© 2013 National Standards of Practice for Case Management


Standard Three – Monitoring Phase

Including: Client Key Stakeholders

Examine, review &measure effectiveness

Client ready for transition?

Seek approval & consent

Document progress

Identify next step



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?



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

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