© 2015 National Skill Set For Effective Case Management in AUS & NZ: Skills Workbook

NATIONAL SKILL SET FOR EFFECTIVE CASE MANAGEMENT in Australia and New Zealand

SKILLS WORKBOOK Case Management Society of Australia and New Zealand Author: Frieda Marfleet

First published in 2015 COPYRIGHT © 2015 Case Management Society of Australia and New Zealand (CMSA).

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval systemwithout prior permission from both publishers. The Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10 percent of this book, whichever is the greater, to be photocopied by any educational institution for its educational purposes provided that the educational institution (or body that administers it) has given a remuneration notice to the Copyright Agency (Australia) under the Act. ACKNOWLEDGEMENT The CMSA Board of Directors wish to acknowledge Kathy Day, Lorraine Poulos (Lorraine Poulos & Associates) and Raechel Barber for their contribution. The CMSA Board of Directors wish to acknowledge Catholic Community Services NSW/ACT commitment, support and alignment to the Society’s vision to lead the advancement of excellence in case management knowledge, expertise and practice and attribute national recognition to the role of the case management practitioner and professional as a specialist discipline within Australia and New Zealand.

PUBLISHER Case Management Society of Australia and New Zealand (CMSA).

Email: cmsa@cmsa.org.au Website: www.cmsa.org.au

ISBN: 978-0-646-93541-6

TABLE OF CONTENTS

INTRODUCTION: NATIONAL SKILL SET FOR EFFECTIVE CASE MANAGEMENT ......................................................... 1 SCOPE AND PURPOSE OF THE NATIONAL SKILL SET WORKBOOK (NSSW) . ..................................................... 1 INTERPRETATION OF THE NATIONAL SKILL SET WORKBOOK (NSSW) ............................................................. 1 INSTRUCTIONS FOR THE IMPLEMENTATION OF THE NATIONAL SKILL SET WORKBOOK (NSSW) ................... 1 NATIONAL SKILL SET WORKBOOK (NSSW) RECORD .......................................................................................... 2 NSSW STANDARD ONE: CASE IDENTIFICATION (SCREENING) AND ASSESSMENT RECORD.............................. 3 NSSW STANDARD TWO: PLANNING RECORD ..................................................................................................... 4 NSSW STANDARD THREE: MONITORING RECORD ............................................................................................. 5 NSSW STANDARD FOUR: EVALUATION AND OUTCOMES RECORD .................................................................. 6 CHAPTER ONE NATIONAL KEY SKILL SET FOR CASE MANAGEMENT ....................................................................................................... 7 NATIONAL KEY SKILL SET MATRIX ..................................................................................................................................... 7 1. ADVOCACY ............................................................................................................................................................. 7 UNSKILLED ........................................................................................................................................................ 7 SKILLED . ............................................................................................................................................................ 7 2. CARE PLANNING AND GOAL SETTING ................................................................................................................... 8 UNSKILLED ........................................................................................................................................................ 8 SKILLED . ............................................................................................................................................................ 9 3. CASE CONFERENCING ........................................................................................................................................... 10 UNSKILLED ...................................................................................................................................................... 10 SKILLED . .......................................................................................................................................................... 11 4. COMMUNICATION ................................................................................................................................................ 12 UNSKILLED ...................................................................................................................................................... 12 SKILLED . .......................................................................................................................................................... 13 5. CULTURAL SENSITIVITY . ....................................................................................................................................... 14 UNSKILLED ...................................................................................................................................................... 14 SKILLED . .......................................................................................................................................................... 14 6. DOCUMENTATION ................................................................................................................................................ 15 UNSKILLED ...................................................................................................................................................... 15 SKILLED . .......................................................................................................................................................... 16 7. FINANCIAL ACUMEN . ........................................................................................................................................... 18 UNSKILLED ...................................................................................................................................................... 18 SKILLED . .......................................................................................................................................................... 19 8. INTERVIEWING AND ASSESSMENT ....................................................................................................................... 19 UNSKILLED ...................................................................................................................................................... 20 SKILLED . .......................................................................................................................................................... 20 9. MONITORING, REVIEW AND EVALUATION ......................................................................................................... 21 UNSKILLED ...................................................................................................................................................... 21 SKILLED . .......................................................................................................................................................... 23 10. NETWORKING AND COLLABORATION ............................................................................................................... 25 UNSKILLED ...................................................................................................................................................... 25 SKILLED . .......................................................................................................................................................... 27 CHAPTER TWO STANDARD ONE – CASE IDENTIFICATION (SCREENING) AND ASSESSMENT .................................................................. 31 NATIONAL KEY SKILL SET CHECKLIST ............................................................................................................................... 31 REFLECTIVE PRACTICE EXERCISES ..................................................................................................................................... 31 REFERENCES ....................................................................................................................................................................... 44 CHAPTER THREE STANDARD TWO – PLANNING .......................................................................................................................................... 45 NATIONAL KEY SKILL SET CHECKLIST ............................................................................................................................... 45 REFLECTIVE PRACTICE EXERCISES ..................................................................................................................................... 45 REFERENCES ....................................................................................................................................................................... 59 CHAPTER FOUR STANDARD THREE – MONITORING .................................................................................................................................. 60 NATIONAL KEY SKILL SET CHECKLIST ............................................................................................................................... 60 REFLECTIVE PRACTICE EXERCISES ..................................................................................................................................... 60 REFERENCES ....................................................................................................................................................................... 70 CHAPTER FIVE STANDARD FOUR – EVALUATION AND OUTCOMES ....................................................................................................... 71 NATIONAL KEY SKILL SET CHECKLIST ............................................................................................................................... 71 REFLECTIVE PRACTICE EXERCISES ..................................................................................................................................... 71 REFERENCES ....................................................................................................................................................................... 90

INTRODUCTION

SCOPE AND PURPOSE OF THE NATIONAL SKILL SET WORKBOOK (NSSW) The National Skill Set Workbook (NSSW) identifies the key skills for effective case management, in Australia and New Zealand, and aligns these skills to the National Standards of Practice for Case Management and the National Code of Ethics for Case Management. Developed by the Case Management Society of Australia and New Zealand (CMSA), for the case management practitioner, supervisor and agency, the NSSW is both a companion resource for CMSA training and a practical hands-on learning resource for the professional development of the Certified Case Manager™, individual case manager and/or case management teams. Mapped against the national minimum (satisfactory) practice standard for case management, within Australia and New Zealand, the NSSW challenges the case manager to reflect on their day-to-day practice, knowledge and experience to identify any areas of future skill development and advancement. The key learning outcomes from the NSSW, supports the advancement of the case manager’s practice effectiveness, awareness and informs the development of the practitioner’s skills and knowledge of case management. INTERPRETATION OF THE NATIONAL SKILL SET WORKBOOK (NSSW) • in the NSSW unless the contrary intention appears, words in the singular include the plural and words in the plural include the singular; • where any word or phrase is given a defined meaning, any other form of that word or phrase has a corresponding meaning; • where a reference is made to the care plan this refers to a plan (i.e. single or multiple documents) of support, goals or care for the client; • where a reference is made to the Case Manager this refers to an individual whose primary role and function is to facilitate the process of case management; • where a reference is made to the Client this may also refer to the Client Representative; • where a reference is made to a diverse need this refers to: the differences between individuals or groups of people in age, cultural background, disability, ethnicity, family responsibilities, gender, language, marital status, religious belief and sexual orientation; • where a reference is made to the funding body this may also refer to, but is not limited to, the auditing, accreditation or quality and compliance body of the case management service and/or program; • where a reference is made to a key stakeholder, unless specified, this refers to: a person or group with a direct interest, involvement or concern regarding the Client and/or case management care plan. May include, but is not limited to: accreditation body, advocate, agency, allied health professional, clergy, colleague, consultant, employer, family member, friend, funding body, guardian, general practitioner, insurer, lawyer, next of kin, officer, organisation, parent, partner; • where a reference is made to a program this may also refer to provision of the case management service; • where a reference is made to the program/agency guidelines this may also refer to the program/agency policies and procedures; and • where a reference is made to a special need this refers to: a person or group with an identified and/or specific and/ or associated need/s. May Include, but is not limited to, the specific requirements of individuals from: ATSI/CALD communities/backgrounds, rural and remote areas, financially or socially disadvantaged communities/backgrounds; veterans and individuals who are care leavers, homeless or at risk of becoming homeless and/or have an illness, injury or mental, emotional, behavioural, intellectual, learning or physical disability. INSTRUCTIONS FOR THE IMPLEMENTATION OF THE NATIONAL SKILL SET WORKBOOK (NSSW) Applying the principles of reflective practice (i.e. self-awareness, critical thinking and analytic ability) to their day-to-day practice, the case manager should read and respond to each of the reflective practice activities. If in doubt as to the definitions contained within, and /or for further clarification, the case manager refers to the following publications: • Marfleet, F., Trueman, S. & Barber, R. (2013). 3rd Edition, National Standards of Practice for Case Management. Case Management Society of Australia & New Zealand; • Marfleet, F. & Trueman, S. (2015). 1st Edition, National Self Assessment for Case Management Practice. Case Management Society of Australia & New Zealand; and • Marfleet, F. & Trueman, S. (2013). 2nd Edition, National Code of Ethics for Case Management . Case Management Society of Australia & New Zealand. On completing an activity the case manager records the date, along with any identified areas and actions for skill development and advancement, within the relevant NSSW Record.

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Introduction

NATIONAL SKILL SET WORKBOOK (NSSW) RECORD The NSSW Record provides the case manager with the tools to map their progress and completion of the NSSW and is a concise summation of their key learnings and identified areas and actions for skill development and advancement; for

further deliberation, discussion and action. There are four (4) NSSW Records as follows:

NSSW Standard One: Case Identification (Screening) and Assessment Record

Records the Case Manager’s completion of the twenty one (21) reflective practice exercises from Chapter Two: Standard One.

Records the Case Manager’s identified areas for skill development and advancement against each of the twenty one (21) reflective practice exercises.

Records the Case Manager’s identified actions for skills development and advancement from Chapter Two: Standard One.

NSSW Standard Two: Planning Record

Records the Case Manager’s completion of the twenty one (21) reflective practice exercises from Chapter Three: Standard Two.

Records the Case Manager’s identified areas for skill development and advancement against each of the twenty one (21) reflective practice exercises.

Records the Case Manager’s identified actions for skills development and advancement from Chapter Three: Standard Two.

NSSW Standard Three: Monitoring Record

Records the Case Manager’s completion of the twelve (12) reflective practice exercises from Chapter Four: Standard Three.

Records the Case Manager’s identified areas for skill development and advancement against each of the twelve (12) reflective practice exercises.

Records the Case Manager’s identified actions for skills development and advancement from Chapter Four: Standard Three.

NSSW Standard Four: Evaluations and Outcomes Record

Records the Case Manager’s completion of the twenty (20) reflective practice exercises from Chapter Five: Standard Four.

Records the Case Manager’s identified areas for skill development and advancement against each of the twenty (20) reflective practice exercises.

Records the Case Manager’s identified actions for skills development and advancement from Chapter Five: Standard Four.

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Introduction

NSSW STANDARD ONE : CASE IDENTIFICATION (SCREENING) AND ASSESSMENT RECORD

NAME: JOB ROLE/JOB TITLE:

EMPLOYER: LOCATION: SUPERVISOR:

COMPLETION RECORD ACTIVITY DATE COMPLETED IDENTIFIED AREAS FOR SKILL DEVELOPMENT AND ADVANCEMENT

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21

SKILLS DEVELOPMENT AND ADVANCEMENT ACTION LIST SKILL COMMENTS

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Introduction

NSSW STANDARD TWO: PLANNING RECORD

NAME: JOB ROLE/JOB TITLE:

EMPLOYER: LOCATION: SUPERVISOR:

COMPLETION RECORD ACTIVITY DATE COMPLETED IDENTIFIED AREAS FOR SKILL DEVELOPMENT AND ADVANCEMENT

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21

SKILLS DEVELOPMENT AND ADVANCEMENT ACTION LIST SKILL COMMENTS

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Introduction

NSSW STANDARD THREE: MONITORING RECORD

NAME: JOB ROLE/JOB TITLE:

EMPLOYER: LOCATION: SUPERVISOR:

COMPLETION RECORD ACTIVITY DATE COMPLETED IDENTIFIED AREAS FOR SKILL DEVELOPMENT AND ADVANCEMENT

1 2 3 4 5 6 7 8 9

10 11 12

SKILLS DEVELOPMENT AND ADVANCEMENT ACTION LIST SKILL COMMENTS

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Introduction

NSSW STANDARD FOUR: EVALUATION AND OUTCOMES RECORD

NAME: JOB ROLE/JOB TITLE:

EMPLOYER: LOCATION: SUPERVISOR:

COMPLETION RECORD ACTIVITY DATE COMPLETED IDENTIFIED AREAS FOR SKILL DEVELOPMENT AND ADVANCEMENT

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20

SKILLS DEVELOPMENT AND ADVANCEMENT ACTION LIST SKILL COMMENTS

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Introduction

CHAPTER ONE NATIONAL KEY SKILL SET FOR CASE MANAGEMENT

1. Advocacy 2. Care Planning and Goal Setting 3. Case Conferencing 4. Communication 5. Cultural Sensitivity 6. Documentation 7. Financial Acumen 8. Interviewing and Assessment 9. Monitoring, review and evaluation 10. Networking and Collaboration NATIONAL KEY SKILL SET MATRIX 1. Advocacy Unskilled

Standard 2B, Standard 3D – 3E, Standard 4A The CM cannot provide documentation to show that they have made/discussed referrals to appropriate services to facilitate independence [S2B] CM is unable to provide examples of supporting a Client’s decisions and choices [S3D] CM does not review and/or adjust the intensity of case management where Clients have demonstrated an ability to advocate for themselves [S3E] CM is unable to demonstrate how they test the Client’s ongoing ability to advocate for themselves [S3E] CM can give no examples of assisting a Client to advocate on their own behalf [S3E] CM is unable to identify examples of working with a range of key stakeholders to advocate for Client specific needs [S3E] CM does not review Client’s competence to make informed decisions [S4A] Standard 2B, Standard 3D – 3E, Standard 4A Documentation by the CM demonstrates the increasing self autonomy of the Client’s decisions and the Client’s initiative in the instigation of actions to achieve their long-term and short-term goals [S2B] The CM can provide examples of resources, services and supports the Client has arranged/accessed independent of the CM [S2B] Documentation by the CM demonstrates the involvement of key stakeholders to endorse and support Client independence. The CM (as applicable) facilitates the referral of the Client to appropriate (formal/informal) services to facilitate Client independence [S2B] The CM respects and promotes the importance of a Client’s right to self determination. The CM demonstrates a comprehensive knowledge and thorough understanding of Client self determination and how to effectively respond to and manage barriers and/or limitations in accordance with program/agency guidelines [S3D] The CM supports the Client in self advocacy, including (as applicable) the provision of education and information concerning self knowledge, their rights and responsibilities, communication and negotiation skills, finding support and developing an advocacy action plan [S3E] The CM reviews and/or adjusts the level of case management support provided to the Client subsequent to an evaluation of the Client’s self advocacy skills [S3E] The CM can demonstrate how they evaluate the Client’s self advocacy skills and/or support the Client to develop self advocacy skills. The CM facilitates access by the Client to resources, supports (informal/formal) and services for the support and development of the Client’s self advocacy skills [S3E] Documentation by the CM includes examples of the effective engagement of key stakeholders by the CM to advocate for Client specific needs [S3E] The CM recommends/refers the Client to a suitably qualified individual/service for independent advocacy advice and support for matters outside of the CM’s scope of practice and/or qualifications/expertise [S3E] The CM reviews the Client’s level of competency/capacity to make informed decisions and/or seeks specialist opinion (as applicable) [S4A] Skilled

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2. Care Planning and Goal Setting Unskilled

Standard 1A – 1G, Standard 2A – 2F CM does not take time to explain or clarify Client’s understanding [S1A] CM cannot demonstrate how Client feedback was sought [S1A] CM is unable to demonstrate the process of utilising available information including previous assessments/referrals [S1B] CM does not discuss the priority areas identified from assessment with the Client [S1C] CM practises outside of professional scope or job role [S1C] The care plan developed by the CM and Client does not reflect the information gathered [S1C] CM does not comply with agency/ program guidelines [S1D] CM does not communicate identified risks and management strategies to Client [S1E] CM does not respect a Client’s right to the voluntary assumption of risk when the Client is competent to make this decision [S1E] CM does not individualise communication to suit the Client’s special needs [S1F] CM does not document they have discussed program information with the Client [S1F] Documentation by CM does not demonstrate ongoing person centred planning in consultation with the Client and key stakeholders [S1G] Inadequate documentation by CM of Client goals [S1G] CM is unaware of the Client’s quality of life to assist in needs identification and planning [S1G] Documentation by CM does not demonstrate communication of disengagement parameters to Client [S1H] CM does not source or provide information to the Client [S2A] CM is unable to demonstrate either knowledge of services or a strategy to determine appropriateness of services [S2A] CM cannot demonstrate research into local networks and new services [S2A] No evidence Client is involved in the decision making [S2A] CM documentation does not demonstrate Client driven initiative or decision making [S2B] CM does not discuss barriers or options with Client [S2C] CM not aware of any barriers [S2C] CM does not prepare Client for barriers [S2C] CM does not utilise supports. CM has no knowledge of program/ agency guidelines [S2C] CM identifies barriers but is unable to identify avenues to eliminate/ minimise effects of barriers [S2C] CM does not liaise with agency/key stakeholders over their risk concerns [S2C] Care plan developed by CM with focus only on the available financial resources and not the Client’s goals and needs (including individual, diverse and/or special needs) [S2D] CM is unable to justify rationale for expenditure of resources in relation to care plan and agreed goals [S2D] CM does not maintain accurate records [S2D] CM is unable to demonstrate financial management of budget to meet Client goals within the budgetary constraints [S2D] Alternative sources of funding are identifiable but no application has been made by the CM [S2D] CM does not discuss or disclose financial limitations of care plan [S2D] CM does not discuss privately paid options available to Client to procure additional services outside of the care plan [S2D] No comprehensive assessment is completed by CM. There is no demonstrable link between the Client’s goals and the CM’s assessment [S2E] CM is unable to explain how goal setting and review processes were discussed with Client [S2E]

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Chapter One

Goals are not adequately constructed. Goals are absent/not recorded [S2E] There is no documentary evidence by CM to show that the Client has been given a copy of agreed goals/care plan [S2E] All actions are the CM’s, regardless of ability of Client to contribute [S2E] CM shows no initiative in development or implementation of resources outside of mainstream service system [S2F]

CM documentation does not identify/support Client consultation [S2F] CM cannot provide examples of seeking input from peers, etc [S2F]

Skilled Standard 1C – 1D, Standard 1F – 1H, Standard 2A, Standard 2C – 2F The Client and CM prioritise agreed areas resulting from the comprehensive assessment [S1C] The CM identifies limitations in their professional scope of practice and/or qualifications/expertise and initiates a referral of the Client to a suitably qualified individual/service for specialist expertise/input [S1C] The agreed care plan developed by the CMand the Client incorporates the information acquired from the comprehensive assessment [S1C] The CM utilises formal/informal support and services (as applicable) to ensure effective communication with the Client [S1D] The CM documentation demonstrates the CM has accessed/utilised appropriate information and resources to meet the Client’s individual, diverse and/or special needs [S1D] The CM provides information to the Client in a format/language that is appropriate to the Client’s individual, diverse and/or special needs [S1D] The CM in partnership with the Client and key stakeholders prioritise risks and possible risk management strategies. These risks and strategies are documented [S1E] The CM informs key stakeholders of identified risk factors, including (as applicable) any issues regarding the Client’s level of competency/capacity [S1E] The CM in partnership with the Client and key stakeholders addresses any identified risks. The CM documents (as applicable) the Client’s voluntary assumption of risk in accordance with the program/agency guidelines [S1E] The CM adapts communication to meet the Client’s individual, diverse and/or special needs with due consideration to the Client’s unique personal circumstances [S1F] The CM documentation shows ongoing person centred planning and consultation with the Client and key stakeholders (as applicable) [S1G] The CM, in partnership with the Client, records and prioritises the Client’s agreed long-term and short-term goals [S1G] The CM collects information regarding the Client’s current ‘quality of life’ and uses this information to support planning directions [S1G] The CM in partnership with the Client and key stakeholders facilitates referrals to alternative programs or settings where the Client’s individual, diverse and/or special needs and goals can be met more appropriately [S1H] Documentation by the CM demonstrates the provision of information to the Client about available resources, services and supports (internal and/or external to the program) [S2A] The CM demonstrates a sound knowledge of all available formal/informal resources, services and supports to meet the Client’s identified needs and agreed goals [S2A] The CM actively researches local and regional networks to enhance the CM’s knowledge of new and existing (funded/ non funded) resources, services, supports and folk systems to assist in the attainment of Client outcomes [S2A] Documentation by the CM demonstrates ongoing communication with the Client concerning program service options, including optional formal/informal resources, services and supports and eligibility requirements (as applicable) [S2A] Documentation by the CM demonstrates the increasing self autonomy of the Client’s decisions and the Client’s initiative in the instigation of actions to achieve their long-term and short-term goals [S2B] The CM can provide examples of resources, services and supports the Client has arranged/accessed independent of the CM [S2B] Documentation by the CM demonstrates the involvement of key stakeholders to endorse and support Client independence. The CM (as applicable) facilitates the referral of the Client to appropriate (formal/informal) services to facilitate Client independence [S2B]

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Documentation by the CM demonstrates the process undertaken in partnership with the Client to identify any barrier/s (potential, current or future) and the strategies and/or interventions (as necessary) to minimise the impact on a barrier/s on the Client’s ability to achieve the desired goal [S2C] The CM adheres to program/agency guidelines concerning the management and resolution of conflict between the CM and/or Client and/or key stakeholders arising from a barrier/s to services. The CM utilises available resources and supports to facilitate a mutually beneficial solution and outcome [S2C] The CM acts purposely and decisively, in partnership with the Client, to seek advice and/or recommendations from key stakeholders; engaging their support and collaboration for the removal of Client barriers (within individual local level) [S2C] The CM has a comprehensive understanding and thorough knowledge of program/agency guidelines to safely and effectively respond to and manage barriers concerning Client risk [S2C] The CMdevelops the agreed care plan in alignment with the Client’s goals and identified needs taking into consideration all of the available and anticipated financial resources [S2D] The CM demonstrates responsibility and accountability for the Client budget, financial reporting, justification and disclosure of all expenditure and allocation of funds pursuant to the care plan and in accordance with the program/ agency guidelines [S2D] The CM demonstrates sound management of the Client budget utilising initiative in the allocation of expenditure to meet Client goals [S2D] The CM can demonstrate the application and/or knowledge of sourcing/securing funded/non funded resources, services or supports from external sources to respond to a specific Client need [S2D] The CM can demonstrate competency in financial acumen (i.e. knowledge, skill, and expertise), including the preparation/administration of the Client budget and the interpretation/understanding of financial reports. The CM (as applicable) is competent to communicate and explain financial information to the Client in accordance with the program/agency guidelines [S2D] The CM provides financial information to the Client, in accordance with the program/agency guidelines, including any fees (e.g. program fees and/or Client contribution), funding/budgetary details and the financial limitations/restrictions of the program. The CM ensures the Client understands the information provided [S2D] The CM explains the rationale and steps of developing the care plan with the Client, including the purpose of the goals, objectives, tasks and identified responsibilities (CM and Client), timeframes and the review process [S2E] The CM, in partnership with the Client and/or key stakeholders, applies a strengths based paradigm (e.g. R.O.P.E.S) to develop an agreed person centred care plan that is action orientated, multidisciplinary, flexible, evidence based and time specific. Goals and outcomes are specific, measurable, achievable, realistic and consistent with available resources and program/agency guidelines [S2E] Documentation by the CM demonstrates the agreed Client care plan promotes Client empowerment, self autonomy and self determination and includes a record of well stated, evidenced based and measurable goals, strategies, timeframes, responsibilities and outcomes [S2E] The CM provides the Client with a copy of the care plan for the Client’s feedback, approval and signature. A copy of the signed care plan is given to the client and includes (as applicable) any amendments as requested by the Client [S2E] Documentation by the CM demonstrates the execution of the activities and interventions by the CM and Client necessary for accomplishing the agreed goals within the care plan; including ongoing communication and sharing of information between the CM, the Client and/or key stakeholders [S2E] The CM can demonstrate innovative responses utilising resources outside of the mainstream service system [S2F] Documentation by the CMdemonstrates the CMdocuments Client’s and/or key stakeholder/s engagement, collaboration and contribution to innovative ideas and solutions to meet the Client’s individual, diverse and/or special needs [S2F] The CM can demonstrate the use of peer support, case conferences, interagency collaboration, informal supports and folk systems, contracting and networking to generate ideas for solutions [S2F]

3. Case Conferencing Unskilled

Standard 1B – 1C, Standard 1E, Standard 2B – 2C, Standard 2F, Standard 3B – 3C, Standard 3E, Standard 4E

CM does not inform key stakeholders regarding risk factors around identified risk or competency [S1E] The CM cannot provide documentation to show that they have made/discussed referrals to appropriate services to facilitate independence [S2B]

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Chapter One

CM does not liaise with agency/key stakeholders over their risk concerns [S2C] CM cannot provide examples of seeking input from peers, etc [S2F] CM is unable to demonstrate the provision of any active assistance to Client in providing feedback to key stakeholders [S3B] CM documentation does not demonstrate allocation of roles/ responsibilities between multiple stakeholders [S3B] CM is unable to demonstrate engagement with key stakeholders (both formal and informal) where these are deemed essential in the Client achieving their agreed goals [S3C] CM can give no examples of assisting a Client to advocate on their own behalf [S3E] CM is unable to identify examples of working with a range of key stakeholders to advocate for Client specific needs [S3E] CM does not facilitate disengagement phase in accordance with the Client and key stakeholders (as applicable) expectations, needs and preferences and agency/program and/or funding body guidelines and/or policies and procedures [S4E] The CM seeks the Client’s informed consent for the dissemination of Client information [S1B] Documentation by CM demonstrates the dissemination of Client information prior to obtaining consent [S1B] The CM identifies limitations in their professional scope of practice and/or qualifications/expertise and initiates a referral of the Client to a suitably qualified individual/service for specialist expertise/input [S1C] The CM utilises formal/informal support and services (as applicable) to ensure effective communication with the Client [S1D] The CM informs key stakeholders of identified risk factors, including (as applicable) any issues regarding the Client’s level of competency/capacity [S1E] The CM in partnership with the Client and key stakeholders facilitates referrals to alternative programs or settings where the Client’s individual, diverse and/or special needs and goals can be met more appropriately [S1H] Documentation by the CM demonstrates the involvement of key stakeholders to endorse and support Client independence. The CM (as applicable) facilitates the referral of the Client to appropriate (formal/informal) services to facilitate Client independence [S2B] The CM acts purposely and decisively, in partnership with the Client, to seek advice and/or recommendations from key stakeholders; engaging their support and collaboration for the removal of Client barriers (within individual local level) [S2C] Documentation by the CM demonstrates the execution of the activities and interventions by the CM and Client necessary for accomplishing the agreed goals within the care plan; including ongoing communication and sharing of information between the CM, the Client and/or key stakeholders [S2E] Documentation by the CMdemonstrates the CMdocuments Client’s and/or key stakeholder/s engagement, collaboration and contribution to innovative ideas and solutions to meet the Client’s individual, diverse and/or special needs [S2F] The CM can demonstrate the use of peer support, case conferences, interagency collaboration, informal supports and folk systems, contracting and networking to generate ideas for solutions [S2F] Documentation by the CM demonstrates engagement with key stakeholders (including conflict resolution) and all collaborative actions undertaken to clarify issues pertaining to resources, services, supports and joint goals, for and/on behalf of the Client [S3B] The CM actively assists the Client to communicate constructive feedback to key stakeholders. The CM provides feedback as requested by the Client for and/on their behalf [S3B] The CM plays a lead role in the facilitation of collaborative activities between key stakeholders [S3B] Documentation by the CM demonstrates ongoing consultation with key stakeholders (both formal and informal) concerning their role in supporting the Client to achieve the agreed goals [S3C] The CM demonstrates a sound knowledge and understanding of the process to facilitate a referral of the Client to a specialist (individual/service) in response to the changing needs of the Client [S3C] Documentation by the CM demonstrates the communication of required statutory or mandatory reporting by the CM to the Client and/or key stakeholders, including the role and responsibilities of all parties [S3D] Skilled Standard 1B, Standard 1D – 1E, Standard 1H, Standard 2B – 2C, Standard 2E – 2F, Standard 3B – 3C, Standard 3E, Standard 4E

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Chapter One

Documentation by the CM includes examples of the effective engagement of key stakeholders by the CM to advocate for Client specific needs [S3E] The CM recommends/refers the Client to a suitably qualified individual/service for independent advocacy advice and support for matters outside of the CM’s scope of practice and/or qualifications/expertise [S3E] The CM facilitates the disengagement phase in accordance with the Client and key stakeholders (as applicable) expectations, needs and preferences and in accordance with the program/agency guidelines [S4E]

4. Communication Unskilled

Standard 1A, Standard 1C – 1F, Standard 1H, Standard 2B – 2F, Standard 3A – 3D, Standard 4A, Standard 4C, Standard 4E

CM does not take time to explain or clarify Client’s understanding [S1A] CM does not explain program parameters. No documentation of Client involvement [S1A] Client is admitted onto program with no understanding of their rights and responsibilities. Non-compliance to agency policy [S1A] CM cannot demonstrate how Client feedback was sought [S1A] Case Manager does not discuss with Client the priority areas identified from assessment [S1C] No provision of information. CM provides information in a format that does not meet the Client’s special needs [S1D] CM does not communicate identified risks and management strategies to Client [S1E] CM does not inform key stakeholders regarding risk factors around identified risk or competency [S1E] Documentation by CM does not demonstrate communication of disengagement parameters to Client [S1H] The CM cannot provide documentation to show that they have made/discussed referrals to appropriate services to facilitate independence [S2B] CM does not discuss barriers or options with Client [S2C] CM does not liaise with agency/key stakeholders over their risk concerns [S2C] CM does not discuss or disclose financial limitations of care plan [S2D] CM does not discuss privately paid options available to Client to procure additional services outside of the care plan [S2D] CM is unable to explain how goal setting and review processes were discussed with Client [S2E] CM documentation does not identify/ support Client consultation [S2F] CM cannot provide examples of seeking input from peers, etc [S2F] CM does not clarify their role [S3A] Documentation does not demonstrate the timely advisement of changes affecting Clients [S3A] CM is unable to demonstrate the provision of any active assistance to Client in providing feedback to key stakeholders [S3B] CM is unable to demonstrate engagement with key stakeholders (both formal and informal) where these are deemed essential in the Client achieving their agreed goals [S3C] CM is unable to demonstrate communication with Client regarding limitations and/or variations to resources, services and support; including disengagement [S3C] CM does not provide Clients with information about legal services [S3D] There is no documentary evidence by CM that rights and responsibilities have been reviewed and discussed with the Client [S4A] No documentation by CM to show feedback from key stakeholder has been received and used to evaluate Client progress/experience towards agreed goals [S4A] CM does not individualise communication to suit the Client’s special needs [S1F] CM does not document they have discussed program information with the Client [S1F]

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CM does not inform the agency if Client need/case load surpasses the CM ability to perform and or exceeds program parameters/resources [S4C] CM documentation demonstrates no Client and key stakeholder feedback is sought and received by CM [S4E]

Skilled

Standard 1B, Standard 1D – 1E, Standard 1H, Standard 2B – 2C, Standard 2E – 2F, Standard 3B – 3C, Standard 3E, Standard 4E

The CM clarifies that the Client has understood the reason for the referral and the case management process [S1A] The CM explains the aims and objectives of the CM program to the Client, including any limitations, in order for the Client to make informed choices [S1A] The CM seeks feedback from the Client to confirm the Client’s knowledge and understanding of their rights and responsibilities [S1A] The CM seeks feedback of the Client’s understanding of the complaints/appeals process [S1A] Documentation by the CM demonstrates engagement with key stakeholders (including conflict resolution) and all collaborative actions undertaken to clarify issues pertaining to resources, services, supports and joint goals, for and/on behalf of the Client [S3B] The CM actively assists the Client to communicate constructive feedback to key stakeholders. The CM provides feedback as requested by the Client for and/on their behalf [S3B] The CM seeks the Client’s informed consent for the dissemination of Client information [S1B] The CM utilises formal/informal support and services (as applicable) to ensure effective communication with the Client [S1D] The CM provides information to the Client in a format/language that is appropriate to the Client’s individual, diverse and/or special needs [S1D] The CM informs key stakeholders of identified risk factors, including (as applicable) any issues regarding the Client’s level of competency/capacity [S1E] The CM adapts communication to meet the Client’s individual, diverse and/or special needs with due consideration to the Client’s unique personal circumstances [S1F] Documentation by the CM demonstrates regular communication with the Client, inclusive of the Client’s knowledge and understanding of the program expectations and guidelines [S1F] The CM documentation shows ongoing person centred planning and consultation with the Client and key stakeholders (as applicable) [S1G] Documentation by the CM demonstrates communication of disengagement parameters with the Client [S1H] Documentation by the CM demonstrates the provision of information to the Client about available resources, services and supports (internal and/or external to the program) [S2A] Documentation by the CM demonstrates ongoing communication with the Client concerning program service options, including optional formal/informal resources, services and supports and eligibility requirements (as applicable) [S2A] The CM acts purposely and decisively, in partnership with the Client, to seek advice and/or recommendations from key stakeholders; engaging their support and collaboration for the removal of Client barriers (within individual local level) [S2C] The CM (as applicable) is competent to communicate and explain financial information to the Client in accordance with the program/agency guidelines [S2D] The CM provides financial information to the Client, in accordance with the program/agency guidelines, including any fees (e.g. program fees and/or Client contribution), funding/budgetary details and the financial limitations/restrictions of the program. The CM ensures the Client understands the information provided [S2D] The CM explains the rationale and steps of developing the care plan with the Client, including the purpose of the goals, objectives, tasks and identified responsibilities (CM and Client), timeframes and the review process [S2E] Documentation by the CMdemonstrates the CMdocuments Client’s and/or key stakeholder/s engagement, collaboration and contribution to innovative ideas and solutions to meet the Client’s individual, diverse and/or special needs [S2F] The CM can demonstrate the use of peer support, case conferences, interagency collaboration, informal supports and folk systems, contracting and networking to generate ideas for solutions [S2F] Documentation by the CM demonstrates regular communication with the Client in accordance with best practice and program/agency guidelines [S3A]

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The CM demonstrates clear communication strategies that are consistent with the Client’s goals e.g. frequency of contact [S3A] The CM documents ongoing discussions with the Client regarding the clarification of the CM role and the agreed actions and responsibilities within the care plan [S3A] Documentation by the CM demonstrates the prompt communication to the Client of any changes to agreed services within the care plan, including delays, interruption and/or termination of services [S3A] Documentation by the CM demonstrates ongoing consultation with key stakeholders (both formal and informal) concerning their role in supporting the Client to achieve the agreed goals [S3C] Documentation by the CM demonstrates communication with the Client concerning any program limitations and/or variations to resources, services and support; including disengagement [S3C] Documentation by the CM demonstrates the communication of required statutory or mandatory reporting by the CM to the Client and/or key stakeholders, including the role and responsibilities of all parties [S3D] The CM supports the Client in self advocacy, including (as applicable) the provision of education and information concerning self knowledge, their rights and responsibilities, communication and negotiation skills, finding support and developing an advocacy action plan [S3E] Documentation by the CM includes examples of the effective engagement of key stakeholders by the CM to advocate for Client specific needs [S3E] The CM documents feedback from the Client and/or key stakeholders and uses this information to evaluate progress toward the Client’s goals or impacts on the Client’s experiences [S4A] Documentation by the CM demonstrates that the Client’s feedback and evaluation has been central to the review and adjustments to the agreed goals within the care plan [S4D] Documentation by the CM demonstrates the Client and key stakeholder’s feedback is sought and received by the CM in accordance with program/agency guidelines [S4E] Standard 1D, Standard 1F, Standard 2A, Standard 2C, Standard 2D, Standard 2F CM does not respond to prompts indicating the Client’s individual, diverse and/or special needs [S1D] CM does not access appropriate services to support the Client’s individual, diverse and/or special needs [S1D] CM documentation does not demonstrate CM has accessed/utilised appropriate information and resources to meet Client’s individual, diverse and/or special needs [S1D] No provision of information. CM provides information in a format that does not meet the Client’s individual, diverse and/or special needs [S1D] CM is unable to demonstrate either knowledge of services or a strategy to determine appropriateness of services [S2A] CM cannot demonstrate research into local networks and new services [S2A] CM does not discuss barriers or options with Client [S2C] CM not aware of any barriers [S2C] CM does not prepare Client for barriers [S2C] Care plan developed by CM with focus only on the available financial resources and not the Client’s goals and needs (including individual, diverse and/or special needs) [S2D] CM shows no initiative in development or implementation of resources outside of mainstream service system [S2F] Standard 1D, Standard 1F, Standard 1H, Standard 2A, Standard 2C, Standard 2F The CM identifies prompts from referral sources and key stakeholders to indicate that the Client may have a diverse and/or special need/s [S1D] The CM incorporates a comprehensive assessment model to identify the Client’s individual, diverse and/or special needs [S1D] The CM utilises formal/informal support and services (as applicable) to ensure effective communication with the Client that meet their individual, diverse and/or special needs [S1D] Skilled

5. Cultural Sensitivity Unskilled

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