© 2013 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
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