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11
National Standards of Practice for Case Management
May include:
Case summary
Contact details for next agency (as applicable)
Discharge summary & plan
Evaluation forms
Self care management instructions & resources
May include:
Billing & accounts
Criteria for reengagement
Education
Equipment
Exit interview
Pharmaceutical
Referral documentation
Transition records
Transportation
Including:
Client
Key
Stakeholders
Next agency
(as applicable)
Including:
Agency/program reporting
requirements
Case closure
Compliance documentation
(agency, program &/or funding
body)
Obtain approval
& consent
Prepare
transition
records
Communicate
transition plan
Identify &
resolve barriers
Commence
transition
Commence
disengagement
Complete
transition
Standard Three – Transitioning (transitional care) Phase
Diagram 8
Diagram 7
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
Including:
Resources
Services
Supports
Including:
Client
Key
Stakeholders
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
Document progress
Examine, review
&measure
effectiveness
Continue with
current care plan
Identify next step
Return to
Planning phase
Seek approval &
consent
Client ready for
transition?
Adjust care plan?
STANDARDS OF PRACTICE
Standard Three – Monitoring Phase
No
Yes
Yes
No