© 2013 National Standards of Practice for Case Management

Na tion al Standards of Practice for Case Management Case Management Society of Australia Editors : Frieda Marfleet, Raechel Barber and Scott WT Trueman

COPYRIGHT © 2013 Case Management Society of Australia Limited (CMSA) 3rd Edition, Revised. Previous editions copyrighted 2004, 2009. All rights reserved. Apart from fair dealing for the purpose of study, research, criticism and review as permitted by the Copyright Act 1968, no part of these Materials may be reproduced, modified, or reused or redistributed for any commercial purpose, or distributed to a third party for any such purpose, without the prior written permission of CMSA. Any permitted reproduction including fair dealing must acknowledge CMSA as the source of any such material reproduced and any reproduction made of the material must include a copy of this original notice. Published by Case Management Society of Australia Limited. Email: cmsa@cmsa.org.au Web: www.cmsa.org.au ISBN: 978-0-646-50468-1

TABLE OF CONTENTS

Introduction Scope and Purpose of the Standards.................................................................................... 1 Interpretation of the Standards.............................................................................................. 1 Application of the Standards.................................................................................................... 1 Case Management Definition................................................................................................... 1 Case Management Concepts.................................................................................................... 1 Guiding Principles of Case Management............................................................................. 3 Case Identification (screening ) and Assessment................... 4 Standard Two Planning................................................................................................... 5 Standard Three Monitoring............................................................................................... 6 Standard Four Evaluation and Outcomes................................................................. 7 Diagrams Diagram One Case Management Process.............................................................. 8 Standard One Case Identification (screening ) Phase........................................ 8 Standard One Assessing Phase................................................................................... 9 Standard One Stratifying Risk (risk assessment) Phase................................... 9 Standard Two Planning Phase...................................................................................10 Standard Two Implementing (care coordination) Phase..................................10 Standard Three Monitoring Phase...............................................................................11 Standard Three Transitioning (transitional care) Phase.....................................11 Standard Three Disengagement and Feedback Phase.......................................12 Standard Four Evaluating Phase...............................................................................12 Standards Standard One Purpose of the Self Assessment Framework (SAF)......................................................13 Structure of the Self Assessment Framework (SAF)....................................................13 Application of the Self Assessment Framework (SAF)................................................13 Standard One Case Identification (screening ) and Assessment.................14 Standard Two Planning.................................................................................................19 Standard Three Monitoring.............................................................................................24 Standard Four Evaluation and Outcomes...............................................................28 Self Assessment Framework (SAF)

Glossary...........................................................................................................................................35

INTRODUCTION

SCOPE AND PURPOSE OF THE STANDARDS The profession of case management recognises the inherent rights of Clients to professional and effective case management services. The Standards specify the minimum level of practice (benchmark) to be attained by a Case Manager throughout the casemanagement process andprovides the foundation for a best practice framework and uniform approach for practitioners throughout Australia. CMSAmembersmake a commitment to read, understand, utilise and apply the Standards within all professional practice. This commitment is renewable through annual membership and/or undertaking any certification processes of the CMSA. The Standards are not intended to detract from any responsibilities which may be imposed by law or regulation. INTERPRETATION OF THE STANDARDS • in the Standards unless the contrary intention appears: words in the singular include the plural and words in the plural include the singular; • where any word or phrase is given a defined meaning, any other form of that word or phrase has a corresponding meaning; • headings are for convenience only and do not affect interpretation of the Standards; and • where a reference is made to the Client this may also refer to the Client Representative. APPLICATION OF THE STANDARDS The Standards have been designed to encapsulate the full case management process and the phases undertaken by the Case Manager within this process. The overall process is iterative and cyclical with phases being revisited by the practitioner as necessary until the desired outcome is achieved. The Case Manager navigates each phase of the case management process (as applicable) with careful consideration of the Client’s individual, diverse and special needs, including aspirations, choices, expectations, motivations, preferences and values, and available resources, services and supports. Each Standard has a Rationale, Interpretation, Guidelines and Self Assessment Framework (SAF). The Standards should be applied by the Case Manager in conjunction with the CMSA National Code of Ethics for Case Management.

CASE MANAGEMENT CONCEPTS

Client centred

Evidence based

Strengths based

CMSA Case Management Approach

Inclusive

Holistic

Figure 1: CMSA Case Management Approach

Client Centred The Case Manager leads and facilitates Client-centred practice in collaboration with the Provider (agency) and Payer (funding body/key stakeholder).

Case Manager

Monitoring

Implementing

Transitioning

Planning

Advocacy

Facilitation

Client

Communication

Collaboration

Assessment

Evaluation

Strengths building

Provider

Payer

Screening

Figure 2: Client Centred Case Management Model

Evidence Based The Case Manager works within an evidence-based practice framework providing effective and innovative case management of the highest quality through the use of the most contemporary, relevant and reliable evidence. This approach recognises the contribution from numerous sources including, butnot limitedto, contemporaryresearch and theoretical knowledge, data and statistical information,

CASE MANAGEMENT DEFINITION CMSA revised and adopted definition, 2010.

“Case management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s holistic needs through communication and available resources to promote quality cost-effective outcomes.”

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National Standards of Practice for Case Management

INTRODUCTION

Inclusive TheCaseManagers practice is inclusive anddemonstrates compliance with all enabling legislation, professional (industry) standards and agency standards. Within this framework the Case Manager recognises the stipulations of previous legislation and/or standards, including any incumbent professional (industry) standards pursuant to the terms and conditions of the practitioner’s employment contract and/or registration with a professional body or entity.

information from evaluation and reflective processes, and, drawing on existing professional practice standards, values, ethical practice and professional conduct.

Case Management Standards & Code of Ethics

Agency standards

Increasing specificity to case management

Contemporary Relevant &

CMSA standards

Reliable Evidence

aspirations, choices, expectations, goals, Client motivations, needs (individual, diverse, special), values

Professional standards

Enabling legislation

Figure 5: Inclusive Case Management Framework Agencies that choose to further contextualise the CMSA standards are required to demonstrate how all amendments retain the intent of the CMSA standards, applicable professional (industry) standards and any enabling legislation. Strengths Based In collaboration with the Client the Case Manager concentrates on the inherent strengths, skills and aptitudes of the Client, as opposed to their deficits, and promotes self efficacy and a belief by the Client in their own abilities. Fundamental to this process is the acknowledgement by the practitioner that the Client has unique talents, skills and life experiences, in addition to specific unmet needs.

Figure 3: Evidence Based Framework

Holistic The Case Manager practises within a holistic framework (including general socioeconomic, cultural and environmental conditions). Within this context, the CMSA identifies with the Social Model of Health (Dahgren & Whitehead 1991).

S o c i a l a n d c o m m u n i t y n e t w o r k s G e n e r a l s o c i o e c o n o m i c , c u l t u r a l a n d e n v i r o n m e n t a l c o n d i t i o n s I n d i v i d u a l l i f e s t y l e f a c t o r s A^k^c\ VcY ldg`^c\ XdcY^i^dch Ldg` Zck^gdcbZci :YjXVi^dc JcZbeadnbZci LViZg VcY HVc^iVi^dc

=ZVai] VcY HZgk^XZh

abilities, aspirations,

capabilities,creativity, culture,determination, dignity,diversity,experience, Client goals,knowledge, interests, motivation,ownership, preferences,relationships, resilience,rights,strengths, skills,values

6\g^XjaijgZ VcY[ddY egdYjXi^dc

Age, sex and constitutional factors

=djh^c\

8VhZ BVcV\Zg

Strengths Based Practice

Case Management Standards

Case Manager collaborative, empowering, flexible, non judgemental, encouraging, engaging, personable, positive, respectful, sustaining, transparent

Figure 4: Holistic Case Management Framework

Underpinning and supporting this conceptual framework is the Alm Ata declaration and World Health Organisation definition of health, “Health is a complete state of physical, mental and social wellbeing, not merely the absence of disease or infirmity.” (World Health Organisation, 1958)

Code of Ethics

Figure 6: Strengths Based Practice Framework

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National Standards of Practice for Case Management

GUIDING PRINCIPLES

The CMSA has developed the following five (5) principles to guide practice. Case Managers must be able to demonstrate their approach and success against each of these Guiding Principles. The Principles are foundational for achieving success in the areas of identification, assessment, planning, monitoring and evaluating outcomes and therefore case management practice. 1. Case management facilitates the personal development of Clients Case management cultivates productive and professional working relationships with the Client that identify with the Client’s individual, diverse and special needs, including the Client’s aspirations, choices, expectations, motivations, preferences and values. Maintaining appropriate professional boundaries, the Case Manager supports and promotes the self autonomy, self determination and independence of the Client. The Case Manager applies a strengths based approach to all interactions with the Client and focuses on optimising the Client’s functional and psychosocial independence. Case Managers develop the strengths of the Client to effectively advocate for themselves. As necessary, Case Managers advocate for the rights of Clients within the funding and legislative frameworks that affect the relationship between the Client, providers and payers. Case Managers may advocate for the procurement of resources, services or support for the Client that would not otherwise be provided. Additionally, Case Managers may advocate for amendments to existing legislation, policies or procedures (or new) to affect change in the best interests of the Client. Case Managers: • act on behalf of Clients in situations when they are unable to speak for or represent themselves; • act in their Clients’ best interest; and • assist Clients and/or defend and/or plead on their behalf. 3. Case management is purposeful The actions of Case Managers must address the specific needs of Clients as documented in the Client’s agreed goals. The interventions used should be in line with the best evidence available that demonstrates they can meet the Client’s needs. Case management must balance Client needs with the available resources by assisting Clients in the selection of services and resources that are of the highest possible quality within the accessible range of options. 2. Case management advocates for Client rights

In order to link Clients with the most appropriate resources, services and supports, the Case Manager must be aware of their own limitations in terms of knowledge and experience. Case Managers will refer Clients to specialists who have skills and knowledge beyond those of the Case Manager. 4. Case management promotes sustainable solutions Case Managers endeavour to move through crises to develop sustainable solutions for Clients. Sustainability is achieved when the Case Manager works with the Client to implement an agreed plan of care that: • Fits within the available resources of Clients, agency program and/or funding body guidelines and/or policies and procedures; • Addresses current needs and probable future needs; and • Moves beyond crises to stable solutions. 5. Effective communication underpins case management Case Managers are competent and skilled in effective communication (verbal and written) to meet the needs of the Client and all key stakeholders involved in the case management process. Case Managers: • communicate clearly ensuring unambiguous delivery of the information; • check to ensure information is received, correctly interpreted and understood by the Client and key stakeholders (as applicable) as intended; • keep the Client and key stakeholders (as applicable) updated and informed of any changes to the original communication; • listen actively to ensure views and information are properly exchanged; • use and adapt communication method, as necessary, to meet the individual, diverse and/or special needs of the Client and key stakeholders (as applicable); • create opportunities to engage and listen to Clients and key stakeholders (as applicable) whose input adds value; • allow for a genuine contest of ideas, pull disparate views into a coherent position and find common ground to facilitate agreement and acceptance of mutually beneficial solutions; and • take responsibility for ensuring communication is effective (including evaluation).

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National Standards of Practice for Case Management

STANDARDS OF PRACTICE

One – Case Identification (screening) and Assessment

Standard 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. Interpretation Standard Onemay include, but is not limited to, the phases of Screening, Assessing and Stratifying Risk. Case Managers and Clients may be linked through processes of referral or outreach. In some programs, participation in a case management program may be mandated. Case identification involves the collection and screeningof informationabout perceivedClient needsand/ or risks. Stratifying Client risk may also be combined with the Assessing phase depending on the case management setting. Case Identification (screening) results in a decision to either accept or decline case management services for a person based on appropriateness within the aims and objectives of the case management program. Assessment is a phase that underpins all subsequent case management actions. It is an ongoing phase of gathering and appraising data from various sources to identify areas where the Case Manager and Client will focus their efforts. The depth of an assessment will be determined by the limitations of the case management program. The identification of needs commences during the assessment phase and may be facilitated through actions such as interviews and risk assessments. The Case Manager listens to, respects and documents the Client’s individual, diverseandspecial needs, includingaspirations choices, expectations, motivations, preferences and values. Stratifying risk is undertaken by the Case Manager for the purpose of determining (as applicable) the appropriate level of required intervention/s; based on the Client’s situation, special needs and interests. This action allows for the implementation, in partnership with the Client, of targeted risk category-based interventions to enhance Client outcomes. The categories of risk vary depending on the risk assessment tool/model applied inaccordancewith the agency, program and/or funding body guidelines.

Guidelines Case Managers are expected to:

1A Ensure that Clients understand their rights and responsibilities, supported by evidence of Clients consenting to be involved in the program providing case management. 1B Gather information about Clients while respecting their confidentiality and privacy with the aim of not duplicating assessments. 1C Identify and prioritise the Client’s initial needs to inform more comprehensive assessment once initial screening is completed. The CaseManager and Client focus on areas within a defined model (appropriate for the specific case management program), that may influence the Client’s holistic needs. 1D Understand the Client’s individual, diverse and/ or special needs so that appropriate services and support for Client development occurs. 1E Stratify and analyse risk factors that the Client experiences/may experience. 1F Communicate those needs which fall within the aims and objectives of the program (including any third party restrictions). 1G Consider the Client’s current situation, probable future situation and ensuing holistic needs. 1H Communicate the criteria for disengagement with Client. 1I Hold a valid license/certificate to practise, and/or evidence of the necessary skills and qualifications to undertake the case management role pursuant to the relevant specifications and/or mandatory requirements of a professional body, agency, case management program and/or funding body.

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National Standards of Practice for Case Management

STANDARDS OF PRACTICE

Two – Planning

Standard 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 case load of the Case Manager who must recognise their own abilities and limitations to be able to work effectively with the Client. Interpretation Standard Twomay include, but is not limited to, the phases of Planning and Implementing (care coordination). The Planning phase establishes specific objectives, agreed goals (short-termandlong-term) and interventionsnecessary to meet a Client’s needs as identified during the Assessment phase. The process of planning interventions with Clients must be evident in a format that is meaningful to Clients. The Case Manager develops an agreed person centred case management care plan in partnership with the Client. The plan is action-oriented, multidisciplinary, strengths based and time specific in nature. It identifies outcomes that are measurable and achievablewithin amanageable time frame and based on evidence-based standards and guidelines. Case Managers procure services and supports on behalf of Clients with an expectation that the intervention will have some benefit (outcome) for the Client. The allocation of case management resources requires the Case Manager to demonstrate this allocation is within the agency, program and/or funding body guidelines and/or policies and procedures.

Case Managers link Clients to resources based upon the Client’s individual, diverse and special needs and the ability of the Case Manager to demonstrate that the need is within the program rules that govern the allocation of resources. Case Managers must ensure that timelines for evaluation are communicated in a manner that is understood by the Client. The implementing phase (care coordination) focuses on the execution of the specific case management activities and interventions that are necessary for accomplishing the agreed goals within the care plan. During this phase, the Case Manager organizes, secures, integrates, and modifies (as needed) the health and human resources, services and supports necessary to meet the Client’s needs. The Case Manager shares information on an ongoing basis with the Client and key stakeholders. Guidelines Case Managers are expected to: 2A Support Clients to make informed decisions through the provision of information and available options regarding an identified need. 2B Develop Clients decision-making abilities to foster personal growth and independence. 2C Evaluate any barriers that may restrict the Client’s ability to meet the expected goal and determine strategies to minimise the impact of barriers. 2D Develop and implement a care plan that is within the financial resources available to support the Client. 2E Document Client goals (including measurable criteria) to determine the effectiveness of the interventions provided. 2F Use collaboration to generate innovative responses to meet Client needs where immediate solutions are not available. 2G Reflect and operate in an ethical manner in accordance with the CMSA National Code of Ethics for Case Management (i.e. Values, Principles, Ethical Practice and Professional Conduct).

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National Standards of Practice for Case Management

STANDARDS OF PRACTICE

Three – Monitoring

Standard 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. Interpretation Standard Three may include, but is not limited to, the phases of Monitoring, Transitioning and Disengagement and Feedback. Routine monitoring reflects the Case Manager’s accountability to ensure that the Client’s individualised care plan is being implemented. This requires communication between the Client, Case Manager and key stakeholders (both formal and informal). The Case Manager monitors the quality of the services provided, and makes adjustments in collaboration with the Client and key stakeholders, in an endeavour to provide the Client with the opportunity to meet their goals. Case Managers work toward a responsive service delivery system at both the policy-making level and the direct service delivery level. At the policy-making level, the Case Manager creates the capacity for policy to drive service development that meets the needs of a population of Clients. At the service delivery level, Case Managers advocate for tailored services that meet the needs of the individual Client. The Transitioning phase focuses onmoving a Client across the health and human services continuum, or levels of care, in response to the Client’s achievement and/or variations to the agreed goals within the care plan. During this phase, the Case Manager prepares the Client and key stakeholders to exit the current program or to transfer to another program or setting or agency. TheDisengagement andFeedbackphase involves theCase Manager formally disengaging (exiting) the Client from the program, including the preparation of reports and/or case summaries for transition (as applicable). Disengagement (or case closure) occurs in accordance with the agency, program and/or funding body guidelines and/or policies and procedures. At this time the Case Manager solicits feedback (verbal or written) from the Client and key stakeholders for the purpose of evaluation.

Guidelines Case Managers are expected to:

3A Maintain rapport and communication with the Client to develop a partnership regarding the delivery of resources, services and supports affecting the achievement of goals. 3B Maintain professional rapport with key stakeholders so that the case management plan can be discussed objectively, problems identified and adjustments made as needed. 3C Adjust resources, services and supports to best meet the needs of the Client in line with identified goals. 3D Practise within applicable legislation while recognising and respecting the Client’s right to self-determination within legal parameters. 3E Support the Client’s self-advocacy skills wherever possible.

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National Standards of Practice for Case Management

STANDARDS OF PRACTICE

Four – Evaluation and Outcomes

Standard Casemanagement actions are outcome oriented. Periodic reassessment and evaluation of Client outcomes is 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 and at the request of Clients. Interpretation Case management is a dynamic process that is driven by the desire to meet targeted outcomes. These outcomes are Client centred and must satisfy the criteria set by agency, program and/or funding body guidelines and/or policies and procedures. Identifying the ongoing needs of the Client occurs during the evaluative actions of case management. This includes information from Clients and key stakeholders to determine progress against the agreed goals within the care plan. Case Managers implement/adjust resources, services and supports to meet agreed goals and must therefore determine the movement made towards or away from these goals. This includes determining Client satisfaction and the assessment of the costs against the benefits achieved, assessment of the services provided (quality/ effectiveness), and Case Manager quality/effectiveness in supporting the Client.

Guidelines Case Managers are expected to:

4A Indicate how outcomes have been achieved through the phases of Screening, Assessing, Stratifying Risk, Planning, Implementing (care coordination), Monitoring, Transitioning, Disengagement and Feedback (as applicable). 4B Promote the development/extension of resources where service gaps are identified. 4C Examine issues related to sustainability of care for the Client’s level of need. 4D Demonstrate actions to support improvement/ maintenance of quality of life for Clients. 4E Review with the Client the quality/volume of ongoing support required to meet Client goals. This includes the identification/review of parameters for disengagement of Clients (where applicable). 4F Practise within guidelines for currently identified evidence based best practice. 4G Practise in accordance with the CMSA National Code of Ethics for Case Management and agency/program and/or funding body guidelines and/or policies and procedures. 4H Participate in research activities as a means to continually improve practise. 4I Access a person experienced in case management who is able to provide supervision and/or mentoring (as applicable). 4J Undertake at least minimum levels of continuing professional training and development in accordance with CMSA certification requirements and/or pursuant to the relevant specifications and/or mandatory requirements of a professional body, agency, case management program and/or funding body. 4K Develop skills and knowledge to meet specific Client group needs (specialisation). 4L Participate in public discussion and debate to raise the profile and understanding of Case Managers/ case management.

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National Standards of Practice for Case Management

STANDARDS OF PRACTICE

Case Management Process

Case Identification (screening)

Implementing (care coordination)

Transitioning (transitional care)

Assessing

Planning

Monitoring

Evaluating

Stratifying Risk (risk assessment)

Disengagement and Feedback

Standard One Standard Two Planning Standard Three Monitoring Standard Four

Case Identification (screening) and Assessment

Evaluation and Outcomes

Diagram 1

Standard One – Case Identification (screening) Phase

Risk Stratification (risk assessment)

Initial contact by Client, Provider or Payer

Client consent (rights & responsibilities)

Check eligibility

Yes

Accept Client

Allocate case

No

No

Gather essential information

Educate & refer

Note: Where a reference is made to a Client this may also refer to the Client Representative

Diagram 2

8

National Standards of Practice for Case Management

STANDARDS OF PRACTICE

Standard One – Assessing Phase

Validated tools may include: Demographics & background Employment & socioeconomic class Need for longer term support Past medical history & background Previous agency involvement Psychosocial & behavioural health Psychosocial support systems

Assessment tools

Identify &prioritise needs (current & future)

Gather information

Analyse information

Allocate case

Engage Client

Including: Introduce yourself as the Case Manager and describe your role Clarify Client’s understanding of the reason for referral Clarify any issues regarding Client’s competency, including any formal guardianship or administration orders Check Client’s understanding of consent & rights & responsibilities Communicate criteria for disengagement Provide information about the program (i.e. program outline including limitations, fees, grievance & complaints process, privacy & confidentiality policy, statutory &/or mandatory reporting obligations) Provide Client with contact information

Domains may include: Clinical Cognitive function Court, Administrative or Regulatory Orders Education Employment history Environment & safety Functional assessment (ADLs & IADLs) Immediate/acute needs Medical (history, medications, hospitalisation) Psychosocial Socioeconomical Special needs & Interests

Including Client’s: Aspirations Choices Expectations Motivations Needs Preferences Values

Note: Where a reference is made to a Client this may also refer to the Client Representative

Diagram 3

Standard One – Stratifying Risk (risk assessment) Phase

Including: Alerts documented in case file and/or case management software

Define population & desired outcome of risk stratification

Gather & enter information

Identify risk aversion strategies & interventions

Analyse information

Enter information into care plan

Identify tools

For example: Agency risk Client risk Community risk Program risk

Determine risk: Low Medium High

Including: Barriers that may restrict Client from meeting goals Crisis intervention Crisis response Equipment &/or modifications Specialist advice

Note: Where a reference is made to a Client this may also refer to the Client Representative

Diagram 4

9

National Standards of Practice for Case Management

STANDARDS OF PRACTICE

Standard Two – Planning Phase

Client and Key Stakeholder input Funding body obligations Legislative requirements National Code of Ethics for Case Management Standards of Care (industry specific guidelines)

Care plan is: Action orientated Evidence based Multidisciplinary Strengths based Time specific

Short-term goals Long-term goals Anticipated outcomes & measurable criteria

Collaborate with Client & Key Stakeholders

Identify & prioritise agreed goals

Select interventions

Develop care plan

Document care plan

Identify issues

Obtain approval &/ or authorisation from Client & Key Stakeholders

Stratify risk

Note: Where a reference is made to a Client this may also refer to the Client Representative Where a reference is made to a Key Stakeholder this may refer to a person or group with a direct interest, involvement, or concern regarding the Client and/or case management care plan

Diagram 5

Standard Two – Implementing (care coordination) Phase

Implement individual interventions (care coordination)

Communicate information (ongoing)

Document progress

Identify & allocate tasks

Including: Client Key Stakeholders

Case Manager organises, secures, integrates & modifies services & resources to meet the Client’s needs.

Note: Where a reference is made to a Client this may also refer to the Client Representative Where a reference is made to a Key Stakeholder this may refer to a person or group with a direct interest, involvement, or concern regarding the Client and/or case management care plan

Diagram 6

10 National Standards of Practice for Case Management

STANDARDS OF PRACTICE

Standard Three – Monitoring Phase

Including: Client Key Stakeholders

Examine, review &measure effectiveness

Client ready for transition?

Seek approval & consent

Document progress

Identify next step

Yes

No

Including: Resources Services Supports

Transition indicators: Client withdraws consent Court, Administrative or Regulatory Order Death Goals achieved Goals may be better met in an alternative setting, program &/or agency Request &/or recommendation by Client and/ or Key Stakeholder Variations (increase or decrease) to Client needs Variations to Client eligibility

Adjust care plan?

No

Yes

Continue with current care plan

Return to Planning phase

Diagram 7

Standard Three – Transitioning (transitional care) Phase

Including: Agency/program reporting requirements Case closure Compliance documentation (agency, program &/or funding body)

Including: Client Key

May include: Case summary Contact details for next agency (as applicable) Discharge summary & plan Evaluation forms Self care management instructions & resources

Stakeholders Next agency (as applicable)

Prepare transition records

Commence transition

Complete transition

Commence disengagement

Communicate transition plan

Obtain approval & consent

May include: Billing & accounts Criteria for reengagement Education Equipment Exit interview Pharmaceutical Referral documentation Transition records Transportation

Identify & resolve barriers

Diagram 8

Note: Where a reference is made to a Client this may also refer to the Client Representative Where a reference is made to a Key Stakeholder this may refer to a person or group with a direct interest, involvement, or concern regarding the Client and/or case management care plan

11 National Standards of Practice for Case Management

STANDARDS OF PRACTICE

Standard Three – Disengagement and Feedback Phase

May include: Verbal Written

Contact Client

Disengage & close case

Obtain feedback

Move to evaluating phase

Complete this step only as applicable Based on agency/program guidelines &/or policies & procedures

Note: Where a reference is made to a Client this may also refer to the Client Representative

Diagram 9

Standard Four – Evaluating Phase

Identify evaluation tool

Gather & enter information

Analyse information

Prepare reports (internal/external)

Communicate outcomes

May include: Agency/program limitations or gaps Client & Key Stakeholder feedback

May include: Agency/program effectiveness Agency/program targets & outputs Client & Key Stakeholder satisfaction Continuous Quality Improvement Financial WHS (Workplace Health & Safety)

Including (as applicable): Client & Key Stakeholders

Note: Where a reference is made to a Client this may also refer to the Client Representative Where a reference is made to a Key Stakeholder this may refer to a person or group with a direct interest, involvement, or concern regarding the Client and/or case management care plan

Diagram 10

12 National Standards of Practice for Case Management

SELF ASSESSMENT FRAMEWORK (SAF)

Purpose of the Self Assessment Framework (SAF) TheSelfAssessmentFrameworkhasbeendevelopedfortheCaseManagertoreview,measureandassesstheirprofessional practice, performance and compliance against the CMSA National Standards of Practice for Case Management (i.e. the National benchmark in excellence and best practice standards for Case Managers in Australia). The Self Assessment Framework, in conjunction with the Standards and the CMSA National Code of Ethics for Case Management, promotes discussion and conformity with best practice standards within the profession of case management. Structure of the Self Assessment Framework (SAF) The Self Assessment Framework lists the guiding principles for each of the Standards and describes the practices and evidence that Case Managers must be able to produce to demonstrate their level of practice. The Self Assessment Framework accommodates for variances in programs/settings which may present obstacles that prevent the Case Manager from achieving the satisfactory level. The Self Assessment Framework challenges Case Managers to locate examples of their practice (i.e. scenarios, case studies, documentations and observed practices) to meet the various practice levels within the Self Assessment Framework. The levels within the Self Assessment Framework are cumulative. There is a logical level of performance between substantive, good, satisfactory and not satisfactory. The limited number of items at the good and substantive levels is indicative of the expectation that Case Managers must perform a broad and deep level of practice to fulfil the role.

Substantive achievement

substantive level of practise often working at a systemic level

Good achievement

incremental level of practice above the fundamental level representing a broader level of practice development

Satisfactory

fundamental level of practice desired

Below satisfactory

practice not acceptable to comply with the National Standards for Case Managers and warrants further investigation of practise development

Not applicable

not relevant to the program the Case Manager operates within

SUBSTANTIVE ACHIEVEMENT

GOOD ACHIEVEMENT

BELOW SATISFACTORY

NOT APPLICABLE

SATISFACTORY

Application of the Self Assessment Framework (SAF) The CMSA recommends: • The Self Assessment Framework is completed at least annually (i.e. once a year) or more often as identified (i.e. performance management); • The Self Assessment Framework is undertaken in a formal practice setting (i.e. the workplace); • The Self Assessment Framework is completed prior to an annual performance review to assist in the identification of any future professional practice development and education requirements of the Case Manager; and • The process is supported by the Case Manager’s employer, supervisor and/or mentor (as applicable) who provides professional instruction and guidance to the Case Manager. Self Assessment The Case Manager undertakes the Self Assessment Framework by reading across the page from left to right in rows (rather than down the page in columns). Boxes in the same row are shaded the same, making it easy to identify the

practice requirements. Verified Assessment

The Self Assessment Framework provides the opportunity for a further level of rigour whereby the Case Manager’s self assessment is critiqued by an independent person (i.e. supervisor and/or mentor) who checks the examples of evidence against the criteria defined. This level of assessment enables the Case Manager to receive feedback of their professional performance and practice compliance and allows for the identification and/or verification of areas for improvement and/ or professional development.

13 National Standards of Practice for Case Management

STANDARD 1 – CASE IDENTIFICATION AND ASSESSMENT

1A Ensure that Clients understand their rights and responsibilities, supported by evidence of Clients consenting to be involved in the program providing case management.

SATISFACTORY

BELOW SATISFACTORY

CM clarifies that the Client has understood the reason for the referral, the case management process.

CM does not take time to explain or clarify Client’s understanding.

Before obtaining consent, CM clarifies any issues regarding the Client’s competency and includes any formal guardians.

CM does not check for any questions about competency in referral information. CM continues to have Client sign consent despite questions around competency.

CM explains and documents the aims and objectives of the CM program including limitations to Client so they can make informed choices.

CM does not explain program parameters. No documentation of Client involvement.

CM seeks feedback of the Client’s understanding of their rights and responsibilities.

Client is admitted onto program with no understanding of their rights and responsibilities. Non-compliance to agency policy.

CM gains evidence of informed consent at the commencement of the program and accommodates those unable to sign a document.

No documentation by CM regarding the process taken to gain consent.

CM seeks feedback of the Client’s understanding of the complaints/appeals process.

CM cannot demonstrate how Client feedback was sought.

Self Assessment

Satisfactory

Below satisfactory

Verified Assessment

Satisfactory

Below satisfactory

1B Gather information about Clients while respecting their confidentiality and privacy with the aim of not duplicating assessments

SATISFACTORY

BELOW SATISFACTORY

CM seeks Client’s informed consent for the dissemination of Client information.

Documentation by CM demonstrates the dissemination of Client information prior to obtaining consent.

CM can show the process of conducting research, interviews and otherwise gathering information (including previous assessments and referral information) to establish the factual base to proceed with the assessment.

CM is unable to demonstrate the process of utilising available information including previous assessments/ referrals.

Self Assessment

Satisfactory

Below satisfactory

Verified Assessment

Satisfactory

Below satisfactory

14 National Standards of Practice for Case Management

STANDARD 1 – CASE IDENTIFICATION AND ASSESSMENT

1C Identify and prioritise the Client’s initial needs to inform more comprehensive assessment once initial screening is completed. The Case Manager and Client focus on areas within a defined model (appropriate for the specific case management program), that may influence the Client’s holistic needs.

SATISFACTORY

BELOW SATISFACTORY

NOT APPLICABLE

The Client’s perception of their own needs is the base of the assessment process. A comprehensive assessment is completed according to the program/ agency guidelines and eligibility criteria.

Assessment does not reflect Client’s perception of their own needs.

A comprehensive assessment is achieved outside of the program/ agency guidelines. No comprehensive assessment is completed. Case Manager does not discuss with Client the priority areas identified from assessment.

Client and CM prioritise agreed areas resulting from the assessment.

CM applies the use of validated tools to support comprehensive assessment.

No evidence of validated tools within assessment.

No agency/program requirement for the use of validated assessment tools.

Referrals sent for expertise/input when practise is outside of CM scope.

CM practises outside of professional scope or job role.

The agreed care plan developed by the CM and Client directly reflects the full range of information available.

The care plan developed by the CM and Client does not reflect the information gathered.

Self Assessment

Satisfactory

Below satisfactory

Not applicable

Verified Assessment

Satisfactory

Below satisfactory

Not applicable

15 National Standards of Practice for Case Management

STANDARD 1 – CASE IDENTIFICATION AND ASSESSMENT

1D Understand the Client's individual, diverse and/or special needs so that appropriate services and support for Client development occurs.

SATISFACTORY

BELOW SATISFACTORY

NOT APPLICABLE

CM identifies prompts from referral sources to indicate that the Client may have a special need.

CM does not respond to prompts.

A comprehensive assessment model identifies special needs.

CM does not access appropriate services to support Client’s special needs.

The CM utilises professional support and services (formal and informal) as a first option to ensure communication is effective. CM documentation demonstrates CM has accessed/utilised appropriate information and resources to meet Client’s special needs.

No support and services (formal and informal) are accessed.

CM documentation does not demonstrate CM has accessed/utilised appropriate information and resources to meet Client’s special needs.

CM complies with any agency/ program special needs guidelines.

CM does not comply with agency/ program guidelines.

Agency has not developed any special needs guidelines.

CM provides information in an appropriate format/language appropriate to Client’s special needs.

No provision of information. CM provides information in a format that does not meet the Client’s special needs.

Self Assessment

Satisfactory

Below satisfactory

Not applicable

Verified Assessment

Satisfactory

Below satisfactory

Not applicable

1E Stratify and analyse risk factors that the Client experiences/may experience.

SATISFACTORY

BELOW SATISFACTORY

CM completes risk assessment as per agency guidelines.

CM undertakes risk assessments outside their professional boundaries.

The CM and Client work together to prioritise risks and possible risk management strategies. These risks and strategies are documented.

CM does not attain prior risk assessment documentation (if any). CM does not initiate risk assessment. CM does not communicate identified risks and management strategies to Client.

The CM informs key stakeholders regarding identified risk factors.

CM does not inform key stakeholders regarding risk factors around identified risk or competency.

CM approaches identified risks in partnership with the Client and key stakeholders and acknowledges the Client’s voluntary assumption of risk.

CM does not respect a Client’s right to the voluntary assumption of risk when the Client is competent to make this decision.

Self Assessment

Satisfactory

Below satisfactory

Verified Assessment

Satisfactory

Below satisfactory

16 National Standards of Practice for Case Management