10 / 44
6
National Standards of Practice for Case Management
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.
STANDARDS OF PRACTICE
Three – Monitoring