Contents. Before you begin. How to work through this learner guide Assessment

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1 Contents Contents Before you begin How to work through this learner guide Assessment Introduction: Developing, facilitating and monitoring all aspects of case management v v vi 1 Chapter 1: Conducting case management meetings Facilitating information sharing with the client by establishing rapport and implementing procedures 1.2 Identifying and agreeing on boundaries and processes within service delivery Defining and exploring individual, family and community needs and rights, and organisation responsibilities Chapter summary 21 Assessment activity 1: Conducting case management meetings 22 Record your employability skills 23 Chapter 2: Developing an appropriate approach to case management 2.1 Developing and utilising case management processes to implement statutory requirements 2.2 Implementing processes to facilitate client goal-setting and participation in case management processes 2.3 Integrating cultural considerations into management planning Providing information on rights of appeal and avenues of complaint 43 Chapter summary 46 Assessment activity 2: Developing an approach to case management 47 Record your employability skills Chapter 3: Developing a case management plan Developing a case management plan to reflect initial assessment of needs Identifying immediate, short- and long-term needs of the client and other parties 3.3 Developing action plans Establishing processes for monitoring and changing the case management plan iii

2 CHCCM503C Develop, facilitate and monitor all aspects of case management 3.5 Identifying strategies to deal with complex or high-risk situations Matching the requirements of the case management plan to experience, workload and geographical location of the worker 3.7 Focusing the plan on assisting clients to set and achieve realistic targets 76 Chapter summary 79 Assessment activity 3: Developing a case management plan 80 Record your employability skills Chapter 4: Managing case work activities and processes Implementing strategies to monitor the effectiveness of case management processes 4.2 Assessing the need for changes to the plan and developing alternatives 4.3 Successfully negotiating proposed changes following a case review Utilising processes for case closure to comply with organisation procedures 103 Chapter summary 107 Assessment activity 4: Managing case work activities and processes 108 Record your employability skills Final assessment: CHCCM503C Develop, facilitate and monitor all aspects of case management 111 Employability skills 117 Appendices 119 Appendix 1: How the learner guide addresses the unit of competency 119 Appendix 2: Employability skills 123 iv

3 Chapter 1: Conducting case management meetings Chapter 1 Conducting case management meetings 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 wellbeing of the client. They may be working with clients who have disabilities or mental health issues, older people, young people, domestic or sexual abuse victims, or clients with behavioural concerns or drug and alcohol addictions. 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. In this chapter you will learn about: 1.1 Facilitating information sharing with the client by establishing rapport and implementing procedures 1.2 Identifying and agreeing on boundaries and processes within service delivery 1.3 Defining and exploring individual family and community needs and rights, and organisation responsibilities 3

4 Chapter 1: Conducting case management meetings Other industry-specific statutory requirements Other more industry-specific statutory requirements that need to be considered and applied to case management processes are explained in the following table. Industry-specific statutory requirement Community Care Common Standards Child protection Acts Mandatory reporting requirements Guardianship and administrative Acts Mental health legislation Explanation Home and community care (HACC) can be provided by government, non-government, commercial and non-profit agencies. The Community Care Common Standards have been developed to ensure that all funded agencies provide services that meet these quality requirements. Each state and territory in Australia has its own set of laws that apply to the protection of children. These Acts contain information about how children s rights should be protected. The type of abuse or suspected abuse that professionals are required to report varies between states and territories. If you suspect that a client is being abused or is abusing others, you must follow your organisation s mandatory reporting procedures. Acts relating to guardianship and administration vary between states and territories. If you suspect that a client is unable to manage their own affairs, it may be appropriate to contact the relevant tribunal to arrange for the appointment of a guardian. If the client already has a guardian, you must check the extent of the guardian s authority. There are different types of guardianship that determine what areas of the client s life the guardian can make decisions about. Mental health legislation is designed to protect the rights of people with mental illness by explaining: processes for admission into care who has authority to admit people involuntarily into care who has the power to review decisions to admit people into care how often reviews must take place when clients can appeal admission into care. Clients with mental illness may require support to exercise their rights under relevant mental health Acts and other legislation. You need to understand client rights so you can help clients appeal any decisions made and, if it is appropriate to your job role, make complaints on behalf of clients who give you their consent. 19

5 CHCCM503C Develop, facilitate and monitor all aspects of case management Assessment activity 1 Conducting case management meetings Your trainer or assessor may require you to complete this assessment activity and will provide you with instructions as to how to present your responses. They may provide alternative or additional assessment activities depending on the circumstances of your training program. The following table maps the assessment activity for this chapter against the element and performance criteria of Element 1 in CHCCM503C Develop, facilitate and monitor all aspects of case management. Part Element Performance criteria A 1 1.1, 1.2, 1.3 B 1 1.1, 1.2, 1.3 C 1 1.1, 1.2, 1.3 Part A 1. Name at least five procedures and standards that an organisation should have in place to protect the rights of individuals, families and communities. 2. List at least five relevant policies, procedures, pieces of legislation and statutory mandates implemented in your place of work or one you are familiar with. 3. How can family dynamics affect the decision-making process during case management meetings? 4. Why is it important to document case management meetings? 5. Name at least four community services available in your local area? 6. Why is it important to agree upon boundaries during case management meetings? 7. How can the facilitator ensure information is effectively shared in case management meetings? Part B Conduct the following role-play with other learners or colleagues. Set up a formal meeting between a case manager (yourself), a client and any other relevant persons, such as the client s guardian or family member, a supervisor and support worker. The meeting can be based on a scenario from this chapter, one you have experienced or one you create. It needs to include an issue of conflict. 22

6 Chapter 2: Developing an appropriate approach to case management continued Models of behaviour change Theory of planned behaviour Stages of change model (transtheoretical model) Information Behaviour is reliant on a person s intention Intention is the most important variable in affecting behaviour change Intention is informed by attitudes and beliefs Behaviour is influenced by self-efficacy and self-control The stages of change model has six stages: Pre-contemplation Contemplation Preparation Action Maintenance Termination The following example demonstrates how behaviour change models can be integrated into the goal-setting process. 1. Social cognitive theory Example Models of behaviour change and goal-setting Personal factors Environment Behaviour The case manager can assist the client to identify personal factors, like self-efficacy and selfcontrol, and how these factors can influence their ability to achieve a goal. The case manager can link the client to community resources, which can improve the client s environment and enhance personal factors like self-efficacy, which support the client to achieve goals. continued 35

7 CHCCM503C Develop, facilitate and monitor all aspects of case management 3.1 Developing a case management plan to reflect initial assessment of needs 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. Developing the plan During the initial needs assessment, the case manager and the client identified: 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 developed plan needs to take these factors into account in a holistic way, to ensure the following domains of the client s life are addressed: Social a person s social interactions with others, including family members, program or service staff and other service users Cognitive a person s ability to understand rules, use communication and participate effectively; examples of cognitive differences include dementia, stroke, intellectual disabilities and acquired brain injury (ABI) Spiritual/cultural a person s beliefs and cultural practices can play an important role in their lifestyle; examples include proficiency in English and other languages, religious beliefs and customs. Physical/medical a person s ability to participate in tasks that require movement and dexterity; examples include physical disabilities and medical conditions such as diabetes Psychological/emotional can impact on their desire and ability to benefit from activities; examples include grief and depression As all these areas can impact others, it is important to consider the person s needs collectively rather than individually when developing the case management plan. For example, a person who is experiencing pain as a result of a medical condition may also have crossover effects in several other domains, including social and psychological/ emotional areas. Pain can cause a person to feel anxious or withdrawn, which can then lead to social isolation and reduced interest in activities. The effects of each part of the assessment on other domains should be continually assessed and the management plan reviewed. 52

8 CHCCM503C Develop, facilitate and monitor all aspects of case management A permanent housing solution is a long-term need for clients. The following case study demonstrates a client s and other parties immediate, shortand long-term needs. Case study Angelo is an older man, living alone. His daughter Arabella has, until recently, lived close by and helped her father with activities of daily living. Arabella s husband is suddenly required to relocate interstate for his work, so Arabella will no longer be able to assist her father. To complicate issues, Angelo recently fractured his hip and is due to have a hip replacement operation within the month. Arabella and Angelo are concerned about Angelo s isolation, particularly leading up to and following the operation. Angelo is feeling very distressed about his daughter leaving and the impending operation. The case manager is working with Angelo to assess and provide a case plan to address Angelo s immediate, short-term and long-term needs. Immediate needs include: physical support for Angelo leading up to the operation psychological support to address Angelo s distress practical support with activities of daily living following Arabella s departure. Short-term needs include: transport and practical support getting to and from the hospital for the operation possible short-term respite accommodation following the operation support with activities of daily living following the operation rehabilitation exercises and monitoring following the operation. Long-term needs include: ongoing rehabilitation support ongoing psychological support, if necessary a permanent housing solution, with additional care if necessary social networks and activities to connect Angelo with members of the community. Practice task 9 Think about your own needs. Draw a diagram or write a brief report that outlines your immediate, short-term and long-term needs. Take a holistic approach and consider physical, mental, emotional, religious, social and spiritual needs. 60

9 Chapter 3: Developing a case management plan Client: Jacob Strain Goal: Reconnect with children Example Action plan Situation: Jacob is divorced with two children aged 9 and 11. Jacob abused alcohol for over 10 years, and was abusive towards his ex-wife. Having undergone rehabilitation for his alcohol abuse, Jacob now wants to reconnect with his children who he has not seen for over a year. Strategies to address goal Priority Resource Agreed responsibility for delivery Realistic indicators for success Progress/ review Regular relationship counselling with Relationships Australia to address communication skills High Relationships Australia Sarah Rhodes Attends regular appointments Develops effective communication skills Fortnightly appointments with case manager Weekly mediated meetings with children High Relationships Australia Sarah Rhodes Attends meetings as agreed Increased trust from children Increased confidence using communication skills Fortnightly appointments with case manager Attending monthly support group High Community health counselling and support Lance Richards Increased selfesteem Enhanced communication skills Feeling supported Attending support group monthly Practice task 10 Consider the previous example, then answer the following questions. 1. Who are the relevant stakeholders? 2. What are the relevant resources and experts? 3. What strategies could be employed to address each goal and maximise participation? 4. What should the case manager communicate to relevant service providers, and what factors should be considered? 67

10 CHCCM503C Develop, facilitate and monitor all aspects of case management 3.4 Establishing processes for monitoring and changing the case management plan 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 may client 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. Agreeing on the monitoring process 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 evaluation process generally includes: monitoring case plan implementation facilitating review activities and feedback from workers on progress of intervention liaising with service providers and significant others advising on how case plans can be modified, ensuring that changes are communicated appropriately. The processes for monitoring the plan may be generic to the organisation you work for, or specific to the client. Generic processes may need to be modified for the needs of each client. Monitoring processes may 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, ) accompanying the client to a service. The monitoring process 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 or letter. Doctors, for example, usually write a letter to the referrer to inform them about the client s progress. 68

11 Chapter 4: Managing case work activities and processes Example The Department of Human Services funds disability employment services (DES). These services are provided by approved commercial and not-for-profit organisations. DES helps people with disabilities find and maintain employment. Each client has a case manager who works with them and their employer to identify and address any issues that have the potential to impact on their employment. Sometimes clients who access DES services also access HACC services. Allied health professionals may also be engaged to review the case management process on a yearly basis through ongoing support assessment (OSA) processes. Allied health professionals, such as occupational therapists, psychologists and rehabilitation counsellors, speak with DES case managers, clients and clients employers to find out about each client s issues, processes in place to utilise the client s strengths and overcome barriers, and the outcomes of the support. The OSA assessor reflects on the information from all stakeholders and case notes from the last 12 months to recommend whether each client will need more support, the same amount of support or less support, depending on the needs and preferences of all stakeholders. Practice task 15 Read the case study, then answer the questions that follow. Case study Muriel is a client who suffers from acute anxiety and panic disorders. A case review meeting identifies that Muriel has not been attending scheduled appointments with her psychologist. This relates to the fact that Muriel has not managed to meet her target goal of leaving the house at least once a day. The case manager discusses the issues with Muriel and her psychologist, who attends the meeting. Muriel reveals that leaving the house once a day is impossible for her, and the prospect of doing so has heightened her anxiety. The psychologist and Muriel discuss the possibility that Muriel re-evaluates her goal, so it is more realistic and at her pace. They decide that it is more reasonable for Muriel to try to leave the house only to attend her scheduled appointments, rather than every day. If she identifies panic attack symptoms, Muriel agrees that she must call her psychologist or Lifeline to enable her to move through the process. 1. What methods were used to review Muriel s case? 2. What was the purpose of reviewing Muriel s case? 89

12 Chapter 4: Managing case work activities and processes Practice task 18 Read the case study, which is based on Donna from the case study in section 4.2, then complete the task that follows. Case study Donna s baby is now 2 years old. Donna has ongoing support for her depression and is on medication for both schizophrenia and depression. Her child is in day care three days a week, while Donna attends TAFE to study community services. She has also found permanent housing, which is covered by her pension. Donna and Angela, the case manager, discuss the possibility of closing the case. Donna says she feels secure in her accommodation and is happy with her life. She feels that things are under control and agrees that she doesn t require ongoing case management support. They decide that Donna needs to continue seeing her psychologist monthly, and should book more frequent appointments if in a crisis. They talk about the possibility of Donna attending the local gym to help lose weight and hopefully meet some other mums. Angela helps Donna locate the number for the gym and find out when classes are scheduled. Donna expresses to Angela that, although she is happy she has come so far, she does worry about not having ongoing support. Angela tells Donna that her feelings are perfectly natural and assures her that services are available for her to access whenever she needs them. Angela reminds Donna that she will still be visiting the psychologist regularly, and Angela herself will be doing follow-ups every month for the first three months. Angela fills out a case closure form, advises Donna s services about the closure, writes a formal letter to Donna and keeps a copy of the form in the organisation s file. Write a formal letter to Donna summarising the reasons for case closure and the agreed options for receiving ongoing support. Chapter summary Once established, goals and implemented services and programs need to be continually monitored for effectiveness. Procedures should be in place for how and how often goals, services and the satisfaction of clients and stakeholders will be monitored. Changes may occur or need to be implemented during the case. Processes need to be in place to facilitate these changes, and for alternative interventions to be decided upon. Negotiation should occur with the client and relevant stakeholders about which changes need to be made, how changes need to be made and when changes need to be made. Facilitation, assertiveness, effective communication and interpersonal skills are required to successfully negotiate changes or sustain ongoing interventions. Organisational policies and procedures must to be followed when closing a case to ensure the process is successful for all involved. 107