© 2013 National Standards of Practice for Case Management


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.


National Standards of Practice for Case Management

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