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5
National Standards of Practice for Case Management
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-termand long-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).
STANDARDS OF PRACTICE
Two – Planning