© 2013 National Standards of Practice for Case Management


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).


National Standards of Practice for Case Management

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