Posted: March 11th, 2023
CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements
Hi, there are 3 files,One file is a learner guide, and other need to be done.Please answer all questions in the same file attached.
Assessment Booklet
CHCCSM005
Develop, facilitate and review all aspects of
case management
CHCCCS004
Assess co-existing needs
CHCCSM004
Coordinate complex case requirements
Student Name:
Student Number:
Intake Date:
CHCCSM005 Develop, facilitate and review all aspects of case management
CHCCCS004 Assess co-existing needs
CHCCSM004 Coordinate complex case requirements
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Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302
ASSESSMENT COMPETENCY RECORD
This form is to be completed by the assessor and used as the final record of the student competence in these discipline. All
student submissions including any associated documents and checklists are to be attached to this cover sheet before placing on
the students file.
Student results are not to be entered onto the Student Database unless all relevant paperwork is completed and attached to this
form.
Student ID Final Assessment Submission Date:
Student Name
Assessor Declaration
In completing this assessment, it is confirmed that the participant has demonstrated all unit outcomes through consistent and
repeated application of skills with competent performance.
Evidence is confirmed as: ❑ Valid ❑ Sufficient ❑ Current ❑ Authentic
Please attach the following documentation to this form Result
FINAL ASSESSMENT
RESULT:
❑ Competent (C)
❑ Not Yet Competent
(NYC)
Assessment Task 1 ❑ Case study S / NS
Assessment Task 2 ❑ Project S / NS
Assessment Task 3 ❑ Project S / NS
Assessment Task 4 ❑ Project S / NS
Assessment Task 5 ❑ Case study S / NS
Assessment Task 6 ❑ Written/Oral Questions S / NS
Attempt Date Assessor’s feedback (as required):
1
2
3
Final Feedback:
DO NOT SIGN BELOW UNTIL FINAL ASSESSMENTS RESULT IS GRANTED BY THE ASSESSOR.
Assessor: I declare that I have conducted a fair, valid, reliable and flexible
assessment with this student, and I have provided appropriate feedback.
Signature: _______________________
Name: __________________________
Date: ____/_____/_____
Student: I declare that I accept the assessment competency outcome and consider
the feedback of my assessor positively. I also declare that the work submitted is my
own, and has not been copied or plagiarised from any person or source.
Signature: ______________________
Date: ____/_____/_____
Administrative use only:
Entered into Student
Management Database
❑ Signature/Initial ________________ Date: ________________
CHCCSM005 Develop, facilitate and review all aspects of case management
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Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302
Unit Code/Name CHCCSM005 Develop, facilitate and review all aspects of case management
Pre-requisites N/A
Co-requisites N/A
Unit Summary
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 organisation
guidelines.
This unit applies to work in a range of health and community services contexts.
The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation,
Australian/New Zealand standards and industry codes of practice.
Conditions and context
of the assessments
Skills must have been demonstrated in the workplace or in a simulated environment that reflects
workplace conditions. The following conditions must be met for this unit:
▪ use of suitable facilities, equipment and resources, including individualised case plans
▪ modelling of industry operating conditions, including:
▪ scenarios that reflect standard operating conditions and contingencies
▪ links to other local service agencies or organisations
Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF
mandatory competency requirements for assessors.
Unit Code/Name CHCCCS004 Assess co-existing needs
Pre-requisites N/A
Co-requisites N/A
Unit Summary
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 in a range of community service contexts.
The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation,
Australian/New Zealand standards and industry codes of practice.
Conditions and context
of the assessments
Skills must have been demonstrated in the workplace or in a simulated environment that reflects
workplace conditions. The following conditions must be met for this unit, including:
▪ use of suitable facilities, equipment and resources, including:
▪ organisation policies and procedures
▪ use of peoples information on which to base assessment
▪ individualised plans and any relevant equipment outlined in the plan
▪ assessment tools and processes
▪ modelling typical workplace conditions and contingencies, including:
▪ interactions with people with a range of needs
▪ typical workplace reporting processes
Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF
mandatory competency requirements for assessors.
Unit Code/Name CHCCSM004 Coordinate complex case requirements
Pre-requisites N/A
Co-requisites N/A
Unit Summary This unit describes the skills and knowledge required to coordinate multiple service requirements for
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Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302
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.
The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation,
Australian/New Zealand standards and industry codes of practice.
Conditions and context
of the assessments
Skills must have been demonstrated in the workplace or in a simulated environment that reflects
workplace conditions. The following conditions must be met for this unit:
▪ use of suitable facilities, equipment and resources, including individualised case plans
▪ modelling of industry operating conditions, including:
▪ scenarios that reflect standard operating conditions and contingencies
▪ links to other local service agencies or organisations
Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF
mandatory competency requirements for assessors.
Assessment venue
This assessment will be conducted in the CAC classroom or simulated workplace environment or
at actual designated workplace:
• Address of actual designated workplace:
……………………………………………..
……………………………………………..
……………………………………………..
Specific Resources
Required
Candidate will need access to:
▪ Computer with Internet and email access and a working web browser
▪ Installed software: MS Word, Adobe Acrobat Reader
▪ Access to legislation and protocols relevant to the community services industry,
social work and case management, including codes of conduct, practice standards,
etc.
▪ Video camera or a mobile phone with video and audio recording capabilities
▪ Three (3) volunteers for the roleplay activities
▪ Access to a document printer or printing services
Re-assessment
To gain competency you need to get Satisfactory (S) result in all the tasks. If Not Satisfactory (NS)
result is given even for a task you will be deemed Not Yet Competent (NYC). Students who are
unsuccessful at achieving competency at the first attempt will be offered coaching, information and
additional time (other needs if required) before a second and possibly a third attempt is made. If the
student is not able to satisfactorily complete the assessment after the third attempt the student will
be deemed Not Competent and resulted as such. The student may re-enrol in the qualification at a
later date to gain successful completion of the unit/s.
For further details, refer to CAC Assessment Policy and Procedure. https://cac.edu.au/policies-and-
procedures/
Plagiarism
CAC considers plagiarism and cheating as serious student misconduct and this may result either in a
student’s exclusion from a unit or course or may have to complete a re-assessment depending on
individual case. Refer to CAC Plagiarism & Cheating Policy and Procedure.
Complaints and appeal
Where a student wishes to appeal an assessment decision they are required to notify their assessor
in the first instance. Where appropriate the assessor may decide to re-assess the student to ensure a
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fair and equitable decision is gained. The assessor shall complete a written report regarding the re-
assessment outlining the reasons why assessment was or was not granted. Refer to CAC Complaints
and Appeals Policy & Procedure for details.
Assessors Intervention
Assessors are to check that the student is ready for assessment, and defer the assessment if they are
not. It is important that assessors do not teach at the assessment but allow students to competence
for themselves.
Feedback is to be given at the completion of the assessment using the feedback to student. If a
student does not meet a standard, the assessor is to sit down with them and assist them in their
understanding. Should you disagree with the assessment outcome, you can appeal the decision as
stated in the Student Handbook.
Your student record must indicate that you have all required skills and knowledge in completing the
task. For each assessment, the assessor is to act as a supervisor and not interfere with the assessment.
If the assessment activities will impact on your safety or that of others, the assessment must be
stopped immediately.
Attaching documents
Attached documents are accepted but must be labelled with the following information:
Unit Name and Title, Students name, Student ID, Date of Submissions, Student signature.
Assessment Instruction
Assessment is mapped to the unit and must be completed by the end of each unit. For answers to
written questions, reports and projects, you must:
• Print clearly in black or blue pen or type it as a word document
• Answer each of the key points and /or follow instructions
• Assessments written in pencil or are illegible will not be accepted.
Please NOTE: Student has to submit each and every assessment task. Ask your assessor if you do
not understand any part of the assessment. Whist your assessor cannot tell you the answer, he/she
may be able to re-word a question or instruction to assist in a better understanding for you.
Case Study
Assessment Task 1:
Based on the case study, students are supposed to:
Task 1: Answer the questions
Task 2: Perform role play activity
Task 3: Perform role play activity
Task 4: Document outcome of the interview
Task 5: Analyse information and prioritise needs
Assessment Task 2:
As part of the planning process, students are supposed to:
Task 1: Develop an appropriate case management plan
Task 2: Perform a roleplay activity
Assessment Task 3:
As part of monitoring and reviewing, students are supposed to:
Task 1: Review of a care plan
Task 2: Communicate the outcomes of the review
Assessment Task 4:
As part of case closure and exit, students are supposed to:
Task 1: Write a case closure summary
Task 2: Write a reflective journal
Assessment Task 5: Based on the case study, students are supposed to:
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Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302
Task 1a: Analyse information and identify needs
Task 2a: Interpreter arrangement
Task 1b: Analyse information and identify needs
Task 2b: Interpreter arrangements
Assessment Task 6:
This is a written assessment that will test student’s knowledge. This assessment may be completed
over the duration of the training days. As the students learn, practice and review knowledge and
skills, students will keep Assessment Task 6 in front of them and answer the questions as the
information becomes clearer. At the beginning of each review session students will be given a few
minutes to familiarise themselves with the questions. Students will be given extra time at the end of
the day to complete this assessment or to clarify facts with the Trainer/Assessor
Competency Decision
Student must satisfactorily complete each assessment tasks to be Competent (C) in the unit.
Student with unsatisfactory completion of any of the assignment tasks will be deemed Not Yet
Competent (NYC).
Reasonable adjustment
To meet the needs of all learners’ adjustments can be made to the way assessments are conducted but not to the requirements of
the assessment. The purpose of these adjustments is to enhance fairness and flexibility so that the specific needs of students can
be met.
CAC will take meaningful, transparent and reasonable steps to consult, consider and implement reasonable adjustments for
students with disability and learning difficulties.
Reasonable adjustment provided Reason for reasonable adjustment Outcome
❑ Educational and bilingual support
❑ Presenting questions orally
❑ Presenting work instructions in
diagrammatic or pictorial form
instead of words and sentences
❑ Extra time to complete a course or
assessment
❑ Others:
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Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302
Instructions to Assessor
This is a compulsory assessment to be completed by all students. This assessment tests the student’s ability to understand
the underpinning generic knowledge related to the units of competency.
Reasonable adjustment applies here, and while the majority of students will complete this assessment as a written
assessment, verbal assessment may be an option for those who need it. Assessor must use the response guide as the
principal marking tool unless reasonable adjustment is demonstrated.
The Assessor Guide provides model answers to all the questions, setting out which key responses must be included, as
well as indicating where flexibility is acceptable.
Where there is a number of responses required, this is specified to avoid ambiguity. In these cases, the model answer will
provide a list of possible answers. For instance, if a question requires the student to list three (3) examples, then their
response must include three of the items listed in the model answer.
Note to assessors: Contact details are requested from observers in the feedback forms in case you will have to call them to verify content of
the feedback forms.
IMPORTANT REMINDER
Candidates must achieve a satisfactory result to ALL assessment tasks to be awarded COMPETENT for the
units relevant to this cluster.
CHCCSM005 Develop, facilitate and review all aspects of case management
CHCCCS004 Assess co-existing needs
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Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302
INSTRUCTIONS TO CANDIDATE
The questions in this workbook are divided into two categories: Knowledge Assessment and Case Studies.
The questions under Knowledge Assessments are all in a short-answer format. The longer questions, requiring creative
and analytical thought processes, are covered in the Case Studies assessment. You must answer all questions using
your own words. However, you may reference your Learner Guide and other relevant resources and learning materials
to complete this assessment.
Some questions cover processes you will likely encounter in a workplace. Ideally, you should be able to answer these
questions based on the processes that are currently in place in your workplace. If this is not the case, then answer the
questions based on processes that should be implemented in your workplace.
Accessing Intranet Pages and External Links
There are instructions in this workbook that will refer you to intranet pages and or external links. These intranet pages
and external links are formatted in Blue Underlined Text.
To access these, hold the Ctrl key for Windows users or the Command ⌘ key for Mac users while clicking on these
links.
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Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302
CASE STUDIES
Instructions to Assessor
This assessment supports the industry requirement of working with clients as a case manager in community services. In
real life, case managers will be required to assess the diverse and multi-faceted needs of people, and determine both
internal and external services required to meet those needs; undertake case management meetings to plan, monitor and
review service provision; and, coordinate multiple service requirements for clients with complex needs within a case
management framework. This assessment will demonstrate the candidate’s ability to use analytical and thinking skills in
such situations.
Instructions to Candidate
These case studies are a hypothetical situation which will not require you to have access to a workplace, although, your
past and present workplace experiences may help with the responses you provide. You will be expected to encounter
similar situations to these in the future as you work with clients with clients as a case manager in community services.
In real life, case managers will be required to assess the diverse and multi-faceted needs of people and determine both
internal and external services required to meet those needs, undertake case management meetings to plan, monitor and
review service provision, and coordinate multiple service requirements for clients with complex needs within a case
management framework. This assessment will allow you to demonstrate your ability to use analytical and thinking skills
in such situations.
CHCCSM005 Develop, facilitate and review all aspects of case management
CHCCCS004 Assess co-existing needs
CHCCSM004 Coordinate complex case requirements
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Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302
CASE STUDY
Philip
SCENARIO
Philip is a 36-year-old man who is married with two children.
He has been homeless for almost a year now. He may not fit
the stereotypical story of a homeless person because not so
long ago, he was living a healthy life with his family. But, when
he lost his job, he found himself in a downward spiral.
Philip and his wife rented a two-bedroom apartment in a safe
neighbourhood. Philip liked his job as a delivery driver for a
large food service distributor, where he had worked for more
than five years. He was working towards getting the supervisor position in the next year. Philip’s wife was a stay-at-
home mom.
Philip has never been seriously ill, although he smokes half a pack of cigarettes each day and drinks socially a couple
times a month.
One afternoon, Philip’s company notified him that they were laying him off along with more than a hundred other
employees. Though he was devastated, he was not at all worried because he and his wife had some savings they could
use for rent and other bills, in addition to the unemployment payments he would receive for a few months.
Philip searched aggressively for jobs in the newspaper and online, but nothing worked out. He began to have feelings
of anger and worry that led to panic. His self-esteem fell, and he became depressed. When Philip’s wife was hired
part-time to work in a school canteen, the couple felt better about finances. But demoralised by the loss of his job,
Philip started to drink more often.
With the drinking becoming more regular, Philip and his wife started to argue more often. Then, about six months
after losing his job, Philip stopped receiving Centrelink payments. That week, he went on a drinking binge that ended
with another argument with his wife. In the heat of the fight, he struck her. The next day, Philip’s wife took the
children and moved in with her parents. Philip was also evicted from the apartment on the same day because he was
unable to pay rent.
Philip tried to reconcile with his wife, but she said she had had enough as he is becoming more angry and violent.
Over the next few months, Philip asked friends and family members if he could board with them for a couple of
days. They reluctantly agreed but his heavy drinking and anger only got worse, and his hosts always asked him to
leave.
Finally, when Philip couldn’t ask help from anyone anymore and he didn’t have a place of his own, he started sleeping
at the park. For a couple of nights, he also stayed at a shelter run by a church. Each morning, he had to leave the
shelter at 5 AM. He walked the streets all day and begged for money to buy alcohol.
Philip was referred to your service (Operation Hope) by the community hospital, after he was taken to their
emergency department due to injuries caused by some teenage boys who jumped him in the park, beat him up and
stole his backpack. He was discharged after a day and was screened as “homeless”.
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ASSESSMENT TASK 1 – CASE STUDY
Student ID
Student Name
This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this
assessment task
Student Declaration: I declare that the work submitted is my
own, and has not been copied or plagiarized from any person or
source.
Signature: ___________________________
Date: ____/_____/_____
Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials
1 S/NS
2 S/NS
3 S/NS
Feedback to student:
Assessor: I declare that I have conducted a fair, valid, reliable
and flexible assessment with this student, and I have provided
appropriate feedback.
Signature: _________________________
Name: _________________________
Date: ____/_____/_____
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Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302
PART 1:
ASSESSMENT TASK 1.
Your supervisor assigned you to complete the intake interview with Philip. In order to prepare for the first meeting
with him, read Philip’s referral form found below and Operation Hope’s policies and procedures found at this link:
Referral Form
CLIENT DETAILS
Name Philip Stockinger
Address N/A
Phone no. N/A Date of birth N/A
Gender ☒ Male ☐ Female
Marital Status ☐ Single ☒ Married ☐ De facto ☐ Divorced
Background Islander
☐ Aboriginal ☐ Torres Strait Islander ☐ Aboriginal and Torres Strait
Others, please specify N/A
Next of kin or contact person Karen Stockinger
Address 90 Martens Place, Port of Brisbane
Phone (07) 3651 2680
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REFERRAL DETAILS
Referral agency Mater Public Hospital
Referral agency contact person/details Melissa Dame/ER Nurse
Previous contact with the service ☐ Yes ☒ No
When and what services were provided Emergency service – treatment of injuries
PROGRAM/ACTIVITY DETAILS
Broadly, what programs/activities do you need to access?
Children ☐ Youth ☐ Substance Abuse ☐ Training ☐
Elderly ☐ Parenting ☐ Disabilities ☐ Health ☐
Others (please specify) Accommodation/housing
Recommendations/Action take (e.g., that a formal assessment be undertaken)
Schedule an initial contact with Philip for intake and assessment.
Additional comments
Philip was brought to the emergency dept. three days ago due to injuries. He said some boys beat him up and took his backpack
containing his clothes and some food from the church. He usually sleeps on the park benches. When asked where we can find him more
often, he said he stays around City Tabernacle church for food, and sometimes they let him stay for the night when it gets really cold
outside.
REFERRAL APPROVAL
Referral Officer/Case Worker
Kiara Henderson
Signature
Date
18 January 2017
Supervisor/Manager
Dylan Nyhan
Signature
Date
18 January 2017
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TASK 1
Written/Oral Questions
1. Statutory requirements
a. What information from the above scenario may raise your concern and may prompt you to undertake further
assessment and reporting as necessary?
b. You decide to further assess, and you find out that there is a need to report your concern. What will be your
basis for reporting?
a.
b.
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2. Identify the assessment tools you need to prepare prior to the first meeting with Philip. (This question asked for
the tools – the marking guide is not a tool)
Guidance: Refer to Operation Hope’s Policies and Procedures.
3. What are the assessment processes that you will utilise as Philip’s case manager?
Guidance: Refer to Operation Hope’s Policies and Procedures.
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TASK 2
Roleplay activity: Intake interview
This part of the assessment is a Roleplay Activity.
This activity will require you to perform an intake interview.
To complete this part of the assessment, you will need access to:
1. One (1) volunteer who will roleplay as Philip.
2. Video camera or a mobile phone with video and audio recording capabilities.
3. Forms and checklists:
▪ Intake Checklist
Intake
Checklist x
▪ Intake Form
Intake Form x
▪ Consent Form
Consent Form x
▪ Intake Action Plan
Intake Action
Plan x
*Click on the icons above to open the forms/checklists
Read the instructions carefully before proceeding.
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Steps to take:
1. Prepare for the intake interview by:
a. Reading and understanding Operation Hope’s (the hypothetical service) policies and procedures.
b. Filling out the Intake Form with the details already provided. Refer to the scenario and Referral
Form.
c. Gathering the forms and checklist needed during the interview. These include the Intake Checklist,
completed Intake Form, and Consent Form.
d. Explaining Philip’s case to your volunteer.
2. Proceed with the intake interview. During the first part of the interview you must be able to:
a. Introduce yourself and the service, and seek introduction from the client. Engage the client in
establishing rapport and trust.
b. Identify the purpose of the meeting and orient the client. Clarify the context of the interview and
seek the client’s participation in the process. Encourage the client to ask questions and seek
clarification as necessary.
3. Present the completed Intake Form to the client. Review the details already included in the form with the
client and ask him to provide the remaining information.
4. Explain the following information to the client. Ensure that you seek feedback from the client to identify
whether the client understood the points being discussed.
a. What is your role as the client’s case manager?
b. What is your role as the client’s case coordinator?
c. What is the assessment process and what are its practical aspects?
Guidance: To be able to explain the assessment process and its practical aspects, the following must be included
in the discussion:
▪ 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.
d. What are the client’s rights and responsibilities, including his rights to appeal and avenues for
complaints?
e. What will the methods of communication be between the case manager and the client (e.g. phone,
face-to-face meeting, home visits, email, etc.)?
f. What are the procedures for release of personal information to another party and the requirement
for informed consent for release?
5. After the discussion of the points above, complete the Intake Checklist and the Consent Form.
6. Use interpersonal communication skills in engaging the client to explore the urgent issues and needs that
the client is experiencing. When the most urgent needs are identified, work with the client in prioritising
these.
7. Together with the client, accomplish the Intake Action Plan and identify the:
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a. Three (3) most urgent needs of the client
b. Desired results (goal/s) of each need
c. Activity/-is that will be used to pursue each goal for each issue (plan/strategy)
d. Responsible person/s and/or service/s who will carry out each plan/strategy
e. Time frame in which the responsible person/s and/or service/s hopes to achieve each specific
plan/strategy (target date)
Guidance in accomplishing the Intake Assessment Action Plan:
▪ The issues and goals recorded should reflect the words and sentiments of the client.
▪ The goals should be measurable so that you, as the case manager, and the client will know when they have
been achieved or need to be re-evaluated.
▪ There may be more than one activity for each issue/goal.
▪ The responsible person may include you, other service providers, the client’s family/caregiver, and other
formal/informal support.
▪ The client receiving support should be given appropriate responsibility in implementing and pursuing their
plan.
▪ The time frame (target date) should be appropriate and specific to the issue, goal, plan/strategy (i.e. exact
date should be provided).
f. Review the points discussed during the interview and close it by scheduling another appointment
in a week to make a formal plan.
Guidelines
1. To demonstrate your completion of this activity, the intake interview must be recorded. Save the recorded
video using the filename:
[Last Name, First Name]_Subject 4 – Roleplay Activity-1
For example, as seen below:
Smith, John_Subject 4 –
Roleplay Activity-1.avi
2. Your video submission must not be longer than forty-five (45) minutes in length. Any submission longer than
forty-five (45) minutes will be considered not satisfactory.
3. There is no specific script to be followed in the roleplaying activity. However, you must be able to demonstrate
all steps outlined above. Moreover, your submission will be assessed against the checklist provided below.
4. Submit the following completed forms and checklist together with the video:
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Filename
Intake Checklist [Last Name, First Name]_Subject 4 – Intake Checklist
Intake Form [Last Name, First Name]_Subject 4 – Intake Form
Consent Form [Last Name, First Name]_Subject 4 – Consent Form
Intake Action Plan [Last Name, First Name]_Subject 4 – Intake Action Plan
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Part 1: Task 2 – Roleplay Activity: Intake Interview
Assessor’s Checklist
(For the assessor’s use only)
Has the following been demonstrated in
candidate’s video submission?
Yes No Comment
1. Information sharing is facilitated, and
appropriate rapport is established.
☐ ☐
2. Information about the coordination role is
provided.
☐ ☐
3. The assessment process is explained to the
client.
☐ ☐
4. Informed consent is explained and
obtained from the client.
☐ ☐
5. Practical aspects of assessment are
consulted with the client.
☐ ☐
6. Client’s rights and responsibilities,
including rights of appeal and avenues of
complaint are explained.
☐ ☐
7. Communication requirements are
established with the client.
☐ ☐
8. The client is empowered to identify and
prioritise own needs. ☐ ☐
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TASK 3
Roleplay activity: Assessment interview
After a week, Philip returned to the service to have the formal assessment interview with you. During the intake
interview, you explained to Philip that this second meeting would involve a more detailed assessment with a view of
creating the case management plan with him.
Prior to this meeting, you phoned the service providers with whom you made appointments on behalf of Philip. All
of them told you that Philip failed to show up to the scheduled appointments. One of the coordinators in another
service informed you that she instinctively phoned Mater Public Hospital. She found out that Philip was admitted
for a couple of days due to severe abdominal pain and was diagnosed with gastritis.
This part of the assessment is a Roleplay Activity.
This activity will require you to perform a formal assessment.
To complete this part of the assessment, you will need access to:
1. One (1) volunteer who will roleplay as Philip.
2. Video camera or a mobile phone with video and audio recording capabilities.
3. Assessment form and checklist.
▪ Assessment Checklist
Assessment
Checklist x
▪ Assessment Form
Assessment
Form x
*Click on the icons above to open the forms/checklists
Read the instructions carefully before proceeding.
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Steps to take:
1. Prepare for the assessment interview by:
a. Reading and understanding Operation Hope’s (the hypothetical service) policies and procedures.
b. Gathering the forms and checklist needed during the interview. These include the Assessment Form
and Assessment Checklist.
c. Explaining the next scenario of Philip’s case to your volunteer.
2. Proceed with the assessment interview. During the first part of the interview, you must be able to:
a. Re-establish rapport and trust (e.g. ask the client how he has been since the first meeting, what were
his activities last week, etc.).
b. Review what happened during the previous meeting and discuss the intake action plan and its results
with the client.
c. Explain to the client the agenda for the meeting and encourage asking questions and raising
concerns, if there are any.
3. Conduct the assessment in a semi-structured narrative format and use the Assessment Checklist in collecting
the following information:
a. Presenting concerns
▪ What are the concerns for which the client came or was referred for help?
▪ How does the client view these concerns?
▪ What is/is the client’s expectation(s) when he came in or when he was referred to the service?
▪ How long has the client been the impacted by these concerns?
▪ Were there prior attempts to resolve the concerns?
▪ Was there previous involvement with social agencies/services for assistance with these
concerns?
b. Past medical history and background
Obtain this by asking the client to describe his/her:
▪ Family history – include any health information (i.e. conditions and illnesses that run in the
family) about the client’s close relatives from three generations.
▪ Past illnesses and conditions – include childhood illnesses and diagnosed conditions the client
has had previously.
▪ Hospitalisations – include the primary reason for admission.
▪ Surgeries and procedures – include any past surgeries or other major medical procedures.
▪ Significant injuries – include all types of injuries that resulted in disability or altered activity.
▪ Medications – include prescription, over-the-counter and supplementary medicines that the
client has taken in the past.
▪ History of mental concerns.
c. Previous agency involvements
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▪ Has the client asked for assistance or was referred to any social agencies/services prior? If
yes, list all the names and include the services that the client received previously.
d. Psychosocial and behavioural health
▪ Ask the client the following questions to be able to gather data about his level of psychosocial
and behavioural well-being:
– How do you feel about the things going on in your life at the moment?
– What is it that troubles you most about the situation?
– How are you handling this/these thing(s) that trouble you?
▪ Observe the attitude, appearance, behaviour, thought process, and insight of the client all
throughout the interview
e. Psychosocial support systems
▪ Ask the client to describe his relationships with his:
– Immediate family (i.e. wife and children)
– Relatives (including his in-laws)
– Friends
– Other groups/support
f. Risk Assessment
Determine the presence of the following risk and vulnerability factors which may affect the safety
and well-being of the client. Explore the factors below through the course of the conversation.
Guidance: Below are sample questions you may use during the assessment. You may ask additional/other questions
as necessary.
▪ Depression/mental health issue
– Are you feeling down or hopeless?
– Do you feel bad about yourself or that you are a failure and have let yourself or your
family down?
– Do you have thoughts of hurting yourself, or that you would be better off dead?
▪ Drug and/or alcohol misuse/abuse
– Do you drink heavily when you are disappointed, under pressure or have had a
quarrel with someone?
– Has a family member or close friend expressed concern or complained about your
drinking?
– Have you ever spent your rent or bill money to buy drugs or alcohol?
– Have you had trouble getting along with your friends because of your alcohol or drug
use?
▪ Suicidal ideas
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– Have you ever tried to kill yourself or attempt suicide?
– When did you begin having suicidal thoughts?
– Did any event (stressor) precipitate the suicidal thoughts?
– What would it accomplish if you were to end your life?
▪ Isolation
– Do you feel that you have nobody to talk to?
– Do you feel as if nobody really understands you?
– Do you feel shut out and excluded by others?
▪ Has access to weapons
– Do you have access to weapons of any kind?
▪ Has ever harmed or threatened people and/or animals
– Have you ever harmed or threatened to harm family, friends or pets?
– Did someone do something, or did something happen that made you harm or
threaten people and/or animals?
▪ Controlling behaviours
– Have you exercised complete control over another person’s activities, for example,
telling him/her who they can friends with, determining when he/she can see friends
and family, etc.?
– Have you ever tried influencing another person’s decisions by blackmailing them?
▪ Unemployed
– Do you feel that you are no longer in control of your life since you have lost your
job?
– Do you feel helpless and unable to change the circumstance you are in?
– Do you feel that you lose the status that comes with having a job?
▪ History of violent behaviour
– Have you ever hit other people or damaged things when you are angry?
– Have you ever been in a physical fight (e.g. punching, kicking, slapping, etc.) with
another person?
– Did someone do something, or did something happen that made you act out
violently?
▪ Recent separation
– Has there been a recent separation or planned separation in the near future?
– Do you have plans of working with your wife/family towards reconciliation?
▪ Financial difficulties
– Have you asked someone, or have you contacted a financial service for assistance?
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– When was the last time you tried looking for a job?
g. Need for short-term and long-term support
▪ Help the client identify the short-term and long-term support needs
– Short-term needs are those that can be addressed immediately and resolved.
– Long-term needs are the complex needs of the client that can only be addressed by
careful planning and coordination with other support/services.
h. Strengths, weaknesses, goals
Assist the client in identifying his strengths, weaknesses, and goals. The following questions may
assist the client:
▪ What are your personal attributes?
▪ What are your talents and skills?
▪ What are your environmental strengths (e.g. personal relations, physical resources,
opportunities, etc.)?
▪ What are your interests, aspirations, and goals?
▪ What are the barriers that may have a negative effect on achieving your goals?
i. Additional information
Additional questions you may ask the client include the following:
▪ What is/are the expectation(s) of the client?
▪ Is there any person the client does not want to see and/or have contact with?
▪ Is there any information that the client does not wish to be disclosed?
▪ Does the client have any special request that they would like the service to assist them with?
▪ Does the client have any additional information that they would like you to know about in
order to offer them support?
4. Review the points discussed during the interview, inform the client that the information collected will be used
to create a case management plan and close it by scheduling another appointment in a week for the case
conference.
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Guidelines
1. To demonstrate your completion of this activity, the intake interview must be recorded. Save the recorded video
using the filename:
[Last Name, First Name]_Subject 4 – Roleplay Activity-2
For example, as seen below:
Smith, John_Subject 4 – Roleplay
Activity-2.avi
2. Your video submission must not be longer than forty-five (45) minutes in length. Any submission longer than
forty-five (45) minutes will be considered not satisfactory.
3. There is no specific script to be followed in the roleplaying activity. However, you must be able to demonstrate
all steps outlined above. Moreover, your submission will be assessed against the checklist provided below.
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Part 1: Task 3 – Roleplay Activity: Assessment Interview
Assessor’s Checklist
(For the assessor’s use only)
Has the following been demonstrated in
candidate’s video submission?
Yes No Comment
1. Collaborated with the client to identify
strengths, abilities and goals.
☐ ☐
2. Worked with the client to identify
immediate, short and long-term needs.
☐ ☐
3. Assessed potential risk factors for service
delivery.
☐ ☐
4. Applied strengths-based approach to
assessment.
☐ ☐
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TASK 4
Document the outcome of the Assessment interview
This part of the assessment will require you to document the outcome of the assessment interview using the
Assessment Form.
Assessment
Form x
*Click on the icons above to open the forms
Read the instructions carefully before proceeding.
Steps to take:
1. Transcribe the information collected from the Assessment Interview using the Assessment Form.
2. Summarise each item listed in the Assessment Checklist.
▪ Bullet points may be used in lieu of a narrative/essay format.
▪ Paraphrasing may be used to convey the general idea of what is being said.
▪ Record the client’s exact words using quotations marks if there is a need to highlight his/her
statement(s).
3. Follow these guidelines in documenting the assessment interview:
▪ Use simple but appropriate language. ‘Slang’ may only be used if the client’s exact words are being
recorded.
▪ Write objectively, concisely in the active voice and include only necessary information.
4. Submit the completed Assessment Form and Checklist using the following naming convention:
Filename
Assessment
Checklist
[Last Name, First Name]_Subject 4 – Assessment Checklist
Assessment
Form
[Last Name, First Name]_Subject 4 – Assessment Form
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TASK 5
Analyse Information and Prioritise Needs
1. Based on the assessment interview, do you need to arrange for an interpreter to be able to ensure that Philip
understands the service being provided and is able to communicate his needs?
2. What are the most common situations where an interpreter is needed to be arranged for a client?
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3. Find out about using interpreter services that are available in your workplace or in your area by:
▪ Locating and printing a copy of your workplace guidelines and/or procedures regarding the use of
interpreters. Submit the copy together with this workbook.
▪ Locating and printing a copy of the interpreter request form used by your workplace. Submit the copy of the
request form together with this workbook.
▪ Collecting at least two (2) examples, such as brochures or instructions describing workplace or community
interpreting services. Scan the brochures/instructions and submit it together with this workbook.
▪ Identify at least two (2) links to online information that could help.
Guidance: From the options provided, choose and accomplish one (1).
Filename of guidelines/procedures request form or brochures/instructions:
OR
Links to online information:
4. Based on the intake and assessment interview, is Philip eligible for Operation Hope’s services and programs?
Provide the basis for your answer.
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5. Stratify and Analyse Risk Factors
a. Based on your assessment, what are the risk and vulnerability factors which may affect Philip’s safety and
well-being?
b. What is the appropriate level of risk based on the risk factors identified? Provide a brief explanation for
selecting such level of risk.
c. List three (3) risk management strategies that are useful when dealing with high-risk situations that may
affect Philip.
a. Based on your assessment, what are the risk and vulnerability factors which may affect Philip’s safety and
well-being?
b. What is the appropriate level of risk based on the risk factors identified? Provide a brief explanation for
selecting such level of risk.
Guidance: Select the appropriate level of risk based on the following:
☐ At HIGH RISK of serious harm
☒ At RISK of Harm
Level of risk:
☐ At HIGH RISK of serious harm
☐ At RISK of Harm
Explanation:
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c. List three (3) risk management strategies that are useful when dealing with high-risk situations that may
affect Philip.
▪
▪
▪
6. What is Operation Hope’s policy on maintaining and storing client records in accordance with confidentiality
requirements?
7. What are the specialist services and other sources available within your State/Territory that could provide you
with additional information for you to be able to determine the range of issues that Philip is experiencing?
Guidance:
▪ List two (2) specialist services and two (2) other sources. Other sources may include case management organisations,
regulatory body, and peak and industry associations.
▪ Utilise available directories from your State/Territory.
State/Territory:
Specialist services:
Other sources:
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ASSESSMENT TASK 2 – PROJECT
Student ID
Student Name
This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this
assessment task
Student Declaration: I declare that the work submitted is my
own, and has not been copied or plagiarized from any person or
source.
Signature: ___________________________
Date: ____/_____/_____
Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials
1 S/NS
2 S/NS
3 S/NS
Feedback to student:
Assessor: I declare that I have conducted a fair, valid, reliable
and flexible assessment with this student, and I have provided
appropriate feedback.
Signature: _________________________
Name: _________________________
Date: ____/_____/_____
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PART 2: ASSESSMENT TASK 2
Planning
TASK 1
Develop an Appropriate Case Management Plan
This part of the assessment will require you to develop an appropriate case management plan for Philip using the
Case Management Plan template below.
Case Management
Plan x
*Click on the icons above to open the template
Read the instructions carefully before proceeding.
Steps to take:
▪ Before creating the case management plan, reflect on the outcomes of the intake and assessment interview
to be able to identify and analyse the multiple and complex needs that you need to consider in developing
the case management plan.
▪ Evaluate the needs of the client based on the information gathered during intake and assessment. Prioritise
the client’s needs based on his responses in Task 3.
▪ Once the needs are identified, research and compile information on the availability and capacity of other
services that can support the client. Keep in mind that a specialist’s input is of particular importance to
support multiple and complex needs.
▪ Develop the case management plan using the template provided:
o List all known persons currently contributing to the client’s care. This includes the individual,
carer/advocate, key worker/case manager/coordinator, specialists (e.g. GP, health/community
providers, substitute decision maker, family members, volunteers or friends who provide assistance).
The following must also be in the case management plan:
o Full name of the participants involved in care.
o His/her role or kind of support he/she is giving the client.
o Contact details (e.g. phone, emails, etc.)
o Will the participant involved in care be included in the planning process?
o Will the participant involved in care be provided with a copy of the care plan?
o Provide a summary of the outcome of the assessment interview in bullet points. This must include
the identified multiple and complex needs of the client that the plan is meaning to address.
o Complete the Support Plan:
o Under Opportunities, provide five (5) needs/concerns that were identified during the assessment
phase. List these needs/concerns in order of priority.
o For each Opportunity, set two (2) goals that are SMART—specific, measurable, attainable, realistic,
and time-bound.
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o For each goal, identify the action/s or step/s required to achieve them, specify the responsible
person/s, and the expected outcome/s.
Guidance: Identify action/s or step/s that build on the client’s strengths, and also include referral options.
o Specify the date set for the completion of each action/s or step/s.
▪ Consider the following when developing the case management plan:
▪ All available services are explored, and the most appropriate ones are included in the plan.
▪ Ensure that the responsible person/s’ and/or service/s’ experience and capability match the support needed
by the client.
▪ Ensure that the service providers you have identified are accessible to the client and to you, as the client’s
case manager.
Guidance: You may reference real-life service providers that are available within your area in your case management
plan.
▪ Use an inclusive approach when developing the plan.
▪ Complete the rest of the sections on the template except for the following:
▪ Consent checklist
▪ Target review date
▪ Service user (client) agreement
▪ Signature of client, case manager, and service providers
▪ Submit the partially completed Case Management Plan using the following naming convention:
Filename
Case
Management
Plan
[Last Name, First Name]_Subject 4 – CMPlan-Partial
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TASK 2
Collaborate with Client and Key Stakeholders
Before closing the assessment interview, you informed Philip about the
next steps—that a case management plan will be developed, and that a
case conference and meeting will be held. You explained to him, that in
order for you to work with him better and provide him with new
opportunities, it is best to work with other people who may be able to
provide him with additional and specialist support. You noticed that he
seemed wary of this new information.
You: Before I can start preparing for the case conference and meeting, I need to make sure that it is okay with you that we will be
speaking with other people and service providers. May I know your thoughts on this?
Philip: I am okay with the meeting. You said that we would be speaking with other people that I might need to have contact with.
Will you also be inviting my wife?
You: Ideally, we should invite everyone who may be able to help and assist you. Do you want me to arrange for your wife’s attendance
at the meeting?
Philip: Can we not invite her for now? Can we invite her when I’m all sober and fixed?
You: Yes, we certainly could do that. I’ll take note of that. Is there anything else you want to ask or tell me?
Philip: What are we supposed to talk about in the meeting?
You: In a case conference, we might talk about anything, including those things that might be stopping you from doing what you need
to do, like transport or looking for work, or troubles with family.
Philip: Should I attend the meeting?
You: Yes. I recommend for you to be there.
Philip: Okay. If ideas will be shared, what about my privacy and how will you keep things confidential?
You: Before we start the meeting, everyone in attendance will have to agree to maintain confidentiality and not disclose any information
shared in the conference with insignificant others.
Philip: Okay, I understand.
You Thank you, Philip. I will inform you and the others of the exact date, time and venue of the case conference and meeting.
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Roleplay Activity: Facilitate a Case Conference and Meeting
This part of the assessment is a Roleplay Activity.
This activity will require you to develop the Agenda and prepare for the meeting. You are also responsible for
facilitating the meeting and making sure that the meeting remains focused.
To complete this part of the assessment, you will need access to:
1. Three (3) volunteers
▪ Two (2) volunteers to play the role of the personnel from other services you want to provide
assistance to your client.
Guidance: You are to assign what services the two (2) volunteers will represent. For example, you will be the person
responsible for counselling, one of the volunteers will represent the drug/alcohol rehabilitation agency and the other will
be providing support for housing.
▪ One (1) volunteer to play the role of Philip.
2. Video camera or a mobile phone with video and audio recording capabilities.
3. Enough copies of the case plan that you have developed; one for each participant in the meeting.
4. Forms and templates
▪ Consent Form – Case Conference
Consent Form-Case
Conference x
▪ Confidentiality Agreement
Confidentiality
Agreement x
▪ Meeting Agenda
Meeting
Agenda x
▪ Meeting Minutes
Meeting
Minutes x
*Click on the icons above to open the forms/templates
Read the instructions carefully before proceeding.
Steps to take:
1. Prepare for the case conference and meeting by:
a. Gathering the following documents needed for the case conference and meeting:
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▪ Developed case management plan
▪ Consent form for the case conference
▪ Confidentiality agreement form
▪ Meeting agenda
▪ Meeting minutes
b. Creating the meeting agenda. Use the Meeting Agenda and provide the following details:
▪ Description of the meeting
▪ Date and time start/finish
▪ Venue
▪ Attendees
▪ Agenda item, who is assigned to discuss it, how long should it be tackled, and time
start/finish for each
c. Explaining what should transpire in the case conference and meeting with all the volunteers.
2. Proceed with the case conference and meeting. During the first part of the meeting, you must be able to:
a. Initiate a round of introductions and provide the purpose/aims of the meeting.
b. Clarify the allotted time for the meeting and state that you will be facilitating and taking the minutes.
Ensure all the attendees that a copy of the minutes will be sent to all relevant service providers
involved in the case.
c. Obtain the client’s consent for the meeting by providing a recap of the process, purpose, expected
outcomes, level of input required, and the likely tone and context of the meeting. Ask the client to
fill out the Consent Form afterwards.
d. Present the Confidentiality Agreement to all in attendance. Everyone must date and sign it,
including you and the client.
e. Distribute the Agenda and the client’s Case Management Plan (from Task 1).
3. Discuss the Agenda and outline the case history with the help of the client. Prompt him/her to provide
additional information as necessary.
4. Facilitate the meeting proper. Restate that the main objective of the meeting is to discuss how everyone in
attendance will work together, supply support to assist the client and make an agreement to monitor the
client’s progress toward achieving the set outcomes.
If the discussion focus shifts from the main objective of the meeting, your role as facilitator is to remind the
group of the current task at hand and the required outcome.
5. Cover the following during the meeting:
▪ Roles, responsibilities and boundaries of workers/ service providers/ organisations are defined.
▪ Needs, rights and responsibilities of the client, client’s family (if applicable), community, and service
providers are identified and agreed upon.
▪ Processes of coordinated/integrated service delivery and service provision requirements are
explained.
▪ Case management plan is reviewed by the service providers:
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o Prioritised needs of the client are communicated to all service providers.
o Realistic targets for change or action for the client are set.
o Barriers to attaining outcomes are identified.
▪ Collaborative working arrangements and requirements are determined:
o Service duplication must be identified.
o If duplication is identified, steps on how to manage these must be outlined.
o If there are case management plan issues that cannot be met by the services present, it should
be identified which services are to be contacted and who will undertake this role.
o Procedure on how to coordinate must be explained to the client to minimise stress and
confusion.
6. Ask the client to give feedback on the assessment, on the identified recommendations, and the emerging case
management plan.
7. Identify the case meeting outcomes by clarifying the responsibilities and time frames for the client and the
service providers. The process for monitoring and reviewing outcomes must also be established. Ensure that
these are recorded and agreed upon by everyone in attendance.
8. Summarise all points discussed in the meeting. Encourage the client to raise questions that he may have about
accessing the services. Remind him that he may recommend options that he thinks will work for him other
than those identified.
9. Close the meeting by informing all attendees that the minutes and a copy of the revised case management
plan will be sent via email. Method of communication and schedule of future meetings must be noted and
recorded, as well.
10. Complete the following documentation:
▪ Meeting Minutes
▪ Case Management Plan – revise the plan according to recommendations from the case conference
and meeting, and complete the following sections:
o Consent Checklist
o Participants Involved in the Care – include case conference and meeting attendees
o Signatures of client, case manager, and service providers
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Guidelines
1. To demonstrate your completion of this activity, the intake interview must be recorded. Save the recorded
video using the filename:
[Last Name, First Name]_Subject 4 – Roleplay Activity-3
For example, as seen below:
Smith, John_Subject 4 – Roleplay
Activity-3.avi
2. Your video submission must not be longer than forty-five (45) minutes in length. Any submission longer
than forty-five (45) minutes will be considered not satisfactory.
3. There is no specific script to be followed in the roleplaying activity. However, you must be able to
demonstrate all steps outlined above. Moreover, your submission will be assessed against the checklist
provided below.
4. Submit the following completed forms and templates together with the video using the following naming
convention:
Filename
Case Management
Plan (revised)
[Last Name, First Name]_Subject 4 – CMPlan-Revised
Consent Form –
Case Conference
[Last Name, First Name]_Subject 4 –
Consent_Conference
Confidentiality
Agreement
[Last Name, First Name]_Subject 4 – Confidentiality
Agreement
Meeting Agenda [Last Name, First Name]_Subject 4 – Meeting Agenda
Meeting Minutes [Last Name, First Name]_Subject 4 – Meeting Minutes
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Part 2: Task 2 – Roleplay Activity: Assessment Interview
Assessor’s Checklist
(For the assessor’s use only)
Has the following been demonstrated in candidate’s
video submission?
Yes No Comment
1. Facilitated case conference and meeting to
coordinate responsibilities and roles.
☐ ☐
2. Facilitated communication between service
providers to identify and manage service
duplication.
☐ ☐
3. Identified and agreed on client and worker
roles, responsibilities, boundaries and processes
of service delivery.
☐ ☐
4. Determined and agreed on organisation, family
and community needs, responsibilities and
rights.
☐ ☐
5. Assisted clients to achieve realistic targets for
change or action and to take personal
responsibility.
☐ ☐
6. Worked with other services to minimise client
confusion and concerns in a coordinated
manner.
☐ ☐
7. Worked with the client to prioritise needs and
communicate these with service providers. ☐ ☐
8. Worked with the client and other services to
identify barriers to attaining outcomes. ☐ ☐
9. Worked within the scope of own role and seek
assistance from colleagues and experts as
required.
☐ ☐
10. Sought feedback about assessment processes
from the person and other networks. ☐ ☐
11. Worked with the client and other services to
determine the service provision requirements. ☐ ☐
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12. Negotiated collaborative working arrangements
for all services involved. ☐ ☐
13. Worked with the services to agree on
coordination requirements and boundaries. ☐ ☐
14. Provided the person with service information
and supported their decision-making process. ☐ ☐
15. Encouraged the person to advocate on their
own behalf to access services. ☐ ☐
16. Worked with the client and services to monitor
progress toward outcomes. ☐ ☐
17. Routinely sought feedback.
☐ ☐
18. Considered service delivery and referral
options. ☐ ☐
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ASSESSMENT TASK 3 – PROJECT
Student ID
Student Name
This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this
assessment task
Student Declaration: I declare that the work submitted is my
own, and has not been copied or plagiarized from any person or
source.
Signature: ___________________________
Date: ____/_____/_____
Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials
1 S/NS
2 S/NS
3 S/NS
Feedback to student:
Assessor: I declare that I have conducted a fair, valid, reliable
and flexible assessment with this student, and I have provided
appropriate feedback.
Signature: _________________________
Name: _________________________
Date: ____/_____/_____
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PART 3: ASSESSMENT TASK 3
Monitoring and Review
A week after the case conference and meeting, you scheduled to meet up with Philip to review his progress. Prior to
the meeting, you rang the drug/alcohol rehabilitation centre to check how Philip’s doing. The coordinator informed
you that Philip showed up for the scheduled assessment and was able to talk to one of the centre’s counsellors. Philip
informed the counsellor that he read about Ozcare, also a recovery centre, in a newspaper and is interested in
transferring to their program.
On the day of the meeting, you observed that Philip is now cleanly shaven and is wearing a clean set of clothes.
You: Hi, Philip. Thank you for coming in today.
Philip: No worries. What are we going to talk about today?
You: We are going to review your case plan and progress. Before we start, I’d like to know how you’re doing and how’s it been since
last week.
Philip: I think I’m much better now. The emergency accommodation provides showers and hot meals. They also gave me new clothes.
You: That’s wonderful. How do you feel about that?
Philip: The place is great, and the people are really helpful, but the rehab centre is quite far from the shelter. I still have to take a bus,
and I am saving some money from my Centrelink payments. I actually have some money in the bank now.
You: I see. I phoned the rehab centre, and the coordinator said that you were able to complete the assessment and interview with the
counsellor. How was the interview?
Philip: It was okay, the counsellor was nice. I told him about Ozcare. I said I saw it in the newspaper the other day and it’s much
closer, and I don’t have to take the bus. She said I could suggest it to you and see what you think.
You: All good, Philip. I’ll look into Ozcare and see if you are eligible to transfer to their program. You said earlier that you are saving
up some money from your Centrelink payment. Is that correct?
Philip: Ah, yes. I actually want to look for work, but I really don’t know where to start.
You: That’s okay, Philip. We can also help you with that. We can help you start by developing an employment plan and mapping out
your employment history. We will schedule another time for us to work on your employment plan.
Philip: I’m okay with that. Thank you.
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TASK 1
Review of Care Plan
This part of the assessment will require you to review the care plan and the client’s progress and plan the next steps
using the Review of Care Plan form.
Review of Care
Plan x
*Click on the icons above to open the forms
Read the instructions carefully before proceeding.
Steps to take:
1. Complete the Review of Care Plan based on the meeting with Philip. Refer to the revised case management
plan for the identified opportunities and goals.
2. Document the Progress of each opportunity and goal, and note:
▪ Whether the goals are being achieved
▪ Whether they are being achieved in the timelines
▪ Whether there are any barriers to implementation
▪ Whether there is a failure to achieve the goals
▪ Whether the client is satisfied with the service/s received
▪ What needs to be changed to meet the client’s situation (e.g., the goals themselves, or the steps to
meet those goals).
Guidance: Refer to the conversation provided in the scenario for the details of Philip’s progress.
3. Include who the source of information is (e.g. client – Philip, service coordinator [name of service provider],
counsellor from [name of service provider, etc.) in the review plan.
4. Determine the adjustments to be made or the next steps to take to be able to overcome any barriers identified
or the needs that have changed over time. Provide the rationale for identifying these next steps/actions to
take.
5. Submit the completed review of care plan using the following naming convention:
Filename
Review of Care
Plan
[Last Name, First Name]_Subject 4 – Review_Care Plan
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TASK 2
Communicate the Outcomes of the Review
You are tasked to send an email to the following parties to inform them of the proposed changes arising from the
case review:
▪ Coordinator and counsellor of the rehab facility Philip is currently attending
▪ the employment counsellor of Operation Hope
Your emails must contain the outcomes of the review of the care plan that is relevant to their respective
responsibilities. You must provide them with the details and the reason behind the proposed changes arising from
the review. The next steps/actions identified during the short meeting with the client must be outlined, and clearly
but concisely explained to all the parties involved in the care of the client.
Guidelines
1. Draft two (2) separate emails—one for the coordinator and counsellor of the rehab facility, and another for
Operation Hope’s employment counsellor.
2. The email for the coordinator and counsellor of the rehab facility Philip is currently attending must provide
them information about the changes brought about by the review and the wishes of Philip to transfer to
another facility’s program.
3. The email for the employment counsellor of Operation Hope must include the referral and the basis for your
recommendation.
4. Write the draft of the templates provided below.
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To:
(Include name/s
and email
address/es)
Subject:
(Write an
appropriate subject)
Message:
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To:
(Include name/s
and email
address/es)
Subject:
(Write an
appropriate subject)
Message:
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ASSESSMENT TASK 4 – PROJECT
Student ID
Student Name
This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this
assessment task
Student Declaration: I declare that the work submitted is my
own, and has not been copied or plagiarized from any person or
source.
Signature: ___________________________
Date: ____/_____/_____
Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials
1 S/NS
2 S/NS
3 S/NS
Feedback to student:
Assessor: I declare that I have conducted a fair, valid, reliable
and flexible assessment with this student, and I have provided
appropriate feedback.
Signature: _________________________
Name: _________________________
Date: ____/_____/_____
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PART 4: ASSESSMENT TASK 4
Case Closure and Exit
Philip was able to transfer to Ozcare’s live-in detox program, and after a week, he dropped by your office to inform
you that he will be exiting Operation Hope’s program. He said that he needs more than a week to fully recover from
his alcohol dependency and that Ozcare offered a structured program that will help him be free of alcohol. Philip told
you that he is very grateful for all the help and that he was satisfied with how you assisted him and coordinated his
care.
You started preparing for the case closure and Philip’s exit by reviewing his case and the service’s exit policy and
procedure.
(Click on the icon above to open Operation Hope’s policies and procedures)
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TASK 1
Case Closure and Summary
You are required to complete the Case Closure Summary and Exit form in accordance with Operation Hope’s
policies and procedures.
Case Closure
Summary x
*Click on the icons above to open the forms
Read the instructions carefully before proceeding.
Steps to take:
1. Complete the Case Closure and Exit form based on the scenario above. Refer to the Client Exit Policy for
further guidance.
2. Summarise the services rendered to the client and reason/s why the case is being closed. Comment on the
progress made toward goals in the case management plan. Where necessary, include provisions for continued
services listing agencies and contact persons.
3. In the Transfer, Discharge, or Follow up Plans, include the following information:
▪ Additional support that should be provided to the client prior transfer and discharge.
▪ How the client can access your service again should the need arise.
▪ Procedures for exit documentation, file closure and secure archiving.
1. Submit the completed case closure and exit form using the following naming convention:
Filename
Review of Care
Plan
[Last Name, First Name]_Subject 4 – Case Closure and Exit
Form
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TASK 2
Reflective Journal
For this assessment, you will be required to reflect on your learning experience and your performance in completing
all the previous tasks.
Guidelines:
1. Reflection guides are provided to assist you in providing the relevant information required for this activity.
2. You must always provide complete responses, where required. If the guide asks you to list at least two (2)
examples, then you must list two (2) or more, and not less than.
3. Your responses must always be based on your experience during the completion of the case study. The
reflective journal shall be the last task you will accomplish in this workbook.
Journal Entry Date:
Reflection Guide
1. Reflect on your own performance as the case manager of Philip. How did you fare as a case manager and
coordinator? Do you think you were able to provide effective case management to Philip? What aspects of
his case management could be improved? What strategies (at least three (3)) will you use to become a more
effective and efficient case manager? (Write your reflection in not less than 200 words)
2. In not less than 100 words, describe how you integrated appropriate cultural considerations into all aspects of
the planning phase?
3. In not less than 100 words, discuss how you provided the standard of care that is reasonable and consistent
with duty of care responsibilities?
1.
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2.
3.
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ASSESSMENT TASK 5 – CASE STUDY
Student ID
Student Name
This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this
assessment task
Student Declaration: I declare that the work submitted is my
own, and has not been copied or plagiarized from any person or
source.
Signature: ___________________________
Date: ____/_____/_____
Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials
1 S/NS
2 S/NS
3 S/NS
Feedback to student:
Assessor: I declare that I have conducted a fair, valid, reliable
and flexible assessment with this student, and I have provided
appropriate feedback.
Signature: _________________________
Name: _________________________
Date: ____/_____/_____
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ASSESSMENT TASK 5: Case Study 2
Thuy and Paloma
SCENARIO 1 – Thuy
Thuy is a 42-year-old man from a Vietnamese background. He is a single
father with a teenage son, whom he has raised after his wife passed away five
years ago. Thuy also lives with his ageing parents whom he also supports.
He has two other siblings who have moved to the city because of work
opportunities, so he was left to take care of their parents on his own.
Thuy dropped out of high school because he was bullied by his peers. He
tried to learn the English language, but the other students said that he sounds
funny when he speaks English. Thuy developed a low self-esteem and
decided not to return to school and stay at home. Thuy had several part-time
jobs that did not last for long as he had trouble understanding his co-workers and the company clients.
Thuy’s last job was on a construction site. He had an accident where he fell from a scaffold and sustained injuries and
a broken hip. He is now unable to leave the house and apply for a new job. A few weeks after his accident, his father
became ill and now requires ongoing medication. Thuy started to feel upset and worthless. There were days when he
would not talk with anyone in his family. He felt angry at times and would blame himself for the accident. At one
point, he tried to cut his wrist with a sharp object, but his son caught him and stopped him.
Thuy was referred to your service (Operation Hope), a month after his accident, by one of his neighbours. His son
feared for his father’s life, and the family did not know what to do with Thuy.
Thuy has limited responses during the assessment interview whilst you are trying to collect data. He nodded when you
asked him if he could understand English. He was able to answer questions relating to his name, age, and where he
lives.
When you asked him about his injury, he gave you a blank stare then looked at his son as if asking for help. You asked
him more questions, and he did not respond.
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TASK 1a
Analyse Information and Identify Needs
1. Based on the scenario, do you need to arrange for an interpreter for Thuy to ensure that he understands the service
being provided and is able to communicate his needs? Explain your reason.
2. Supposing that an assessment interview has been conducted for Thuy, identify two (2) needs that he needs to
communicate.
a.
b.
3. List two (2) ways on how you can identify Thuy’s spoken language.
Guidance: For this assessment, you are only informed that Thuy’s family came from Vietnam.
1.
2.
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You informed Thuy that you will be arranging an interpreter for him in order to proceed with his assessment interview.
Thuy shook his head, and you repeated that instruction about arranging an interpreter. He shook his head and waved
his hand. You reckoned that he understood the word ‘interpreter’, but he refused to have one.
4. Explain the action you should do when a client refuses to use an interpreter.
After seeking assistance from one of your multi-lingual staff, Thuy had agreed to have an interpreter. He preferred to
have a female interpreter who speaks Vietnamese as he thinks that they understand better.
He also asked if his son could be present with him during the assessment interview so that he could help him
understand the discussion.
5. Refer to the schedule of fees from the Translating and Interpreter Service:
http://www.pirsws.com.au/wp-content/uploads/2016/05/TIS-Services-charges-FY2013-14
How much would the interpreting service for Thuy cost?
http://www.pirsws.com.au/wp-content/uploads/2016/05/TIS-Services-charges-FY2013-14
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TASK 2a
Interpreter Arrangement
For this assessment, you will be booking an interpreter for Thuy. Complete the booking form below.
Interpreter Booking
Form x
*Click on the icons above to open the forms
Read the instructions carefully before proceeding.
Steps to take:
a. Complete the Interpreter Booking form based on the scenario above.
b. In the Type of Job Booking, specify what type of interpreter service you require for the client/s (i.e. on-site,
phone interpreting)
c. Complete the Appointment Details using your nominated date and time.
Guidance: For this assessment, on-site interpreting services require a minimum booking period of 90 minutes, and phone
interpreting, is 30 minutes.
d. Submit the completed booking for the client using the following naming convention:
Filename
Interpreter
Booking
[Last Name, First Name]_Subject 4 – Interpreter_[Client Name]
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CLIENT DETAILS
Type of job booking
Organisation/Agency
CONTACT DETAILS
Name
Job Title
Phone no.
Email Address
APPOINTMENT DETAILS
State/Territory of where
interpreter service is required
Non-English speaker’s name
Preferred booking time
Date
Start
time
End
time
Language of interpreter required
Preferred gender interpreter
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SCENARIO 2
Paloma, a 16-year-old teenager, is from a refugee family from Iraq. Since
she was two, she and her family have been moving from cities in Iraq to
escape the violence and armed conflict. She was sexually abused at seven
years old by some soldiers, while her parents were tortured. Because of
these experiences, Paloma’s parents decided that they needed to move out
of the country. She was 14-years-old when they came to Australia.
Paloma seems like a happy teenager, shy at first but easy to talk with when
she’s comfortable with the people she is with. As her family live in a rural
town among other refugees, Paloma has very little knowledge of the English
language, but she is determined to learn more.
One day, Paloma went to the city with a group of teenage friends. They met with other Australian teenagers who told
them that they would teach them English if they hang out with them. From then on, Paloma and some of her friends
visited the city often to spend time with their new friends.
Her parents became worried when Paloma started to become defiant and talk back to them, which was very
uncharacteristic of her. Sometimes, she would come home drunk at late hours of the night. Her father confronted her
one time about this behaviour – she yelled at her father and stormed out of the house. She came home three days later.
One of her friends told her parents that Paloma has been going out with different teenage boys from the city and some
of them they did not know.
Paloma was brought to the hospital a few days ago because she overdosed on pills. The doctor reported that Paloma
is two weeks pregnant. She regained consciousness after some medical treatment, and the doctor suggested that she
needs to seek help. She was then referred to your service.
At the assessment interview, Paloma speaks the same Arabic phrase as a response to your questions.
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TASK 1b
Analyse Information and Identify Needs
1. Based on the scenario, do you need to arrange for an interpreter for Paloma? Explain your reason.
2. Supposing that an assessment interview has been conducted for Paloma, identify two (2) needs that she needs to
communicate.
▪
▪
You informed Paloma that you will be arranging an interpreter for her in order to proceed with her assessment
interview. You wanted to collect information on what has been going on with Paloma since she started hanging out
with the Australian teenagers.
With the help of a staff member who can speak Arabic, you ask the client if it’s alright for her to meet with the
interpreter. She seemed hesitant and shook her head and asked for her mother to speak on her behalf instead.
You asked again if it would be okay to speak with an offsite interpreter and she nodded in agreement.
3. Explain one (1) possible reason when a client refuses to meet an interpreter.
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4. Refer to the schedule of fees from the Translating and Interpreter Service:
http://www.pirsws.com.au/wp-content/uploads/2016/05/TIS-Services-charges-FY2013-14
How much would the standard interpreting service for Paloma cost?
http://www.pirsws.com.au/wp-content/uploads/2016/05/TIS-Services-charges-FY2013-14
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TASK 2b
Interpreter Arrangements
For this assessment, you will be booking an interpreter for Paloma. Complete the booking form below.
Interpreter Booking
Form x
*Click on the icons above to open the forms
Read the instructions carefully before proceeding.
Steps to take:
1. Complete the Interpreter Booking form based on the scenario above.
2. In the Type of Job Booking, specify what type of interpreter service you require for the client/s (i.e. on-site, phone
interpreting).
3. Complete the Appointment Details using your nominated date and time.
Guidance: For this assessment, on-site interpreting services require a minimum booking period of 90 minutes, and phone
interpreting, is 30 minutes.
4. Submit the completed booking for using the following naming convention:
Filename
Interpreter
Booking
[Last Name, First Name]_Subject 4 – Interpreter_[Client Name]
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CLIENT DETAILS
Type of job booking
Organisation/Agency
CONTACT DETAILS
Name
Job Title
Phone no.
Email Address
APPOINTMENT DETAILS
State/Territory of where
interpreter service is required
Non-English speaker’s name
Preferred booking time
Date
Start
time
End
time
Language of interpreter required
Preferred gender interpreter
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ASSESSMENT TASK 6 – WRITTEN/ORAL QUESTIONS
Student ID
Student Name
This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this
assessment task
Student Declaration: I declare that the work submitted is my
own, and has not been copied or plagiarized from any person or
source.
Signature: ___________________________
Date: ____/_____/_____
Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials
1 S/NS
2 S/NS
3 S/NS
Feedback to student:
Assessor: I declare that I have conducted a fair, valid, reliable
and flexible assessment with this student, and I have provided
appropriate feedback.
Signature: _________________________
Name: _________________________
Date: ____/_____/_____
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ASSESSMENT TASK 6 – WRITTEN/ORAL QUESTIONS
STUDENT INSTRUCTIONS:
This is a written assessment that will test your knowledge. This assessment may be completed over the duration of the
training day. As you learn, practice and review knowledge and skills, you will keep Assessment Task 6 in front of you
and answer the questions as the information becomes clear to you. At the beginning of each review session you will be
given a few minutes to familiarise yourself with the questions. You will be given extra time at the end of the day to
complete this assessment or to clarify facts with the Trainer/Assessor.
Make sure you:
• Answer all questions
• Print clearly a
• Use a blue or black pen. Assessments written in pencil will not be accepted.
• Ask your assessor if you do not understand a question. Whist your assessor cannot tell you the answer, he/she
may be able to re-word the question for you
• Do not talk to your classmates. If you are caught discussion the answers you will be asked to leave and your
assessment will not be marked.
• Do not cheat. Anyone caught cheating will automatically be marked Not Competent for this unit. There are
NO EXCEPTIONS to this rule.
Answer the following questions in the space provided. You may use extra sheet if the space provided isn’t
enough. To those who wish to type your answers in word document must reflect the question numbers
clearly.
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1. Match the following descriptions to the correct models of case management by writing the corresponding letters
on the spaces provided:
A. A model of case management in which case workers help clients identify their needs
and broker support services.
B. Utilises the commonly accepted functions of case management and is characterised by
a closer involvement between case manager and client.
C. Assumes a comprehensive role for a team of case managers by providing services such
as skills-building, family consultations, and crisis intervention.
D. Provides outreach and direct counselling services with a smaller caseload and without a
team approach.
E. Combines case management and clinical or rehabilitation activities.
F. Focuses on client’s strengths, self-direction, and the use of informal help networks.
i. Assertive community treatment case management
ii. Brokerage case management
iii. Clinical case management
iv. Generalist case management
i. Intensive case management
ii. Strengths-based case management
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2. Briefly, explain the Case Management Approach diagram shown below.
Case
Managemen
t Approach
Client
centred
Evidenc
e based
HolisticInclusive
Strengths
based
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3. Match the following descriptions to the correct approaches to service delivery by writing the corresponding
letters on the spaces provided:
A. An approach in which the individual is at the centre of the decision-making processes
and is supported to exercise greater choice and control over their services, how they are
delivered, and by whom.
B. An approach to providing support and resources to individuals that focuses on
identifying and building their assets and skills, to help them create the needed change.
Clients will achieve much more if they are assisted to identify, recognise, and use the
strengths they have identified.
C. Invests individuals as ‘rights-holders’, creates an avenue for their voices to be heard and
enables them to be empowered.
D. This approach is based on the basic understanding that clients are the leaders of self-
change for their lives. Workers need to believe that the client has within them, the
capacity of knowing what they need to do to resolve their own issues. The worker is to
provide a non-judgemental environment using a non-directive approach. This will
enable clients to find their own solutions to problems.
i. Needs-based
ii. Person-centred
iii. Rights-based
iv. Strength-based
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4. Illustrate the requirements of evidence-based practice using a Venn diagram.
Guidance: Click on this resource to read more about Venn diagrams.
Insert your Venn diagram below:
https://www.lucidchart.com/pages/venn-diagram
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5. Briefly, explain the application of each contemporary behaviour change models and provide two (2) examples of
general interventions used in case management.
Behaviour Change
Model
Application Interventions
Trans-Theoretical Model
Relapse Prevention
Model
Ecological Approaches
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6. Which three (3) statements below are true about the scope and purpose of the Case Management Standards of
Practice (Australia)?
☐ i. Standards of practice are designed to enhance case management practice.
☐
ii. Standards of practice are intended to detract from any responsibilities which may be
imposed by law or regulation.
☐
iii. Standards of practice provide a basis for quality guarantee, expectations and
accountability for clients, employers, and other professionals.
☐
iv. Standards of practice reinforce current practices and are designed to provided objectives
and guidelines to assist the case manager in competently practising case management.
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7. Briefly, describe the following types of assessment and their use in different contexts.
a. Generic assessment
b. Intake assessment
c. Social assessment
d. Social history report
e. Risk assessment
f. Biopsychosocial assessment
a. Generic assessment
b. Intake assessment
c. Social assessment
d. Social history report
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e. Risk assessment
f. Biopsychosocial assessment
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8. Explain the role and responsibilities of the following who may be involved in the assessment process:
a. Case manager
b. Client
c. Key Stakeholders
d. Agency
Guidance: Provide at least two (2) responsibilities for each.
a. Case manager
b. Client
c. Key stakeholders
d. Agency
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9. Which three (3) statements below are true about the impact of the setting on the assessment process?
☐
i. It is important to establish and maintain rapport throughout the assessment to help the
client feel comfortable and receptive to assessment.
☐
ii. It is not appropriate to conduct and complete the assessment in a client’s home as this
may inconvenience the case manager and make him/her uncomfortable with the
unfamiliar environment.
☐
iii. Maintain client’s focus and take care that the interview remains on track to obtain the
necessary information by minimising outside distraction and noise.
☐
iv. The assessment must be conducted 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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10. Answer the following questions:
a. What are the functions of assessment tools?
b. List three (3) examples of assessment tools.
c. What are the validity and reliability requirements of assessment tools?
a. Functions of assessment tools
b. Examples of assessment tools
c. Validity and reliability requirements
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11. Briefly, describe the following methods of collecting information:
a. Self-reports
b. Informant reports
c. Health records
a. Self-reports
b. Informant reports
c. Health records
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12. Mandatory reporting requirements and format related to community services:
a. Complete the table below about the mandatory reporting requirements when working with children in your State/Territory.
b. Provide a photo or a screenshot of a reporting template used in community services. If the screenshot of the template is taken online, specify the link on the
space provided. If there is no reporting template used in your State/Territory, provide the URL of the relevant Child Protection website that provides instructions
on how to report child abuse in your State/Territory.
State/Territory:
Legislation:
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Who is mandated to report? What must be reported? Abuse and neglect types which must be reported
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Reporting template used in your State/Territory
Link to reporting template / relevant Child Protection website if the state/territory does not have a reporting template:
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13. Briefly, explain the following legal and ethical considerations that must guide the case manager’s assessment
practice:
a. Confidentiality
b. Disclosure
c. Duty of care
d. Informed consent
e. Privacy
a. Confidentiality
b. Disclosure
c. Duty of care
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d. Informed consent
e. Privacy
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14. Identify two (2) risks of harm and your responsibilities relating to duty of care as a case manager for:
a. Children and young people
b. People with a disability
c. People experiencing domestic violence
d. A situation of elder abuse
e. Someone contemplating suicide
a. Children and young people
Risks of harm Responsibilities
b. People with a disability
Risks of harm Responsibilities
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c. People experiencing domestic violence
Risks of harm Responsibilities
d. A situation of elder abuse
Risks of harm Responsibilities
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e. Someone contemplating suicide
Risks of harm Responsibilities
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15. Answer the questions below:
a. Define family structure and family dynamics.
b. List and describe two (2) types of communication patterns followed by families.
c. Describe the three (3) types of decision-making processes utilised by families.
a.
b.
c.
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16. Complete the table below by providing the:
▪ brief history (if applicable)
▪ protocols & systems
▪ considerations
▪ special needs
of the following diverse client/population:
a. Aboriginal and/or Torres Strait Islander people
b. Children and young people
c. Culturally and linguistically diverse (CALD)
d. Lesbian, gay, bi-sexual, transgender, intersex (LGBTI)
e. Older people
f. People experiencing or at risk of homelessness
g. People with a disability
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Aboriginal and/or Torres Strait Islander people
History Protocols & systems
Guidance: Provide at least three (3)
cultural protocols & systems that may apply
when working with this group.
Considerations
Guidance: Provide at least three (3) things
workers need to consider when working with this
group.
Special needs
Guidance: List any needs that may relate specifically
to this group, i.e. support, type of services, etc.
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Children and young people
History Protocols & systems
Guidance: Provide at least three (3)
cultural protocols & systems that may apply
when working with this group.
Considerations
Guidance: Provide at least three (3) things
workers need to consider when working with this
group.
Special needs
Guidance: List any needs that may relate specifically
to this group, i.e. support, type of services, etc.
**No need to fill out this column.
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Culturally and linguistically diverse (CALD)
History Protocols & systems
Guidance: Provide at least three (3)
cultural protocols & systems that may apply
when working with this group.
Considerations
Guidance: Provide at least three (3) things
workers need to consider when working with this
group.
Special needs
Guidance: List any needs that may relate specifically
to this group, i.e. support, type of services, etc.
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Lesbian, gay, bi-sexual, transgender, intersex (LGBTI)
History Protocols & systems
Guidance: Provide at least three (3)
cultural protocols & systems that may apply
when working with this group.
Considerations
Guidance: Provide at least three (3) things
workers need to consider when working with this
group.
Special needs
Guidance: List any needs that may relate
specifically to this group, i.e. support, type of
services, etc.
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Older people
History Protocols & systems
Guidance: Provide at least three (3)
cultural protocols & systems that may apply
when working with this group.
Considerations
Guidance: Provide at least three (3) things
workers need to consider when working with this
group.
Special needs
Guidance: List any needs that may relate specifically
to this group, i.e. support, type of services, etc.
**No need to fill out this column. State/territory:
Protocol/systems:
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People experiencing or at risk of homelessness
History Protocols & systems
Guidance: Provide at least three (3)
cultural protocols & systems that may apply
when working with this group.
Considerations
Guidance: Provide at least three (3) things
workers need to consider when working with this
group.
Special needs
Guidance: List any needs that may relate specifically
to this group, i.e. support, type of services, etc.
**No need to fill out this column. State/Territory:
Protocol/systems:
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People with a disability
History Protocols & systems
Guidance: Provide at least three (3)
cultural protocols & systems that may apply
when working with this group.
Considerations
Guidance: Provide at least three (3) things
workers need to consider when working with this
group.
Special needs
Guidance: List any needs that may relate specifically
to this group, i.e. support, type of services, etc.
**No need to fill out this column. State/territory:
Protocol/systems:
.
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17. Briefly, explain the common service requirements of community care providers in your State/Territory.
State/territory:
Common service requirements:
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18. Briefly, explain the following aspects of community services:
a. Community support
b. Education and training
c. Employment
d. Financial support
e. Housing
f. Physical and mental health
g. Social inclusion
a. Community support
b. Education and training
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c. Employment
d. Financial support
e. Housing
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f. Physical and mental health
g. Social inclusion
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19. List three (3) examples of each of the following as they apply to Community Services in your State/Territory:
a. Specialist services and support available
b. Networks available
c. Examples of local services and supports available in your State/Territory
a. Specialist services and support
b. Networks
c. Local services and supports
State/Territory:
Examples:
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20. Funding for organisations can be accessed in a number of ways. Briefly, explain the following:
▪ Commonwealth-direct funding
▪ Commonwealth-State Agreements
▪ State/Territory-direct funding
a. Commonwealth-direct funding
b. Commonwealth-State Agreements
c. State/Territory-direct funding
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21. Identify three (3) occasions when a service may need to refer a client to another service provider.
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22. Explain the following formal processes used in case management for information sharing and planning?
a. Case conferences
b. Case review meetings
c. Formal briefings on client progress
a. Case conferences
b. Case review meetings
c. Formal briefings on client progress
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23. What are the relevant documentation protocols/requirements observed by community services case managers?
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24. What are the strategies used by a community service organisation in monitoring and reviewing casework
activities and processes?
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25. What are the rights of the client, family, community, and organisation in the decision-making and case
management process?
The rights of the client:
The rights of the client’s family:
The rights of the community:
The rights of the organisation providing services:
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26. What are the requirements and boundaries of a case manager’s coordination role in the community services?
Guidance: Provide at least five (5).
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27. Every individual has their own value system which may have an effect on the case management process. Briefly,
discuss how the individual value systems of the client and workers/key stakeholders can impact on case
management outcomes.
a. Client
b. Worker and key stakeholders
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28. In 150 words, summarise the principles and practices 0f planning for individuals with complex needs.
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29. In 150 words, summarise the principles and practices 0f working across multiple services.
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30. What are the issues/concerns/barriers that may cause client confusion when they are accessing multiple
services?
31. What are the issues faced by clients, their family and carers when accessing multiple services?
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32. What are the impacts of service duplication to clients, families, and carers?
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33. Identify and explain at least three (3) impacts of generational abuse to individuals who have experienced this.
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34. What are the impacts of welfare dependency on individuals?
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35. What is the basic feature of multiple and complex needs affecting client groups?
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36. In 150 words, describe the impact of having clients with multiple and complex needs of community service
organisations and service providers?
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37. Chris is a 24-year-old male who was first diagnosed with anxiety and depression during high school. He has been
diligently visiting his psychiatrist and attending therapy sessions ever since. But, he stopped seeing his psychiatrist
and therapy sessions when his mother passed away last month.
Over the past few weeks, Chris’ family and friends have noticed increasingly bizarre behaviour. On many
occasions, they’ve overheard him whispering in an agitated voice, even though no one is nearby.
At the supermarket where Chris works, his supervisor has already warned him that he might lose his job due to
an incident with a male customer. There was a number of times he arrived at work appearing to be under the
influence of alcohol/drugs.
a. What are the complex issues that Chris might be experiencing?
b. What are the potential interrelationships between the complex issues you have identified?
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c. In this scenario, what are the indicators of imminent self-harm or harm to others?
Guidance: Provide five (5) for each.
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38. You have received a call from an anonymous neighbour of Leticia Thompson. The caller did not want to give
her name because she did not want to be involved, but reported being concerned about her neighbours. The
caller reported that the family’s home is just across the road from her house.
Two nights before, the neighbour heard banging, crying, and shouting. Last night, the caller heard Paul, Leticia’s
husband, shouting and cursing at the children and heard more crying. This morning, the neighbour bumped into
Leticia and noticed that she had a black eye that was badly concealed with makeup. The caller greeted Leticia’s
two children who were with her, Amber (4 y/o) and Aaron (1 y/0) and noticed that there are bruises and welts
on the children’s arms. When the caller tried to talk to Amber and Aaron, the two hid behind their mother and
would not speak.
When you checked the Thompson’s family records, Paul had already been charged with domestic violence in a
previous relationship.
a. What are the issues that Leticia and her family might be experiencing?
b. What are the potential interrelationships between the complex issues you have identified?
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39. Philip, 36 years old, married with two children, has been working as a delivery driver for a large food service
distributor for four years. One afternoon, Philip’s company notified him that it was laying him off along with
more than a hundred other employees.
He searched aggressively for jobs in the newspaper and online but could not secure a position. His self-esteem
fell, and he became depressed. Philip was so demoralised by the loss of his job that he started to drink more
often. The drinking became regular and so did the fights with his wife. The fights became so physical that his
wife left him, took the children and moved in with her parents. About six months after losing his job, Philip
stopped receiving support from Centrelink as he was not actively looking for a job. He was evicted from the
apartment because he was unable to pay the rent.
Family and friends allowed him to stay with them, but his heavy drinking and anger issues got worse, and his
hosts always asked him to leave. When Philip ran out of people to stay with, he found himself without a place
to stay for the night and started sleeping at the park.
a. What are the issues that Philip might be experiencing?
b. What are the potential interrelationships between the complex issues you have identified?
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40. Danvir, a 9-year-old boy, is often teased by his classmates because he wears a turban and has a long hair. They
call him a girl, saying he shouldn’t go to the boy’s restroom, and threatens to cut off his hair. Unlike other mums,
his mum had sent a letter to the school to explain their family’s faith.
Danvir and his family are Sikh, and confusion about their religion has led to bullying in the past. Each new
school year seemed to bring Danvir more tears and frustration. Danvir has told his parents many times that he
does not want to go to school anymore because “everybody is being mean”.
a. What are the issues that Danvir might be experiencing?
b. What are the potential interrelationships between the complex issues you have identified?
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Assessment Workbook Checklist
When you have completed this assessing the assessment workbook, review the candidate’s assessment against the
checklist below:
The candidate has completed all the assessments in the workbook and has submitted all of the
required evidence:
Case Studies
Case Study 1: Philip
Case Study 2: Thuy and Paloma
The candidate has submitted all of the following evidence:
This completed workbook
Hand-signed and scanned Assessment Workbook Cover Sheet
Case Study 1: Philip
Part 1: Assessment Task 1
Task 1 – Answer Questions
Case study questions
Task 2 – Roleplay activity: Intake Interview
Video recording of roleplay
[Last Name, First Name]_Subject 4 – Intake Checklist
[Last Name, First Name]_Subject 4 – Intake Form
[Last Name, First Name]_Subject 4 – Consent Form
[Last Name, First Name]_Subject 4 – Intake Action Plan
Task 3 – Roleplay activity: Assessment Interview
Video recording of roleplay
Task 4 – Document the Outcome of the Assessment Interview
[Last Name, First Name]_Subject 4 – Assessment Checklist
[Last Name, First Name]_Subject 4 – Assessment Form
Task 5 – Analyse Information and Prioritise Needs
Case study questions
Part 2: Assessment Task 2 – Planning
Task 1 – Develop an Appropriate Case Management Plan
[Last Name, First Name]_Subject 4 – CMPlan-Partial
Task 2 – Roleplay activity: Facilitate a Case Conference and Meeting
Video recording of roleplay
[Last Name, First Name]_Subject 4 – CMPlan-Revised
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[Last Name, First Name]_Subject 4 – Consent Conference
[Last Name, First Name]_Subject 4 – Confidentiality Agreement
[Last Name, First Name]_Subject 4 – Meeting Agenda
[Last Name, First Name]_Subject 4 – Meeting Minutes
Part 3: Assessment Task 3 – Monitoring and Review
Task 1 – Review of Care Plan
[Last Name, First Name]_Subject 4 – Review Care Plan
Task 2 – Communicate the Outcomes of the Review
Simulated email to the coordinator and counsellor of the rehab facility
Simulated email to Operation Hope’s employment counsellor
Part 4: Assessment Task 4 – Case Closure and Exit
Task 1 – Case Closure and Summary
[Last Name, First Name]_Subject 4 – Case Closure and Exit Form
Task 2 – Reflective Journal
Reflective journal guide questions
Assessment Task 5 – Case Study 2: Thuy and Paloma
Task 1a – Analyse Information and Identify Needs
Case study questions
Task 2a – Interpreter Arrangement
Case study questions
Task 1b – Analyse Information and Identify Needs
Case study questions
Task 2b – Interpreter Arrangements
[Last Name, First Name]_Subject 4 – Interpreter_[Client Name]
Assessment Task 6 – Written/Oral Questions
Knowledge assessment (40 Questions)
IMPORTANT REMINDER
Candidates must achieve a satisfactory result to ALL assessment tasks to be awarded COMPETENT
for the units relevant to this cluster.
To award the candidate competent in the units relevant to this subject, the candidate must successfully complete
all the requirements listed above according to the prescribed benchmarks.
Learner Guide
CHCCSM005
Develop, facilitate and review all
aspects of case management
CHCCCS004
Assess co-existing needs
CHCCSM004
Coordinate complex case requirements
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This learner guide is copyright protected by:
Compliant Learning Group (Australia)
Level 13, 269 Wickham St, Fortitude Valley 4006
Email: support@compliantlearningresources.com.au
Website: http://compliantlearningresources.com.au/
© 2021 Precision Group (Australia)
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TABLE OF CONTENTS
This is an interactive table of contents if you are viewing this document in Acrobat clicking on a heading will transfer
you to that page. If you have this document open in Word you will need to hold down the Control key while clicking for
this to work.
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
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
http://www.supportingcarers.snaicc.org.au/wp-content/uploads/2015/03/02497
http://www.supportingcarers.snaicc.org.au/wp-content/uploads/2015/03/02497
http://www.carersaustralia.com.au/storage/2011Working%20with%20Aboriginal%20People%20and%20Communities
http://www.carersaustralia.com.au/storage/2011Working%20with%20Aboriginal%20People%20and%20Communities
https://www.kidsmatter.edu.au/sites/default/files/public/Handbook_engaging_with_web
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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
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
http://www.victimsservices.justice.nsw.gov.au/sexualassault/Documents/Child-Protection-Interagency-Guidelines
http://www.victimsservices.justice.nsw.gov.au/sexualassault/Documents/Child-Protection-Interagency-Guidelines
http://www.kidsguardian.nsw.gov.au/children-s-employment/information-for-employers/code-of-practice
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
https://www.communities.qld.gov.au/resources/childsafety/practice-manual/prac-paper-working-cald
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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
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/08_2014/national_ageing_and_aged_care_strategy_lgbti_print_version
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/08_2014/national_ageing_and_aged_care_strategy_lgbti_print_version
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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
http://www.elderabusehelpline.com.au/uploads/pdf/FACS-NSW-Interagency-Policy-updated-November-2015
http://www.elderabusehelpline.com.au/uploads/pdf/FACS-NSW-Interagency-Policy-updated-November-2015
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 &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
http://www.sa.agedrights.asn.au/files/49_1095_aras_abuseprotocols_final3
http://www.sa.agedrights.asn.au/files/49_1095_aras_abuseprotocols_final3
http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0017/231812/Protecting_Older_Tasmanians_from_Abuse
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
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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
https://housing.nt.gov.au/__data/assets/pdf_file/0010/117694/Homelessness_fact_sheetv3
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
https://www.dhhs.tas.gov.au/__data/assets/pdf_file/0003/203691/150596_TAH_Action_Plan_WCAG_d1
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 &usg=AFQjCNEImPt19nlgaxu0Nrh_YhZR2cqi7w&bvm=bv.145822982,d.dGc
https://www.dcp.wa.gov.au/servicescommunity/information/Documents/Service%20Excellence/Protocols/WAPoliceProtocols
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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.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
http://www.disability.wa.gov.au/Global/Publications/About%20us/Policies/protocol_for_younger_people_with_disabilties
http://www.disability.wa.gov.au/Global/Publications/About%20us/Policies/protocol_for_younger_people_with_disabilties
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
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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
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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)
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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/
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
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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
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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/
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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REFERENCES
Australian Association of Social Workers (AASW). (2015). Scope of social work practice: Case management
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