c) Phases of case management

i) Phases of case management

Typical phases of case management are:

  • engagement and relationship building;
  • information collection and assessment;
  • planning and prioritisation of needs;
  • allocation, development and negotiation of resources;
  • implementation of a plan;
  • monitoring of the plan; and
  • review of the plan, case closure or reassessment.

The nature, intensity and duration of each of the case management phases will vary for each individual.

When working with people with ABI there are ideas tools and resources that may be especially useful. See the tabs for each phase.

ADHC's model

ADHC describes its stages of case management in Case Management Practice Guide 7 Phases of Case Management March 2010 PDF

 

 

ii) Engagement and relationship building

The purpose of engagement is to nurture and develop a professional and trusting relationship with the client and their family and/or carer.

Effective engagement is achieved through active listening, and creating a safe, trusting environment.

In working with people with ABI it may be useful to review what makes the person with ABI unique. It may also be useful to review what are common emotional and relationship responses to ABI

 

iii) Information collection and assessment

This includes identifying the person's strengths, assets and resources, and life areas the person wants to change.

Assessment includes identifying difficulties the person may be experiencing in areas of their life including personal and community relationships, their health, and environment. It is also appropriate at this time to bring together other sources of information such as verbal and written reports, to help build a picture.

In working with people with ABI the following tools may be useful:

Tool 3: Looking for indicators of ABI - Tool 3
Tool 6: Sources of information

iv) Planning and prioritisation of needs

Planning is a holistic ongoing process, occurring in a variety of ways including informal and formal elements. It explores the interests and life circumstances of the person.

The development of any plan must be realistic and take into account the ability of those involved to work towards meeting the identified goals.

A number of initial goals may be identified that address short term and immediate issues relevant to the person with a disability. However, a holistic plan is future focused.

In working with people with ABI the following tools may be useful

Tool 7: Individual Program Plan and
Tool 8: Tips for setting goals

 Toolkit B. Working Together Promoting Independence  may also be useful. It includes section on .

Identifying issues .
Setting goals
Making goals happen
Monitoring progress

v) Implementation

Implementation of any plan can occur at three significant levels. They are;

1. the person with a disability,

Once the plan has been developed in collaboration with the person with a disability, goals should be prioritised, desired outcomes identified and strategies agreed on, taking into account the range of informal and formal enablers and constraints

2. family, friends, supporters and community

This may involve assisting family, friends and supporters to build knowledge, skills and resources that will support them and the person with a disability to meet the identified outcomes

3. intervention at a systems level

The case manager working at this level will undertake a range of tasks. For example,
i. analysing the strengths and constraints of the service systems.
ii. selecting strategies to improve systems
iii. assessing the effectiveness of strategies and continuing to revise desired outcomes and strategies.

The Toolkit B. Working Together Promoting Independence provides practical tips and tools for working with people with ABI.

vi) Monitoring

Monitoring occurs at a number of levels and is an ongoing process. It identifies the effectiveness and relevance of goals identified and the timeliness and effectiveness of strategies, focusing on elements of the overall plan.

Critical to the integrity of this process is the perceived effectiveness by the person being case managed. Some responsibility for monitoring also rests with the family and support networks of the person being case managed who have been involved in the planning process.

In working with people with ABI the section on Monitoring provides tips on how to ask good questions and how to support the person with ABI in reviewing their situation.

vii) Review

The review process is distinguished from monitoring in that it should reflect on all elements of the plan including the goals, strategies and outcomes. However, as with the monitoring process, it should also be driven by, and be inclusive of, the perceptions of the effectiveness by the person being case managed.

A good review will be characterised by the following elements;

  • what has been achieved to date? For example has the person been more involved in the community; do they have more confidence; do they see their future differently?
  • do the achievements relate to the original goals set?
  • did anything change along the way such as a change in personal or family circumstances or health status?
  • what were the most significant positive outcomes for the person with a disability?
  • how have the outcomes made a difference?
  • what wasn't achieved?
  • how can these points be addressed in future planning activities?

Responses to all the above questions need to be taken into account for subsequent planning. Collaboratively looking at the whole plan to see if the identified goals have been achieved, and if what the person with a disability wanted has occurred, is also required. They identify achievements, fulfilment and areas requiring more attention and new or emerging issues, concerns or aspirations.

In working with people with ABI the section on Monitoring that provides tips on how to ash good questions and how to support the person with ABI in reviewing their situation.

 

viii) Closure

Closure can be influenced by two key variables. First, is the outcome of discussing the ongoing goals of the person. This includes the capacity of all parties to remain involved and the willingness of the person and their networks to maintain contact with the case management practitioner.

The second key variable is the organisational constraints on the practitioner, influencing their capacity to maintain involvement with the person with a disability. When the organisation requires closure, despite the person with a disability wishing to remain in contact, the practitioner has several ethical obligations that should be supported by the organisation. This may involve ensuring that other supports, both formal and informal, have the capacity and intent to provide ongoing support.

With people with ABI who have damage to the frontal lobe

People who have damage to the frontal lobe of the brain often have difficulty with

  • planning
  • coordinating
  • initiating

One of the consequences of this is that often people who have frontal lobe damage are also the ones who need ongoing case management. In these situations the Case manager's roles is to act as their frontal lobe. The case management is likely to be episodic as it will be needed when new situations will continue to arise in his life - moving house, changing job, getting sick.

People with frontal lobe damage will need episodic case management for life.

To provide an appropriate service case management services need to ensure there are policies and procedures in place so that a person can re-enter case management quickly. If case management doesn't happen quickly when needed the person's life may spiral out of control.