7 Phases of Case Management

[Pages:28]Case Management Practice Guide

7 Phases of Case Management

Version 2.0 Community Access Ageing, Disability and Home Care, Department of Human Services NSW

March 2010 Final

Document approval

The Case Management Practice Guide ? 7 Phases of Case Management has been endorsed and approved by:

Lauren Murray Deputy Director General, ADHC Approved: 29 March 2010

Signature on file

Peter De Natris Executive Director, ADHC Approved: 21 December 2009

Signature on file

Document version control

Distribution:

Community Access Teams

Document name:

Version: Document status: File name: Authoring unit: Date:

Case Management Practice Guide - 7 phases of case management 2.0 Final Case Management Practice Guide Community Access March 2010

Version 2.0 March 2010

Table of contents

1 Introduction ......................................................................................................1 2 Phases of Case Management ..........................................................................3

2.1 Engagement..............................................................................................3 2.1.1 Practice Points.............................................................................................5

2.2 Assessment...............................................................................................7 2.2.1 Practice Points.............................................................................................9

2.3 Planning ..................................................................................................11 2.3.1 Types of plans ...........................................................................................12 2.3.2 Practice Points...........................................................................................13

2.4 Implementation........................................................................................16 2.4.1 Practice Points...........................................................................................17

2.5 Monitoring ...............................................................................................18 2.5.1 Practice Points...........................................................................................19

2.6 Review ....................................................................................................19 2.6.1 Practice Points...........................................................................................20

2.7 Closure....................................................................................................22 2.7.1 Practice Points...........................................................................................24

2.8 Guide Review..........................................................................................25

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1 Introduction

The Practice Guide This practice guide is a companion document to the Case Management Practice Policy 2009 and is designed to support and guide case managers working in Community Access Teams in their every day practice. The guide is based on the 7 phases of case management practice as outlined in the Case Management Framework. This practice guide is not prescriptive but provides endorsed examples of practice points and tools for case managers to assist them to implement the Case Management Policy 2009. Case management practice can be brief and intense but can also be delivered over a long period. Regardless of its duration, case management practice should move through all seven phases, although sometimes phases will happen simultaneously. This practice guide should be used in conjunction with a range of policies and procedures relevant to case managers. Its application in practice should be supported through line management and practice supervision from your access manager and any coaching or mentoring you may receive in your role as case manager within Ageing, Disability and Home Care, Department of Human Services NSW (ADHC).

The 7 Phases of Case Management

The 7 phases of case management are:

Case management practice in all phases should be based on the principles outlined in the Case Management Practice Policy 2009. It is important to note that whilst it is useful to describe the activities of case management by categorisation into seven distinct phases, case managers need to be aware that case management is not a linear process and activities and phases often overlap. Case management should be a seamless process for people with a disability.

ADHC promotes a person centred approach to all its work with people with disability and their families and / or carers. Case management practice will have a different emphasis and focus in circumstances where the person with a disability is a child. A family centred approach will be critical in understanding the needs of a child or young person. Refer to Keeping Families Together Framework for further information.

Case Management Practice Outcomes

The expected outcome of case management practice is "to maximise opportunities for a person with a disability to achieve their goals, and chosen quality of life" (Case Management Practice Policy 1.6). This is achieved by individualised planning and support coordination. One of the key principles of case management practice is "to minimise the intrusiveness and involvement of formal support services in the life of a person with a disability" and "to work with person with a disability to create opportunities for their

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participation in their community which are rewarding, respectful and valued by the person with a disability and other community members" " (Case Management Practice Policy, 2.2)

Working with Others

Case management in ADHC is not offered in isolation from other supports that the person with a disability may be receiving. Case managers will work alongside staff from many disciplines, agencies and organisations. This may include therapists, respite coordinators and people who provide the informal supports to the person with a disability. Whilst it is important to build collaborative relationships with all stakeholders involved, it is essential that these relationships maximise participation of the person with a disability. Conversations need to be with the person rather than about the person to reflect a person centred approach.

Information Exchange

Information shared with others needs to be accurate, relevant and with the explicit consent of the person with disability or their consent giver. Consent for the disclosure, gathering or exchange of information must be obtained in writing. The full policy is available at Decision Making and Consent Policy and Procedures.

Children and young people Chapter 16A of the Children and Young Persons (Care and Protection) Act 1998 (The Act) helps clear the way for better interagency information exchange provisions. Government and non-government agencies (known as "prescribed bodies") can exchange information with each other that relates to a child or young person's safety, welfare or wellbeing, whether or not the child or young person is known to Community Services. As per section 245G of the Act, a person who provides information in good faith in accordance with Chapter 16A, will not be liable for providing this information

ADHC is a prescribed body under Chapter 16A, which means that it can request and provide information to other prescribed bodies under Chapter 16A without the need for the consent of the child, young person or family. However, it is best practice for ADHC staff to inform a child, young person or their family that information about them may be provided to another organisation if needed, but only if:

? it will not jeopardise a child/young person's safety, welfare or wellbeing ? it will not place the worker or child/young person at risk, and/or ? you are unable to contact a parent/carer, and the matter is urgent.

A fact sheet on information exchange has been developed for ADHC staff in relation to information exchange. Further information regarding information exchange can also be found in ADHC's Child Protection Policy 2010.

Although Chapter 16A applies to the exchange of information between prescribed bodies, section 248 will still apply to the exchange of information concerning statutory cases between Community Services and other relevant human services and justice agencies and non-government organisations.

Reflective Practice

Reflective practice is a process where the individual thinks through a series of actions or activities to identify positive and negative elements contributing to any situation in which they have been involved or have observed. These elements can include, but are not confined to, the following:

? Relationships

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? Feelings ? Experiences ? Events ? Context ? Actions ? Values and belief system ? Culture

The process can have two key components:

? Reflecting on the knowledge you have about people and events or outcomes. ? Using the knowledge to inform subsequent thinking, actions and practice.

Reflective practice is a critical component of good case management practice and can occur in a range of situations including individual problem solving and analysis, informal discussions with others such as colleagues, students, and academics in the same and different disciplines. It is an integral part of good supervision in which joint exploration of some of the issues arising in practice should be encouraged in an environment of safety and shared learning.

It is in conversation with others that ideas are challenged, new approaches and perspectives can be considered, and notions of what is possible and what is 'good practice' are developed and shared.

The process involves problem solving from a point of having knowledge and understanding about something and applying analysis to this knowledge to inform future thinking and actions. It is an ongoing process in which an individual case manager can draw on both the current situation and previous experiences to explore possible future action and consider the relative merits of any particular approach.

2 Phases of Case Management

2.1 Engagement

Successful engagement is the basis of effective case management. Engagement establishes the relationship and sets the ground rules which are enhanced and reviewed throughout the phases of case management. Engagement begins prior to the initial contact between the ADHC case manager and the person with a disability and their family and/or carer.

Engagement and relationship building involves meeting with and getting to know people with a disability and their circle of support. It is important that the case management relationship does not replace the natural supports of the person with a disability. Rather, practice is to support the person with a disability to enhance and strengthen these supports. Practice should build on a person's skills, abilities and strengths and support them to achieve what is important to them. To find out what these skills and strengths are, what their visions and hopes are, you must build a positive relationship with the person and their family and/or carer.

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Engagement is about building a case management relationship marked by:

? Case managers ensuring they have good knowledge of disability and the service system.

? Good level of rapport between the case manager and the person with a disability and their supports.

? Knowledge and understanding of the expectations and experiences of the person with a disability, their family and/or carers in relation to the Agency and your role.

? Clarity about the case management purpose, focus and approach.

? Understanding of the functions and limitations of the case manager role.

? Honesty and trust in information exchange and decision making.

? Partnership of two way communication and mutuality in setting and pursuing goals.

Engagement is necessary for accurate and comprehensive assessment of the needs of a person with a disability and their family to identify their strengths, aspirations and priorities, and promotes active involvement and motivation to implement a plan. Successful engagement is essential in short or long term relationships, in a crisis situation or in a longer lasting relationship.

When you meet someone for the first time, you need to be clear about your role and you need to explain this role to each person. You are meeting someone as a case manager employed within the NSW Public Service and this role brings responsibilities of working within the Agency's policy and processes. You may use advocacy skills in your case management practice, but as a public servant you cannot fulfil the role of an independent advocate. Many people with disabilities may seek support from you as well as support from an independent advocacy service. Part of your role may be to help a person with a disability and their family locate and engage with an independent advocacy service.

Establishing rapport and building trusting relationships improves the likelihood of effective communication and facilitates information sharing. Communication may take a range of formats tailored to an individual. To understand the most effective means of communication, it is beneficial to involve a range of people from the person's formal and informal supports. In some situations extended family members and/or friends may be very involved with the person with a disability and should be factored into consideration of informal and family supports.

Time must be allowed to support the person with a disability to engage in meaningful communication, ask questions, participate and make their own decisions. A strengthsbased non-judgmental approach, transparency, and prompt and accurate responses can facilitate cohesive working partnerships. In addition, maintaining regular contact and being reliable and accessible to people fosters collaborative relationships.

Case managers are part of the ADHC Community Support Team. The role of the Community Support Team (CST) is explained in a brochure that can be given to the person with a disability, their family and/or carer. It provides CST contact phone numbers for each region, and is available in the following languages:

Arabic; Croatian; English; Greek; Italian; Korean; Serbian; Simplified Chinese; Spanish; Traditional Chinese; Turkish; and Vietnamese

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2.1.1 Practice Points

Following a service request, it is the responsibility of the case manager to make contact with the person with a disability and, where appropriate, their family and/or carers. It may not be the first contact the person has had with ADHC.

Preparing for engagement

? Read, collate, and understand any existing information about the person and their family and/or carer, including the referral report, Client Information System (CIS) data, and historic ADHC files and be aware of any other professionals involved with the person. While this can minimise repetition of fact finding questions, it is vital to hear the perspective of the person and carer first hand, rather than relying on secondary sources of information. Any other sources should be checked with the person for accuracy.

? Gain an understanding of the skills and forms of communication of the person. i.e. communication aids, culture, language and disability. Consider what will facilitate communication and engagement.

? Determine how you will explain the case management process to the person, including your role and that of their family and/or carers.

? Depending on the age and circumstances of the client, you will need to consider what engagement strategies you would use to support the identification of priorities. You may use the person centred thinking tool ? `important to and important for'.

Ways to achieve positive engagement

? Explain the case management process to the person, including your role and the family and/or carers.

? Discuss with the person how they wish to engage individual members of the family and the family as a whole. Engaging family members, informal supports and identifying family strengths is a critical part of supporting a child or young person with a disability.

? Take time to learn about the person's specific cultural needs and use communication styles that reflect an understanding of these.

? Explain confidentiality and exceptions to confidentiality, such as protecting child safety.

? If appropriate, written documents should to be translated by an accredited translation service for the person and their family to understand.

? Whenever possible, an accredited interpreter will be employed to support communication with individuals and families who do not speak English. Face to face interpreters are to be employed when meeting with the person or family whenever possible. Telephone interpreter services are to be employed when contacting the person or family by telephone. It is not appropriate to use children, regardless of their age, to translate for parents or other family members.

? Regularly communicate and stay involved with people, their families and /or carers and appropriate stakeholders within set timeframes to maintain active engagement.

? Establish and maintain open, two way communication in a format that is appropriate to the person.

? Set and meet timeframes for appointments at times that suit the person.

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