and should:

Include on each page the name and date of birth or other identifying information of the

client. This can be handwritten, typed or constitute an electronic tag where an electronic

case recording program is utilised.

Be dated.

Be recorded as soon as possible after an interaction or event.

Be typed or clearly readable if handwritten.

Include the name, signature and profession/role of the author.

Include the time of contact, particularly where there is a high volume of interactions in a

day.

Changing or amending a case note

Care should be taken to avoid errors or omissions. In some instances, it is illegal to change, white-

out or amend case notes after the fact (on a later date).

If a change must be made to correct an error or omission, the change can be recorded as a new

and separate case note. In addition to outlining the error or omission as part of this new case note,

it is also advisable to:

Provide an explanation for the inaccuracy of the information recorded, and

add a note in the margin of the original case note referring the reader to the additional or

amended detail.

A case note should never be amended or changed in light of additional information obtained at a later date. This

should always constitute a new case note.

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Legislative responsibilities with regard to case note recording

Case notes may be subject to a range of legislative processes and requirements, during and

following, the conclusion of the professional relationship. The nature of these requirements may

differ greatly according to the State and the nature or context of practice.

Organisations may have policies and procedures for ensuring these and other legislative

obligations are met, in addition to general guidelines for case note recording and management.

As such, it is important for case managers to:

✓ Be familiar with the specific legal requirements and processes impacting on practice.

✓ Consider the implications of federal and State legislation to the recording of case notes.

✓ Understand how these requirements are implemented within your organisation (where

relevant).

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4.5 Implement Case Closure in Accordance with Organisation Procedures

The case manager should appropriately terminate case management services based on established

organisation procedures.

Case closure planning begins during the development of the case management plan and continues

throughout the entire case management process. The ultimate aim of case management is to

implement and identify a diverse range of formal and informal supports and resources to enhance

a client’s ability to be as independent as possible. The disengagement phase comes about when

the client reaches their nominated goals and is acting independently.

Case closure planning or exit planning is a supportive way to help clients prepare to continue

without the service you have been providing. Some services have guidelines that only allow service

provision for a time-limited period.

Possible reasons for case closure

The case manager may withdraw case management support for a number of reasons including the

following:

The client moves out of the service area

The case manager is unable to locate the client

Identified problems are resolved, and the client is now independent

The client enters a residential facility (i.e. nursing home, correctional centre, etc.) and

services are no longer needed

The client chooses to withdraw from services

Resources necessary to support the client are not available from your service

The client dies

Tasks to be completed for case closure

While all services will have specific requirements in relation to case closure, there are a number

of common tasks that need to be successfully completed in the process:

Identifying the need for the client to exit from the case management process.

Advising the client verbally and in writing of the decision and reasons to withdraw from

case management services.

Conducting an exit interview with the client, their family and their significant others to

facilitate transition to other services, if appropriate.

Reviewing the achievements of the case management plan in meeting agreed on goals.

Completing the transition process.

Collecting any supplied equipment.

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Notifying the client, all service providers and informal support networks of

relinquishment of the case management role.

Completing and securely storing all documentation.

Services need to determine what information they need to record when a client exits a service,

when the case is closed, and how that information is to be recorded.

Client exit form – may be used to record exit details and follow up plan

Exit planning checklist – an alternative to a client exit form is to keep a checklist of the

kinds of information you may need to record when a client leaves. This checklist can be

used as a prompt and the information recorded in case notes.

After the client has exited the service, it is important that the case manager maintain a relationship

to enable positive engagement and support to transition and stabilise into their accommodation

and the community.

This is formalised and implemented via outreach services to the client and in collaboration with

other service providers and significant people in the client’s life. Be sure to check your

organisation’s policies and procedures as not all services are able to provide this follow-up.

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II. ASSESS CO-EXISTING NEEDS

1. Prepare for Assessment

Assessment is a dynamic and ongoing

process of gathering and analysing relevant

information to determine appropriate

support services.

Due to the often-complex nature of the

issues facing clients, assessment is not

always a single event or a linear process.

Assessment occurs at different times

throughout case management.

It is essential to prepare for assessments to

ensure that the assessment process takes into account the different physical, emotional, social,

cognitive, and cultural needs of individuals. Establish rapport during initial consultations to identify

the need for assessments. When you identify a need, negotiate an appropriate time and place for

assessment, and inform the person about relevant policies, such as their right to privacy. The

individual also needs to provide their written consent for the assessment. To ensure the individual

understands the process, you need to arrange for an interpreting service.

When preparing for assessment, the following questions should be considered:

Is an assessment required?

What is the reason for the assessment?

What issues/needs are being assessed?

Which type of assessment will best address these needs/issues?

Will the assessment tool be relevant to the person’s individual characteristics and

circumstances?

What is my role in the assessment process?

Does the person require referral to a more qualified or specialised agency for assessment?

How will the assessment be conducted?

Where should you conduct the assessment?

What resources will you need to conduct the assessment?

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1.1 Identify and Prepare Assessment Tools and Processes According to Organisation

Policy and Procedures

A diverse range of assessment tools and processes are available for use in the community service

sector. Identification of the most appropriate assessment tool requires a thorough understanding

of the types of tools available, their use in different contexts, and the processes, policies,

procedures, and guidelines of your organisation.

Different types of assessments

The type of assessment required varies depending on the context and the person’s specific needs.

Generic assessment

Generic assessment involves the collection of information about a client’s situation in greater

depth. This information may include past and current health conditions, service utilisation,

socioeconomic and financial status, insurance coverage, home condition and safety, availability of

prior services, physical/emotional/cognitive functioning, psychosocial network system, self-care

knowledge and ability, and readiness for change. This type of assessment identifies the client’s key

problems to be addressed, as well as individual needs and interests.

Intake assessment

Intake assessment is the initial meeting with the client during which the case manager gathers

information to address the client’s immediate needs to encourage his/her engagement and

retention in services. This type of assessment may also be used to screen clients to determine if

they need case management services and if so, to determine the model of case management most

appropriate to meet a client’s needs and to assess the client’s willingness and readiness to engage

in case management services.

Social assessment

Social assessment is the process of determining individuals’ perceptions of their own needs or

quality of life, and their aspirations for the common good, through broad participation and the

application of multiple information-gathering activities designed to expand understanding of the

community. This type of assessment helps in identifying and interpreting the social conditions

and perceptions shared by the community or organisation level.

Social history report

Social history report focuses on, and describes, the social aspects of the client’s functioning and

their situation. This documents the social aspect of the past and current life experiences of the

client. Information collected can assist the social work practitioner or the case manager to better

understand the client’s level of functioning and the most appropriate plan of intervention.

Risk assessment

Risk assessment focuses on identifying any immediate or potential risks to the safety of the client

or others. This is used to determine the client’s vulnerability to harm and potential risk including

immediate housing circumstances, physical and mental health concerns and any external safety

risk, such as domestic or family violence.

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Biopsychosocial assessment

Biopsychosocial assessment is used to identify the unique contributions of multiple domains of

possible factors to an individual’s overall physical and psychological health. This approach looks

into the varying levels of physical, cognitive, emotional, behavioural, and environmental factors

that contribute to the overall assessment of a client.

Roles and responsibilities of the following who may be involved in the assessment process

Case Manager

The Case Manager’s role in the assessment process is to facilitate the ongoing gathering and

appraising of data from various sources to identify areas where the Case Manager and the client

will focus their efforts.

Responsibilities of the Case Manager include:

Ensuring that the clients understand their rights and responsibilities, supported by

evidence of the client’s consent

Gathering information about clients while respecting their confidentiality and privacy

Identifying and prioritising the client’s initial needs to inform more comprehensive

assessment once initial screening is completed

Understanding the client’s individual, diverse and/or special needs so that the appropriate

services and support for client development occurs

Stratifying and analysing risk factors that the client experience/may experience

Communicating the needs of the client which fall within the aims and objectives of the

program

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Considering the client’s current situation, probable future situation and ensuring holistic

needs

Communicating the criteria for disengagement with client

Facilitating information sharing across the client, key stakeholders and agency

Client

The client’s role is to collaborate with the case manager, agency and other key stakeholders in

determining his/her individual, diverse and special needs, including aspirations choices,

expectations, motivations, preferences and value.

Responsibilities of the client include:

Informing the service if they will not be available to attend an appointment

Respecting the rights of the case manager, staff, management, volunteers and other clients

Taking responsibility for the decisions that they make

Providing accurate and complete information that enables the case manager/staff to

provide appropriate service

Following through on tasks that have been agreed to

Respecting and abiding by the rules of the services (as long as these are reasonable and

have been agreed to in the first place)

Key stakeholders

The key stakeholders’ (a person or group with a direct interest, involvement, or concern regarding

the client and/or the case management care plan) role in the assessment process is to provide

input on the identified client needs and/or issues.

Responsibilities of the key stakeholders include:

Assisting the client and case manager in identifying diverse and/or special needs/s, risk

factors, and issues regarding the client’s level of competency/capacity

Collaborating with the client and case manager in prioritising and addressing risks, and

identifying risk management strategies

Participating in ongoing planning and consultation with the case manager and the client

Providing feedback on referrals to alternative programs or settings where the client’s

individual, diverse and/or special needs and goals can be met more appropriately as

suggested by the case manager

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Agency

The agency or provider’s role is to provide case management services to effectively and efficiently

coordinate and organise the range of services clients would be referred to in the health and

community services industry.

Responsibilities of the agency or provider include:

Providing equitable and non-discriminatory access to people eligible for service

Providing adequate information about the service, how services will be delivered, and how

the client will be involved in any decisions that affect them

Ensuring that there are documented policies and procedures to maintain client’s privacy

and confidentiality

Ensuring that policies and procedures for handling complaints are in place so that client

can raise issues and have them deal with in open and supportive environments

Providing services in a safe manner and secure environment

Responding effectively to a client’s decision to involve an advocate in their dealings with

the service

Roles and types of assessment tools

Assessment tools are used to support comprehensive assessment and provide baselines for future

assessments. It can also help identify the indications for particular interventions.

Types of assessment tools

▪ Demographics and background

▪ Employment and socioeconomic class

▪ Need for longer-term support

▪ Past medical history and background

▪ Previous agency involvements

▪ Psychosocial and behavioural health

▪ Psychosocial support systems

▪ Normed depression screening tools

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Assessment tools—reliability and validity

It is important to consider the reliability and validity of the results when using questionnaires and

screening tools. The tools should accurately measure what they are supposed to, and they should

be reliable in that they produce the same results across time and can be interpreted in the same

way by different case managers.

Methods of collecting information

▪ Self-reports – involves direct communication with the person. Corroboration from other

sources should be sought if the person’s capacity to provide accurate information is in

doubt.

▪ Informant reports – these reports from other key sources may be informal (family

members, carers and neighbours) or formal (GPs, service providers, teachers). It is often

assumed that carer reports will be more accurate than those provided by people

themselves.

▪ Health records – these are existing health records, such as referral summaries, medical

records or previous assessment reports, which can be accessed with the person’s consent.

Preparing for assessment

Prepare the client for assessment by clearly explaining the assessment processes, and ensuring that

he or she has the advocacy and additional support they require to complete the assessment and

express their needs.

Establishing rapport

When conducting complex assessments, it is important to first establish rapport with the client.

Assessments are often conducted in individual sessions, meaning one assessor is assessing one

client. There are several reasons why establishing rapport is important. Rapport:

▪ helps establish trust between the assessor and the client

▪ helps facilitate effective communication between the assessor and the client

▪ makes the client feel comfortable and more open to assessment

▪ helps the client to not feel judged or undervalued

▪ is required for valid testing and assessment, and accurate results

▪ minimises client apprehension and resistance

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Impact of the setting on the process

Arranging an assessment that involves other parties, such as the client’s family members or a

health professional must be scheduled at a time and location that suit all relevant parties. All

relevant parties must be informed of the time and place well ahead of schedule so they can make

arrangements.

The assessment must be conducted in a location that is convenient for the case manager, the

client, and other relevant parties. Ensure that the assessment will be conducted in a safe and secure

environment. There are times that the assessment will be conducted in the client’s home or in the

service. Even in different environments, the case manager is responsible for conducting the

assessment in a comfortable room that is private to ensure that confidentiality can be maintained

and that others cannot hear the conversation.

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1.2 Gather Existing Information about the Person

Establish the sorts of information you need as a basis for working with a client, thinking broadly

about what aspects of a person’s life will impact on his or her ability to achieve their goals.

Existing information about an individual can be gathered from a variety of sources. Additional

ways of collecting information include:

Interviews with the person

Questionnaires

Specific screening tools

Speaking with the person’s family members, guardian, carers, and friends

Speaking to other care workers and service providers

Observing the individual

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Assessment of needs and strengths across life domains may include, but are not limited to the

following:

Children

Cultural

Employment, education, and training

Health and well-being

Housing and accommodation

Interpersonal relationships (family and social systems)

Personal safety planning

Daily living requirements

Financial and legal

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1.3 Seek Additional Information from Specialists and Other Sources as Required to

Determine the Range of Issues that May Be Affecting the Person

Assistance from external and specialist assessment support may be required to undertake a

thorough assessment (e.g. psychiatric services, physiotherapy services, etc.). With the client’s

consent, use internal or external specialist supports to help inform the assessment.

Additional services which are currently involved, or have a history of involvement, can also inform

the assessment process. Such services can assist in validating information gathered.

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1.4 Organise Practical Aspects of Assessment in Consultation with the Person Being

Assessed

Prepare the client for assessment by clearly explaining the assessment processes and ensuring that

they have the advocacy and additional support they require to complete the assessment and

express their needs.

The practical aspects of the assessment must be discussed with the client. These aspects include

the:

Reason for the assessment

Role of the client in the assessment process

Role of the case manager in the assessment process

Where and how the assessment will be conducted

Rights of the client, including his or her right to:

o Privacy and confidentiality

o Refuse to give personal information

o Access personal information

o Make a complaint

Legal and ethical considerations to guide your assessment practice

▪ Confidentiality - There is an obligation that restricts an individual or organisation from using

or disclosing information about a person that is outside of the scope for which the

information was collected. In the course of the assessment process, the case manager must

treat all information as confidential, unless otherwise required by law.

▪ Disclosure - Information about clients or confidences made by clients and others must not

be disclosed, unless:

o Client’s consent is in existence

o Required by law

o There are compelling and overwhelming moral and ethical reasons for disclosure.

When and if records are required to be shared across professions or agencies, information

will be disclosed only to the extent that it reasonably addresses/supports the client’s needs

and meets the essential requirements of those to be notified.

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▪ Duty of care - The obligation to take responsible care to avoid injury to a person whom, it

can be reasonably foreseen, might be injured by an act or omission. Duty of care exists

when someone’s actions could reasonably be expected to affect other people.

A breach of duty of care exists when it is proven that the person who is negligent has not

provided the appropriate standard of care.

▪ Informed consent - The client must be given sufficient information about assessment to make

a decision for consent to be given voluntarily. Without full consent, assessment should

not take place.

Before assessment commences, the client must fully understand and consent to:

o The assessment taking place

o The purpose of the assessment

o How assessment is conducted

o The dissemination of assessment results and personal information to other relevant

parties

▪ Privacy - Client’s records must be protected, stored and secured, and where applicable,

retained for any required statutory period.

When and if records are required to be shared across professions or agencies, information

will be disclosed only to the extent that it reasonably addresses/supports the client’s needs

and meets the essential requirements of those to be notified.

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1.5 Provide Information About the Assessment Process to the Person and Obtain

Consent

Client involvement in the assessment and selection of services to meet their needs is good

professional practice, but there is also a legal obligation to obtain client consent. Some legislation

(e.g. Child Protection Act of 1999, Qld) enshrines the client’s right to participate in decision-making

related to case management.

Before assessment commences, the client must fully understand and consent to:

The assessment taking place

The purpose of assessment

How the assessment is conducted

The dissemination of assessment results and personal information to other relevant parties

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The essential elements of the law about consent are as follows:

The person who is giving consent must

have the intellectual capacity and maturity

to understand the situation they are

consenting to, the choices that are

available and the consequences of their

decisions (i.e. the likely risks and benefits).

This applies to all people, regardless of age

and whether or not they have a disability.

In order for a person to provide informed

consent, the person must be given

sufficient accurate information about the matter or procedure, and that information must

be presented in such a way that the person can fully understand it.

Any consent must be freely given and must not be obtained by force, threat, deception or

undue influence.

A person may be able to make decisions and give valid consent in some areas of their life

but not in others depending on their skills and experience.

Consent must be obtained in writing from the client being assessed. The record of consent must

detail exactly what the client has consented to. If the assessment results need to be shared, the

client must be informed about who results will be shared with and the purpose of sharing results.

The record of consent must be filed according to organisation policies.

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2. Analyse the Person’s Needs Using a Collaborative Approach

The analysis and prioritisation of needs identified during assessment should be undertaken in

collaboration with the person and, if necessary, through consultation with a specialist. A specialist’s

input is of particular importance if the person’s needs are complex and urgent. Once the needs are

identified, information about available services can be compiled and the person’s eligibility to access

the services can be determined. Decisions about how to proceed can then be made by the client.

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2.1 Work Within Scope of Own Role and Seek Assistance from Colleagues and Experts

as Required

The scope of work provided by a case manager varies according to organisation context. In many

services, a particular case manager takes on the responsibility for providing support consistently

to a client. Day-to-day tasks may be carried out by other staff or workers. However, the case

manager completes the assessments (where appropriate) and gathers other relevant information.

The case manager may need to consult with others when analysing client assessment results, such

as other workers or service providers who have provided input to the process. For example, where

a psychologist has identified that a client is depressed, the case manager may need to discuss how

this may affect other areas of the client’s life, such as their ability to engage in self-care tasks and

relate to others. It is a must that the case manager adheres to his or her own work role and

responsibilities and does not attempt to interpret results outside his or her own scope of practice.

It is important to clarify your own work role and work with organisational protocols, your scope

of practice, your position description and your qualifications. When necessary, seek assistance

from colleagues and experts.

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2.2 Empower the Person to Identify and Prioritise Their Own Needs

Empowerment is the ongoing capacity of individuals to act on their own behalf to achieve a

greater measure of control over their lives and destinies. Empowerment is consistent with a

collaborative approach and client self-determination.

Use verbal and nonverbal communication skills, such as empathy, active listening and maintaining

eye contact when identifying the diverse needs of the client. Effective interpersonal

communication skills can be used to communicate respect and empower clients.

By assisting the client to identify their own needs, the case manager empowers him or her and

enhances his or her participation in the assessment process. It is good practice to prioritise needs

in close collaboration with the client, and if necessary, with the client’s family, guardian or carer.

Viewing the client as an equal, who plays an important role in the case management process,

promotes the client’s sense of control and self-efficacy, which in turn promotes active

participation in dealing with issues.

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2.3 Evaluate Needs Based on Full Range of Relevant Information

Case managers need to adopt an approach that emphasises the need to look at the whole person

and consider their physical, environmental, emotional, social, spiritual, and lifestyle situation. To

achieve this, the case manager must attempt to understand the interplay of personal, relationship,

and social factors that affect the current situation for each client.

In evaluating the client’s needs based on a full range of relevant information, the case manager

should:

Appreciate the complexity of the client’s concerns/situations and the environment in

which these concerns/situations occur.

Understand how these concerns/situations affect the client in all aspects of their

functioning; physical, emotional, spiritual, and mental.

Establish an effective and trusting relationship with the client to be able to explore their

needs.

Liaise with other significant people or organisations in the client’s life to facilitate the

client’s goals and action plans.

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2.4 Identify and Analyse Complex, Multiple and Interrelated Issues

Working with clients in a holistic approach allows the case manager to realise that individuals and

the situations in which they find themselves, may be very complex. Clients are likely to present

with multiple issues, and it is the case manager’s task to be able to effectively identify and analyse

these possible interrelated issues.

People with complex needs may have to negotiate several issues in their life, such as physical or

mental illness, substance abuse and disability. They may be living in unsatisfactory circumstances

and lack access to suitable housing, employment or meaningful daily activities.

Each individual with multiple and complex needs has unique concerns tied closely to the

interaction between his/her social, economic and health care needs, and so requires an

individualised response.

The case manager must apply his or her knowledge of complex issues to identify specific needs.

This includes working with an awareness that one complex issue will often obscure another.

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Cycle of Disadvantage

A common feature of many clients, who present with complex needs, is a history of

marginalisation and disadvantage, trauma (including childhood and/or adult sexual, physical

and/or emotional abuse), dysfunctional family relationships, low education attainment, low or no

employment and stigmatisation.

(Source: Complex Needs Capable, NADA, 2013)

http://www.nada.org.au/media/45224/complex_needs_capable_web_120813.pdf

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MENTAL HEALTH

Many people with mental illness have a complex array of needs that must be considered. Rates of mental illness are high for people with intellectual disability, autism spectrum disorders, alcohol and drug use, physical disability, brain injury, problematic gambling, and those who are experiencing homelessness. Multiple physical health problems are also commonly present. Many people with high and complex needs remain undiagnosed and not effectively connected to mental health services.

The experience of coexisting conditions frequently goes hand in hand with:

Financial problems

Lack of family or carer

Lack of housing

Loneliness and social isolation

Poor physical health and disease

Stigma and discrimination

Uncontrollable symptoms of mental illness

Unemployment

ALCOHOL AND OTHER DRUGS

Although drug and alcohol misuse is the primary presenting need for a person seeking to access drug and alcohol programs, all people present with multiple needs that may include:

Borderline personality disorder

Child protection issues

Cognitive impairment

Criminal justice system involvement

Family breakdown

Homelessness

Mental illness

Poor physical health

Unemployment

Every person accessing drug and alcohol services has multiple needs. However, it is the interaction of these multiple needs that leads to complexity.

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IMPRISONMENT

People may come into contact with services at a number of points in the criminal justice system. They may self- refer before their offending matters come to the attention of the police or courts, be referred by the court as part of their bail or sentencing conditions, be on a diversion program, or have finished their sentence and be exiting prison.

There are many health and social factors that are overrepresented in people involved in the criminal justice system as compared to the general population. These

include higher levels of drug and alcohol problems, mental health issues and cognitive impairment. Other complex issues may include:

Abuse

Dysfunctional relationships and domestic violence

Neglect and trauma

Parental incarceration: juvenile detention

Poor educational attainment and consequent limited employment opportunities

Previous episodes of imprisonment

Unstable housing

CHILD PROTECTION

Child protection involves the protection of all children and young people from harm or neglect. There are many different causes of harm that can have a detrimental effect on a child’s physical or emotional health, development and well-being. Forms of child abuse include neglect, physical, sexual or emotional. Children who require protection are those who have suffered harm, are presently suffering harm or those who are at risk of suffering significant harm. These injuries can impact a child’s mental health. Children who suffer from abuse or neglect may experience effects of low self-

esteem, anxiety, depression or PTSD. Neglect can impact upon a child’s cognitive development due to lack of adequate cognitive stimulation. Physical health may also be impacted due to poor nutrition, injury and lack of medical care.

There are many factors that may contribute to child abuse, and poverty has been considered the single best predictor of child neglect. While these issues alone are not indicative that child abuse is occurring, in some instances they may impact upon the parent’s ability to ensure that a child is safe from harm or neglect. Other potential indicators of child abuse include lack of support, unemployment, financial pressures, poverty, mental health issues, limited parenting skills, and alcohol and drug dependence.

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FAMILY VIOLENCE

Domestic violence occurs in both heterosexual and homosexual relationships and includes married, de facto and separated adolescents and adults. Domestic violence is also commonly referred to as relationship violence, intimate partner violence and gender-based violence. In Indigenous communities, ‘family violence’ is often the preferred term as it encapsulates the broader issue of violence within extended families.

Domestic violence is not limited to physical violence and involves a range of different forms of abuse: sexual, psychological, social, and economic abuse. It is also associated with a range of problems, such as:

Child maltreatment and neglect

Impact on general health and well-being of individuals by causing physical injury, anxiety, depression, impairing social skills

Increased likelihood of engaging in practices harmful to health (e.g., self-harm or substance abuse

Physical abuse which also increases the risk of criminal offending and a significant proportion of women in prison

HOMELESSNESS

‘Homeless’ is statistically defined as a person who does not have suitable accommodation alternatives. They are considered homeless if their current living arrangement:

Is in a dwelling that is inadequate.

Has no tenure, or if their initial tenure is short and not extendable.

Does not allow them to have control of and access to space for social relations.

A number of complex, multiple and interrelated issues linked to people experiencing homelessness include:

Discrimination

Domestic and family violence

Lack of income

Mental illness

Physical health and disability

Poverty

Substance addiction

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POVERTY

Poverty describes the inability to afford essential goods and services that most people take for granted. People living in poverty not only have low levels of income, they also miss out on opportunities and resources such as adequate health and dental care, housing, education, employment opportunities, food and recreation. Consequently, the living standards of people in poverty fall below overall community standards.

Poverty is a complex situation by itself and is made more complex by the following interrelated issues:

Abuse, neglect and trauma

Discrimination

Dysfunctional relationships

Family violence

Greater levels of physical and mental illness

Health risks, such as smoking and poor diet

Homelessness

HEALTH

People who have complex health needs require both medical and social services and support from a wide variety of providers and caregivers. Chronic and complex health care arises due to the impact and severity of diagnoses and/or conditions. Chronic and complex health care issues are characterised by those that involve many risk factors, may take time to develop, resulting in a long illness (which often cannot

be cured), or can lead to functional impairment or disability.

Multiple, interrelated issues which may affect the complexity of one’s health condition may include:

Conflicting conditions, chronic pain, medication intolerance, unexplained symptoms, cognitive issues

Depression resulting in poor medication adherence, addiction and anxiety

Family stressors or neglect/abuse

Low levels of health literacy

Unaffordability of medication due to poverty or unemployment

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AGE

Clients with complex needs can be of any age. Many issues can impact the client’s age and his or her ability to participate in the management of his or her needs. These include issues related to transport, physical access, social acceptance, and communication. The needs of some clients, who have complex needs, will change over time as they age.

DISABILITY

According to the Australian Institute of Health and Welfare, over half of Australians with disability had a combination of two or more intellectual, psychiatric, sensory/speech, acquired brain injury and physical/diverse disabilities.

Support needs of people with early onset multiple disabilities vary depending on the nature of their disabilities and their life stages. As they grow older, they may have higher support needs at an earlier age than people with single or late-onset disability.

The more disabilities people had, the more likely they were to need help with ‘core’ daily activities of self-care, mobility and communication. Some combinations of disabilities had more marked effects on people’s activity, participation in major life areas and related need for assistance.

A substantial proportion of care for people with multiple disabilities was provided by their family members and friends.

Multiple, interrelated issues which may affect the complexity of one’s disability may include:

Abuse, neglect, and trauma

Assistance with core activities

Community/social participation restrictions (inability to go out more due to disability)

Discrimination

Drug use

Dysfunctional relationships

Education restrictions

Homelessness

Mental health problems

Significant behaviour problems (e.g., difficult behaviour)

Unemployment

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BEHAVIOURS OF CONCERN

Behaviours of concern were previously known as challenging behaviours. A behaviour is considered to be of concern when it threatens the quality of life or physical safety of an individual, other people such as family or carers, or the community. This term is used to describe behaviour that interferes with an individual’s support and daily life. Examples of behaviours of concern include:

Verbal or physical aggression

▪ Indicators of imminent harm to others

o Social withdrawal

o Excessive feelings of isolation or rejection

o Being a victim of violence

o Feelings of being picked on or persecuted

o Verbal and/or non-verbal expression of violence

o Uncontrolled anger

o Patterns of impulsive and chronic hitting, intimidating, and bullying behaviours

o History of violent and aggressive behaviour

o Intolerance of differences and prejudicial attitude

o Drug or alcohol abuse

o Inappropriate access to, possession of, and use of firearms

Self-harm

▪ Indicators of self-harm

o Behaviour changes, severe anxiety, or extreme agitation

o Withdrawing from family, friends, and society

o Engaging in risky behaviours or activities

o Displaying dramatic mood changes

o Communicating an intent to kill or harm oneself or other suicide ‘talk’

o Preoccupation with death and dying

o Increasing alcohol and drug use

o Giving away special possessions

o Loss of interest in usual activities

o Actively looking for ways to kill oneself

o Dramatic changes in personal appearance

Destruction of property

Impulsive or dangerous behaviour

Disinhibition

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Hyper-sexuality

A disorder or injury can affect the brain functions which control emotions, impulses, self-awareness and the ability to monitor behaviour. Other interrelated issues include:

Alcohol and/or drug issues

Dual diagnosis (diagnosed as having more than one condition)

Issues related to past experience of trauma or neglect

Multiple disabilities, adversities and/or disadvantages

Severe or profound intellectual disability

Significant medical conditions and/or deteriorating health

EMPLOYMENT

The complex and interrelated factors that may contribute to, or result from, unemployment must be considered when determining a person’s service requirements.

For instance, if a person who is unemployed, homeless, has an untreated mental illness and a physical illness, they may require a coordinated multi-agency approach. Housing and financial services, medical and mental health services may all be required to support the person to address needs in order to contribute to the person’s work-readiness.

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CULTURE AND RELIGION

Case managers are facing new challenges in case management planning for a diverse population, which can present barriers to the traditional case management plan due to cultural and religious beliefs. Almost one quarter of Australia’s population were born in another country, yet mainstream services mirror only broad Australian values and attitudes. Many multicultural clients may prefer to talk with a Case Manager from their own cultural background, but often this may not be possible. It is therefore important that case managers are able to offer a consistent and competent service to all clients regardless of their culture and religion.

While a person’s cultural, ethnic, or religious identity is likely to have a significant influence on his or her needs, other related issues may include:

Age, gender, education, and socioeconomic status

Denial of human rights, forced separation from members of their family/family fragmentation (specifically with refugees)

Exploitation

Exposure to violence (domestic and family violence)

Homelessness

Illness and starvation

Level of proficiency in English

Physical, emotional, and sexual abuse

Racism and discrimination

Unemployment

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2.5 Evaluate Issues of Urgency and Eligibility

At times, an assessment made may require immediate response from the case manager, client or

both. As much as possible, the case manager must work with the client to determine an immediate

action plan, with clear time frames.

Ensure it is clear to the client that immediate action and support is only to address immediate

concerns, and that through the development of case plan, less urgent and longer-term action

planning can take place.

Evaluate the individual’s eligibility

Eligibility is the process where client’s needs

and characteristics are compared against

criteria for acceptance into programs or

service.

When a client is taken into a service or is

referred to another service, the case manager

must be aware of the eligibility criteria for

each service. Many organisations have

criteria which specify who can and cannot

access a particular service. Sometimes, these

are determined by the agreements that

organisations have with their funding

bodies. For example, a service may only take

young people between the ages of 12 and 24,

or a disability service may only take clients who are in receipt of a disability pension. The case

manager needs to be aware of the eligibility criteria for his or her service and to find out about

other services before a client is referred.

Agencies and organisations are usually restricted by the number of clients they can have. An

accommodation service will have a limited number of beds, as well as a detox unit. A counselling

service will need to control the caseload of their workers, and many centres have waiting lists

because of this. It is up to the case manager to keep well informed about what is currently available

in their area and know whether services have waiting lists.

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2.6 Assess Potential Risk Factors for Service Delivery

Risk factors are the aspects of a person (or group) and environment or personal experience that

make it more likely or less likely that people will experience a given problem or achieve a desired

outcome. Risk factors are key to figuring out how to address concerns/issues/needs. It is a matter

of taking a step back from the problem, looking at the behaviours and conditions that originally

caused it, and then figuring out how to change those conditions. The more risk factors a person

has, the greater the likelihood they will engage in a given unhealthy behaviour.

Assessing potential risk factors for service delivery can be accomplished using a risk assessment

tool. One good example is the SAAP client risk assessment tool.

*Double click on the icon above to open the assessment tool

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3. Determine Appropriate Services

3.1 Consider Service Delivery and Referral Options from Strengths-Based Perspective

Individuals often need supports and resources that may include people, organisations,

information, knowledge, material resources, and decision-making resources. For many community

agencies, their mandate and identity are often reflected in the type of services and resources they

offer. This can be a challenge in that the services offered takes a central role in the delivery model

practised; this is what we offer, and the client needs to accommodate.

In a strengths-based perspective, not only are the types of resources important but how they are

offered and mobilised to complement the intended client’s strengths and goals is just as important.

If external resources and supports are not offered in the context of what is meaningful and

building upon the person’s existing strengths and resources, it can undermine the person’s ability

to learn and be self-determining. It can send a message such as: ‘You have no strengths that are

relevant’.

(Source: A Strengths-Based Perspective, Hammond and Zimmerman, 2017)

Reasons for referral

What are some reasons for needing to refer a client?

The client may ask to be referred to another service.

The client may have underlying issues that need to be dealt with by someone who

specialises in that area (e.g. sexual assault issues, detox).

The client may be dealing with multiple issues (e.g. mental health issues as well as drug

dependency) or with multiple drug use.

The client may need specialist care (e.g. they may have an acquired brain injury or a

disability that requires special equipment).

The client may feel more comfortable working with people of a particular cultural or

linguistic background.

The case manager might not have the skills or experience to work with some clients.

The case manager may not have been very successful in helping a client.

The client might be moving to a new suburb or location.

The case manager might be leaving their job at the agency.

A person’s strengths and capabalities are supported as

necessary by resources in their natural networks.

If necessary, commonly used

community resources are added,

and

only if necessary, specialised resources

are introduced.

https://www.esd.ca/Programs/Resiliency/Documents/RSL_STRENGTH_BASED_PERSPECTIVE.pdf

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There are also situations when we may choose not to refer a client, despite the fact that we are

not able to provide the perfect service for them. Such scenarios could include:

The client has started making changes in their lives and referring them to another service

could interrupt the change process.

A client has had a negative experience with another service and refuses the referral.

Other issues impact on the success of the referral (e.g. the service is too far away, or the

client has no transport, or there is no childcare or no interpreter service).

There are no places available at the other service, and the client would have to be placed

on a waiting list.

In these circumstances, you would be better to maintain the client at your service until the situation

alters.

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3.2 Evaluate Internal Capability and Other Service Networks to Determine Best Fit

for the Person

Your organisation will be able to cater to some needs, but not all. It is, therefore, appropriate to

find out about services other agencies and organisations provide. There are benefits to including

external support mechanisms: client will have access to a wider range of services, will have a

broader support network, and will be less likely to become dependent on you or your agency.

You can learn more about other agencies and service providers by:

Joining professional networks

Subscribing to other organisations’ mailing lists

Using an Internet directory (e.g. https://www.infoxchange.org/au/)

Speaking with clients about services they are currently using or have used in the past

Contacting other organisations to clarify details about the services they provide

Reading your local paper. Local newspapers often provide paid and unpaid publicity for a

variety of community-based organisations

Your role, as the case manager, is to sort through the options with your client to let them know

what is available. To accomplish this, you need a good understanding of the services in your area

and should be able to accurately assess the needs of the client.

Keep up to date with what is available and what the criteria are for entry to other services. Try to

keep track of changes in staffing as well as policy changes that might affect the type of services

that an organisation delivers.

Maintaining a database or contact list is a good way to manage information about available service

and support options, so you always have access to the information you need.

https://www.infoxchange.org/au/

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3.3 Provide the Person with Service Information and Support Their Decision-Making

Process

Clients have the right to be informed about different service options so that they can make

decisions about which option will best meet their needs. It is important to encourage and support

clients in making decisions that are consistent with their case management plan. As the case

manager, you must identify, seek out and make available any support required to assist people to

make their own decisions and act upon them.

There are some common factors which can affect the client’s ability to make good decisions.

However, most can be addressed with some thought about how they affect each individual. Some

of these include:

The type of decision being made

Timing

The complexity of the decision

The urgency of the decision

Currency of the decision

The availability of information

The physical environment

The sensitivity of the decision

Personal issues faced by the person

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3.4 Encourage the Person to Advocate on Their Own Behalf to Access Services

At times, case managers will need to advocate on behalf of their client to ensure access to adequate

supports and the involvement of relevant services. Be clear about the need for which you are

advocating and the reason the involvement of others is critical.

There are also times that a client may wish to refer themselves to a service. This is desirable, so,

where possible, the client should be encouraged to self-refer. Clients need to:

Be aware of how to approach service providers and make their needs known.

Have skills in communicating to express what they need to find out about their

responsibilities.

Have the confidence to ask questions and approach new people.

Be literate so they can read information from the service provider and fill out appropriate

forms.

The case manager has to find out about the client’s level of competence by accessing other

assessments, watching the client, interacting with them, speaking with others involved in the

client’s care and asking the client.

It is the case manager’s job to ensure that clients are equipped to self-refer. To assist the client to

advocate on his or her own behalf and to promote their autonomy, the case manager should:

Provide the client with information about how to self-refer.

Helping the client develop communication skills through role-plays.

Encourage the client by providing positive feedback and engaging in other reaffirming

activities.

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Keep in mind that high-level support is not always the best form of support. The best form of

support is one that encourages client competence, self-worth and self-efficacy as well as facilitating

access to appropriate services.

The following diagram shows examples of different levels of support.

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4. Complete Reporting

4.1 Document the Outcomes of the Assessment Process According to Organisation

Procedures

Documentation is perhaps the most important part of case management. Documentation serves

as the proof that services were rendered. An organisation’s policies and procedures provide

specific guidelines for documenting the outcome of the assessment process. If you are unsure of

the policies and procedures that apply in your workplace, ask a more experienced co-worker to

assist you, or refer you to your organisation’s guidelines or manuals.

Documentation of the outcomes of the assessment process may vary on the basis of organisational

setting and practice speciality. What is important is that it should reflect the individual needs and

strengths of each client. Assessment process documentation with the client and other members

of the client’s system may include the following domains, as they pertain to client priorities,

strengths, and service needs:

Motivating factors in seeking case management services or reason for referral to the social

work case manager.

Living arrangements, including suitability and safety of the home environment.

Vocational history (for example, employment, education, volunteer work, or significant

hobbies), challenges, and goals.

Language preferences and proficiency levels.

Preferred methods of communication and learning (such as oral explanation, written

information, or practical demonstration).

Degrees of literacy, including health, behavioural health, and financial literacy.

Cultural values, beliefs, and practices (including, but not limited to, spirituality and

religion) related to client’s goals for case management.

Effects of culturally based

discrimination on client’s ability to

realise case management goals.

Psychosocial strengths, protective

factors, and points of resilience.

Family composition, structure,

roles, and communication patterns.

Relationships with community

organisations or other social supports.

Physical, cognitive, and psychosocial functioning, including the ability to fulfil social roles.

Desire and capacity for independence.

Desire for support from other members of the family or client system.

Desire and capacity of family or other members of the client system to support the client.

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Need for economic or other psychosocial resources, supports, and services ability to

navigate relevant service systems (such as educational, employment, healthcare, housing,

legal, nutritional, social services, or transportation systems).

Individual and systemic barriers to client’s participation in the community or use of

resources and services.

Changes in resources, policies, and programs needed to support the client and, if

applicable, other members of the family system.

Behavioural health, including coping style, crisis management skills, substance use history,

and risk of suicide or homicide.

Health conditions and impact of those conditions on the client’s goals.

Risk of abuse, neglect, or exploitation of or by the client, and underlying causes for such

mistreatment.

Lifespan planning (which may include advance care planning, anticipation of caregiving

responsibilities, permanency planning for minor children, retirement planning, or other

domains).

Past strategies used to resolve the client’s concerns or enhance the client’s strengths.

Client’s perceptions of changes needed to improve her or his situation.

Client’s engagement in case management process and participation in shared decision

making.

Congruence with, and adherence to, pre-existing service plans.

Patterns of service over- and underutilisation.

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4.2 Maintain and Store the Person’s Information According to Confidentiality

Requirements

Confidentiality is the protection of personal information. Confidentiality means keeping a client’s

information between you and the client, and not telling others including co-workers, friends,

family, etc.

Examples of maintaining confidentiality include:

Individual files are locked and secured.

Support workers do not tell other people what is in a client’s file unless they have

permission from the client.

Information about clients is not told to people who do not need to know.

Client’s medical details are not discussed without consent.

Adult clients have the right to keep any information about themselves confidential, which

includes that information being kept from family and friends.

There is, however, no such thing as absolute confidentiality in the case management industry.

Case managers and workers are required to keep notes on all interactions with clients and often

to keep statistics about who is seen and what issues are addressed.

There are few exceptions to the general rule of confidentiality, and they all have legal bases. These

include:

If the client tells you they have committed a serious crime.

If the client is a child and is being abused or is at risk of abuse.

If you are concerned that the client might harm themselves or someone else.

If a child is under the age of 16 years, and especially under the age of 14, parents legally

have the right to know what happens in counselling.

Making records available to the police if they have a warrant to inspect documents.

Making information available in the case of suspected or confirmed physical or sexual

abuse.

Responding to a summons or subpoena.

Responding to a request under freedom of information legislation.

In the case where legal obligations override a client’s right to keep information private and

confidential, a community service organisation has the responsibility to inform the client and

explain in a way that they can understand, the limits of confidentiality.

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Checkpoint! Let’s Review

1. All case managers need to be aware that there are State and federal laws the cover confidentiality. Research these Acts related to privacy and confidentiality of clients. Write your answers in the space provided.

Answers:

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4.3 Provide the Person’s Information to Other Services According to Consent and

Confidentiality Requirements

As much as maintaining confidentiality within the service is important, it is also essential to ensure

that client privacy is protected when liaising with external agencies.

Services should ensure with all referrals, that appropriate and accurate information is provided.

The only information that needs to be shared is basic contact details for the client, the reason for

the referral, the extent and nature of your involvement with the client and your role in the future.

Under the freedom of information legislation, clients are within their rights to request to see their

client file. Any written correspondence in relation to the client is kept in this file. Wherever

possible, work in close partnership with your client, initiate the referral together and agree on what

information needs to be shared.

Bear in mind that another important consideration in sharing information is not withholding

information that the service should know if they are to fulfil their duty of care to the client and

other clients within the service.

Client permission must be gained (preferably in writing) before sharing information. It is a good

idea to discuss with the client what you are going to talk about with the other agency. Also, be

sure that the client understands the policy and criteria of the service to which they are being

referred.

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5. Evaluate Assessment and Referral Processes

5.1 Seek Feedback About Assessment Processes from the Person and Other Networks

Obtaining feedback from clients and other networks is important in ensuring that on an individual

level, the assessment processes utilised are

continuing to meet client needs which may

change over time, and on a broader level to

obtain information that will be useful for case

management planning. However, clients tend to

provide very little formal feedback on the

assessment. For this reason, case managers

should encourage informal feedback from

clients to provide varied and frequent

opportunities to give feedback.

Opportunities for informal feedback include:

Discussing the assessment process informally with clients and other networks during

follow-ups via email, phone or face-to-face.

Encouraging clients to talk on a one-to-one basis about their needs and the services

provided.

Feedback concerning difficulties with the assessment process, way to improve the processes or

positive feedback on specific aspects of the assessment should be briefly recorded in writing in

the client’s case notes.

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5.2 Monitor Processes and Their Outcomes in Terms of Success in Meeting the

Person’s Needs

Assessment is an ongoing activity, not a one-time event. Reassessment serves both monitoring

and evaluative functions, enabling the case manager and the client to determine whether services

have been effective in helping achieve the client’s goals. During the reassessment process, the case

manager and client, and if appropriate, the other support systems of the client, revisit the needs,

assets, and priorities identified in the initial assessment and discuss the client’s emerging concerns.

On the basis of such reassessment, the case manager and the client may determine the case

manager goals or service plans that need to be adjusted.

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5.3 Routinely Seek Feedback and Reflect on Own Performance

As part of your work as a case manager, you should also evaluate how well you are using and

developing your professional skills.

Reflective practice is when one takes the time to think about what he or she has been doing at

work and how well he or she has been doing it. Reflective practice is the process of monitoring

and analysing our work so that you can improve our work practices.

Self-evaluation is a circular process. One reflects on what has happened, he or she adjusts his or

her responses or practise new skills, implement these responses or new skills and then repeat the

reflection process again.

Seeking feedback from others

Self-evaluation is important for case managers in order to identify and develop their skills in a

constantly changing work environment. Part of a case manager’s professional development

involves securing feedback about our individual performance from a variety of sources.

Feedback about one’s performance can be sought from:

Clients

Members of the work team

Other workers in the service

Workers in related services/agencies

Colleagues, peers, team leaders, supervisors, and managers

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5.4 Use Feedback and Own Evaluation as a Basis for Improving Processes

As in all aspects of case management, the processes utilised, and the services provided, should be

continually reviewed to ensure these are relevant, appropriate, and effective. Evaluation helps case

managers to recognise and use resources in the most effective and efficient way possible. It makes

him or her accountable for the actions he or she take and the decisions we make. There is no

point in seeking and receiving feedback about how services can be improved if the information

will not be used to actually redevelop processes or resources, or change the way service is

provided. It must be ensured that there is a process in place where feedback is reviewed by staff

and management and suggested changes are implemented.

Using feedback and own evaluation allows case managers to:

Determine the effectiveness of the services provided.

See whether a particular intervention was appropriate for the client.

Minimise the effects of an intervention that is inappropriate.

Bring about improvements in the services delivered.

Respond to controversy or criticism.

Provide information to management and funding bodies.

Enable planning for the future about the types of services that are provided.

Draw conclusions about what works best for clients.

Review and reflect on the skills and strategies utilised.

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III. COORDINATE COMPLEX CASE REQUIREMENTS

Complex needs are not easily defined. They depend on the individual and their situation, and are often

referred to as ‘multiple unmet needs’. Complex needs can be viewed as a framework for understanding

multiple, interlocking needs that span health and social issues.

People with complex needs are understood as having multiple issues in their lives which can include

mental health and/or addictions, developmental issues, involvement in the Criminal Justice system,

problems finding and maintaining housing etc. These needs, often in combination with one another,

require individuals to access services and support from a wide variety of government systems and

community organisations.

Each individual with multiple and complex needs has unique concerns tied closely to the interaction

between his/her social, economic and health care needs, and so requires an individualised response.

1. Establish Coordination Function

1.1 Work with the Client and Other Services to Determine the Service Provision

Requirements

A multifaceted approach is needed to address client issues. This approach should incorporate a

range of service and support options that are appropriate to each client’s individual needs. Clients

have the right to be informed about different service options and provision requirements so that

they can make decisions about which will best meet their needs.

Community organisations and agencies will require different requirements depending on the

services they provide. These include, but are not limited to the following:

▪ Personal and social support — Provides support for personal or social functioning in

daily life. Such activities promote the development of personal skills for successful

functioning as individuals, family members and members of the wider community.

Personal and social support activities include the provision of information, advice and

referral, personal, social and systemic advocacy, counselling, domestic assistance,

provision of services that enable people to remain in their homes, and disability services

and other personal assistance services. The purpose of such support is to enable

individuals to live and function in their own homes or normal places of residence.

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▪ Support for children, families and carers — Seek to promote child and family welfare

by supporting families and protecting children from abuse and neglect or harm through

statutory intervention.

▪ Training, vocational rehabilitation and employment — Assist people who are

disadvantaged in the labour market by providing training, job search skills, help in finding

work, placement and support in open employment or, where appropriate, supported

employment.

▪ Financial and material assistance — Enhance personal functioning and facilitate

access to community services, through the provision of emergency or immediate financial

assistance and material goods.

▪ Residential care and supported accommodation — Provided in special purpose

residential facilities, including accommodation in conjunction with other types of support,

such as assistance with necessary day-to-day living tasks.

▪ Corrective services — In relation to young people and people with intellectual and

psychiatric disabilities on court orders that involve correctional and rehabilitative

supervision and the protection of public safety, through corrective arrangements and

advice to courts and releasing authorities.

▪ Service and community development and support — Provide support aimed at

articulating and promoting improved social policies; promoting greater public awareness

of social issues; developing and supporting community-based activities, special interest

and cultural groups; and developing and facilitating the delivery of quality community

services. Activities include the development of public policy submissions, social planning

and social action, the provision of expert advice, coordination, training, staff and volunteer

development, and management support to service providers.

Clients with complex needs may need the services of a combination of the following:

Mental health and allied health professionals

Specialists, general practitioners, and nurses

Housing services

Family therapists

Aged care services

HACC services

Disability support services

Drug and alcohol services

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Some of these services may address immediate needs, while others may be part of longer-term

strategies. While it’s true that clients’ needs can change, it is important to develop a plan of action that

includes information about time frames for service delivery.

Checkpoint! Let’s Review

Research about the common service requirements of community care providers in your state/territory. For example, if you are in Queensland, organisations delivering Community Care services enter into a Service Agreement with the Queensland Government. Community Care providers are also required to demonstrate or provide evidence that the Community Care services are being delivered in compliance with the Human Services Quality Standards (HSQS). There are two main methods for this process:

1. Self-assessment using a template provided by the government, OR, 2. Provide evidence of other relevant current accreditation or

certification, e.g. accreditation against the Australian Government’s Home Care Standards.

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1.2 Negotiate Collaborative Working Arrangements for All Services Involved

When there are a number of services involved with the same client, it is important that case

managers and workers liaise to ensure that the client’s needs are met in the best possible way.

Conflict can occur between services if communication and negotiation do not occur. Services

could find that they are overlapping in their roles rather than complimenting each other. Without

negotiating the working arrangements, disagreements can occur over what kind of support the

client requires and who should provide it, important information is not shared, and services can

be quite unaware about what each other provides. When this happens, it is the client that suffers

and not the services, workers or case manager.

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Services should aim for the following working arrangements:

Stay client focused. Focus on what the client identifies as his or her main goals and

priorities, not on what the case manager or services may see as important.

Develop a trusting relationship between the client and the various services.

Develop clear lines of communication between the client and the various services. This

may involve regular phone calls or meetings, or written reports, depending on what is

deemed appropriate by the parties involved.

Define clear roles, responsibilities, and limitations of each service and the client. This

should clearly relate to client goals, skills and expertise of the services, the service type,

and the client’s preferences.

Respect and value the contribution that each individual and agency makes to the case

management process.

By negotiating roles and working arrangements clearly, clients are able to receive assistance that

might otherwise not be possible.

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1.3 Develop a Plan to Identify All Available Services, Their Appropriateness,

Timeframes and Expected Outcomes

Principles and practices of planning for individuals with complex needs

For clients experiencing complex issues that include combinations of physical, social, economic and personal factors, planning complex service inputs should be holistic; it should accommodate each client’s strengths and address all the factors that act as barriers to their well-being.

It is the case manager’s responsibility to ensure that these factors and barriers are identified so he/she can work with each

client, their family and their carers to develop an appropriate set of support processes involving service providers. Service inputs may include formal interventions, support services, services to clients, and services to family and carers.

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A clear plan for working together should specify:

How referrals are made (e.g. by telephone or writing)

What sort of referrals can and cannot be accepted. This should be in line with the service’s

eligibility criteria for accepting clients.

The kinds of information that can be shared among agencies with the client’s consent.

How that information can be used (e.g. can it be written into a report for distribution to

all parties involved?)

Time frames for responses and for service delivery

Nature of services that can be provided

Process for communicating and sharing information

Ongoing involvement of the referring agency

Time frames for service delivery

Clients will have long-term goals that may relate to any of the following areas:

Their living situation, for example, moving from a metropolitan location to a rural area,

moving into residential care, accepting home support, deciding who they wish to live with.

Educational needs, for example, developing new skills, relearning skills lost through injury

or illness, undertaking formal or informal training.

Vocational needs, for example, finding and maintaining employment or making a career

change.

Leisure and spending time doing things they enjoy, such as reading, walking or listening

to music.

Community access, for example, achieving social inclusion or joining community groups.

Health, including physical and mental health and primary, secondary and tertiary care.

Family support, including support for their carers.

Communication, including understanding others and being understood.

Advocacy and personal support, including support to achieve their rights.

Human relationships, for example, learning how to interact appropriately to build good

relationships.

Behaviour management, for example, minimising behavioural issues and learning how to

cope with stressful situations and deal appropriately with everyday challenges.

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1.4 Work with the Services to Agree on Coordination Requirements and Boundaries

It is important, that, when working in collaboration with others, the needs and the abilities of the

other services/workers are respected. As with all plans, the roles and responsibilities of each

stakeholder should be worked out, and there should be a clear understanding of what type of

support will be provided and how.

The requirements and boundaries of the case manager, such as the following, should be

delineated:

Determine what services are available within the community.

Develop protocols with other agencies that specify the process, eligibility, information

sharing processes, time frames for responses, nature of services to be provided and

arrangements for case management and coordination of services.

Develop relationships with network partners.

Ensure services are not duplicated.

Ensure services are not working in conflict with each other.

Ensure that other services are aware of your service and the role it plays in the network.

Facilitate case management meetings.

Facilitate communication.

Identify issues indicating the need for improved communication between services.

Meet formally and informally with another case manager to identify common issues, or

gaps that may exist and services to the community.

Monitor client confusion, concerns and barriers.

Monitor overall impact of service interventions.

Obtain written information about other agencies that you may need to access; find out

about the services they offer, fees, eligibility, waiting lists and so on.

Participate in a network.

Provide a central point of contact for the client.

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2. Support the Client to Access Multiple Services

2.1 Identify, Implement and Maintain Duty Of Care Responsibilities

Duty of care refers to the responsibility of case managers to avoid injury to a client or relevant

others who it can be reasonably foreseen, might be injured by our act or omission. A duty of care

exists when someone’s actions could reasonably be expected to affect or harm other people.

Fulfilling our duty of care responsibilities involves taking adequate care to avoid injury.

To do this, case managers need to consider the following:

The client’s capabilities and capacities

The dangers of the situation

The client’s awareness of risks

Assessments regarding the client’s needs and vulnerabilities

The potential seriousness of the injury

Placing the least restriction on client’s rights

Compromising the rights of a few people as possible

Empowering clients to take control over and responsibility for the situation

Safety of other clients, their significant others and members of the public.

Examples of risks and responsibilities relating to duty of care

Children and young people

Risks of harm Responsibilities

The child or young person’s basic physical or psychological needs are not being met or are at risk of not being met.

Investigate and assess concerns that a child or young person has been harmed or is at risk of significant harm.

Report to the authorities if there are reasonable grounds to suspect that a child or young person is at risk of harm and if there are concerns about the child’s safety, welfare and well-being.

Follow reporting responsibilities as stated within the workplace policies and procedures

The child or young person has been or is at risk of being physically or sexually abused or ill-treated.

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People with a disability

Risks of harm Responsibilities

Limited communication skills and/or lack of an effective advocate.

Apply a person-centred approach focused on supporting and empowering a person to have control of and make informed choices and decisions about their own life.

Ensure people with disability and their parents and carers are informed of and supported to exercise their rights.

Reliance on others for daily living.

People experiencing domestic violence

Risks of harm Responsibilities

Parent/carer history of violent behaviour both inside and outside the household.

Assess domestic violence threats to adult victims by applying the Domestic Violence Safety Assessment Tool, another risk assessment tool or using professional judgment.

Have clear referral pathways for children and for adult victims to access the support they need to stay safe from domestic violence.

Report and record as required in the workplace policies and procedures and within the laws applicable in your State

Presence of other life stressors such as unemployment or recent loss/es.

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A situation of elder abuse

Risks of harm Responsibilities

Older person and the carer are socially isolated, lacking supportive contacts and social networks.

Report any suspicion of abuse.

Make an appropriate referral to assess their capacity if there is a concern that the older person does not have competence to make decisions. An older person may be dependent on

others for social, emotional, physical, financial and spiritual support.

Someone contemplating suicide

Risks of harm Responsibilities

Current thoughts with expressed intentions/past history/plans.

Take the person and the threat seriously.

Advise the person that threats of suicide or self-harm are taken seriously and that you may need to refer them to someone who is more appropriately trained or qualified to provide assistance.

Report and record accordingly to the workplace policy and procedure or relevant legislation.

Unstable mental illness.

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2.2 Provide Information to the Client About the Coordination Role

Coordination in relation to case management involves having an understanding of the role of

other services and developing cooperative working relationships with relevant services.

For case managers, coordination is about developing a relationship with the client that seeks to

foster collaborative decision-making in assuring the services are well targeted and client-centred.

Clients must understand that coordination is most importantly about building a positive working

relationship in order to develop care plans that address their needs, strengths, and goals.

Specifically, the case manager’s coordination role includes the following:

Collaborate and actively build relationships with other service providers to support efficient

work towards the case plan goals.

Ensure all agencies are aware of each other’s involvement.

Identify and reduce service or support barriers, gaps or overlaps that may arise.

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2.3 Work with the Client to Establish Communication Requirements

Maintain open communication channels with all stakeholders, including the client and hold them

accountable for tasks to be undertaken.

Regular communication helps to maintain a coordinated focus on achieving outcomes and

meetings or case conferences with all stakeholders can support this process.

Make sure information shared is accurate and be sure to discuss progress, challenges and proposed

solutions with the client at all stages of implementation.

Discuss with the client the methods of contacting him or her for updates and follow-ups; phone,

face-to-face meeting, home visit, email, etc.

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2.4 Assess Need and Arrange Interpreter, According to Client’s Needs

Case managers work with a diverse

range of clients who, because of

their disability or personal,

emotional, and cultural situation,

may require workers to develop and

use specialist communication skills.

The case manager must be able to

adapt their communication style to

meet the needs of different client

groups in a fair, non-judgemental,

and effective manner.

Areas of specific need which should be considered when communicating with clients include:

Disability (including but not limited to intellectual impairment, physical impairment,

psychiatric disability, hearing or vision impairment, learning difficulties, and attention

deficits)

Literacy (e.g. false assumptions about level of intelligence and understanding, concerns

about the content of documents and forms, what is being written down)

Language (e.g. non-English-speaking backgrounds, not familiar with service-specific

jargon and acronyms)

Gender, age, experiences, emotional well-being and other individual attributes.

Critical situations - crises traditionally cause disorganisation of thought and hence need

special skills by workers in establishing rapport with clients

Culture (including experiences in other countries, music, spirituality, customs, gender,

social expectations, body language, and position in the community)

Remote location (limited access to services and resources, distance travelled)

Irrespective of their particular needs, all clients must be treated with dignity and all communication

must demonstrate respect and be open and non-judgemental.

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Arrange for interpreters

Interpreters include language interpreters and cultural interpreters, who can provide a cultural

context for communication. Translators work specifically with written materials. When you are

working with interpreters:

The interpreter or translator should be neutral: their purpose is only to relay the message

from one person to another.

The interpreters should not provide advice or give opinions.

Be aware of factors that could impact on the interpretation process. For example,

differences in dialect or conflicting politics, beliefs or values may cause a person to reject

an interpreter.

Make it clear to the interpreter that the message must be communicated as you intended.

Ask them to check with you for nuances or to clarify meaning to ensure this occurs. A

registered interpreter will be required to complete a document stating that they are

fulfilling their role as described above.

Address all questions, eye contact and body language to the client as if you are asking the

questions directly. The focus of the communication should be on the worker and the client

– not on the worker and the interpreter.

Bear in mind that non-professional support people such as family members, carers or professional

advocates are not neutral. If these people are to act as interpreters, be aware that the

communication may be influenced by advice or emotional involvement. If these people are

utilised for interpreting in medical or legal matters any decisions made can be challenged or

become a legal challenge.

Further Reading

Professional interpreters are available for a fee from the Translating and Interpreter Service (TIS)

https://www.tisnational.gov.au/

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2.5 Work with the Client and Other Services to Identify Barriers to Attaining

Outcomes

As someone who works with clients who have complex needs, it is important for the case manager

to further develop his or her knowledge and understanding of issues that may affect the client’s

ability to attain outcomes. It is important that the case manager works with other services in

identifying these barriers to enable them to take steps to modify outcomes or the environment or

provide additional supports or services to help the client.

Barriers to attaining outcomes may be tangible or perceived.

Tangible barriers

Tangible barriers to participation are those barriers you can readily identify. They are often

physical factors that can be seen and touched or factors that relate to real objects or events, such

as:

A lack of available and accessible transport

Insufficient finances to pay for services

A lack of adaptive equipment

Inaccessible buildings or areas

A lack of accessible toilet facilities

Perceived barriers

Perceived barriers to participation are often far more difficult to identify. They include the actions

or inactions of people or groups, perceived attitudes and approaches, and social expectations

about behaviour and inclusion, for example:

The failure of an organisation or business to offer signage in multiple community

languages or to provide translation services when required.

The failure of an organisation or business to make their website fully accessible to people

who use screen-reading software or require larger fonts to read the text.

Attitudes of reception staff to make a person feel welcome and included, or not.

Attitudes of face-to-face staff to make a person feel disempowered and not part of a

group.

Activities/services that are needlessly high in cost.

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2.6 Work with the Client to Prioritise Needs and Communicate These with Service

Providers

When working with the clients to prioritise his or her needs, it is important that the case manager

considers needs holistically rather than focusing on the presenting issues alone. Once the needs

are prioritised, the case manager must ensure that each service provider communicates with each

other to facilitate seamless service delivery and coordination.

Case managers must also ensure that each service provider is clear about their responsibilities in

relation to a client via a case management plan and that regular meetings are held with relevant

stakeholders.

2.7 Facilitate Case Conference and Meetings to Coordinate Responsibilities and Roles

A case manager organises and oversees the delivery of services to clients. They connect clients to

the community and other relevant resources and work to protect the rights and the well-being of

the client.

When working with clients to meet their needs, different parties are often involved, including

family members and health professionals. It may be necessary to organise conferences or meetings

with these parties to plan and regularly review the delivery of a service and/ or if a particular issue

arises.

Case conferences and meetings need to be outcome driven and not just about providing and

sharing information. In general, the purpose of case conferences and meetings is to:

Ensure client involvement, or if more appropriate, a child/client representative.

Review client’s situation, agency assessments and progress towards case plan goals.

Discuss issues, concerns or gaps in current service delivery.

Outline expectations of the client and participating agencies moving forward.

Develop actions that support the case plan and agree on the roles each agency has in

achieving next steps.

Develop and agree on service referrals.

Improve or maintain strong, client centred service coordination.

Case conferences need to include the client or at a minimum ensure their views are represented.

The meetings should be held in a place and through a process that enables the client to feel that

they can actively and safely contribute to the discussion.

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When situations arise that a client is not willing or able to attend or participate, it is important to

have a clear communication strategy to ensure that their views are captured prior to the meeting

and that they are informed of the outcomes.

A case conference without the client being present should only be called under special

circumstances. A client may not be present because they cannot be located; where a case

conference is necessary to progress the case plan because of risk or, the client is a child under the

age of 12 years and their ability to participate and/or be represented has been discussed with a

parent/guardian or child specialist.

Further Reading

Access the Case Management Guidebook to know more about case meetings

2.8 Work with Other Services to Minimise Client Confusion and Concerns in a

Coordinated Manner

Principles and practices of working across multiple services

Working across multiple services involves service delivery coordination initiatives. These may be conceived in various ways depending on the specific needs of the client. Initiatives may simply involve linking two or more distinct service providers to promote cross-agency information sharing and/or referrals, or a more complex service delivery coordination that requires formalised measures to ensure that different agencies work together in a structured and planned manner. Practices may

include referral protocols, services directories, informal interagency networks/working groups, and cross-agency awareness training.

Issues that cause client confusion, concerns, and barriers

Needing to provide the same information to multiple services

Not understanding how services complement each other

Not understanding the relevance of different service inputs

Time required to commit to service demands

http://www.casemanagementguidebook.ie/Protocols/Protocols/Interagency-case-meetings.aspx

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Issues faced by clients, their family and carers, accessing multiple services

A lack of quality and/or specialist staff.

Chaotic daily life or complex lives that limit the clients, their family and carers to consider

the benefits of the service.

Communication difficulties, including being unable to understand what the services are

offering.

Hostility or disapproval towards the service from trusted family members and carers.

Intimidation, fear or distrust about accessing a service.

Provision of services that is or is perceived as irrelevant, inappropriate or stigmatising.

Service duplication.

Service fatigue.

Service location is difficult to get to, or the client or geographically isolated or is unable to

access transport.

Impact of service duplication

Service providers may struggle to reconcile organisational differences which limit the

effectiveness of coordination efforts.

Potential competition for resources between providers.

Gaps or inconsistencies in service provision.

Service fatigue.

There is a tendency to treat people as passive recipients rather than active participants.

If poorly coordinated and fragment, people may have difficulty navigating and receiving

the support they need.

Multiple access points where many people have to tell their stories too many times to

different parties.

Often costly and inefficient.

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Impacts of generational abuse and welfare dependency

Individuals who have experienced generational abuse:

Can develop into parents who physically abuse their own children.

Can have relational problems both with significant others and in less intimate

relationships.

May enter relationships where they are emotionally abused or in which they abuse others.

May expose their children to age-inappropriate sexual information or may become

overprotective.

May form quick, over-involved and inappropriate attachments with others leaving them

vulnerable to abuse.

Find it difficult to tolerate intimacy, and may remain socially and emotionally distant.

Can fail to meet the nurturance needs of their own children if and when they became

parents. If they have witnessed domestic violence, they are at an increased risk of entering

adult relationships in which there is intimate partner violence.

May have Posttraumatic Stress Disorder and other mental health concerns that impair

their ability to parent effectively.

May have anger management problems, depression, anxiety, and substance abuse

disorders.

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Case coordination

Case coordination includes communication, information sharing, and collaboration with other

mainstream and specialist services that are required to support the client to achieve identified

goals. Involvement of other services is required to addresses potential gaps in meeting social,

developmental, behavioural, educational, informal support network, and financial needs in order

to achieve client outcomes.

Coordination activities may include:

Providing assistance to the client to support the client to navigate the service system, for

example, through providing information about the available services and access criteria

and processes.

Making referrals to other mainstream and specialist services or programs, such as drug

and alcohol, mental health, family services, anger management programs.

Facilitating access to other services, such as attending meetings and helping clients to

complete paperwork.

Reducing barriers to obtaining services, for example through supporting clients to access

relevant health, mental health and legal services.

Sharing and exchanging information, such as assessments and case plans, with other

services, with the client’s consent.

Joint working with clients, as required.

Maintaining regular contact with other services involved in the client’s case, with the

client’s consent, to inform monitoring and review of the case plan.

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3. Monitor Client Progress

3.1 Facilitate Communication Between Service Providers to Identify and Manage

Service Duplication

One of the greatest challenges in having a client

access multiple services is confusion, which has

an impact on understanding roles, responsibilities,

and actions. When agencies come together, each

often believes that it is responsible for providing

case management with a dedicated case manager

in place. This conflict usually occurs either

because no formal discussion has been

undertaken regarding which agency will take the

lead, or that a specialist agency is also

coordinating a range of specialist services for a

client.

In such cases it remains important and necessary to identify who the lead agency/case manager is

for the client, recognising that, while individual case managers are involved in

coordination/facilitating action and referrals within the field of expertise, one agency still needs

to be identified as the leader who will plan and coordinate the overall responsibility for the client.

It is important to note that being the lead agency means taking responsibility for the direction, but

it does not presume sole decision-making powers.

It is important that the case manager of the lead agency keep in close communication, to avoid

duplication and ensure the case plan is being implemented smoothly. It is also an opportunity to

keep informed of other stakeholders and who is liaising with them.

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3.2 Work with the Client and Services to Monitor Progress Toward Outcomes

Ongoing monitoring and revision of case management plans and timeframes are essential in

helping the client set achievable goals that increase confidence, self-determination and motivation

for further change. Many of the skills and strategies used in interventions are utilised in the

evaluation process, as listed below:

Engaging the client and involving them as the centrepiece of the evaluation process.

Contracting at the

beginning of the

intervention that an

evaluation will take place

and identify how it will be

undertaken.

Negotiating the revision of

case management plans and

goals in collaboration with the client.

Disengagement and confirmation of how follow-up contact is to take place, for example,

by telephone or mail and who will contact the client.

Discussing issues of confidentiality involved with the evaluation process.

Clear and concise record keeping and documentation of intervention processes.

Liaison with others such as individuals, professionals or services involved in the

intervention process.

3.3 Obtain Client Feedback About Services

Clients are experts in their own life experiences and are best placed to provide feedback about

how services and responses can best support them and address their needs. It is therefore

important to capture client input and feedback to inform continuous improvement of services.

Feedback can be sought in a number of ways:

Face-to-face or telephone interviews

Online surveys

Written questionnaires

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Although the mechanism for seeking feedback may vary depending on the client’s preference,

questions should be consistent to enable comparability to inform service improvements. Good

practice in seeking feedback from clients includes:

Ensuring confidentiality of responses.

Recognising the client’s time in completing the feedback.

Minimising the likelihood that the client feels pressured into answering in a particular way.

These mechanisms for seeking feedback complement wider feedback activities, such as focus

groups and point-in-time surveys that may take place for specific program evaluations or reviews.

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3.4 Identify and Implement Further Support Required to Meet Changing Needs and

Progress Towards Outcomes

Ongoing monitoring and evaluation of client case management plans and timeframes are essential

in helping the client achieve their desired goals. The client is centrally involved in the evaluation

process as the case manager will not be the only person who helps the client in goal achievement.

The key role of the case manager at this point will be to assess just how often the client needs to

be contacted or seen, with regard to the progression of the case management plan.

A goal that is agreed to in the client case management plan may change or need to be revised over

time. The client’s progress will be influenced by many factors, and therefore the case management

process needs to be flexible.

Revision of goals and outcomes are undertaken throughout the process of case management

allowing responsiveness to the individual’s changing circumstances and progression through case

plan objectives.

Knowledge gained by working with clients and service systems is used to advocate at both

individual and system levels.

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