Posted: March 11th, 2023

CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements

Hi, there are 3 files,One file is a learner guide, and other need to be done.Please answer all questions in the same file attached. Assessment Booklet CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Student Name: Student Number: Intake Date: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 2 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ASSESSMENT COMPETENCY RECORD This form is to be completed by the assessor and used as the final record of the student competence in these discipline. All student submissions including any associated documents and checklists are to be attached to this cover sheet before placing on the students file. Student results are not to be entered onto the Student Database unless all relevant paperwork is completed and attached to this form. Student ID Final Assessment Submission Date: Student Name Assessor Declaration In completing this assessment, it is confirmed that the participant has demonstrated all unit outcomes through consistent and repeated application of skills with competent performance. Evidence is confirmed as: ❑ Valid ❑ Sufficient ❑ Current ❑ Authentic Please attach the following documentation to this form Result FINAL ASSESSMENT RESULT: ❑ Competent (C) ❑ Not Yet Competent (NYC) Assessment Task 1 ❑ Case study S / NS Assessment Task 2 ❑ Project S / NS Assessment Task 3 ❑ Project S / NS Assessment Task 4 ❑ Project S / NS Assessment Task 5 ❑ Case study S / NS Assessment Task 6 ❑ Written/Oral Questions S / NS Attempt Date Assessor’s feedback (as required): 1 2 3 Final Feedback: DO NOT SIGN BELOW UNTIL FINAL ASSESSMENTS RESULT IS GRANTED BY THE ASSESSOR. Assessor: I declare that I have conducted a fair, valid, reliable and flexible assessment with this student, and I have provided appropriate feedback. Signature: _______________________ Name: __________________________ Date: ____/_____/_____ Student: I declare that I accept the assessment competency outcome and consider the feedback of my assessor positively. I also declare that the work submitted is my own, and has not been copied or plagiarised from any person or source. Signature: ______________________ Date: ____/_____/_____ Administrative use only: Entered into Student Management Database ❑ Signature/Initial ________________ Date: ________________ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 3 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Unit Code/Name CHCCSM005 Develop, facilitate and review all aspects of case management Pre-requisites N/A Co-requisites N/A Unit Summary This unit describes the skills and knowledge required to undertake case management meetings to plan, monitor and review service provision. Workers at this level work autonomously and are responsible for own outputs within organisation guidelines. This unit applies to work in a range of health and community services contexts. The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice. Conditions and context of the assessments Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit: ▪ use of suitable facilities, equipment and resources, including individualised case plans ▪ modelling of industry operating conditions, including: ▪ scenarios that reflect standard operating conditions and contingencies ▪ links to other local service agencies or organisations Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors. Unit Code/Name CHCCCS004 Assess co-existing needs Pre-requisites N/A Co-requisites N/A Unit Summary This unit describes the skills and knowledge required to assess the diverse and multi-faceted needs of people and determine both internal and external services required to meet those needs. This unit applies in a range of community service contexts. The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice. Conditions and context of the assessments Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit, including: ▪ use of suitable facilities, equipment and resources, including: ▪ organisation policies and procedures ▪ use of peoples information on which to base assessment ▪ individualised plans and any relevant equipment outlined in the plan ▪ assessment tools and processes ▪ modelling typical workplace conditions and contingencies, including: ▪ interactions with people with a range of needs ▪ typical workplace reporting processes Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors. Unit Code/Name CHCCSM004 Coordinate complex case requirements Pre-requisites N/A Co-requisites N/A Unit Summary This unit describes the skills and knowledge required to coordinate multiple service requirements for CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 4 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 clients with complex needs within a case management framework. Workers at this level work under supervision within established guidelines but take on a team leadership role in the coordination of services and service providers. This unit applies to work in a range of health and community services contexts. The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice. Conditions and context of the assessments Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit: ▪ use of suitable facilities, equipment and resources, including individualised case plans ▪ modelling of industry operating conditions, including: ▪ scenarios that reflect standard operating conditions and contingencies ▪ links to other local service agencies or organisations Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors. Assessment venue This assessment will be conducted in the CAC classroom or simulated workplace environment or at actual designated workplace: • Address of actual designated workplace: …………………………………………….. …………………………………………….. …………………………………………….. Specific Resources Required Candidate will need access to: ▪ Computer with Internet and email access and a working web browser ▪ Installed software: MS Word, Adobe Acrobat Reader ▪ Access to legislation and protocols relevant to the community services industry, social work and case management, including codes of conduct, practice standards, etc. ▪ Video camera or a mobile phone with video and audio recording capabilities ▪ Three (3) volunteers for the roleplay activities ▪ Access to a document printer or printing services Re-assessment To gain competency you need to get Satisfactory (S) result in all the tasks. If Not Satisfactory (NS) result is given even for a task you will be deemed Not Yet Competent (NYC). Students who are unsuccessful at achieving competency at the first attempt will be offered coaching, information and additional time (other needs if required) before a second and possibly a third attempt is made. If the student is not able to satisfactorily complete the assessment after the third attempt the student will be deemed Not Competent and resulted as such. The student may re-enrol in the qualification at a later date to gain successful completion of the unit/s. For further details, refer to CAC Assessment Policy and Procedure. https://cac.edu.au/policies-and- procedures/ Plagiarism CAC considers plagiarism and cheating as serious student misconduct and this may result either in a student’s exclusion from a unit or course or may have to complete a re-assessment depending on individual case. Refer to CAC Plagiarism & Cheating Policy and Procedure. https://cac.edu.au/policies-and-procedures/ Complaints and appeal Where a student wishes to appeal an assessment decision they are required to notify their assessor in the first instance. Where appropriate the assessor may decide to re-assess the student to ensure a CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 5 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 fair and equitable decision is gained. The assessor shall complete a written report regarding the re- assessment outlining the reasons why assessment was or was not granted. Refer to CAC Complaints and Appeals Policy & Procedure for details. https://cac.edu.au/policies-and-procedures/ Assessors Intervention Assessors are to check that the student is ready for assessment, and defer the assessment if they are not. It is important that assessors do not teach at the assessment but allow students to competence for themselves. Feedback is to be given at the completion of the assessment using the feedback to student. If a student does not meet a standard, the assessor is to sit down with them and assist them in their understanding. Should you disagree with the assessment outcome, you can appeal the decision as stated in the Student Handbook. Your student record must indicate that you have all required skills and knowledge in completing the task. For each assessment, the assessor is to act as a supervisor and not interfere with the assessment. If the assessment activities will impact on your safety or that of others, the assessment must be stopped immediately. Attaching documents Attached documents are accepted but must be labelled with the following information: Unit Name and Title, Students name, Student ID, Date of Submissions, Student signature. Assessment Instruction Assessment is mapped to the unit and must be completed by the end of each unit. For answers to written questions, reports and projects, you must: • Print clearly in black or blue pen or type it as a word document • Answer each of the key points and /or follow instructions • Assessments written in pencil or are illegible will not be accepted. Please NOTE: Student has to submit each and every assessment task. Ask your assessor if you do not understand any part of the assessment. Whist your assessor cannot tell you the answer, he/she may be able to re-word a question or instruction to assist in a better understanding for you. Case Study Assessment Task 1: Based on the case study, students are supposed to: Task 1: Answer the questions Task 2: Perform role play activity Task 3: Perform role play activity Task 4: Document outcome of the interview Task 5: Analyse information and prioritise needs Assessment Task 2: As part of the planning process, students are supposed to: Task 1: Develop an appropriate case management plan Task 2: Perform a roleplay activity Assessment Task 3: As part of monitoring and reviewing, students are supposed to: Task 1: Review of a care plan Task 2: Communicate the outcomes of the review Assessment Task 4: As part of case closure and exit, students are supposed to: Task 1: Write a case closure summary Task 2: Write a reflective journal Assessment Task 5: Based on the case study, students are supposed to: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 6 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Task 1a: Analyse information and identify needs Task 2a: Interpreter arrangement Task 1b: Analyse information and identify needs Task 2b: Interpreter arrangements Assessment Task 6: This is a written assessment that will test student’s knowledge. This assessment may be completed over the duration of the training days. As the students learn, practice and review knowledge and skills, students will keep Assessment Task 6 in front of them and answer the questions as the information becomes clearer. At the beginning of each review session students will be given a few minutes to familiarise themselves with the questions. Students will be given extra time at the end of the day to complete this assessment or to clarify facts with the Trainer/Assessor Competency Decision Student must satisfactorily complete each assessment tasks to be Competent (C) in the unit. Student with unsatisfactory completion of any of the assignment tasks will be deemed Not Yet Competent (NYC). Reasonable adjustment To meet the needs of all learners’ adjustments can be made to the way assessments are conducted but not to the requirements of the assessment. The purpose of these adjustments is to enhance fairness and flexibility so that the specific needs of students can be met. CAC will take meaningful, transparent and reasonable steps to consult, consider and implement reasonable adjustments for students with disability and learning difficulties. Reasonable adjustment provided Reason for reasonable adjustment Outcome ❑ Educational and bilingual support ❑ Presenting questions orally ❑ Presenting work instructions in diagrammatic or pictorial form instead of words and sentences ❑ Extra time to complete a course or assessment ❑ Others: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 7 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Instructions to Assessor This is a compulsory assessment to be completed by all students. This assessment tests the student’s ability to understand the underpinning generic knowledge related to the units of competency. Reasonable adjustment applies here, and while the majority of students will complete this assessment as a written assessment, verbal assessment may be an option for those who need it. Assessor must use the response guide as the principal marking tool unless reasonable adjustment is demonstrated. The Assessor Guide provides model answers to all the questions, setting out which key responses must be included, as well as indicating where flexibility is acceptable. Where there is a number of responses required, this is specified to avoid ambiguity. In these cases, the model answer will provide a list of possible answers. For instance, if a question requires the student to list three (3) examples, then their response must include three of the items listed in the model answer. Note to assessors: Contact details are requested from observers in the feedback forms in case you will have to call them to verify content of the feedback forms. IMPORTANT REMINDER Candidates must achieve a satisfactory result to ALL assessment tasks to be awarded COMPETENT for the units relevant to this cluster. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 8 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 INSTRUCTIONS TO CANDIDATE The questions in this workbook are divided into two categories: Knowledge Assessment and Case Studies. The questions under Knowledge Assessments are all in a short-answer format. The longer questions, requiring creative and analytical thought processes, are covered in the Case Studies assessment. You must answer all questions using your own words. However, you may reference your Learner Guide and other relevant resources and learning materials to complete this assessment. Some questions cover processes you will likely encounter in a workplace. Ideally, you should be able to answer these questions based on the processes that are currently in place in your workplace. If this is not the case, then answer the questions based on processes that should be implemented in your workplace. Accessing Intranet Pages and External Links There are instructions in this workbook that will refer you to intranet pages and or external links. These intranet pages and external links are formatted in Blue Underlined Text. To access these, hold the Ctrl key for Windows users or the Command ⌘ key for Mac users while clicking on these links. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 9 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 CASE STUDIES Instructions to Assessor This assessment supports the industry requirement of working with clients as a case manager in community services. In real life, case managers will be required to assess the diverse and multi-faceted needs of people, and determine both internal and external services required to meet those needs; undertake case management meetings to plan, monitor and review service provision; and, coordinate multiple service requirements for clients with complex needs within a case management framework. This assessment will demonstrate the candidate’s ability to use analytical and thinking skills in such situations. Instructions to Candidate These case studies are a hypothetical situation which will not require you to have access to a workplace, although, your past and present workplace experiences may help with the responses you provide. You will be expected to encounter similar situations to these in the future as you work with clients with clients as a case manager in community services. In real life, case managers will be required to assess the diverse and multi-faceted needs of people and determine both internal and external services required to meet those needs, undertake case management meetings to plan, monitor and review service provision, and coordinate multiple service requirements for clients with complex needs within a case management framework. This assessment will allow you to demonstrate your ability to use analytical and thinking skills in such situations. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 10 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 CASE STUDY Philip SCENARIO Philip is a 36-year-old man who is married with two children. He has been homeless for almost a year now. He may not fit the stereotypical story of a homeless person because not so long ago, he was living a healthy life with his family. But, when he lost his job, he found himself in a downward spiral. Philip and his wife rented a two-bedroom apartment in a safe neighbourhood. Philip liked his job as a delivery driver for a large food service distributor, where he had worked for more than five years. He was working towards getting the supervisor position in the next year. Philip’s wife was a stay-at- home mom. Philip has never been seriously ill, although he smokes half a pack of cigarettes each day and drinks socially a couple times a month. One afternoon, Philip’s company notified him that they were laying him off along with more than a hundred other employees. Though he was devastated, he was not at all worried because he and his wife had some savings they could use for rent and other bills, in addition to the unemployment payments he would receive for a few months. Philip searched aggressively for jobs in the newspaper and online, but nothing worked out. He began to have feelings of anger and worry that led to panic. His self-esteem fell, and he became depressed. When Philip’s wife was hired part-time to work in a school canteen, the couple felt better about finances. But demoralised by the loss of his job, Philip started to drink more often. With the drinking becoming more regular, Philip and his wife started to argue more often. Then, about six months after losing his job, Philip stopped receiving Centrelink payments. That week, he went on a drinking binge that ended with another argument with his wife. In the heat of the fight, he struck her. The next day, Philip’s wife took the children and moved in with her parents. Philip was also evicted from the apartment on the same day because he was unable to pay rent. Philip tried to reconcile with his wife, but she said she had had enough as he is becoming more angry and violent. Over the next few months, Philip asked friends and family members if he could board with them for a couple of days. They reluctantly agreed but his heavy drinking and anger only got worse, and his hosts always asked him to leave. Finally, when Philip couldn’t ask help from anyone anymore and he didn’t have a place of his own, he started sleeping at the park. For a couple of nights, he also stayed at a shelter run by a church. Each morning, he had to leave the shelter at 5 AM. He walked the streets all day and begged for money to buy alcohol. Philip was referred to your service (Operation Hope) by the community hospital, after he was taken to their emergency department due to injuries caused by some teenage boys who jumped him in the park, beat him up and stole his backpack. He was discharged after a day and was screened as “homeless”. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 11 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ASSESSMENT TASK 1 – CASE STUDY Student ID Student Name This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this assessment task Student Declaration: I declare that the work submitted is my own, and has not been copied or plagiarized from any person or source. Signature: ___________________________ Date: ____/_____/_____ Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials 1 S/NS 2 S/NS 3 S/NS Feedback to student: Assessor: I declare that I have conducted a fair, valid, reliable and flexible assessment with this student, and I have provided appropriate feedback. Signature: _________________________ Name: _________________________ Date: ____/_____/_____ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 12 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 PART 1: ASSESSMENT TASK 1. Your supervisor assigned you to complete the intake interview with Philip. In order to prepare for the first meeting with him, read Philip’s referral form found below and Operation Hope’s policies and procedures found at this link: Referral Form CLIENT DETAILS Name Philip Stockinger Address N/A Phone no. N/A Date of birth N/A Gender ☒ Male ☐ Female Marital Status ☐ Single ☒ Married ☐ De facto ☐ Divorced Background Islander ☐ Aboriginal ☐ Torres Strait Islander ☐ Aboriginal and Torres Strait Others, please specify N/A Next of kin or contact person Karen Stockinger Address 90 Martens Place, Port of Brisbane Phone (07) 3651 2680 CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 13 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 REFERRAL DETAILS Referral agency Mater Public Hospital Referral agency contact person/details Melissa Dame/ER Nurse Previous contact with the service ☐ Yes ☒ No When and what services were provided Emergency service – treatment of injuries PROGRAM/ACTIVITY DETAILS Broadly, what programs/activities do you need to access? Children ☐ Youth ☐ Substance Abuse ☐ Training ☐ Elderly ☐ Parenting ☐ Disabilities ☐ Health ☐ Others (please specify) Accommodation/housing Recommendations/Action take (e.g., that a formal assessment be undertaken) Schedule an initial contact with Philip for intake and assessment. Additional comments Philip was brought to the emergency dept. three days ago due to injuries. He said some boys beat him up and took his backpack containing his clothes and some food from the church. He usually sleeps on the park benches. When asked where we can find him more often, he said he stays around City Tabernacle church for food, and sometimes they let him stay for the night when it gets really cold outside. REFERRAL APPROVAL Referral Officer/Case Worker Kiara Henderson Signature Date 18 January 2017 Supervisor/Manager Dylan Nyhan Signature Date 18 January 2017 CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 14 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 1 Written/Oral Questions 1. Statutory requirements a. What information from the above scenario may raise your concern and may prompt you to undertake further assessment and reporting as necessary? b. You decide to further assess, and you find out that there is a need to report your concern. What will be your basis for reporting? a. b. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 15 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 2. Identify the assessment tools you need to prepare prior to the first meeting with Philip. (This question asked for the tools – the marking guide is not a tool) Guidance: Refer to Operation Hope’s Policies and Procedures. 3. What are the assessment processes that you will utilise as Philip’s case manager? Guidance: Refer to Operation Hope’s Policies and Procedures. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 16 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 2 Roleplay activity: Intake interview This part of the assessment is a Roleplay Activity. This activity will require you to perform an intake interview. To complete this part of the assessment, you will need access to: 1. One (1) volunteer who will roleplay as Philip. 2. Video camera or a mobile phone with video and audio recording capabilities. 3. Forms and checklists: ▪ Intake Checklist Intake Checklist x ▪ Intake Form Intake Form x ▪ Consent Form Consent Form x ▪ Intake Action Plan Intake Action Plan x *Click on the icons above to open the forms/checklists Read the instructions carefully before proceeding. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 17 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Steps to take: 1. Prepare for the intake interview by: a. Reading and understanding Operation Hope’s (the hypothetical service) policies and procedures. b. Filling out the Intake Form with the details already provided. Refer to the scenario and Referral Form. c. Gathering the forms and checklist needed during the interview. These include the Intake Checklist, completed Intake Form, and Consent Form. d. Explaining Philip’s case to your volunteer. 2. Proceed with the intake interview. During the first part of the interview you must be able to: a. Introduce yourself and the service, and seek introduction from the client. Engage the client in establishing rapport and trust. b. Identify the purpose of the meeting and orient the client. Clarify the context of the interview and seek the client’s participation in the process. Encourage the client to ask questions and seek clarification as necessary. 3. Present the completed Intake Form to the client. Review the details already included in the form with the client and ask him to provide the remaining information. 4. Explain the following information to the client. Ensure that you seek feedback from the client to identify whether the client understood the points being discussed. a. What is your role as the client’s case manager? b. What is your role as the client’s case coordinator? c. What is the assessment process and what are its practical aspects? Guidance: To be able to explain the assessment process and its practical aspects, the following must be included in the discussion: ▪ Reason for the assessment. ▪ Role of the client in the assessment process. ▪ Role of the case manager in the assessment process. ▪ Where and how the assessment will be conducted. d. What are the client’s rights and responsibilities, including his rights to appeal and avenues for complaints? e. What will the methods of communication be between the case manager and the client (e.g. phone, face-to-face meeting, home visits, email, etc.)? f. What are the procedures for release of personal information to another party and the requirement for informed consent for release? 5. After the discussion of the points above, complete the Intake Checklist and the Consent Form. 6. Use interpersonal communication skills in engaging the client to explore the urgent issues and needs that the client is experiencing. When the most urgent needs are identified, work with the client in prioritising these. 7. Together with the client, accomplish the Intake Action Plan and identify the: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 18 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 a. Three (3) most urgent needs of the client b. Desired results (goal/s) of each need c. Activity/-is that will be used to pursue each goal for each issue (plan/strategy) d. Responsible person/s and/or service/s who will carry out each plan/strategy e. Time frame in which the responsible person/s and/or service/s hopes to achieve each specific plan/strategy (target date) Guidance in accomplishing the Intake Assessment Action Plan: ▪ The issues and goals recorded should reflect the words and sentiments of the client. ▪ The goals should be measurable so that you, as the case manager, and the client will know when they have been achieved or need to be re-evaluated. ▪ There may be more than one activity for each issue/goal. ▪ The responsible person may include you, other service providers, the client’s family/caregiver, and other formal/informal support. ▪ The client receiving support should be given appropriate responsibility in implementing and pursuing their plan. ▪ The time frame (target date) should be appropriate and specific to the issue, goal, plan/strategy (i.e. exact date should be provided). f. Review the points discussed during the interview and close it by scheduling another appointment in a week to make a formal plan. Guidelines 1. To demonstrate your completion of this activity, the intake interview must be recorded. Save the recorded video using the filename: [Last Name, First Name]_Subject 4 – Roleplay Activity-1 For example, as seen below: Smith, John_Subject 4 – Roleplay Activity-1.avi 2. Your video submission must not be longer than forty-five (45) minutes in length. Any submission longer than forty-five (45) minutes will be considered not satisfactory. 3. There is no specific script to be followed in the roleplaying activity. However, you must be able to demonstrate all steps outlined above. Moreover, your submission will be assessed against the checklist provided below. 4. Submit the following completed forms and checklist together with the video: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 19 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Filename Intake Checklist [Last Name, First Name]_Subject 4 – Intake Checklist Intake Form [Last Name, First Name]_Subject 4 – Intake Form Consent Form [Last Name, First Name]_Subject 4 – Consent Form Intake Action Plan [Last Name, First Name]_Subject 4 – Intake Action Plan CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 20 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Part 1: Task 2 – Roleplay Activity: Intake Interview Assessor’s Checklist (For the assessor’s use only) Has the following been demonstrated in candidate’s video submission? Yes No Comment 1. Information sharing is facilitated, and appropriate rapport is established. ☐ ☐ 2. Information about the coordination role is provided. ☐ ☐ 3. The assessment process is explained to the client. ☐ ☐ 4. Informed consent is explained and obtained from the client. ☐ ☐ 5. Practical aspects of assessment are consulted with the client. ☐ ☐ 6. Client’s rights and responsibilities, including rights of appeal and avenues of complaint are explained. ☐ ☐ 7. Communication requirements are established with the client. ☐ ☐ 8. The client is empowered to identify and prioritise own needs. ☐ ☐ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 21 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 3 Roleplay activity: Assessment interview After a week, Philip returned to the service to have the formal assessment interview with you. During the intake interview, you explained to Philip that this second meeting would involve a more detailed assessment with a view of creating the case management plan with him. Prior to this meeting, you phoned the service providers with whom you made appointments on behalf of Philip. All of them told you that Philip failed to show up to the scheduled appointments. One of the coordinators in another service informed you that she instinctively phoned Mater Public Hospital. She found out that Philip was admitted for a couple of days due to severe abdominal pain and was diagnosed with gastritis. This part of the assessment is a Roleplay Activity. This activity will require you to perform a formal assessment. To complete this part of the assessment, you will need access to: 1. One (1) volunteer who will roleplay as Philip. 2. Video camera or a mobile phone with video and audio recording capabilities. 3. Assessment form and checklist. ▪ Assessment Checklist Assessment Checklist x ▪ Assessment Form Assessment Form x *Click on the icons above to open the forms/checklists Read the instructions carefully before proceeding. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 22 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Steps to take: 1. Prepare for the assessment interview by: a. Reading and understanding Operation Hope’s (the hypothetical service) policies and procedures. b. Gathering the forms and checklist needed during the interview. These include the Assessment Form and Assessment Checklist. c. Explaining the next scenario of Philip’s case to your volunteer. 2. Proceed with the assessment interview. During the first part of the interview, you must be able to: a. Re-establish rapport and trust (e.g. ask the client how he has been since the first meeting, what were his activities last week, etc.). b. Review what happened during the previous meeting and discuss the intake action plan and its results with the client. c. Explain to the client the agenda for the meeting and encourage asking questions and raising concerns, if there are any. 3. Conduct the assessment in a semi-structured narrative format and use the Assessment Checklist in collecting the following information: a. Presenting concerns ▪ What are the concerns for which the client came or was referred for help? ▪ How does the client view these concerns? ▪ What is/is the client’s expectation(s) when he came in or when he was referred to the service? ▪ How long has the client been the impacted by these concerns? ▪ Were there prior attempts to resolve the concerns? ▪ Was there previous involvement with social agencies/services for assistance with these concerns? b. Past medical history and background Obtain this by asking the client to describe his/her: ▪ Family history – include any health information (i.e. conditions and illnesses that run in the family) about the client’s close relatives from three generations. ▪ Past illnesses and conditions – include childhood illnesses and diagnosed conditions the client has had previously. ▪ Hospitalisations – include the primary reason for admission. ▪ Surgeries and procedures – include any past surgeries or other major medical procedures. ▪ Significant injuries – include all types of injuries that resulted in disability or altered activity. ▪ Medications – include prescription, over-the-counter and supplementary medicines that the client has taken in the past. ▪ History of mental concerns. c. Previous agency involvements CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 23 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ▪ Has the client asked for assistance or was referred to any social agencies/services prior? If yes, list all the names and include the services that the client received previously. d. Psychosocial and behavioural health ▪ Ask the client the following questions to be able to gather data about his level of psychosocial and behavioural well-being: - How do you feel about the things going on in your life at the moment? - What is it that troubles you most about the situation? - How are you handling this/these thing(s) that trouble you? ▪ Observe the attitude, appearance, behaviour, thought process, and insight of the client all throughout the interview e. Psychosocial support systems ▪ Ask the client to describe his relationships with his: - Immediate family (i.e. wife and children) - Relatives (including his in-laws) - Friends - Other groups/support f. Risk Assessment Determine the presence of the following risk and vulnerability factors which may affect the safety and well-being of the client. Explore the factors below through the course of the conversation. Guidance: Below are sample questions you may use during the assessment. You may ask additional/other questions as necessary. ▪ Depression/mental health issue - Are you feeling down or hopeless? - Do you feel bad about yourself or that you are a failure and have let yourself or your family down? - Do you have thoughts of hurting yourself, or that you would be better off dead? ▪ Drug and/or alcohol misuse/abuse - Do you drink heavily when you are disappointed, under pressure or have had a quarrel with someone? - Has a family member or close friend expressed concern or complained about your drinking? - Have you ever spent your rent or bill money to buy drugs or alcohol? - Have you had trouble getting along with your friends because of your alcohol or drug use? ▪ Suicidal ideas CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 24 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 - Have you ever tried to kill yourself or attempt suicide? - When did you begin having suicidal thoughts? - Did any event (stressor) precipitate the suicidal thoughts? - What would it accomplish if you were to end your life? ▪ Isolation - Do you feel that you have nobody to talk to? - Do you feel as if nobody really understands you? - Do you feel shut out and excluded by others? ▪ Has access to weapons - Do you have access to weapons of any kind? ▪ Has ever harmed or threatened people and/or animals - Have you ever harmed or threatened to harm family, friends or pets? - Did someone do something, or did something happen that made you harm or threaten people and/or animals? ▪ Controlling behaviours - Have you exercised complete control over another person’s activities, for example, telling him/her who they can friends with, determining when he/she can see friends and family, etc.? - Have you ever tried influencing another person’s decisions by blackmailing them? ▪ Unemployed - Do you feel that you are no longer in control of your life since you have lost your job? - Do you feel helpless and unable to change the circumstance you are in? - Do you feel that you lose the status that comes with having a job? ▪ History of violent behaviour - Have you ever hit other people or damaged things when you are angry? - Have you ever been in a physical fight (e.g. punching, kicking, slapping, etc.) with another person? - Did someone do something, or did something happen that made you act out violently? ▪ Recent separation - Has there been a recent separation or planned separation in the near future? - Do you have plans of working with your wife/family towards reconciliation? ▪ Financial difficulties - Have you asked someone, or have you contacted a financial service for assistance? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 25 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 - When was the last time you tried looking for a job? g. Need for short-term and long-term support ▪ Help the client identify the short-term and long-term support needs - Short-term needs are those that can be addressed immediately and resolved. - Long-term needs are the complex needs of the client that can only be addressed by careful planning and coordination with other support/services. h. Strengths, weaknesses, goals Assist the client in identifying his strengths, weaknesses, and goals. The following questions may assist the client: ▪ What are your personal attributes? ▪ What are your talents and skills? ▪ What are your environmental strengths (e.g. personal relations, physical resources, opportunities, etc.)? ▪ What are your interests, aspirations, and goals? ▪ What are the barriers that may have a negative effect on achieving your goals? i. Additional information Additional questions you may ask the client include the following: ▪ What is/are the expectation(s) of the client? ▪ Is there any person the client does not want to see and/or have contact with? ▪ Is there any information that the client does not wish to be disclosed? ▪ Does the client have any special request that they would like the service to assist them with? ▪ Does the client have any additional information that they would like you to know about in order to offer them support? 4. Review the points discussed during the interview, inform the client that the information collected will be used to create a case management plan and close it by scheduling another appointment in a week for the case conference. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 26 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Guidelines 1. To demonstrate your completion of this activity, the intake interview must be recorded. Save the recorded video using the filename: [Last Name, First Name]_Subject 4 – Roleplay Activity-2 For example, as seen below: Smith, John_Subject 4 – Roleplay Activity-2.avi 2. Your video submission must not be longer than forty-five (45) minutes in length. Any submission longer than forty-five (45) minutes will be considered not satisfactory. 3. There is no specific script to be followed in the roleplaying activity. However, you must be able to demonstrate all steps outlined above. Moreover, your submission will be assessed against the checklist provided below. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 27 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Part 1: Task 3 – Roleplay Activity: Assessment Interview Assessor’s Checklist (For the assessor’s use only) Has the following been demonstrated in candidate’s video submission? Yes No Comment 1. Collaborated with the client to identify strengths, abilities and goals. ☐ ☐ 2. Worked with the client to identify immediate, short and long-term needs. ☐ ☐ 3. Assessed potential risk factors for service delivery. ☐ ☐ 4. Applied strengths-based approach to assessment. ☐ ☐ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 28 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 4 Document the outcome of the Assessment interview This part of the assessment will require you to document the outcome of the assessment interview using the Assessment Form. Assessment Form x *Click on the icons above to open the forms Read the instructions carefully before proceeding. Steps to take: 1. Transcribe the information collected from the Assessment Interview using the Assessment Form. 2. Summarise each item listed in the Assessment Checklist. ▪ Bullet points may be used in lieu of a narrative/essay format. ▪ Paraphrasing may be used to convey the general idea of what is being said. ▪ Record the client’s exact words using quotations marks if there is a need to highlight his/her statement(s). 3. Follow these guidelines in documenting the assessment interview: ▪ Use simple but appropriate language. ‘Slang’ may only be used if the client’s exact words are being recorded. ▪ Write objectively, concisely in the active voice and include only necessary information. 4. Submit the completed Assessment Form and Checklist using the following naming convention: Filename Assessment Checklist [Last Name, First Name]_Subject 4 – Assessment Checklist Assessment Form [Last Name, First Name]_Subject 4 – Assessment Form CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 29 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 5 Analyse Information and Prioritise Needs 1. Based on the assessment interview, do you need to arrange for an interpreter to be able to ensure that Philip understands the service being provided and is able to communicate his needs? 2. What are the most common situations where an interpreter is needed to be arranged for a client? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 30 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 3. Find out about using interpreter services that are available in your workplace or in your area by: ▪ Locating and printing a copy of your workplace guidelines and/or procedures regarding the use of interpreters. Submit the copy together with this workbook. ▪ Locating and printing a copy of the interpreter request form used by your workplace. Submit the copy of the request form together with this workbook. ▪ Collecting at least two (2) examples, such as brochures or instructions describing workplace or community interpreting services. Scan the brochures/instructions and submit it together with this workbook. ▪ Identify at least two (2) links to online information that could help. Guidance: From the options provided, choose and accomplish one (1). Filename of guidelines/procedures request form or brochures/instructions: OR Links to online information: 4. Based on the intake and assessment interview, is Philip eligible for Operation Hope’s services and programs? Provide the basis for your answer. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 31 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 5. Stratify and Analyse Risk Factors a. Based on your assessment, what are the risk and vulnerability factors which may affect Philip’s safety and well-being? b. What is the appropriate level of risk based on the risk factors identified? Provide a brief explanation for selecting such level of risk. c. List three (3) risk management strategies that are useful when dealing with high-risk situations that may affect Philip. a. Based on your assessment, what are the risk and vulnerability factors which may affect Philip’s safety and well-being? b. What is the appropriate level of risk based on the risk factors identified? Provide a brief explanation for selecting such level of risk. Guidance: Select the appropriate level of risk based on the following: ☐ At HIGH RISK of serious harm ☒ At RISK of Harm Level of risk: ☐ At HIGH RISK of serious harm ☐ At RISK of Harm Explanation: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 32 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 c. List three (3) risk management strategies that are useful when dealing with high-risk situations that may affect Philip. ▪ ▪ ▪ 6. What is Operation Hope’s policy on maintaining and storing client records in accordance with confidentiality requirements? 7. What are the specialist services and other sources available within your State/Territory that could provide you with additional information for you to be able to determine the range of issues that Philip is experiencing? Guidance: ▪ List two (2) specialist services and two (2) other sources. Other sources may include case management organisations, regulatory body, and peak and industry associations. ▪ Utilise available directories from your State/Territory. State/Territory: Specialist services: Other sources: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 33 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ASSESSMENT TASK 2 – PROJECT Student ID Student Name This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this assessment task Student Declaration: I declare that the work submitted is my own, and has not been copied or plagiarized from any person or source. Signature: ___________________________ Date: ____/_____/_____ Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials 1 S/NS 2 S/NS 3 S/NS Feedback to student: Assessor: I declare that I have conducted a fair, valid, reliable and flexible assessment with this student, and I have provided appropriate feedback. Signature: _________________________ Name: _________________________ Date: ____/_____/_____ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 34 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 PART 2: ASSESSMENT TASK 2 Planning TASK 1 Develop an Appropriate Case Management Plan This part of the assessment will require you to develop an appropriate case management plan for Philip using the Case Management Plan template below. Case Management Plan x *Click on the icons above to open the template Read the instructions carefully before proceeding. Steps to take: ▪ Before creating the case management plan, reflect on the outcomes of the intake and assessment interview to be able to identify and analyse the multiple and complex needs that you need to consider in developing the case management plan. ▪ Evaluate the needs of the client based on the information gathered during intake and assessment. Prioritise the client’s needs based on his responses in Task 3. ▪ Once the needs are identified, research and compile information on the availability and capacity of other services that can support the client. Keep in mind that a specialist’s input is of particular importance to support multiple and complex needs. ▪ Develop the case management plan using the template provided: o List all known persons currently contributing to the client’s care. This includes the individual, carer/advocate, key worker/case manager/coordinator, specialists (e.g. GP, health/community providers, substitute decision maker, family members, volunteers or friends who provide assistance). The following must also be in the case management plan: o Full name of the participants involved in care. o His/her role or kind of support he/she is giving the client. o Contact details (e.g. phone, emails, etc.) o Will the participant involved in care be included in the planning process? o Will the participant involved in care be provided with a copy of the care plan? o Provide a summary of the outcome of the assessment interview in bullet points. This must include the identified multiple and complex needs of the client that the plan is meaning to address. o Complete the Support Plan: o Under Opportunities, provide five (5) needs/concerns that were identified during the assessment phase. List these needs/concerns in order of priority. o For each Opportunity, set two (2) goals that are SMART—specific, measurable, attainable, realistic, and time-bound. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 35 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 o For each goal, identify the action/s or step/s required to achieve them, specify the responsible person/s, and the expected outcome/s. Guidance: Identify action/s or step/s that build on the client’s strengths, and also include referral options. o Specify the date set for the completion of each action/s or step/s. ▪ Consider the following when developing the case management plan: ▪ All available services are explored, and the most appropriate ones are included in the plan. ▪ Ensure that the responsible person/s’ and/or service/s’ experience and capability match the support needed by the client. ▪ Ensure that the service providers you have identified are accessible to the client and to you, as the client’s case manager. Guidance: You may reference real-life service providers that are available within your area in your case management plan. ▪ Use an inclusive approach when developing the plan. ▪ Complete the rest of the sections on the template except for the following: ▪ Consent checklist ▪ Target review date ▪ Service user (client) agreement ▪ Signature of client, case manager, and service providers ▪ Submit the partially completed Case Management Plan using the following naming convention: Filename Case Management Plan [Last Name, First Name]_Subject 4 – CMPlan-Partial CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 36 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 2 Collaborate with Client and Key Stakeholders Before closing the assessment interview, you informed Philip about the next steps—that a case management plan will be developed, and that a case conference and meeting will be held. You explained to him, that in order for you to work with him better and provide him with new opportunities, it is best to work with other people who may be able to provide him with additional and specialist support. You noticed that he seemed wary of this new information. You: Before I can start preparing for the case conference and meeting, I need to make sure that it is okay with you that we will be speaking with other people and service providers. May I know your thoughts on this? Philip: I am okay with the meeting. You said that we would be speaking with other people that I might need to have contact with. Will you also be inviting my wife? You: Ideally, we should invite everyone who may be able to help and assist you. Do you want me to arrange for your wife’s attendance at the meeting? Philip: Can we not invite her for now? Can we invite her when I’m all sober and fixed? You: Yes, we certainly could do that. I’ll take note of that. Is there anything else you want to ask or tell me? Philip: What are we supposed to talk about in the meeting? You: In a case conference, we might talk about anything, including those things that might be stopping you from doing what you need to do, like transport or looking for work, or troubles with family. Philip: Should I attend the meeting? You: Yes. I recommend for you to be there. Philip: Okay. If ideas will be shared, what about my privacy and how will you keep things confidential? You: Before we start the meeting, everyone in attendance will have to agree to maintain confidentiality and not disclose any information shared in the conference with insignificant others. Philip: Okay, I understand. You Thank you, Philip. I will inform you and the others of the exact date, time and venue of the case conference and meeting. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 37 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Roleplay Activity: Facilitate a Case Conference and Meeting This part of the assessment is a Roleplay Activity. This activity will require you to develop the Agenda and prepare for the meeting. You are also responsible for facilitating the meeting and making sure that the meeting remains focused. To complete this part of the assessment, you will need access to: 1. Three (3) volunteers ▪ Two (2) volunteers to play the role of the personnel from other services you want to provide assistance to your client. Guidance: You are to assign what services the two (2) volunteers will represent. For example, you will be the person responsible for counselling, one of the volunteers will represent the drug/alcohol rehabilitation agency and the other will be providing support for housing. ▪ One (1) volunteer to play the role of Philip. 2. Video camera or a mobile phone with video and audio recording capabilities. 3. Enough copies of the case plan that you have developed; one for each participant in the meeting. 4. Forms and templates ▪ Consent Form – Case Conference Consent Form-Case Conference x ▪ Confidentiality Agreement Confidentiality Agreement x ▪ Meeting Agenda Meeting Agenda x ▪ Meeting Minutes Meeting Minutes x *Click on the icons above to open the forms/templates Read the instructions carefully before proceeding. Steps to take: 1. Prepare for the case conference and meeting by: a. Gathering the following documents needed for the case conference and meeting: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 38 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ▪ Developed case management plan ▪ Consent form for the case conference ▪ Confidentiality agreement form ▪ Meeting agenda ▪ Meeting minutes b. Creating the meeting agenda. Use the Meeting Agenda and provide the following details: ▪ Description of the meeting ▪ Date and time start/finish ▪ Venue ▪ Attendees ▪ Agenda item, who is assigned to discuss it, how long should it be tackled, and time start/finish for each c. Explaining what should transpire in the case conference and meeting with all the volunteers. 2. Proceed with the case conference and meeting. During the first part of the meeting, you must be able to: a. Initiate a round of introductions and provide the purpose/aims of the meeting. b. Clarify the allotted time for the meeting and state that you will be facilitating and taking the minutes. Ensure all the attendees that a copy of the minutes will be sent to all relevant service providers involved in the case. c. Obtain the client’s consent for the meeting by providing a recap of the process, purpose, expected outcomes, level of input required, and the likely tone and context of the meeting. Ask the client to fill out the Consent Form afterwards. d. Present the Confidentiality Agreement to all in attendance. Everyone must date and sign it, including you and the client. e. Distribute the Agenda and the client’s Case Management Plan (from Task 1). 3. Discuss the Agenda and outline the case history with the help of the client. Prompt him/her to provide additional information as necessary. 4. Facilitate the meeting proper. Restate that the main objective of the meeting is to discuss how everyone in attendance will work together, supply support to assist the client and make an agreement to monitor the client’s progress toward achieving the set outcomes. If the discussion focus shifts from the main objective of the meeting, your role as facilitator is to remind the group of the current task at hand and the required outcome. 5. Cover the following during the meeting: ▪ Roles, responsibilities and boundaries of workers/ service providers/ organisations are defined. ▪ Needs, rights and responsibilities of the client, client’s family (if applicable), community, and service providers are identified and agreed upon. ▪ Processes of coordinated/integrated service delivery and service provision requirements are explained. ▪ Case management plan is reviewed by the service providers: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 39 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 o Prioritised needs of the client are communicated to all service providers. o Realistic targets for change or action for the client are set. o Barriers to attaining outcomes are identified. ▪ Collaborative working arrangements and requirements are determined: o Service duplication must be identified. o If duplication is identified, steps on how to manage these must be outlined. o If there are case management plan issues that cannot be met by the services present, it should be identified which services are to be contacted and who will undertake this role. o Procedure on how to coordinate must be explained to the client to minimise stress and confusion. 6. Ask the client to give feedback on the assessment, on the identified recommendations, and the emerging case management plan. 7. Identify the case meeting outcomes by clarifying the responsibilities and time frames for the client and the service providers. The process for monitoring and reviewing outcomes must also be established. Ensure that these are recorded and agreed upon by everyone in attendance. 8. Summarise all points discussed in the meeting. Encourage the client to raise questions that he may have about accessing the services. Remind him that he may recommend options that he thinks will work for him other than those identified. 9. Close the meeting by informing all attendees that the minutes and a copy of the revised case management plan will be sent via email. Method of communication and schedule of future meetings must be noted and recorded, as well. 10. Complete the following documentation: ▪ Meeting Minutes ▪ Case Management Plan – revise the plan according to recommendations from the case conference and meeting, and complete the following sections: o Consent Checklist o Participants Involved in the Care – include case conference and meeting attendees o Signatures of client, case manager, and service providers CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 40 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Guidelines 1. To demonstrate your completion of this activity, the intake interview must be recorded. Save the recorded video using the filename: [Last Name, First Name]_Subject 4 – Roleplay Activity-3 For example, as seen below: Smith, John_Subject 4 – Roleplay Activity-3.avi 2. Your video submission must not be longer than forty-five (45) minutes in length. Any submission longer than forty-five (45) minutes will be considered not satisfactory. 3. There is no specific script to be followed in the roleplaying activity. However, you must be able to demonstrate all steps outlined above. Moreover, your submission will be assessed against the checklist provided below. 4. Submit the following completed forms and templates together with the video using the following naming convention: Filename Case Management Plan (revised) [Last Name, First Name]_Subject 4 – CMPlan-Revised Consent Form – Case Conference [Last Name, First Name]_Subject 4 – Consent_Conference Confidentiality Agreement [Last Name, First Name]_Subject 4 – Confidentiality Agreement Meeting Agenda [Last Name, First Name]_Subject 4 – Meeting Agenda Meeting Minutes [Last Name, First Name]_Subject 4 – Meeting Minutes CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 41 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Part 2: Task 2 – Roleplay Activity: Assessment Interview Assessor’s Checklist (For the assessor’s use only) Has the following been demonstrated in candidate’s video submission? Yes No Comment 1. Facilitated case conference and meeting to coordinate responsibilities and roles. ☐ ☐ 2. Facilitated communication between service providers to identify and manage service duplication. ☐ ☐ 3. Identified and agreed on client and worker roles, responsibilities, boundaries and processes of service delivery. ☐ ☐ 4. Determined and agreed on organisation, family and community needs, responsibilities and rights. ☐ ☐ 5. Assisted clients to achieve realistic targets for change or action and to take personal responsibility. ☐ ☐ 6. Worked with other services to minimise client confusion and concerns in a coordinated manner. ☐ ☐ 7. Worked with the client to prioritise needs and communicate these with service providers. ☐ ☐ 8. Worked with the client and other services to identify barriers to attaining outcomes. ☐ ☐ 9. Worked within the scope of own role and seek assistance from colleagues and experts as required. ☐ ☐ 10. Sought feedback about assessment processes from the person and other networks. ☐ ☐ 11. Worked with the client and other services to determine the service provision requirements. ☐ ☐ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 42 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 12. Negotiated collaborative working arrangements for all services involved. ☐ ☐ 13. Worked with the services to agree on coordination requirements and boundaries. ☐ ☐ 14. Provided the person with service information and supported their decision-making process. ☐ ☐ 15. Encouraged the person to advocate on their own behalf to access services. ☐ ☐ 16. Worked with the client and services to monitor progress toward outcomes. ☐ ☐ 17. Routinely sought feedback. ☐ ☐ 18. Considered service delivery and referral options. ☐ ☐ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 43 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ASSESSMENT TASK 3 – PROJECT Student ID Student Name This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this assessment task Student Declaration: I declare that the work submitted is my own, and has not been copied or plagiarized from any person or source. Signature: ___________________________ Date: ____/_____/_____ Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials 1 S/NS 2 S/NS 3 S/NS Feedback to student: Assessor: I declare that I have conducted a fair, valid, reliable and flexible assessment with this student, and I have provided appropriate feedback. Signature: _________________________ Name: _________________________ Date: ____/_____/_____ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 44 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 PART 3: ASSESSMENT TASK 3 Monitoring and Review A week after the case conference and meeting, you scheduled to meet up with Philip to review his progress. Prior to the meeting, you rang the drug/alcohol rehabilitation centre to check how Philip’s doing. The coordinator informed you that Philip showed up for the scheduled assessment and was able to talk to one of the centre’s counsellors. Philip informed the counsellor that he read about Ozcare, also a recovery centre, in a newspaper and is interested in transferring to their program. On the day of the meeting, you observed that Philip is now cleanly shaven and is wearing a clean set of clothes. You: Hi, Philip. Thank you for coming in today. Philip: No worries. What are we going to talk about today? You: We are going to review your case plan and progress. Before we start, I’d like to know how you’re doing and how’s it been since last week. Philip: I think I’m much better now. The emergency accommodation provides showers and hot meals. They also gave me new clothes. You: That’s wonderful. How do you feel about that? Philip: The place is great, and the people are really helpful, but the rehab centre is quite far from the shelter. I still have to take a bus, and I am saving some money from my Centrelink payments. I actually have some money in the bank now. You: I see. I phoned the rehab centre, and the coordinator said that you were able to complete the assessment and interview with the counsellor. How was the interview? Philip: It was okay, the counsellor was nice. I told him about Ozcare. I said I saw it in the newspaper the other day and it’s much closer, and I don’t have to take the bus. She said I could suggest it to you and see what you think. You: All good, Philip. I’ll look into Ozcare and see if you are eligible to transfer to their program. You said earlier that you are saving up some money from your Centrelink payment. Is that correct? Philip: Ah, yes. I actually want to look for work, but I really don’t know where to start. You: That’s okay, Philip. We can also help you with that. We can help you start by developing an employment plan and mapping out your employment history. We will schedule another time for us to work on your employment plan. Philip: I’m okay with that. Thank you. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 45 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 1 Review of Care Plan This part of the assessment will require you to review the care plan and the client’s progress and plan the next steps using the Review of Care Plan form. Review of Care Plan x *Click on the icons above to open the forms Read the instructions carefully before proceeding. Steps to take: 1. Complete the Review of Care Plan based on the meeting with Philip. Refer to the revised case management plan for the identified opportunities and goals. 2. Document the Progress of each opportunity and goal, and note: ▪ Whether the goals are being achieved ▪ Whether they are being achieved in the timelines ▪ Whether there are any barriers to implementation ▪ Whether there is a failure to achieve the goals ▪ Whether the client is satisfied with the service/s received ▪ What needs to be changed to meet the client’s situation (e.g., the goals themselves, or the steps to meet those goals). Guidance: Refer to the conversation provided in the scenario for the details of Philip’s progress. 3. Include who the source of information is (e.g. client – Philip, service coordinator [name of service provider], counsellor from [name of service provider, etc.) in the review plan. 4. Determine the adjustments to be made or the next steps to take to be able to overcome any barriers identified or the needs that have changed over time. Provide the rationale for identifying these next steps/actions to take. 5. Submit the completed review of care plan using the following naming convention: Filename Review of Care Plan [Last Name, First Name]_Subject 4 – Review_Care Plan CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 46 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 2 Communicate the Outcomes of the Review You are tasked to send an email to the following parties to inform them of the proposed changes arising from the case review: ▪ Coordinator and counsellor of the rehab facility Philip is currently attending ▪ the employment counsellor of Operation Hope Your emails must contain the outcomes of the review of the care plan that is relevant to their respective responsibilities. You must provide them with the details and the reason behind the proposed changes arising from the review. The next steps/actions identified during the short meeting with the client must be outlined, and clearly but concisely explained to all the parties involved in the care of the client. Guidelines 1. Draft two (2) separate emails—one for the coordinator and counsellor of the rehab facility, and another for Operation Hope’s employment counsellor. 2. The email for the coordinator and counsellor of the rehab facility Philip is currently attending must provide them information about the changes brought about by the review and the wishes of Philip to transfer to another facility’s program. 3. The email for the employment counsellor of Operation Hope must include the referral and the basis for your recommendation. 4. Write the draft of the templates provided below. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 47 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 To: (Include name/s and email address/es) Subject: (Write an appropriate subject) Message: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 48 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 To: (Include name/s and email address/es) Subject: (Write an appropriate subject) Message: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 49 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ASSESSMENT TASK 4 – PROJECT Student ID Student Name This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this assessment task Student Declaration: I declare that the work submitted is my own, and has not been copied or plagiarized from any person or source. Signature: ___________________________ Date: ____/_____/_____ Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials 1 S/NS 2 S/NS 3 S/NS Feedback to student: Assessor: I declare that I have conducted a fair, valid, reliable and flexible assessment with this student, and I have provided appropriate feedback. Signature: _________________________ Name: _________________________ Date: ____/_____/_____ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 50 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 PART 4: ASSESSMENT TASK 4 Case Closure and Exit Philip was able to transfer to Ozcare’s live-in detox program, and after a week, he dropped by your office to inform you that he will be exiting Operation Hope’s program. He said that he needs more than a week to fully recover from his alcohol dependency and that Ozcare offered a structured program that will help him be free of alcohol. Philip told you that he is very grateful for all the help and that he was satisfied with how you assisted him and coordinated his care. You started preparing for the case closure and Philip’s exit by reviewing his case and the service’s exit policy and procedure. (Click on the icon above to open Operation Hope’s policies and procedures) CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 51 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 1 Case Closure and Summary You are required to complete the Case Closure Summary and Exit form in accordance with Operation Hope’s policies and procedures. Case Closure Summary x *Click on the icons above to open the forms Read the instructions carefully before proceeding. Steps to take: 1. Complete the Case Closure and Exit form based on the scenario above. Refer to the Client Exit Policy for further guidance. 2. Summarise the services rendered to the client and reason/s why the case is being closed. Comment on the progress made toward goals in the case management plan. Where necessary, include provisions for continued services listing agencies and contact persons. 3. In the Transfer, Discharge, or Follow up Plans, include the following information: ▪ Additional support that should be provided to the client prior transfer and discharge. ▪ How the client can access your service again should the need arise. ▪ Procedures for exit documentation, file closure and secure archiving. 1. Submit the completed case closure and exit form using the following naming convention: Filename Review of Care Plan [Last Name, First Name]_Subject 4 – Case Closure and Exit Form CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 52 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 2 Reflective Journal For this assessment, you will be required to reflect on your learning experience and your performance in completing all the previous tasks. Guidelines: 1. Reflection guides are provided to assist you in providing the relevant information required for this activity. 2. You must always provide complete responses, where required. If the guide asks you to list at least two (2) examples, then you must list two (2) or more, and not less than. 3. Your responses must always be based on your experience during the completion of the case study. The reflective journal shall be the last task you will accomplish in this workbook. Journal Entry Date: Reflection Guide 1. Reflect on your own performance as the case manager of Philip. How did you fare as a case manager and coordinator? Do you think you were able to provide effective case management to Philip? What aspects of his case management could be improved? What strategies (at least three (3)) will you use to become a more effective and efficient case manager? (Write your reflection in not less than 200 words) 2. In not less than 100 words, describe how you integrated appropriate cultural considerations into all aspects of the planning phase? 3. In not less than 100 words, discuss how you provided the standard of care that is reasonable and consistent with duty of care responsibilities? 1. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 53 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 2. 3. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 54 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 55 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ASSESSMENT TASK 5 – CASE STUDY Student ID Student Name This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this assessment task Student Declaration: I declare that the work submitted is my own, and has not been copied or plagiarized from any person or source. Signature: ___________________________ Date: ____/_____/_____ Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials 1 S/NS 2 S/NS 3 S/NS Feedback to student: Assessor: I declare that I have conducted a fair, valid, reliable and flexible assessment with this student, and I have provided appropriate feedback. Signature: _________________________ Name: _________________________ Date: ____/_____/_____ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 56 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ASSESSMENT TASK 5: Case Study 2 Thuy and Paloma SCENARIO 1 - Thuy Thuy is a 42-year-old man from a Vietnamese background. He is a single father with a teenage son, whom he has raised after his wife passed away five years ago. Thuy also lives with his ageing parents whom he also supports. He has two other siblings who have moved to the city because of work opportunities, so he was left to take care of their parents on his own. Thuy dropped out of high school because he was bullied by his peers. He tried to learn the English language, but the other students said that he sounds funny when he speaks English. Thuy developed a low self-esteem and decided not to return to school and stay at home. Thuy had several part-time jobs that did not last for long as he had trouble understanding his co-workers and the company clients. Thuy’s last job was on a construction site. He had an accident where he fell from a scaffold and sustained injuries and a broken hip. He is now unable to leave the house and apply for a new job. A few weeks after his accident, his father became ill and now requires ongoing medication. Thuy started to feel upset and worthless. There were days when he would not talk with anyone in his family. He felt angry at times and would blame himself for the accident. At one point, he tried to cut his wrist with a sharp object, but his son caught him and stopped him. Thuy was referred to your service (Operation Hope), a month after his accident, by one of his neighbours. His son feared for his father’s life, and the family did not know what to do with Thuy. Thuy has limited responses during the assessment interview whilst you are trying to collect data. He nodded when you asked him if he could understand English. He was able to answer questions relating to his name, age, and where he lives. When you asked him about his injury, he gave you a blank stare then looked at his son as if asking for help. You asked him more questions, and he did not respond. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 57 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 1a Analyse Information and Identify Needs 1. Based on the scenario, do you need to arrange for an interpreter for Thuy to ensure that he understands the service being provided and is able to communicate his needs? Explain your reason. 2. Supposing that an assessment interview has been conducted for Thuy, identify two (2) needs that he needs to communicate. a. b. 3. List two (2) ways on how you can identify Thuy’s spoken language. Guidance: For this assessment, you are only informed that Thuy’s family came from Vietnam. 1. 2. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 58 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 You informed Thuy that you will be arranging an interpreter for him in order to proceed with his assessment interview. Thuy shook his head, and you repeated that instruction about arranging an interpreter. He shook his head and waved his hand. You reckoned that he understood the word ‘interpreter’, but he refused to have one. 4. Explain the action you should do when a client refuses to use an interpreter. After seeking assistance from one of your multi-lingual staff, Thuy had agreed to have an interpreter. He preferred to have a female interpreter who speaks Vietnamese as he thinks that they understand better. He also asked if his son could be present with him during the assessment interview so that he could help him understand the discussion. 5. Refer to the schedule of fees from the Translating and Interpreter Service: http://www.pirsws.com.au/wp-content/uploads/2016/05/TIS-Services-charges-FY2013-14 How much would the interpreting service for Thuy cost? http://www.pirsws.com.au/wp-content/uploads/2016/05/TIS-Services-charges-FY2013-14 CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 59 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 2a Interpreter Arrangement For this assessment, you will be booking an interpreter for Thuy. Complete the booking form below. Interpreter Booking Form x *Click on the icons above to open the forms Read the instructions carefully before proceeding. Steps to take: a. Complete the Interpreter Booking form based on the scenario above. b. In the Type of Job Booking, specify what type of interpreter service you require for the client/s (i.e. on-site, phone interpreting) c. Complete the Appointment Details using your nominated date and time. Guidance: For this assessment, on-site interpreting services require a minimum booking period of 90 minutes, and phone interpreting, is 30 minutes. d. Submit the completed booking for the client using the following naming convention: Filename Interpreter Booking [Last Name, First Name]_Subject 4 – Interpreter_[Client Name] CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 60 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 CLIENT DETAILS Type of job booking Organisation/Agency CONTACT DETAILS Name Job Title Phone no. Email Address APPOINTMENT DETAILS State/Territory of where interpreter service is required Non-English speaker’s name Preferred booking time Date Start time End time Language of interpreter required Preferred gender interpreter CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 61 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 SCENARIO 2 Paloma, a 16-year-old teenager, is from a refugee family from Iraq. Since she was two, she and her family have been moving from cities in Iraq to escape the violence and armed conflict. She was sexually abused at seven years old by some soldiers, while her parents were tortured. Because of these experiences, Paloma’s parents decided that they needed to move out of the country. She was 14-years-old when they came to Australia. Paloma seems like a happy teenager, shy at first but easy to talk with when she’s comfortable with the people she is with. As her family live in a rural town among other refugees, Paloma has very little knowledge of the English language, but she is determined to learn more. One day, Paloma went to the city with a group of teenage friends. They met with other Australian teenagers who told them that they would teach them English if they hang out with them. From then on, Paloma and some of her friends visited the city often to spend time with their new friends. Her parents became worried when Paloma started to become defiant and talk back to them, which was very uncharacteristic of her. Sometimes, she would come home drunk at late hours of the night. Her father confronted her one time about this behaviour – she yelled at her father and stormed out of the house. She came home three days later. One of her friends told her parents that Paloma has been going out with different teenage boys from the city and some of them they did not know. Paloma was brought to the hospital a few days ago because she overdosed on pills. The doctor reported that Paloma is two weeks pregnant. She regained consciousness after some medical treatment, and the doctor suggested that she needs to seek help. She was then referred to your service. At the assessment interview, Paloma speaks the same Arabic phrase as a response to your questions. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 62 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 1b Analyse Information and Identify Needs 1. Based on the scenario, do you need to arrange for an interpreter for Paloma? Explain your reason. 2. Supposing that an assessment interview has been conducted for Paloma, identify two (2) needs that she needs to communicate. ▪ ▪ You informed Paloma that you will be arranging an interpreter for her in order to proceed with her assessment interview. You wanted to collect information on what has been going on with Paloma since she started hanging out with the Australian teenagers. With the help of a staff member who can speak Arabic, you ask the client if it’s alright for her to meet with the interpreter. She seemed hesitant and shook her head and asked for her mother to speak on her behalf instead. You asked again if it would be okay to speak with an offsite interpreter and she nodded in agreement. 3. Explain one (1) possible reason when a client refuses to meet an interpreter. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 63 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 4. Refer to the schedule of fees from the Translating and Interpreter Service: http://www.pirsws.com.au/wp-content/uploads/2016/05/TIS-Services-charges-FY2013-14 How much would the standard interpreting service for Paloma cost? http://www.pirsws.com.au/wp-content/uploads/2016/05/TIS-Services-charges-FY2013-14 CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 64 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 TASK 2b Interpreter Arrangements For this assessment, you will be booking an interpreter for Paloma. Complete the booking form below. Interpreter Booking Form x *Click on the icons above to open the forms Read the instructions carefully before proceeding. Steps to take: 1. Complete the Interpreter Booking form based on the scenario above. 2. In the Type of Job Booking, specify what type of interpreter service you require for the client/s (i.e. on-site, phone interpreting). 3. Complete the Appointment Details using your nominated date and time. Guidance: For this assessment, on-site interpreting services require a minimum booking period of 90 minutes, and phone interpreting, is 30 minutes. 4. Submit the completed booking for using the following naming convention: Filename Interpreter Booking [Last Name, First Name]_Subject 4 – Interpreter_[Client Name] CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 65 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 CLIENT DETAILS Type of job booking Organisation/Agency CONTACT DETAILS Name Job Title Phone no. Email Address APPOINTMENT DETAILS State/Territory of where interpreter service is required Non-English speaker’s name Preferred booking time Date Start time End time Language of interpreter required Preferred gender interpreter CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 66 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 67 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ASSESSMENT TASK 6 – WRITTEN/ORAL QUESTIONS Student ID Student Name This cover sheet is to be completed by the student and assessor and used as a record to determine student competency in this assessment task Student Declaration: I declare that the work submitted is my own, and has not been copied or plagiarized from any person or source. Signature: ___________________________ Date: ____/_____/_____ Attempt Outcome Date Assessor’s feedback (as required): Trainer’s initials 1 S/NS 2 S/NS 3 S/NS Feedback to student: Assessor: I declare that I have conducted a fair, valid, reliable and flexible assessment with this student, and I have provided appropriate feedback. Signature: _________________________ Name: _________________________ Date: ____/_____/_____ CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 68 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 ASSESSMENT TASK 6 – WRITTEN/ORAL QUESTIONS STUDENT INSTRUCTIONS: This is a written assessment that will test your knowledge. This assessment may be completed over the duration of the training day. As you learn, practice and review knowledge and skills, you will keep Assessment Task 6 in front of you and answer the questions as the information becomes clear to you. At the beginning of each review session you will be given a few minutes to familiarise yourself with the questions. You will be given extra time at the end of the day to complete this assessment or to clarify facts with the Trainer/Assessor. Make sure you: • Answer all questions • Print clearly a • Use a blue or black pen. Assessments written in pencil will not be accepted. • Ask your assessor if you do not understand a question. Whist your assessor cannot tell you the answer, he/she may be able to re-word the question for you • Do not talk to your classmates. If you are caught discussion the answers you will be asked to leave and your assessment will not be marked. • Do not cheat. Anyone caught cheating will automatically be marked Not Competent for this unit. There are NO EXCEPTIONS to this rule. Answer the following questions in the space provided. You may use extra sheet if the space provided isn’t enough. To those who wish to type your answers in word document must reflect the question numbers clearly. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 69 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 1. Match the following descriptions to the correct models of case management by writing the corresponding letters on the spaces provided: A. A model of case management in which case workers help clients identify their needs and broker support services. B. Utilises the commonly accepted functions of case management and is characterised by a closer involvement between case manager and client. C. Assumes a comprehensive role for a team of case managers by providing services such as skills-building, family consultations, and crisis intervention. D. Provides outreach and direct counselling services with a smaller caseload and without a team approach. E. Combines case management and clinical or rehabilitation activities. F. Focuses on client’s strengths, self-direction, and the use of informal help networks. i. Assertive community treatment case management ii. Brokerage case management iii. Clinical case management iv. Generalist case management i. Intensive case management ii. Strengths-based case management CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 70 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 2. Briefly, explain the Case Management Approach diagram shown below. Case Managemen t Approach Client centred Evidenc e based HolisticInclusive Strengths based CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 71 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 3. Match the following descriptions to the correct approaches to service delivery by writing the corresponding letters on the spaces provided: A. An approach in which the individual is at the centre of the decision-making processes and is supported to exercise greater choice and control over their services, how they are delivered, and by whom. B. An approach to providing support and resources to individuals that focuses on identifying and building their assets and skills, to help them create the needed change. Clients will achieve much more if they are assisted to identify, recognise, and use the strengths they have identified. C. Invests individuals as ‘rights-holders’, creates an avenue for their voices to be heard and enables them to be empowered. D. This approach is based on the basic understanding that clients are the leaders of self- change for their lives. Workers need to believe that the client has within them, the capacity of knowing what they need to do to resolve their own issues. The worker is to provide a non-judgemental environment using a non-directive approach. This will enable clients to find their own solutions to problems. i. Needs-based ii. Person-centred iii. Rights-based iv. Strength-based CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 72 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 4. Illustrate the requirements of evidence-based practice using a Venn diagram. Guidance: Click on this resource to read more about Venn diagrams. Insert your Venn diagram below: https://www.lucidchart.com/pages/venn-diagram CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 73 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 5. Briefly, explain the application of each contemporary behaviour change models and provide two (2) examples of general interventions used in case management. Behaviour Change Model Application Interventions Trans-Theoretical Model Relapse Prevention Model Ecological Approaches CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 74 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 6. Which three (3) statements below are true about the scope and purpose of the Case Management Standards of Practice (Australia)? ☐ i. Standards of practice are designed to enhance case management practice. ☐ ii. Standards of practice are intended to detract from any responsibilities which may be imposed by law or regulation. ☐ iii. Standards of practice provide a basis for quality guarantee, expectations and accountability for clients, employers, and other professionals. ☐ iv. Standards of practice reinforce current practices and are designed to provided objectives and guidelines to assist the case manager in competently practising case management. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 75 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 7. Briefly, describe the following types of assessment and their use in different contexts. a. Generic assessment b. Intake assessment c. Social assessment d. Social history report e. Risk assessment f. Biopsychosocial assessment a. Generic assessment b. Intake assessment c. Social assessment d. Social history report CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 76 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 e. Risk assessment f. Biopsychosocial assessment CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 77 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 8. Explain the role and responsibilities of the following who may be involved in the assessment process: a. Case manager b. Client c. Key Stakeholders d. Agency Guidance: Provide at least two (2) responsibilities for each. a. Case manager b. Client c. Key stakeholders d. Agency CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 78 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 9. Which three (3) statements below are true about the impact of the setting on the assessment process? ☐ i. It is important to establish and maintain rapport throughout the assessment to help the client feel comfortable and receptive to assessment. ☐ ii. It is not appropriate to conduct and complete the assessment in a client’s home as this may inconvenience the case manager and make him/her uncomfortable with the unfamiliar environment. ☐ iii. Maintain client’s focus and take care that the interview remains on track to obtain the necessary information by minimising outside distraction and noise. ☐ iv. The assessment must be conducted in a comfortable room that is private to ensure that confidentiality can be maintained and that others cannot hear the conversation. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 79 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 10. Answer the following questions: a. What are the functions of assessment tools? b. List three (3) examples of assessment tools. c. What are the validity and reliability requirements of assessment tools? a. Functions of assessment tools b. Examples of assessment tools c. Validity and reliability requirements CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 80 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 11. Briefly, describe the following methods of collecting information: a. Self-reports b. Informant reports c. Health records a. Self-reports b. Informant reports c. Health records CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 81 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 12. Mandatory reporting requirements and format related to community services: a. Complete the table below about the mandatory reporting requirements when working with children in your State/Territory. b. Provide a photo or a screenshot of a reporting template used in community services. If the screenshot of the template is taken online, specify the link on the space provided. If there is no reporting template used in your State/Territory, provide the URL of the relevant Child Protection website that provides instructions on how to report child abuse in your State/Territory. State/Territory: Legislation: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 82 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Who is mandated to report? What must be reported? Abuse and neglect types which must be reported CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 83 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 84 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Reporting template used in your State/Territory Link to reporting template / relevant Child Protection website if the state/territory does not have a reporting template: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 85 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 13. Briefly, explain the following legal and ethical considerations that must guide the case manager’s assessment practice: a. Confidentiality b. Disclosure c. Duty of care d. Informed consent e. Privacy a. Confidentiality b. Disclosure c. Duty of care CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 86 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 d. Informed consent e. Privacy CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 87 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 14. Identify two (2) risks of harm and your responsibilities relating to duty of care as a case manager for: a. Children and young people b. People with a disability c. People experiencing domestic violence d. A situation of elder abuse e. Someone contemplating suicide a. Children and young people Risks of harm Responsibilities b. People with a disability Risks of harm Responsibilities CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 88 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 c. People experiencing domestic violence Risks of harm Responsibilities d. A situation of elder abuse Risks of harm Responsibilities CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 89 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 e. Someone contemplating suicide Risks of harm Responsibilities CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 90 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 15. Answer the questions below: a. Define family structure and family dynamics. b. List and describe two (2) types of communication patterns followed by families. c. Describe the three (3) types of decision-making processes utilised by families. a. b. c. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 91 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 16. Complete the table below by providing the: ▪ brief history (if applicable) ▪ protocols & systems ▪ considerations ▪ special needs of the following diverse client/population: a. Aboriginal and/or Torres Strait Islander people b. Children and young people c. Culturally and linguistically diverse (CALD) d. Lesbian, gay, bi-sexual, transgender, intersex (LGBTI) e. Older people f. People experiencing or at risk of homelessness g. People with a disability CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 92 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Aboriginal and/or Torres Strait Islander people History Protocols & systems Guidance: Provide at least three (3) cultural protocols & systems that may apply when working with this group. Considerations Guidance: Provide at least three (3) things workers need to consider when working with this group. Special needs Guidance: List any needs that may relate specifically to this group, i.e. support, type of services, etc. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 93 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Children and young people History Protocols & systems Guidance: Provide at least three (3) cultural protocols & systems that may apply when working with this group. Considerations Guidance: Provide at least three (3) things workers need to consider when working with this group. Special needs Guidance: List any needs that may relate specifically to this group, i.e. support, type of services, etc. **No need to fill out this column. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 94 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Culturally and linguistically diverse (CALD) History Protocols & systems Guidance: Provide at least three (3) cultural protocols & systems that may apply when working with this group. Considerations Guidance: Provide at least three (3) things workers need to consider when working with this group. Special needs Guidance: List any needs that may relate specifically to this group, i.e. support, type of services, etc. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 95 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Lesbian, gay, bi-sexual, transgender, intersex (LGBTI) History Protocols & systems Guidance: Provide at least three (3) cultural protocols & systems that may apply when working with this group. Considerations Guidance: Provide at least three (3) things workers need to consider when working with this group. Special needs Guidance: List any needs that may relate specifically to this group, i.e. support, type of services, etc. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 96 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Older people History Protocols & systems Guidance: Provide at least three (3) cultural protocols & systems that may apply when working with this group. Considerations Guidance: Provide at least three (3) things workers need to consider when working with this group. Special needs Guidance: List any needs that may relate specifically to this group, i.e. support, type of services, etc. **No need to fill out this column. State/territory: Protocol/systems: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 97 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 People experiencing or at risk of homelessness History Protocols & systems Guidance: Provide at least three (3) cultural protocols & systems that may apply when working with this group. Considerations Guidance: Provide at least three (3) things workers need to consider when working with this group. Special needs Guidance: List any needs that may relate specifically to this group, i.e. support, type of services, etc. **No need to fill out this column. State/Territory: Protocol/systems: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 98 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 People with a disability History Protocols & systems Guidance: Provide at least three (3) cultural protocols & systems that may apply when working with this group. Considerations Guidance: Provide at least three (3) things workers need to consider when working with this group. Special needs Guidance: List any needs that may relate specifically to this group, i.e. support, type of services, etc. **No need to fill out this column. State/territory: Protocol/systems: . CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 99 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 17. Briefly, explain the common service requirements of community care providers in your State/Territory. State/territory: Common service requirements: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 100 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 18. Briefly, explain the following aspects of community services: a. Community support b. Education and training c. Employment d. Financial support e. Housing f. Physical and mental health g. Social inclusion a. Community support b. Education and training CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 101 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 c. Employment d. Financial support e. Housing CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 102 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 f. Physical and mental health g. Social inclusion CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 103 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 19. List three (3) examples of each of the following as they apply to Community Services in your State/Territory: a. Specialist services and support available b. Networks available c. Examples of local services and supports available in your State/Territory a. Specialist services and support b. Networks c. Local services and supports State/Territory: Examples: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 104 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 20. Funding for organisations can be accessed in a number of ways. Briefly, explain the following: ▪ Commonwealth-direct funding ▪ Commonwealth-State Agreements ▪ State/Territory-direct funding a. Commonwealth-direct funding b. Commonwealth-State Agreements c. State/Territory-direct funding CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 105 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 21. Identify three (3) occasions when a service may need to refer a client to another service provider. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 106 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 22. Explain the following formal processes used in case management for information sharing and planning? a. Case conferences b. Case review meetings c. Formal briefings on client progress a. Case conferences b. Case review meetings c. Formal briefings on client progress CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 107 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 23. What are the relevant documentation protocols/requirements observed by community services case managers? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 108 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 24. What are the strategies used by a community service organisation in monitoring and reviewing casework activities and processes? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 109 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 25. What are the rights of the client, family, community, and organisation in the decision-making and case management process? The rights of the client: The rights of the client’s family: The rights of the community: The rights of the organisation providing services: CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 110 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 26. What are the requirements and boundaries of a case manager’s coordination role in the community services? Guidance: Provide at least five (5). CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 111 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 27. Every individual has their own value system which may have an effect on the case management process. Briefly, discuss how the individual value systems of the client and workers/key stakeholders can impact on case management outcomes. a. Client b. Worker and key stakeholders CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 112 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 28. In 150 words, summarise the principles and practices 0f planning for individuals with complex needs. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 113 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 29. In 150 words, summarise the principles and practices 0f working across multiple services. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 114 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 30. What are the issues/concerns/barriers that may cause client confusion when they are accessing multiple services? 31. What are the issues faced by clients, their family and carers when accessing multiple services? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 115 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 32. What are the impacts of service duplication to clients, families, and carers? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 116 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 33. Identify and explain at least three (3) impacts of generational abuse to individuals who have experienced this. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 117 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 34. What are the impacts of welfare dependency on individuals? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 118 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 35. What is the basic feature of multiple and complex needs affecting client groups? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 119 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 36. In 150 words, describe the impact of having clients with multiple and complex needs of community service organisations and service providers? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 120 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 37. Chris is a 24-year-old male who was first diagnosed with anxiety and depression during high school. He has been diligently visiting his psychiatrist and attending therapy sessions ever since. But, he stopped seeing his psychiatrist and therapy sessions when his mother passed away last month. Over the past few weeks, Chris’ family and friends have noticed increasingly bizarre behaviour. On many occasions, they’ve overheard him whispering in an agitated voice, even though no one is nearby. At the supermarket where Chris works, his supervisor has already warned him that he might lose his job due to an incident with a male customer. There was a number of times he arrived at work appearing to be under the influence of alcohol/drugs. a. What are the complex issues that Chris might be experiencing? b. What are the potential interrelationships between the complex issues you have identified? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 121 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 c. In this scenario, what are the indicators of imminent self-harm or harm to others? Guidance: Provide five (5) for each. CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 122 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 38. You have received a call from an anonymous neighbour of Leticia Thompson. The caller did not want to give her name because she did not want to be involved, but reported being concerned about her neighbours. The caller reported that the family’s home is just across the road from her house. Two nights before, the neighbour heard banging, crying, and shouting. Last night, the caller heard Paul, Leticia’s husband, shouting and cursing at the children and heard more crying. This morning, the neighbour bumped into Leticia and noticed that she had a black eye that was badly concealed with makeup. The caller greeted Leticia’s two children who were with her, Amber (4 y/o) and Aaron (1 y/0) and noticed that there are bruises and welts on the children’s arms. When the caller tried to talk to Amber and Aaron, the two hid behind their mother and would not speak. When you checked the Thompson’s family records, Paul had already been charged with domestic violence in a previous relationship. a. What are the issues that Leticia and her family might be experiencing? b. What are the potential interrelationships between the complex issues you have identified? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 123 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 39. Philip, 36 years old, married with two children, has been working as a delivery driver for a large food service distributor for four years. One afternoon, Philip’s company notified him that it was laying him off along with more than a hundred other employees. He searched aggressively for jobs in the newspaper and online but could not secure a position. His self-esteem fell, and he became depressed. Philip was so demoralised by the loss of his job that he started to drink more often. The drinking became regular and so did the fights with his wife. The fights became so physical that his wife left him, took the children and moved in with her parents. About six months after losing his job, Philip stopped receiving support from Centrelink as he was not actively looking for a job. He was evicted from the apartment because he was unable to pay the rent. Family and friends allowed him to stay with them, but his heavy drinking and anger issues got worse, and his hosts always asked him to leave. When Philip ran out of people to stay with, he found himself without a place to stay for the night and started sleeping at the park. a. What are the issues that Philip might be experiencing? b. What are the potential interrelationships between the complex issues you have identified? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 124 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 40. Danvir, a 9-year-old boy, is often teased by his classmates because he wears a turban and has a long hair. They call him a girl, saying he shouldn’t go to the boy’s restroom, and threatens to cut off his hair. Unlike other mums, his mum had sent a letter to the school to explain their family’s faith. Danvir and his family are Sikh, and confusion about their religion has led to bullying in the past. Each new school year seemed to bring Danvir more tears and frustration. Danvir has told his parents many times that he does not want to go to school anymore because “everybody is being mean”. a. What are the issues that Danvir might be experiencing? b. What are the potential interrelationships between the complex issues you have identified? CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 125 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 Assessment Workbook Checklist When you have completed this assessing the assessment workbook, review the candidate’s assessment against the checklist below: The candidate has completed all the assessments in the workbook and has submitted all of the required evidence: Case Studies Case Study 1: Philip Case Study 2: Thuy and Paloma The candidate has submitted all of the following evidence: This completed workbook Hand-signed and scanned Assessment Workbook Cover Sheet Case Study 1: Philip Part 1: Assessment Task 1 Task 1 – Answer Questions Case study questions Task 2 – Roleplay activity: Intake Interview Video recording of roleplay [Last Name, First Name]_Subject 4 – Intake Checklist [Last Name, First Name]_Subject 4 – Intake Form [Last Name, First Name]_Subject 4 – Consent Form [Last Name, First Name]_Subject 4 – Intake Action Plan Task 3 – Roleplay activity: Assessment Interview Video recording of roleplay Task 4 – Document the Outcome of the Assessment Interview [Last Name, First Name]_Subject 4 – Assessment Checklist [Last Name, First Name]_Subject 4 – Assessment Form Task 5 – Analyse Information and Prioritise Needs Case study questions Part 2: Assessment Task 2 - Planning Task 1 – Develop an Appropriate Case Management Plan [Last Name, First Name]_Subject 4 – CMPlan-Partial Task 2 – Roleplay activity: Facilitate a Case Conference and Meeting Video recording of roleplay [Last Name, First Name]_Subject 4 – CMPlan-Revised CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Version: 1.0 Page 126 of 126 Created: April 2021 Last Reviewed: April 2021 Central Australian Institute of Technology Pty Ltd | CRICOS: 03217C |TOID: 22302 [Last Name, First Name]_Subject 4 – Consent Conference [Last Name, First Name]_Subject 4 – Confidentiality Agreement [Last Name, First Name]_Subject 4 – Meeting Agenda [Last Name, First Name]_Subject 4 – Meeting Minutes Part 3: Assessment Task 3 - Monitoring and Review Task 1 – Review of Care Plan [Last Name, First Name]_Subject 4 – Review Care Plan Task 2 – Communicate the Outcomes of the Review Simulated email to the coordinator and counsellor of the rehab facility Simulated email to Operation Hope’s employment counsellor Part 4: Assessment Task 4 - Case Closure and Exit Task 1 – Case Closure and Summary [Last Name, First Name]_Subject 4 – Case Closure and Exit Form Task 2 – Reflective Journal Reflective journal guide questions Assessment Task 5 - Case Study 2: Thuy and Paloma Task 1a – Analyse Information and Identify Needs Case study questions Task 2a – Interpreter Arrangement Case study questions Task 1b – Analyse Information and Identify Needs Case study questions Task 2b – Interpreter Arrangements [Last Name, First Name]_Subject 4 – Interpreter_[Client Name] Assessment Task 6 – Written/Oral Questions Knowledge assessment (40 Questions) IMPORTANT REMINDER Candidates must achieve a satisfactory result to ALL assessment tasks to be awarded COMPETENT for the units relevant to this cluster. To award the candidate competent in the units relevant to this subject, the candidate must successfully complete all the requirements listed above according to the prescribed benchmarks. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 2 This learner guide is copyright protected by: Compliant Learning Group (Australia) Level 13, 269 Wickham St, Fortitude Valley 4006 Email: support@compliantlearningresources.com.au Website: http://compliantlearningresources.com.au/ © 2021 Precision Group (Australia) Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 3 TABLE OF CONTENTS This is an interactive table of contents if you are viewing this document in Acrobat clicking on a heading will transfer you to that page. If you have this document open in Word you will need to hold down the Control key while clicking for this to work. LEARNER GUIDE CLUSTER ...................................................................................................... 6 I. DEVELOP, FACILITATE AND REVIEW ALL ASPECTS OF CASE MANAGEMENT . 14 1. Determine the appropriate response to case management in accordance with organisation and legislative requirements ........................................................................................................................................ 14 1.1 Develop and utilise case management processes in accordance with statutory requirements ........................................................................................................................... 14 1.2 Implement appropriate processes to enable the client to set goals and participate in case management processes .............................................................................................. 30 1.3 Integrate appropriate cultural considerations into all aspects of case management planning ................................................................................................................................. 39 1.4 Provide information on rights of appeal and avenues of complaint so the client understands rights and responsibilities ................................................................................. 53 2. Conduct case management meetings.................................................................................................... 56 2.1 Facilitate information sharing with the client and establish an appropriate rapport . 57 2.2 Identify and agree on client and worker roles, responsibilities, boundaries, and processes of service delivery ................................................................................................... 60 2.3 Determine and agree organisation, family and community needs, responsibilities and rights ...................................................................................................... 64 3. Develop an appropriate case management plan ................................................................................. 69 3.1 Collaborate with the client to identify strengths, abilities and goals and develop an agreed approach to case management ................................................................................... 70 3.2 Develop a case management plan to reflect initial assessment of needs ............... 72 3.3 Work with the client to identify the full range of immediate, short and long-term needs of the client and other relevant parties......................................................................... 73 3.4 Establish and agree on processes to monitor and change case plan ..................... 75 3.5 Identify strategies to deal with complex or high-risk situations ................................ 78 3.6 Match requirements of case plan to experience, workload and geographical location of worker or service provider .................................................................................... 80 3.7 Assist clients to set and achieve realistic targets for change or action and to take personal responsibility ............................................................................................................ 81 4. Monitor and review casework activities and processes ..................................................................... 83 4.1 Implement strategies to regularly monitor the effectiveness of case management processes against agreed goals, service provision and client and stakeholder satisfaction .. 84 4.2 Assess the need for changes in case plan and develop strategies for appropriate alternatives and/or ongoing interventions ............................................................................. 85 4.3 Negotiate with relevant parties any proposed changes arising from case review .. 86 Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 4 4.4 Document all casework interventions in compliance with evidence-based practice and confidentiality requirements ............................................................................. 87 4.5 Implement case closure in accordance with organisation procedures .................... 91 II. ASSESS CO-EXISTING NEEDS ...................................................................................... 93 1. Prepare for assessment ................................................................................................................................ 93 1.1 Identify and prepare assessment tools and processes according to organisation policy and procedures ............................................................................................................ 94 1.2 Gather existing information about the person........................................................... 100 1.3 Seek additional information from specialists and other sources as required to determine the range of issues that may be affecting the person ........................................... 102 1.4 Organise practical aspects of assessment in consultation with the person being assessed ................................................................................................................................. 103 1.5 Provide information about the assessment process to the person and obtain consent .................................................................................................................................. 105 2. Analyse the person’s needs using a collaborative approach ........................................................... 107 2.1 Work within scope of own role and seek assistance from colleagues and experts as required ................................................................................................................................. 108 2.2 Empower the person to identify and prioritise their own needs ........................... 109 2.3 Evaluate needs based on full range of relevant information.................................. 110 2.4 Identify and analyse complex, multiple and interrelated issues ............................ 111 2.5 Evaluate issues of urgency and eligibility ................................................................. 121 2.6 Assess potential risk factors for service delivery .................................................... 122 3. Determine appropriate services ........................................................................................................... 123 3.1 Consider service delivery and referral options from strengths-based perspective .... 123 3.2 Evaluate internal capability and other service networks to determine best fit for the person .............................................................................................................................. 125 3.3 Provide the person with service information and support their decision-making process 126 3.4 Encourage the person to advocate on their own behalf to access services ........... 127 4. Complete reporting ............................................................................................................................... 129 4.1 Document the outcomes of the assessment process according to organisation procedures ............................................................................................................................. 129 4.2 Maintain and store the person’s information according to confidentiality requirements ......................................................................................................................... 131 4.3 Provide the person’s information to other services according to consent and confidentiality requirements ................................................................................................. 133 5. Evaluate assessment and referral processes ...................................................................................... 134 5.1 Seek feedback about assessment processes from the person and other networks .... 134 5.2 Monitor processes and their outcomes in terms of success in meeting the person’s needs 135 5.3 Routinely seek feedback and reflect on own performance ........................................ 136 5.4 Use feedback and own evaluation as a basis for improving processes ................. 137 Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 5 III. COORDINATE COMPLEX CASE REQUIREMENTS ............................................ 138 1. Establish coordination function .............................................................................................................. 138 1.1 Work with the client and other services to determine the service provision requirements ......................................................................................................................... 138 1.2 Negotiate collaborative working arrangements for all services involved .................. 141 1.3 Develop a plan to identify all available services, their appropriateness, timeframes and expected outcomes ......................................................................................................... 143 1.4 Work with the services to agree on coordination requirements and boundaries ...... 145 2. Support the client to access multiple services ................................................................................... 146 2.1 Identify, implement and maintain duty of care responsibilities ............................... 146 2.2 Provide information to the client about the coordination role .............................. 149 2.3 Work with the client to establish communication requirements ........................... 150 2.4 Assess need and arrange interpreter, according to client’s needs ......................... 151 2.5 Work with the client and other services to identify barriers to attaining outcomes .. 153 2.6 Work with the client to prioritise needs and communicate these with service providers 154 2.7 Facilitate case conference and meetings to coordinate responsibilities and roles .... 154 2.8 Work with other services to minimise client confusion and concerns in a coordinated manner .............................................................................................................. 155 3. Monitor client progress ........................................................................................................................ 159 3.1 Facilitate communication between service providers to identify and manage service duplication ................................................................................................................ 159 3.2 Work with the client and services to monitor progress toward outcomes ............. 160 3.3 Obtain client feedback about services ................................................................... 160 3.4 Identify and implement further support required to meet changing needs and progress towards outcomes ................................................................................................... 162 REFERENCES ............................................................................................................................ 163 Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 6 LEARNER GUIDE CLUSTER Description CHCCSM005 – Develop, facilitate and review all aspects of case management ▪ This unit describes the skills and knowledge required to undertake case management meetings to plan, monitor, and review service provision. ▪ Workers at this level work autonomously and are responsible for own outputs within organisational guidelines. ▪ This unit applies to work in a range of health and community services contexts. CHCCCS004 – Assess co-existing needs ▪ This unit describes the skills and knowledge required to assess the diverse and multi-faceted needs of people and determine both internal and external services required to meet those needs. ▪ This unit applies to a range of community service contexts. CHCCSM004 - Coordinate complex case requirements ▪ This unit describes the skills and knowledge required to coordinate multiple service requirements for clients with complex needs within a case management framework. ▪ Workers at this level work under supervision within established guidelines but take on a team leadership role in the coordination of services and service providers. ▪ This unit applies to work in a range of health and community services contexts. Click here for more details https://training.gov.au/Training/Details/CHC52015 https://training.gov.au/Training/Details/CHC52015 Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 7 About this Unit of Study Introduction As a worker, a trainee, or a future worker you want to enjoy your work and become known as a valuable team member. These units of competency will help you acquire the knowledge and skills to work effectively as an individual and in groups. They will give you the basis to contribute to the goals of the organisation which employs you. It is essential that you begin your training by becoming familiar with the industry standards to which organisations must conform. These units of competency introduce you to some of the key issues and responsibilities of workers and organisations in this area. The units also provide you with opportunities to develop the competencies necessary for employees to operate as team members. This Learner Guide Covers Develop, facilitate and review all aspects of case management A. Determine appropriate response to case management in accordance with organisation and legislative requirements B. Conduct case management meetings C. Develop an appropriate case management plan D. Monitor and review case work activities and processes Assess co-existing needs A. Prepare for assessment B. Analyse the person’s needs using a collaborative approach C. Determine appropriate services D. Complete reporting E. Evaluate assessment and referral processes Coordinate complex case requirements A. Establish coordination function B. Support the client to access multiple services C. Monitor client progress Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 8 Learning Program As you progress through this unit of study, you will develop skills in locating and understanding an organisation’s policies and procedures. You will build up a sound knowledge of the industry standards within which organisations must operate. You will become more aware of the effect that your own skills in dealing with people have on your success or otherwise in the workplace. Knowledge of your skills and capabilities will help you make informed choices about your further study and career options. Additional Learning Support To obtain additional support, you may: Search for other resources. You may find books, journals, videos and other materials which provide additional information about topics in this unit. Search for other resources in your local library. Most libraries keep information about government departments and other organisations, services and programs. The librarian should be able to help you locate such resources. Contact information services such as Infolink, Equal Opportunity Commission, Commissioner of Workplace Agreements, Union organisations, and public relations and information services provided by various government departments. Many of these services are listed in the telephone directory. Contact your facilitator. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 9 Facilitation Your training organisation will provide you with a facilitator. Your facilitator will play an active role in supporting your learning. Your facilitator will help you anytime during working hours to assist with: How and when to make contact, what you need to do to complete this unit of study, and what support will be provided. Here are some of the things your facilitator may do to make your study easier: Give you a clear visual timetable of events for the semester or term in which you are enrolled, including any deadlines for assessments. Provide you with online webinar times and availability. Use ‘action sheets’ to remind you about tasks you need to complete, and updates on websites. Make themselves available by telephone for support discussion and provide you with industry updates by email where applicable. Keep in touch with you during your studies. Flexible Learning Studying to become a competent worker is an interesting and exciting thing to do. You will learn about current issues in this area. You will establish relationships with other students, fellow workers, and clients. You will learn about your own ideas, attitudes and values. You will also have fun. (Most of the time!) At other times, study can seem overwhelming and impossibly demanding, particularly when you have an assignment to do and you aren’t sure how to tackle it, your family and friends want you to spend time with them, or a movie you want to see is on television. Sometimes being a student can be hard. Here are some ideas to help you through the hard times. To study effectively, you need space, resources, and time. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 10 Space Try to set up a place at home or at work where: You can keep your study materials, you can be reasonably quiet and free from interruptions, and you can be reasonably comfortable, with good lighting, seating and a flat surface for writing. If it is impossible for you to set up a study space, perhaps you could use your local library. You will not be able to store your study materials there, but you will have quiet, a desk and chair, and easy access to the other facilities. Study Resources The most basic resources you will need are: 1. A chair 2. A desk or table 3. A computer with internet access 4. A reading lamp or good light 5. A folder or file to keep your notes and study materials together 6. Materials to record information (pen and paper or notebooks, or a computer and printer) 7. Reference materials, including a dictionary Do not forget that other people can be valuable study resources. Your fellow workers, work supervisor, other students, your flexible learning facilitator, your local librarian, and workers in this area can also help you. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 11 Time It is important to plan your study time. Work out a time that suits you and plan around it. Most people find that studying, in short, concentrated blocks of time (an hour or two) at regular intervals (daily, every second day, once a week) is more effective than trying to cram a lot of learning into a whole day. You need time to ‘digest’ the information in one section before you move on to the next, and everyone needs regular breaks from study to avoid overload. Be realistic in allocating time for study. Look at what is required for the unit and look at your other commitments. Make up a study timetable and stick to it. Build in ‘deadlines’ and set yourself goals for completing study tasks. Allow time for reading and completing activities. Remember that it is the quality of the time you spend studying rather than the quantity that is important. Study Strategies Different people have different learning ‘styles’. Some people learn best by listening or repeating things out loud. Some learn best by ‘doing’, some by reading and making notes. Assess your own learning style, and try to identify any barriers to learning which might affect you. Are you easily distracted? Are you afraid you will fail? Are you taking study too seriously? Not seriously enough? Do you have supportive friends and family? Here are some ideas for effective study strategies: Make notes. This often helps you to remember new or unfamiliar information. Do not worry about spelling or neatness, as long as you can read your own notes. Keep your notes with the rest of your study materials and add to them as you go. Use pictures and diagrams if this helps. Underline keywords when you are reading the materials in this Learner Guide. (Do not underline things in other people’s books.) This also helps you to remember important points. Talk to other people (fellow workers, fellow students, friends, family, and your facilitator) about what you are learning. As well as helping you to clarify and understand new ideas, talking also gives you a chance to find out extra information and to get fresh ideas and different points of view. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 12 Using This Learner Guide A Learner Guide is just that, a guide to help you learn. A Learner Guide is not a textbook. Your Learner Guide will: Describe the skills you need to demonstrate to achieve competency for this unit. Provide information and knowledge to help you develop your skills. Provide you with structured learning activities to help you absorb knowledge and information and practice your skills. Direct you to other sources of additional knowledge and information about topics for this unit. How to Get the Most out of Your Learner Guide Read through the information in the Learner Guide carefully. Make sure you understand the material. Some sections are quite long and cover complex ideas and information. If you come across anything you do not understand: Talk to your facilitator. Research the area using the books and materials listed under Resources. Discuss the issue with other people (your workplace supervisor, fellow workers, fellow students). Try to relate the information presented in this Learner Guide to your own experience and to what you already know. Ask yourself questions as you go. For example, ‘Have I seen this happening anywhere?’ ‘Could this apply to me?’ ‘What if...’. This will help you ‘make sense’ of new material and build on your existing knowledge. Talk to people about your study. Talking is a great way to reinforce what you are learning. Make notes. Work through the activities. Even if you are tempted to skip some activities, do them anyway. They are there for a reason, and even if you already have the knowledge or skills relating to a particular activity, doing them will help to reinforce what you already know. If you do not understand an activity, think carefully about the way the questions or instructions are phrased. Read the section again to see if you can make sense of it. If you are still confused, contact your facilitator or discuss the activity with other students, fellow workers or with your workplace supervisor. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 13 Learning Checkpoints This learner guide contains learning checkpoints which are represented by the following icons: Checkpoint! Let’s Review Further Reading Further Reading directs you to external resources that are highly recommended for you to read. They also contain additional questions to facilitate supplementary learning and to guide you relate what you have read in real life. Checkpoint! Let’s Review contain review questions for you to answer on your own to ensure that you have learned key points from the relevant section. If you have a hard time answering these questions, worry not. You can always revisit chapters and take another shot at these review questions. Additional Research, Reading and Note Taking If you are using the additional references and resources suggested in the Learner Guide to take your knowledge a step further, there are a few simple things to keep in mind to make this kind of research easier. Always make a note of the author’s name, the title of the book or article, the edition, when it was published, where it was published, and the name of the publisher. This includes online articles. If you are taking notes about specific ideas or information, you will need to note down the page number as well. This is called the reference information. You will need this for some assessment tasks, and it will help you to find the book again if you need to. Keep your notes short and to the point. Relate your notes to the material in your Learner Guide. Put things into your own words. This will give you a better understanding of the material. Start off with a question you want answered when you are exploring additional resource materials. This will structure your reading and save you time. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 14 I. DEVELOP, FACILITATE AND REVIEW ALL ASPECTS OF CASE MANAGEMENT 1. Determine the Appropriate Response to Case Management in Accordance with Organisation and Legislative Requirements 1.1 Develop and Utilise Case Management Processes in Accordance with Statutory Requirements Case management, according to the Case Management Society of Australia and New Zealand (CMSA): ‘is a process encompassing a culmination of consecutive collaborative phases that assist clients to access available and relevant resources necessary for the client to attain their identified goals. Key phases of the case management process include client identification (screening), assessment, stratifying risk, planning, implementation (care coordination), monitoring, transitioning, and evaluation.’ Case management is one of the primary places in human service systems where the whole person is taken into account. Unlike specific services, case management does not focus on just one problem but rather on the strengths, needs, and personal concerns a person has. Case management serves two (2) purposes: It is a method for determining an individualised service plan for each person and monitoring the plan to use it is effective. It is a process used to ensure that the money being spent for the person’s services is being spent wisely and in the most efficient manner. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 15 Models of Case Management Generally, models of case management practice lie on a continuum, from ‘brokerage’ at one end, through models that are based on ‘relationship’ and ‘continuity of care’ to ‘clinical case management’, including specialist interventions and rehabilitation, and ‘intensive case management’ at the other end. There are many different models of case management, but the major approaches are the following: Standard Community Care Models ▪ Brokerage case management o This is a very brief approach to case management in which case workers attempt to help clients identify their needs and broker support services. o The focus of this model is on assessing needs, referring to services and coordinating, and monitoring on-going treatment. o The case manager coordinates services provided by a variety of agencies and professionals. Services are mainly office-based. ▪ Clinical case management o This model combines case management and clinical or rehabilitation activities. o Clinical case management emerged out of a need for case managers to provide some therapeutic services. o Many functions are similar to the brokerage model, including engagement, assessment and planning, and community linking but with the added component of therapeutic interventions such as psychotherapy, psychoeducation, and crisis intervention. o Work is mainly office-based, and case managers are clinicians. ▪ Generalist case management o This model utilises the commonly accepted functions of case management and is characterised by a closer involvement between case manager and client. o This approach is appropriate in instances where treatment and social services in a particular area are relatively integrated, and the need for monitoring and advocacy is minimal. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 16 Intensive Comprehensive Care Models ▪ Assertive community treatment (ACT) case management o The services are usually provided by a community team on an ongoing and intensive basis. o This model of case management assumes a comprehensive role for a team of workers by providing services such as skills-building, family consultations, and crisis intervention. o This approach is defined by: ▪ smaller caseloads, ▪ a multi-disciplinary team approach (usually at least two case managers, a nurse, and a psychiatrist), ▪ shared caseloads, ▪ services delivered by the team in the person’s natural environment versus making referrals outside of the team, and ▪ unlimited time frame and 24-hour coverage. o A range of services is provided including but not limited to, mental health, housing, daily living skills, socialisation, employment, crisis intervention, and/or substance abuse treatment. ▪ Intensive case management o This model provides outreach and direct counselling services with a smaller caseload and without a team approach. o Intensive case management is developed to meet the complex needs of high service users and defined by low staff to client ratio, outreach, services brought to the client, and practical assistance in a variety of areas. o The main distinction from the ACT model is that caseloads are not shared. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 17 Rehabilitation-Oriented Community Care Models ▪ Strengths-based case management o This model focused on client’s strengths, self-direction, and the use of informal help networks. o Strengths-based case management model provides clients support for asserting direct control over their search for resources (e.g., housing and employment), and it examines the client’s own strengths and capabilities as the means for resource acquisition. o To help clients take control and find their strengths, this model of case management: ▪ encourages the use of informal helping networks, ▪ promotes client-case manager relationship, and ▪ provides an active form of outreach to clients. Case Management Approach To identify, analyse and address individual needs, case management takes on a ‘systems approach’. Case Management Approach Client centred Evidence based HolisticInclusive Strengths based Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 18 Client-centred There is a partnership between the case manager and the client in which the client’s goals are given priority during assessment and involvement. The client’s aspirations, choice, expectations, needs, preferences and values are respected, and interventions are adapted according to these. A client-centred case management approach ensures that the person has a major role in identifying goals and service needs and that there is shared accountability. This approach is utilised to empower people, draw on their strengths and capabilities, and promote an improved quality of life by facilitating timely access to the necessary supports. Evidenced-based According to David Sackett, a medical doctor and a pioneer in evidence-based medicine: ‘evidence-based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available clinical evidence from systematic research.’ In case management, the case manager works within a framework that uses that most contemporary, relevant, and reliable evidence to provide effective and innovative case management of the highest quality. Evidence may come from a number of different sources such as: Contemporary research and theoretical knowledge. Data and statistical information. Information from evaluation and reflective processes. Existing professional practice standards, values, ethical practice and professional conduct. The requirements of evidence-based practice are: ▪ Best researched evidence – Usually found in clinically relevant research that has been conducted using sound methodology. ▪ Clinical experience and ethics – Refers to the clinician’s cumulated experience, education, and clinical skills. ▪ Client preferences and culture - Personal preferences and unique concerns, expectations, and values brought by the client. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 19 Holistic The case manager uses a framework that comprehensively considers the general socioeconomic, cultural, and environmental conditions of the client. Working with clients in a holistic approach requires the case manager to look at the person from a whole-of-life- perspective including: Accommodation/housing Culture/religion Education Emotional support Finances Health and mental health Legal issues Networks/community family Recreation Work Inclusive The case manager recognises and demonstrates compliance with enabling legislation and standards pursuant to the terms and conditions of employment and registration with a professional body. Strengths-based The client and the case manager acknowledge and concentrate on the strengths, skills, and aptitudes of the client, in contrast to their deficits, to promote self-efficacy and self-esteem. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 20 Case Management Standards of Practice Standards of practice are designed to specify the minimum level of practice or benchmark to be attained by a case manager throughout the case management process. It also provides the foundation for a best practice framework and uniform approach for practitioners. Standards of practice are designed to enhance case management practice. These standards provide a basis for quality guarantee, expectations and accountability for clients, employers and other professionals. Such standards also reinforce current practices and are designed to provided objectives and guidelines to assist the case manager in competently practising case management. Bear in mind that these standards are not intended to detract from any responsibilities which may be imposed by law or regulation. According to the Australian Association of Social Workers (AASW), the aim of practice standards is to provide a: ✓ Guide to practice. ✓ Measure of accountability for members. ✓ Basis for standardisation of practice across Australia. ✓ Basis for quality guarantee, expectations and accountability for clients, employers and other professionals. ✓ Benchmark for the assessment practice. ✓ Guide for planning ongoing professional development. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 21 STANDARDS OF PRACTICE FOR CASE MANAGEMENT Standard 1: Case Identification (screening) and Assessment Clients who meet the eligibility criteria for case management are identified and an assessment is completed. Rationale: An element of screening occurs to determine the initial needs of the client. These needs and risk stratification are matched against the eligibility criteria of the program providing case management, and the case manager then completes an assessment. Standard 2: Planning 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 caseload of the case manager who must recognise their own abilities and limitations to be able to work effectively with the client. Standard 3: Monitoring 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. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 22 Standard 4: Evaluation and Outcomes Case management actions are outcome oriented. Periodic reassessment and evaluation of client outcomes are conducted against the expected outcomes and available evidence. Rationale: The purpose of case management actions is to support clients to achieve desired goals/outcomes. The outcome is based on available evidence which demonstrates effectiveness. Evaluation activities measure the effectiveness and efficiency of the case management interventions that were planned to meet client goals. The case manager must undertake periodic evaluation as stipulated by the agency, program and/or funding body guidelines and/or policies and procedures are the request of the client. (Source: National Standards of Practice for Case Management (CMSA), 2013) Organisation and Legislative Requirements Case managers have a legal obligation to follow statutory and regulatory requirements when providing case management services. You, as the case manager, have a responsibility to keep clients safe and to protect their safety if you believe they are at risk of harm. The statutory and regulatory requirements contained in Acts and Regulations must guide your decisions about what is right in relation to your clients. Relevant/current legislation includes: Child protection Health and safety Privacy Freedom of information Statutory and policy requirements include: Child protection and guardianship legislation Codes of practice Freedom of information Privacy and confidentiality Health records legislation Privacy legislation Public health Workplace health and safety Access and equity Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 23 Case management processes must also meet relevant service standards, and workers must adhere to relevant codes of practice and organisation requirements. These can vary depending on the nature of the service being provided. However, there are many that are common to all services including: Assessment Codes of conduct Communication Complaints, conflict resolution, and procedures Confidentiality Consent Coordination and networking with external agencies Critical incidents procedures Delegations (who has the authority to make decisions) Duty of care Mandatory notification Workplace health and safety procedures Recruitment and retainment of staff Referral Service provision and practice Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 24 MANDATORY REPORTING OF CHILD ABUSE AND NEGLECT According to Australian Institute of Family Studies: ‘mandatory reporting is a term used to describe the legislative requirement imposed on selected classes of people to report suspected cases of child abuse and neglect to government authorities’. Who is mandated to report? What must be reported? Abuse and neglect types which must be reported State/Territory: Queensland Legislation: Child Protection Act 1999 (Qld) Relevant persons: doctors, registered nurses, teachers, a police officer who, under a direction given by the commissioner of the police service under the Police Service Administration Act 1990, is responsible for reporting under this section, a person engaged to perform a child advocate function under the Public Guardian Act 2014. Has a reasonable suspicion that a child has suffered, is suffering or is at an unacceptable risk of suffering significant harm caused by physical or sexual abuse and may not have a parent able and willing to protect the child from the harm. Physical abuse Sexual abuse https://aifs.gov.au/cfca/publications/mandatory-reporting-child-abuse-and-neglect Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 25 State/Territory: Australian Capital Territory Legislation: Children and Young People Act 2008 (ACT) A person who is: a doctor, a dentist, a nurse, an enrolled nurse, a midwife, a psychologist, a teacher at a school, a person authorised to inspect education programs, materials or other records used for home education of a child or young person under the Education Act 2004, a police officer, a person employed to counsel children or young people at a school, a person caring for a child at a child care centre; a person coordinating or monitoring home-based care for a family day care scheme proprietor, a public servant who, in the course of employment as a public servant, works with, or provides services personally to, children and young people or families, the public advocate, an official visitor, a person who, in the course of the person’s employment, has contact with or provides services to children, young people and their families and is prescribed by regulation. A belief, on reasonable grounds, that a child or young person has experienced or is experiencing sexual abuse or non-accidental physical injury; and the belief arises from information obtained by the person during the course of, or because of, the person’s work (whether paid or unpaid). Physical abuse Sexual abuse Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 26 State/Territory: New South Wales Legislation: Children and Young Persons (Care and Protection) Act 1998 (NSW) A person who, in the course of his or her professional work or other paid employment delivers health care, welfare, education, children’s services, residential services or law enforcement, wholly or partly, to children. A person who holds a management position in an organisation, the duties of which include direct responsibility for, or direct supervision of, the provision of health care, welfare, education, children’s services, residential services or law enforcement, wholly or partly, to children. Reasonable grounds to suspect that a child is at risk of significant harm and those grounds arise during the course of or from the person’s work. Physical abuse Sexual abuse Emotional/ psychological abuse Neglect Exposure to domestic violence State/Territory: Northern Territory Legislation: Care and Protection of Children Act 2007 (NT) Any person. A health practitioner or someone who performs work of a kind that is prescribed by regulation. A belief on reasonable grounds that a child has suffered or is likely to suffer harm or exploitation. Reasonable grounds to believe a child aged 14 or 15 years has been or is likely to be a victim of a sexual offence and the age difference between the child and offender is greater than 2 years. Physical abuse Sexual abuse or other exploitation of the child Emotional/ psychological abuse Neglect Exposure to physical violence (e.g., a child witnessing violence between parents at home) Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 27 State/Territory: South Australia Legislation: Children’s Protection Act 1993 (SA) Medical practitioners, pharmacists, registered or enrolled nurses, dentists, psychologists, police officers, community corrections officers, social workers, a minister of religion, a person who is an employee of, or volunteer in, an organisation formed for religious or spiritual purposes, (with the exception of disclosures made in the confessional), teachers in educational institutions including kindergartens, approved family day care providers, any other person who is an employee/volunteer in a government or non-government organisation that provides health, welfare, education, sporting or recreational, child care or residential services wholly or partly for children, being a person who is actively engaged in the delivery of those services to children or who holds a management position in the relevant organisation, the duties of which include direct responsibility for, or direct supervision of, the provision of those services to children. Reasonable grounds to suspect that a child has been or is being abused or neglected; and the suspicion is formed in the course of the person’s work (whether paid or voluntary) or carrying out official duties. Physical abuse Sexual abuse Emotional/ psychological abuse Neglect Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 28 State/Territory: Tasmania Legislation: Children, Young Persons and Their Families Act 1997 (Tas.) Registered medical practitioners, nurses, midwives, dentists, dental therapists, dental hygienists or oral health therapist, registered psychologists, police officers, probation officers, principals and teachers in any educational institution including kindergartens, persons who provide child care or a child care service for fee or reward; persons concerned in the management of a child care service licensed under the Child Care Act 2001, any other person who is employed or engaged as an employee for, of, or in, or who is a volunteer in, a government agency that provides health, welfare, education, child care or residential services wholly or partly for children, and an organisation that receives any funding from the Crown for the provision of such services; and any other person of a class determined by the Minister by notice in the Gazette to be prescribed persons. A belief, or suspicion on reasonable grounds, or knowledge that: a child has been or is being abused or neglected or is an affected child within the meaning of the Family Violence Act 2004, there is a reasonable likelihood of a child being killed or abused or neglected by a person with whom the child resides, or while a woman is pregnant that there is reasonable likelihood that after the birth of the child the child will suffer abuse or neglect, or may be killed by a person with whom the child is likely to reside, or that the child will require medical treatment or other intervention as a result of the behaviour of the woman or another person with whom the woman resides or is likely to reside, before the birth of the child. Physical abuse Sexual abuse Emotional/ psychological abuse Neglect Exposure to family violence Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 29 State/Territory: Victoria Legislation: Children, Youth and Families Act 2005 (Vic.) Registered medical practitioners, nurses, midwives, a person registered as a teacher or an early childhood teacher under the Education and Training and Reform Act 2006 or teachers granted permission to teach under that Act, principals of government or non- government schools within the meaning of the Education and Training Reform Act 2006, and police officers. Belief on reasonable grounds that a child is in need of protection on a ground referred to in Section 162(1)(c) or 162(1)(d), formed in the course of practising his or her office, position or employment as soon as practicable after forming the belief and after each occasion on which he or she becomes aware of any further reasonable grounds for the belief. Physical abuse Sexual abuse State/Territory: Western Australia Legislation: Children and Community Services Act 2004 Doctors, nurses and midwives, teachers or boarding supervisor, and police officers. Belief on reasonable grounds that child sexual abuse has occurred or is occurring and forms this belief in the course of the person’s work, whether paid or unpaid. Sexual abuse (Source: Australian Institute of Family Studies) https://aifs.gov.au/cfca/publications/mandatory-reporting-child-abuse-and-neglect Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 30 1.2 Implement Appropriate Processes to Enable the Client to Set Goals and Participate in Case Management Processes The development of clear goals is a very important phase of the case management process. A goal is a statement defining the expected outcome for each client by the time case management services are terminated. Goal statements should include a time frame and a date by which the goal will be reached. A goal without a date opens the possibility for an endless service delivery process. Goals for case management services should be established with, not for, each client. Clients need to be involved in the work of figuring out where they want to be at a given time. You, as the case manager, is an important resource in this process, suggesting options, offering opinions, discussing what might be reasonable and possible given the known resources, helping people focus, and when appropriate, supporting clients who want to explore the development of new resources as one of their goals. Case management works much more effectively when clients are intensively involved in all stages of the process to the extent possible. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 31 Behaviour Change Models There are a number of behaviour change models that can be integrated into the goal-setting process. These models help explain specific behaviours by identifying the underlying factors that influence them. It also illustrates the stages through which an individual will progress during a change in his/her behaviour. Transtheoretical Model Useful for selecting appropriate interventions by identifying the client’s position in the change processes (Precontemplation, Contemplation, Preparation, Action, Maintenance, and Termination) so that the interventions can be tailored according to the skills the client already possesses. o Precontemplation is the stage in which people do not intend to make a change in the near future (often defined as the next 6 months). o Contemplation is the stage where people intend to change (within the next 6 months). People in this stage are aware of the pros of changing but can also identify the cons. o Preparation represents the stage where people have a plan of action and intend to take action in the immediate future (within a month). o Action is the stage in which people make the behaviour change. o Maintenance represents the state where people work to prevent relapse. o Termination represents that the stage where individuals have 100 percent efficacy and will maintain their behaviour. This is the most difficult to maintain, so many people remain a lifetime in maintenance. Precontemplation Contemplation Preparation Action Maintenance Termination Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 32 How can you apply this model in practice? It is essential that you match behaviour change interventions to people’s stages. For example: 1. When working with clients in the pre-contemplation stage, encourage them to start thinking about change and the benefits that come with it. 2. If the client is in the contemplation stage, it is important to encourage the client to weigh up the pros and cons of the change/modification. 3. Clients in the preparation stage can now be engaged, and you can now work with him/her to create a plan for adopting changes and overcoming challenges. Action is the stage where the client carries out the prepared plan. During this stage, it is important to offer continuous support and encouragement, while helping the client focus on the long-term advantages of making behaviour changes. It is at this stage where goal- setting (using SMART goals) is particularly useful. It is also important to teach the client how to anticipate and overcome obstacles that might deter his/her motivation or adherence. The client has progressed in the maintenance stage when he/she is maintaining new behaviour changes. It is important to offer continued encouragement so that the client maintains the changed behaviour, and to identify those things that might cause a relapse. Take time to work with the client to identify things that might tempt or undermine the positive changes he/she has made. Help the client strategise how to prevent these newly identified triggers for relapse. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 33 Relapse Prevention Model Original cognitive-behavioural model of relapse (Marlatt & Gordon, 1985) According to the model, people with effective coping responses have confidence that they can cope with the situation (i.e. increased self-efficacy, thereby reducing the probability of a relapse. Conversely, people with ineffective coping responses will experience decreased self-efficacy, which, together with the expectation that a certain behaviour will have a positive effect (i.e. positive outcome expectancies), can result in an initial lapse. This lapse, in turn, can result in feelings of guilt and failure (i.e. an abstinence violation effect). The abstinence violation effect, along with positive outcome expectancies, can increase the probability of a relapse. This model is useful in designing maintenance, stand-alone treatment, and behaviour self- control programs to teach individuals who are trying to maintain changes in their behaviour how to anticipate and cope with the problem of relapse. This model provides a strategy for anticipating barriers and other factors contributing to participant relapse. This model has two (2) main goals: 1. To prevent the occurrence of initial lapses after a commitment to change has been made. 2. To prevent any lapse that does occur from escalating into a full-blown relapse. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 34 How can you apply this model in practice? Use this model as a behavioural self-control program that teaches individuals with substance addiction how to anticipate and cope with the potential for relapse. Use this as a stand-alone substance abuse treatment program or as an aftercare program to sustain gains achieved during initial substance use treatment. Use this in coping skills training, teaching clients strategies to: ✓ Understand relapse as a process. ✓ Identify and cope effectively with high-risk situations such as negative emotional states, interpersonal conflict, and social pressure. ✓ Cope with urges and cravings. ✓ Implement damage control procedures during a lapse to minimise negative consequences. ✓ Stay engaged in treatment even after a relapse. ✓ Learn how to create a more balanced lifestyle. ✓ Acknowledge that a lapse is a normal experience and should not be viewed negatively. Coping skills training strategies include both cognitive and behavioural techniques. ▪ Cognitive techniques provide clients with ways to reframe the habit change process as a learning experience with errors and setbacks expected as mastery develops. ▪ Behavioural techniques include the use of lifestyle modifications such as meditation, exercise, and spiritual practices to strengthen a client’s overall coping capacity. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 35 Ecological Approaches Provides a framework used to develop comprehensive intervention approaches that systematically target mechanisms of change at each level of influence (intrapersonal, interpersonal, institutional, community, and public). o Intrapersonal factors – Characteristics of the individual such as knowledge, attitudes, behaviour, self-concept, skills, and development history. o Interpersonal processes and primary groups – Formal and informal social networks and social support systems, including family, workgroup, and friendship networks. o Institutional factors – Social institutions with organisational characteristics and formal (and informal) rules and regulations for operations. o Community – Relationships among organisations, institutions, and informational networks within defined boundaries. o Public policy – Local, state, national, and global laws and policies. The core concept of an ecological approach is that behaviour has multiple levels of influences. This approach is believed to provide comprehensive frameworks for understanding the multiple and interacting determinants of health behaviours. Public Community Insitutional Interpersonal Intrapersonal Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 36 This approach is based on four core principles: o Multiple factors influence behaviours. o Environments are multidimensional and complex. o Human-environment interactions can be described at varying levels of the organisation. o The interrelationships between people and their environment are dynamic. How can you apply this model in practice? Each level in the ecological model can be thought of as a level of influence and also as a key point for prevention. This approach offers a framework for program planners to determine how to focus prevention activities, specifically what programs and policies to implement, to reduce risk factors and increase protective factors at each of the different levels in the model. This framework can be used to answer the following questions in relation to behaviour change: 1. Where do you want to make the most impact? 2. Where are the gaps? 3. What activities can fill those gaps? An ecological approach to behaviour enables Case Managers to: ✓ Offer support and facilitate continuing change efforts across the levels. ✓ Coordinate and communicate with those in the client’s system about the agreed change efforts. ✓ Identify opportunities to promote participation by recognising the multiple factors that influence an individual’s behaviour. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 37 This model enables workers to identify and implement appropriate strategies at each level: ✓ Strategies which bring change at the intrapersonal level tend to focus on changing an individual’s knowledge, attitudes, behaviour, and skills (e.g. education and mentoring programs). ✓ Strategies which bring change at the interpersonal level include community education, support groups, peer programs, workplace incentives, and social marketing campaigns. ✓ Strategies focusing on institution and community levels including the development of the community, education, and awareness programs. ✓ Strategies on the public level must focus on developing the political will to implement laws and policies that are already in place and encouraging all sectors of the community to comply with such laws and policies. Guidelines in Setting Goals Goals should be clear plans for concrete actions – Goals should be expressed as behaviour/s the client intends to do, which will distinguish them from wishful thinking, good intentions or desirable outcomes. Goals should be realistically challenging – If goals are too hard; the sense of self- efficacy will be lost; if they are they are too easy, they won’t inspire much effort. Goals should incorporate the client’s interests – It is difficult to be motivated to work on something that is not genuinely interesting, and this is why the interest of the client should be considered. Goals should conform to the client’s values – Some of our important basic ideas about ourselves involve a sense of personal integrity, different people have different values, and goals should align with values inherent to a person. Goals should have verifiable outcomes – Verifiable outcomes will allow clients to see themselves being successful in achieving the goals they have set. This, in turn, will build self-efficacy so that they will be more likely to keep achieving the goals. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 38 Goals should depend on the client’s own efforts – It is important that achieving goals does not depend on the actions or reactions of things outside of the client’s control. Goals should be achieved reasonably soon – Distant goals tend to be weaker motivators, while closer goals tend to be stronger motivators. Daunting goals can be broken into manageable steps so that they are seen as a series of sub-goals. Goals should be set with the involvement of the client – collaborative goal-setting is the beginning of all successful behaviour change programs and workers showing practical respect for the client’s autonomy. (Source: The keys to successful behaviour change, Australia Psychological Society, 2017) https://www.psychology.org.au/publications/inpsych/behaviour/ Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 39 1.3 Integrate Appropriate Cultural Considerations into All Aspects of Case Management Planning Cultural considerations are crucial to the effectiveness of any case management approach. Culture refers to everything that defines and distinguishes a person including ethnicity, gender, age, sexual orientation, language, values, goals, and life experiences. Case managers need to be aware of and be sensitive to cultural diversity, life situations, and other various factors that shape a person’s identity. The case manager shall provide and facilitate access to culturally and linguistically appropriate services. He or she must practice cultural competence in all aspects of case management planning by: Treating every client as an individual with a unique frame of reference. Collaborating on the goals and content of the plan. Tailoring services to clients instead of expecting them to conform to the service’s preference. Obtaining ongoing feedback from clients on the usefulness of the service and adjusting the approach accordingly. Community services and organisations have an obligation to develop policies, procedures and standards of practice that aim to integrate appropriate cultural considerations into all aspects of case management planning. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 40 Working with Culturally Diverse Clients Service organisations and service workers need to consider the diversity of their client’s values, beliefs, and cultural expectations. To work effectively with culturally diverse clients, you will need to be culturally responsive and commit to an inclusive approach that is respectful and relevant to the client and their cultural identity. Specifically, you will need to: Be aware of your own cultural background/experiences, attitudes, values and biases that might influence your ability to assist clients from diverse cultural populations. It is essential that you correct any prejudices and biases you may have regarding different cultural groups. Educate yourself wherever possible to enhance your understanding and to address the needs of culturally diverse clients. This may involve learning about cultural, social, psychological, political, economic, and historical material specific to the particular ethnic group being served. Recognise that ethnicity and culture may have an impact on a client’s behaviour. Assist clients to become aware of their own cultural values and norms, and facilitate discovery of ways clients can apply this awareness to their own lives to society at large, as well as within the organisation. Respect the client’s religious and/or spiritual beliefs and values. Work to eliminate biases, prejudices, and discriminatory practices. Provide information in a language that the client can understand. Provide information in writing, along with verbal explanations. (Source: The needs of culturally diverse clients, Community Door, 2016) Special Needs of Diverse Client/Population Aboriginal and/or Torres Strait Islander people Aboriginal peoples are the oldest surviving culture in the world, having established ways of managing their land and society that were sustainable and ensured good health. They have occupied Australia for at least 60,000 years. There were many different Aboriginal and Torres Strait Islander groups and hundreds of languages. However, the population declined rapidly after colonisation. To meet their cultural needs, services to ATSI people must be culturally appropriate, culturally responsive, and holistic. Also, they must be provided with access to workers from within their own community. http://etraining.communitydoor.org.au/mod/page/view.php?id=286 Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 41 Cultural protocols and systems that may apply when working with ATSI people may include the following: A ‘Welcome to Country’ is where an Aboriginal or Torres Strait Islander Traditional Custodian or Traditional Owner (in most cases an Elder), or a senior representative, welcomes people to their land. An ‘Acknowledgment of Country’ is traditionally performed in public events and meetings when a person is about to address the audience. It is an acknowledgement of the Aboriginal or Torres Strait Islander community as the traditional owners of the land, and the special respect held for their Elders. Smoking ceremonies are undertaken in Aboriginal communities in order to cleanse the space in which a ceremony is taking place. They are also used in the context of healing, spiritual renewal and strengthening by some Aboriginal healing practitioners. Things workers need to consider when working with this group may include the following: Respect, acknowledge, actively listen and respond to the needs of Aboriginal peoples and communities in a culturally appropriate manner. Don’t mimic Aboriginal speech patterns or attempt to speak Aboriginal English as a way of encouraging an Aboriginal person to be more open. Be aware and respectful of relevant extended family and kinship structures when working with Aboriginal people. Ensure that extended family is included in important meetings and in making important decisions. Further Reading The following are additional resources for further reading: ▪ Working and Walking Together: Supporting Family Relationship Services to Work with Aboriginal and Torres Strait Islander Families and Organisations ▪ Working with Aboriginal People and Communities: A Practice Resource ▪ Engaging with Aboriginal and Torres Strait Islander Communities http://www.supportingcarers.snaicc.org.au/wp-content/uploads/2015/03/02497 http://www.supportingcarers.snaicc.org.au/wp-content/uploads/2015/03/02497 http://www.supportingcarers.snaicc.org.au/wp-content/uploads/2015/03/02497 http://www.carersaustralia.com.au/storage/2011Working%20with%20Aboriginal%20People%20and%20Communities http://www.carersaustralia.com.au/storage/2011Working%20with%20Aboriginal%20People%20and%20Communities https://www.kidsmatter.edu.au/sites/default/files/public/Handbook_engaging_with_web Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 42 Children and Young People Case managers and workers must bear in mind the following agreed protocols for collaborative practice in child protection when working with children and young people: ▪ UN Convention on the Rights of the Child 1989, a human rights treaty which sets out the civil, political, economic, social, health, and cultural rights of children. ▪ Child protection legislation Principal acts across Australian states and territories: o Australian Capital Territory - Children and Young People Act 2008 o New South Wales - Children and Young Persons (Care and Protection) Act 1998 o Northern Territory - Care and Protection of Children Act 2007 o Queensland - Child Protection Act 1999 o South Australia - Children’s Protection Act 1993 o Tasmania - Children, Young Persons and their Families Act 1997 o Victoria - Children, Youth and Families Act 2005 o Western Australia – Children and Community Services Act 2004 ▪ National Framework for Protecting Australia’s Children ▪ Relevant interagency guidelines – these are guidelines provided by states/territories that cover the purpose, legislative and operational basis, roles, responsibilities, and practice principles for protection of children (e.g., Guidelines for Protecting Children, WA; NSW Interagency Guidelines for Children Protection Intervention) ▪ Codes of practice in child protection network (e.g., NSW – Office of the Children’s Guardian; SA – Interagency Code of Practice) https://www.unicef.org/crc/files/Rights_overview https://aifs.gov.au/cfca/publications/australian-child-protection-legislation https://www.dss.gov.au/our-responsibilities/families-and-children/publications-articles/protecting-children-is-everyones-business?HTML http://www.health.wa.gov.au/circularsnew/attachments/1052 http://www.victimsservices.justice.nsw.gov.au/sexualassault/Documents/Child-Protection-Interagency-Guidelines http://www.victimsservices.justice.nsw.gov.au/sexualassault/Documents/Child-Protection-Interagency-Guidelines http://www.kidsguardian.nsw.gov.au/children-s-employment/information-for-employers/code-of-practice http://www.kidsguardian.nsw.gov.au/children-s-employment/information-for-employers/code-of-practice https://www.childprotection.sa.gov.au/child-protection-initiatives/interagency-code-practice Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 43 The following are the things that workers need to consider when working with children and young people: Safety, welfare and well-being of a child or young person are the paramount consideration. The child’s or young person’s sense of racial, ethnic, religious, individual or cultural identity should be preserved and enhanced. The child’s or young person’s education, training or lawful employment should be encouraged and continued without unnecessary interruption. The child’s or young person’s age, maturity, developmental capacity, sex, background and other relevant characteristics should be considered. Delay in decision-making processes under the Act should be avoided because the delay is likely to prejudice the child’s or young person’s well-being. Special needs that are related, specifically to children and young people, may include the following: Safety and physical and emotional security Accommodation Access to services/information Counselling Ongoing assessment Referrals to specialist services Referrals to community support and/or education groups Information provided to caregivers, such as parenting information Safety plans including protective behaviour techniques Culturally and linguistically diverse (CALD) Culturally and linguistically diverse (CALD) clients are those who may identify as being from a culturally and linguistically diverse background including recently arrived migrants and refugees, migrants and refugees who have lived in Australia for some time, as well as people whose parents or earlier ancestors migrated to Australia. Culturally and linguistically diverse client groups often have complex needs related to their particular life situation or history. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 44 Protocols and systems that may apply when working with CALD individuals include: Using appropriate terminology and avoid stereotyping. Developing cross-cultural competence. Collecting and recording accurate information about cultural, linguistic and religious identity. Developing effective cross-cultural communication skills. Utilising interpreters. Establishing links with service providers and ethnic community organisations. Utilising culturally appropriate placements. Ensuring a culturally appropriate response. Things that workers need to consider when working with CALD individuals may include: People from CALD backgrounds are not homogenous. Develop a working knowledge of the migration experience. Develop an understanding of the refugee experience. Develop a working knowledge of differences in child-rearing practices. Find out about traditional cultural practices. Consider intergenerational issues and their impacts. Be aware of barriers to identifying and reporting child abuse. Understand the impacts of racism and discrimination. Recognise stressors potentially contributing to domestic and family violence. Further Reading The following are additional resources for further reading: ▪ People from culturally and linguistically diverse backgrounds (Department of Health) ▪ Working with people from culturally and linguistically diverse background http://health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-p-mono-toc~mental-pubs-p-mono-pop~mental-pubs-p-mono-pop-cul https://www.communities.qld.gov.au/resources/childsafety/practice-manual/prac-paper-working-cald https://www.communities.qld.gov.au/resources/childsafety/practice-manual/prac-paper-working-cald Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 45 Lesbian, gay, bi-sexual, transgender, intersex (LGBTI) LGBTI people have lived through a time in the nation’s history when they suffered stigma, discrimination, criminalisation, family rejection, and social isolation. Their special needs include: Groups within LGBTI communities have specific social, cultural, psychological, medical, and care needs. Core relationship links with non-biological family or the ‘family of choice’ may be more important to LGBTI people than their biological family and should be included in care planning in the same way family members generally are. LGBTI people also have other diverse characteristics that overlap and influence their specific needs and how they access services, e.g. people from culturally and linguistically diverse backgrounds, Aboriginal and Torres Strait Islander people, those suffering financial disadvantage, etc. Protocols and systems that may apply when working with LGBTI individuals include: Recognition and affirmation of sexuality, sex, or gender diversity. Recognition of the negative impact of discrimination, stigma, homophobia and heterosexism on a person’s well-being. Critical analysis of the assumption that all consumer or staff are heterosexual and not diverse in terms of sex or gender. A client-centred approach that takes into account the broader social determinants that impact on the well-being of LGBTI persons. A culturally competent and safe workforce that is knowledgeable and responds to the lived experience of LGBTI persons. Safe and welcoming environment and services free from discrimination based on sexuality, sex, or gender diversity. The following are the considerations that workers must bear in mind when working with LGBTI individuals: A large number of LGBTI people hide their sexuality or gender identity when accessing services, at social and community events, and at work. Young people aged 16 to 24 years are most likely to hide their sexuality or gender identity. LGBTI young people report experiencing verbal homophobic abuse, physical homophobic abuse and other types of homophobia, including cyberbullying, graffiti, social exclusion, and humiliation. 80% of homophobic bullying involving LGBTI young people, occurs at school and has a profound impact on their well-being and education. Transgender males and females experience significantly higher rates of non-physical and physical abuse compared with lesbians and gay men. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 46 Gay, lesbian, bisexual, and transgender people are three times more likely to experience depression compared to the broader population. Around 61% of same-sex attracted and gender-questioning young people said they experienced verbal abuse because of their sexuality, while 18% reported experiencing sexual abuse. Young men and gender-questioning young people were more likely than young women to experience verbal abuse. Further Reading The following are additional resources for further reading: ▪ Face the facts: Lesbian, Gay, Bisexual, Trans and Intersex People (Australian Human Rights Commission) ▪ LGBTI Cultural Competency Framework (National LGBTI Health Alliance) ▪ National Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI): Ageing and Aged Care Strategy (Department of Health and Ageing) Older people Older people need support for their physical, emotional, and social needs. In cases where nursing homes and other institutional settings are inappropriate, case management serves, as an effective means of fostering an older adult’s autonomy, establish safe living arrangements in the privacy and comfort of their own home. Appropriate case management planning can assist older people in remaining connected to their families, friends, neighbours, pets, and community. The goal should be to maximise the client’s health, self-esteem, quality of life and right to self- determination. https://www.humanrights.gov.au/face-facts-lesbian-gay-bisexual-trans-and-intersex-people http://www.lgbtihealth.org.au/sites/default/files/Cultural%20Competancy%20Framework https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/08_2014/national_ageing_and_aged_care_strategy_lgbti_print_version https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/08_2014/national_ageing_and_aged_care_strategy_lgbti_print_version Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 47 Special needs of older people may include: Material well-being Emotional well-being Social inclusion Physical well-being Interpersonal relationships Self-determination Each State/Territory has its own prevailing protocols and systems that respond to the service needs of older people, for example: ▪ Australian Capital Territory – Elder Abuse Prevention Program Policy ▪ New South Wales – Interagency Policy for Preventing and Responding to Abuse of Older People ▪ Northern Territory – The Health and Well-being of Older Territorians ▪ Queensland – A Guide for Elder Abuse Protocols ▪ South Australia – Protocol for Responding to Abuse of Older People Living at Home in the Community ▪ Tasmania – Protecting Older Tasmanians from Abuse ▪ Victoria - Improving Care for Older People ▪ Western Australia – Elder Abuse Protocol: Guidelines for Action The following are things that workers need to consider when working with older people: ▪ Changes that ageing may bring to: o Physical processes o Cognitive function (including dementia) o Social interaction o Role and family relationships o Living arrangement o Level of independence (financial, community access, self-care) ▪ Loss and grief ▪ Family carer issues ▪ Societal attitudes and expectations http://www.communityservices.act.gov.au/__data/assets/pdf_file/0004/317605/Elder_Abuse_Prevention_Program_Policy_2012_FINAL_2 http://www.elderabusehelpline.com.au/uploads/pdf/FACS-NSW-Interagency-Policy-updated-November-2015 http://www.elderabusehelpline.com.au/uploads/pdf/FACS-NSW-Interagency-Policy-updated-November-2015 https://www.google.com.ph/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&cad=rja&uact=8&ved=0ahUKEwie1Pe7puvRAhVQObwKHfvlDn8QFgg2MAU&url=http%3A%2F%2Fdigitallibrary.health.nt.gov.au%2Fprodjspui%2Fbitstream%2F10137%2F577%2F1%2FThe%2520Health%2520and%2520Wellbeing%2520of%2520Older%2520Territorians &usg=AFQjCNFKvUsXG70mcWHeffkpUfSXkBMKHA&sig2=5eVbHBDecv_zvF_gq2rq0Q&bvm=bv.145822982,d.dGo https://www.eapu.com.au/uploads/EAPU_general_resources/EA_Protocols_FEB_2012-EAPU http://www.sa.agedrights.asn.au/files/49_1095_aras_abuseprotocols_final3 http://www.sa.agedrights.asn.au/files/49_1095_aras_abuseprotocols_final3 http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0017/231812/Protecting_Older_Tasmanians_from_Abuse https://www.google.com.ph/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiu6Ouxs-vRAhVDVZQKHTVGA78QFggZMAA&url=https%3A%2F%2Fwww2.health.vic.gov.au%2FApi%2Fdownloadmedia%2F%257B8DF949D8-2851-4DFC-8B57-57A7E1C24E95%257D&usg=AFQjCNF69JnLhgTVY76BzbG6mpccz_srcA&sig2=jFdz_D286K6y6ELHQJBlYg&bvm=bv.145822982,d.dGo http://www.advocare.org.au/uploaded/files/client_added/SO103%20Elder%20Abuse%20Protocol%20v2 Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 48 People experiencing or at risk of homelessness Homelessness is defined under Australian federal law as inadequate access to safe and secure housing. This exists where the only housing to which a person has access: ▪ is likely to damage the person’s health, ▪ threatens the person’s safety, ▪ marginalises the person by failing to provide access to adequate personal amenities or the normal economic and social support of a home, or ▪ places the person in circumstances that threaten or adversely affect the adequacy, safety, security and affordability of that housing. For some people, being homeless means being ‘roofless’—living on the streets, in parks or in deserted buildings—this is the most visible kind of homelessness. For other people, being homeless means moving between various types of temporary shelters, such as the homes of friends and relatives, refuges and hostels, or living in boarding houses on a long-term basis, with shared amenities and without security of tenure. (Source: Homeless is a Human Rights Issue, Australian Human Rights Commission, 2008) Special needs of people experiencing or at risk of homeless include but are not limited to the following: ▪ Accommodation, that is, supported accommodation and/or assistance to obtain short- term accommodation and independent housing. ▪ Financial or employment assistance. ▪ Counselling/personal support in living skills and relationships. ▪ General support and advocacy, including legal aid. ▪ Specific services, including drug rehabilitation, disability services, health and medical services and culturally appropriate support. ▪ Assistance with basic needs such as meals and transport. https://www.humanrights.gov.au/publications/homelessness-human-rights-issue#2 Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 49 Each State/Territory has its own prevailing protocols and systems that respond to the service needs of people experiencing or at risk of homelessness: ▪ Australian Capital Territory – Social Housing and Homelessness Services ▪ New South Wales – Protocol for People in Public Places ▪ Northern Territory – Housing the Territory ▪ Queensland – Queensland Homelessness Information Platform ▪ South Australia – Homeless to Home ▪ Tasmania – Tasmania’s Affordable Housing Action Plan ▪ Victoria - Protocol for Assisting People Who Sleep Rough ▪ Western Australia – Forging Stronger Partnerships to Address Homelessness The following are things that workers need to consider: ▪ Indigenous people are disproportionately affected by homelessness as they face greater social and economic disadvantage than other sectors of the population. ▪ Women are significantly affected by homelessness, and the major causes include domestic violence, sexual assault, and family breakdown. ▪ Children and young people are disproportionately affected by homelessness, and this is strongly linked to relationship and family breakdown, domestic violence, physical and emotional abuse, anxiety and depression, unemployment, and substance abuse. ▪ People with mental illness are disproportionately affected by homelessness. ▪ People coming to Australia as asylum-seekers or refugees are particularly vulnerable to homelessness due to poverty and social isolation. http://www.communityservices.act.gov.au/hcs/services/social_housing/social_housing_and_homelessness_services http://www.housing.nsw.gov.au/__data/assets/pdf_file/0003/326046/ImplementationGuidelines https://housing.nt.gov.au/__data/assets/pdf_file/0010/117694/Homelessness_fact_sheetv3 http://www.hpw.qld.gov.au/Housing/Homelessness/QldHomelessnessInformationPlatform/Pages/default.aspx https://www.sa.gov.au/__data/assets/pdf_file/0013/13216/Homeless_to_Home_Publication https://www.dhhs.tas.gov.au/__data/assets/pdf_file/0003/203691/150596_TAH_Action_Plan_WCAG_d1 https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwj1uri6xOvRAhVHXbwKHQOkDFcQFggeMAE&url=http%3A%2F%2Fwww.portphillip.vic.gov.au%2FProtocol_for_Assisting_People_who_sleep_rough &usg=AFQjCNEImPt19nlgaxu0Nrh_YhZR2cqi7w&bvm=bv.145822982,d.dGc https://www.dcp.wa.gov.au/servicescommunity/information/Documents/Service%20Excellence/Protocols/WAPoliceProtocols Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 50 People with a disability One in five people in Australia have a disability, and this proportion is increasing with an ageing population. There are many different kinds of disability, and they can result from accidents, illness, or genetic disorders. A disability may be: ▪ Physical – affects a person’s mobility or dexterity ▪ Intellectual – affects a person’s abilities to learn ▪ Mental illness – affects a person’s thinking processes ▪ Sensory – affects a person’s ability to hear or see ▪ Neurological – affects the person’s brain and central nervous system ▪ Learning disability ▪ Physical disfigurement ▪ Immunological – the presence of organisms causing disease in the body Some people may have more than one disability; it may be visible or hidden, may be permanent or temporary and may have minimal or substantial impact on a person’s abilities. Although some people are born with disability, many people acquire disability. For example, a person may acquire a disability through a workplace incident or car accident or may develop a disability as they age. There is a strong relationship between age and disability; as people grow older, there is a greater tendency to develop conditions which cause disability. (Source: What is a Disability?, Australian Network on Disability, 2017) Special needs of people with disability include, but are not limited to the following: ▪ Home and maintenance modifications ▪ Goods and equipment/assistive technology ▪ Allied health (e.g. occupational therapy, physiotherapy, etc.) ▪ Respite care ▪ Independent living centres/services http://www.and.org.au/pages/what-is-a-disability.html Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 51 Each State/Territory may have its own prevailing protocols and systems that respond to the service needs of people with a disability, examples are: ▪ South Australia – Protocol about Young People with Disability in, or at Risk of Entering, Residential Aged Care ▪ Victoria – Disability Services – Aged Care Assessment Services Protocol ▪ Western Australia – Joint protocol to guide the assessment and support of younger people with disability ▪ The Department of Human Services also provides a Protocol for engaging people with disability. The following are things that workers need to consider when working with older people: ▪ Access to services for people with disabilities and their carers ▪ Family and carer issues ▪ Grief and loss ▪ Support in meeting individual needs and personal goals of people with disabilities http://www.dcsi.sa.gov.au/services/disability-sa/disability-sa-policies-and-guidelines/ypirac http://www.dcsi.sa.gov.au/services/disability-sa/disability-sa-policies-and-guidelines/ypirac http://www.dhs.vic.gov.au/__data/assets/pdf_file/0009/595296/cis_acasprotocolyoungpeople_pdf_0509 http://www.disability.wa.gov.au/Global/Publications/About%20us/Policies/protocol_for_younger_people_with_disabilties http://www.disability.wa.gov.au/Global/Publications/About%20us/Policies/protocol_for_younger_people_with_disabilties https://www.humanservices.gov.au/corporate/publications-and-resources/protocol-engaging-people-disability Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 52 STRATEGIES FOR INTEGRATING CULTURAL CONSIDERATIONS INTO ALL ASPECTS OF CASE MANAGEMENT PLANNING ✓ Find out the individuals preferred language and engaging an interpreter if required. ✓ Develop a cultural understanding by acknowledging all three layers of cultural factors and individual culture. ✓ Be sensitive to the individual’s gender preferences. ✓ Be conscious of physical contact, especially with those of the opposite sex. ✓ Be aware of differences in eye contact or handling belongings. ✓ Consult the person regarding their religious practice and make appropriate arrangements for them. ✓ Be aware of differences in communication styles. ✓ Be aware of differences in interpretation of meanings. ✓ Clarify the similarity of and differences between the provisions of services in the person’s country of origin and Australia. ✓ Seek the commitment of those involved in the planning to nurture cultural diversity. ✓ Learn to listen—listen to what is really said, not what you want to hear. ✓ Test for understanding—ask questions to be certain you know what is being said. ✓ Adapt your communication style to fit the situation—individuals from different cultures may react differently that is why you must know who you are communicating with. ✓ Use language that fosters trust and alliance. ✓ Understand the dimensions of diversity, use inclusive and valuing language, use diverse resources, readily adapt to differences in communication styles of diverse people, display respect for human differences and be aware if and comfortable about dealing with diverse issues. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 53 1.4 Provide Information on Rights of Appeal and Avenues of Complaint so the Client Understands Rights and Responsibilities Client rights are protected by legislation, codes of ethics, and standards. From there, the service develops policies and procedures which are the guidelines that operate in the workplace. The rights of the client include: •Clients must be treated with dignitiy and respect by workers while being responsive to social, cultural and physical needs of clients. The right to be treated with respect and courtesy •Informed choice—if a client is referred to another service, they need to understand what is involved and give their consent. The right to be informed and to give his/her views •Clients have access to all information held about them by the service. •Clients’ views should be taken into account in the planning and evaluation of the service. •Clients should be involved in discussions about their assessment and support plan. The right to be part of decisions about his/her care and/or case •Clients should be made aware of the standard of service which they can expect. •Clients have the right to be informed about the service, policy and procedures, expectations and rules of the service. The right to receive quality services •Client privacy should be protected. •Confidentiality—client information is not shared without the client’s approval and that files containing personal information are kept secure. The right to privacy and confidentiality Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 54 Vis-à-vis the concept of rights is the concept of responsibilities; rights cannot be viewed in isolation of responsibilities. While clients have the right to expect organisations to uphold all their rights, they also have responsibilities to fulfil as a client of the service. The client’s role is to collaborate with the case manager, agency and other key stakeholders in determining his/her individual, diverse and special needs, including aspirations choices, expectations, motivations, preferences, and values. His or her responsibilities include the following: As a case manager, you need to be aware of the rights, as well as the responsibilities of your client. You also have an obligation to uphold and support your client’s rights. One of the ways of upholding your client’s rights is to make sure that the clients know how to complain. Informing the service if they will not be available to attend an appointment Respecting the rights of the case manager, staff, management, volunteers, and other clients Taking responsibility for the decisions that they make Providing accurate and complete information that enables the case manager/staff to provide appropriate service Following through on tasks that have been agreed to Respecting and abiding by the rules of the services (as long as these are reasonable and have been agreed to in the first place) •Clients have access to a person who will defend and safeguard their rights and have their views and wishes genuinely considered when decisions are being made about their situation The right to an advocate •Clients have the right to complain about the service they are receiving. The right to make a complaint Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 55 There is always the potential that the services received by the client may not be perceived by the client as fair or appropriate. To enable the client to take action to recover any lost rights or even seek compensation, the service must have a policy that will guide its staff on how to manage complaints and ensure that the client’s right to have complaints and to appeal are fairly assessed. The service must provide information to clients about internal and external mechanisms for making a complaint. It must also act fairly and appropriately when a complaint is received. As the case manager, you may be tasked, in accordance with the organisation policy and procedures to: Inform the clients about their right to make a complaint and to appeal a decision. Inform clients about how to make a complaint and to appeal a decision, using either the internal or external mechanisms available to them. Inform clients about the support and advocacy available to assist them if they make a complaint or appeal a decision. Describe how complaints and appeals are raised, considered, decided upon and actioned in a timely and culturally appropriate manner. Explain procedural fairness and steps to make sure a client will not be disadvantaged by making a complaint or appealing a decision. Discuss how clients will be told of the outcomes of their complaint or appeal. Discuss how the outcomes of complaints and appeals will be used for continuous improvement. Clarify procedures and actions. Clarify the timing of any actions. Show the client when the complaint/appeal is approved and when it was last reviewed. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 56 2. Conduct Case Management Meetings One of your responsibilities as a case manager is to organise and oversee the delivery of services to clients. You connect the clients to the community and other relevant resources, and you work to protect the rights and well-being of the client. When working with clients to meet their needs, different parties are often involved including family members and health professionals. It may be necessary to organise meetings with these parties to plan and regularly review the delivery of a service and/or if a particular issue arises. It is also important to facilitate sharing of information and to establish rapport between parties. Information sharing may occur in the following formal processes: Case conferences – Provide holistic, coordinated, and integrated services across providers and to reduce duplication. Case conferences are usually interdisciplinary and include one or multiple internal and external providers, and if possible and appropriate, the client and family members/support system. Case review meetings – Used for information gathering to assist assessment and planning and interagency planning and coordination, review, and monitoring of the plan. Formal briefings on client progress – Include communication, information sharing and collaboration occur regularly with the case manager and other staff serving the client within and between agencies. These briefings may include activities such as directly arranging access, reducing barriers to obtaining services, establishing linkages, and other activities recorded in progress notes. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 57 2.1 Facilitate Information Sharing with the Client and Establish an Appropriate Rapport Case management generally involves a number of people, all of whom should be actively involved in assisting the client. Meetings are a good forum for all stakeholders to: Share insights about what is and is not working. Develop a shared sense of purpose. Find out how each of the stakeholders is feeling about the process. Develop better ways of working together to improve care. When a number of other services are involved, organisations may need to negotiate which service will take a lead role in coordination, and this role is usually taken up by the case manager of the service that has the most contact with the client. As part of their coordination responsibilities, this service takes on the duty of calling case conferences and chairing the meetings. Role of the Case Conference and Meeting Chairperson The role of the chairperson is to: Facilitate participation of all members. If necessary, to assist the client to put forward their views. Summarise the agreed outcomes. Check with everyone that they agree with the outcome and understand and understand what their role is. Make sure that the plan is written down. Arrange further meeting as required. Follow-up with participants to make sure they undertake the tasks they have agreed to. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 58 Information Sharing with the Client The key person in the meeting is the person receiving support. Information must be shared with the person regarding the purpose of the meeting and why certain people have been asked to attend. The case manager must have consent from the person. If the person is unable to give consent, an advocate, interpreter, or guardian must be included. In the case of unaccompanied young people in case management services, the service with statutory responsibility for the young person would be responsible for providing the consent and attending the case conferences/meetings. Case meetings should always aim to include the attendance of the person receiving support. The tone and context of the meeting should encourage service user participation. A case meeting should only be called in the absence of the person receiving support in the following circumstances: The person cannot be located, and there are concerns regarding their welfare. The person is in an institution (e.g. prison, hospital, etc.) and gives permission for the meeting to be convened. The person is incapable of giving permission (e.g. mental health concerns) and there is a clear need for the meeting to take place. The person is too intoxicated to participate but has given permission for the meeting to be held. There is an identified risk of violent behaviour at the meeting on the part of the person, but it is absolutely necessary to hold the meeting in order to progress the support plan. To inform the service providers of specific clinical information or behavioural traits for the purposes of ensuring a cohesive meeting with the service user. In such circumstances, a pre-case meeting may be convened with relevant service providers prior to the actual case meeting. There have been difficulties in interagency service communications which are related to process rather than the case itself, and these difficulties need to be resolved before the case meeting. Circumstances which may justify exceptions to the involvement of parents/carers (or their limited exclusions) according to statutory/legislative requirements. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 59 Establish Appropriate Rapport Rapport describes a positive relationship that forms between two or more persons. Once you have identified the possible barriers to effective communication and considered some strategies to overcome these, you can then look at how to build rapport with the client. Establishing appropriate rapport is an essential skill of a case manager. It is particularly important when you are interviewing clients, as it allows free and open discussion and provides better outcomes. Strategies for Building Rapport • Being clear about your role and the purpose of the interaction. • Using a person’s preferred name when speaking with them. • Paying attention to making them comfortable. • Using a pleasant tone that is clear and precise. • Explaining words and expressions that may be unfamiliar and not using jargon. • Asking simple and clear questions. • Explaining what you already know. • Explaining clearly any mandated position you have (e.g. You may have to report to other authorities any disclosure of abuse). • Explaining the actions that are undertaken both during the interview and as a result of the interview. • Using age-appropriate language; using words familiar to the other person. • Conveying acceptance by showing interest and concern. • Being sincere and realistic in goal-setting. • Not promising anything that cannot be delivered when the meeting is over . Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 60 2.2 Identify and Agree on Client and Worker Roles, Responsibilities, Boundaries, and Processes of Service Delivery It is very important that you and your client are clear about your role and responsibilities, as well as the service’s involvement in his or her care. Having a clear understanding of what you and the service can do and cannot do, enables you to communicate this clearly to your client and significant others. It helps to avoid misunderstandings, breakdowns in communication and unreal expectations being placed on you and the client. As a case manager, you are likely to be spending a lot of time with your clients, so you need to remember that, whilst you are part of the client’s support network and probably a very important part, you are not a friend. Boundaries in Working Relationships One of the more difficult ethical dilemmas with which you may be confronted relates to boundary violations in working relationships. This occurs when a professional worker or employee forgets that they are in a professional relationship and not a friendship. Once this professional relationship has been lost, there is then potential for the worker to become over-involved with the client and potentially violate the client’s rights. Professional boundaries need to be observed to ensure that professional standards are followed. Professional boundaries do not mean the avoidance of another person and their problems. To be effective in your work, you need to be clear about your role and boundaries, and be able to get this across to the client. The following considerations are useful in communicating the boundaries of your working relationship with the client: Identify the information you need to know. Only seek the information you need, not what you would like to know. Be clear with them about why you need the information. Be clear about the system you are part of. Let the client know what you can, and you cannot offer. Be aware of your own limitations as a person and a worker. Establish ground rules about your working relationship with the client from the outset, depending on the culture of your organisation. Be aware of your own feelings about the client and how those feelings may affect your working relationship with them. Be consistent with ground rules and applying boundaries. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 61 The issue of boundaries may be clarified through the development of guidelines provided for in contracts, codes of ethics, and manuals of practice. Also, provide clients with information on what they need to do or how they can participate in any planning, and empower them in the process. Processes of Service Delivery The social service sector provides the community with services that meet a broad range of needs. The delivery of services aims to promote physical, social, emotional, mental, and spiritual well- being. Service delivery has the following main functions: To provide service to the users. To provide the resources (staff, volunteers, facilities, equipment, skills, knowledge, etc.) necessary for the service. To maintain the service to a standard that can be used by all members. To balance the needs of the service users with the needs of the service and the needs of the community. To share and draw on skills/resources where needed. Service providers are workers in agencies who can offer your clients a service, resource or program to meet their needs. They could be government, private or community-based agencies. They could specialise in meeting particular needs, such as drug and alcohol support services, or they could offer general support to your client, such as counsellors or foster and respite care. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 62 Clarifying the process of service delivery enables the client to understand service offerings, including what the service does and does not include, eligibility, service limitations, cost, how to request services, and how to get help. Sp ec ia lis t se rv ic es a n d s u p p o rt • Income, financial and community support services • Employment services • Housing services • Access to recreation services • Care and support services • Transport and communication services • Family support services • Mediation • Counselling • Drug and alcohol services • Intervention and behaviour management • Specialist cultural liaison and support N et w o rk s • Specialist providers in the community services and health areas including health and cognitive assessments • Specialist services to assist communication with client and identification of their needs • Providers of any of the identified client services required by clients of the organisation Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 63 How are the services provided? The effectiveness of service delivery is determined by the service’s ability to best meet the needs of the client and their community. The integration of service delivery is deemed as one of the most efficient and most effective ways of using resources. Integrated service delivery refers to a number of service agencies working together to collaborate and coordinate their support, services, and interventions to clients. The focus is generally on clients or client target groups who have complex needs that require services for a number of agencies. Some efforts may be one-off, but more typically, there will be a system developed that enables services to meet or communicate and possible streamline processes, to provide ongoing coordination. The primary purpose of integrated service delivery approaches is to improve outcomes for clients. How this is achieved, and the factors that are important, will vary according to service settings, agency capabilities, and specific needs of the clients. They may include: ▪ Improving communication between agencies to monitor client progress and changes, and be more responsive to these. ▪ Identifying areas of duplication, working at cross-purposes, or what is creating confusion for clients about who is doing what. ▪ Developing one plan for the client which includes the work being done by/for all agencies. This plan may include actions and responsibilities the client agrees to do. ▪ Building understanding and capacity between the agencies, such as sharing practice frameworks and legal and funding limitations, so they can work together more effectively and generally support each other in their service delivery. ▪ Identifying systematic issues that create problems for clients and for services in their efforts to meet client needs. This may include identification of client groups or needs that ‘fall between the gaps’. Ideally, there will be a process whereby these issues can be brought to the attention of decision-makers. ▪ Development of streamlined processes which can provide more seamless services to clients, such as a common referral or assessment processes. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 64 How do agencies keep the integrated service process going? The following are tasks to be undertaken by agencies to keep the integrated service process going: ▪ Organise meetings ▪ Identify team member roles ▪ Develop a case plan ▪ Review the plan regularly ▪ Maintain contact between the team and external referrals ▪ Determine a process for conflict resolution or mediation when necessary ▪ Compile, distribute and maintain meeting records ▪ Close or transfer the case ▪ Evaluate the assistance provided (Source: A Guide to Integrated Service Delivery to Clients, QCOSS, 2013) 2.3 Determine and Agree Organisation, Family and Community Needs, Responsibilities and Rights The parties to a case management process include the organisation(s) providing services, the person receiving services, the family of the person receiving services, and the community. Organisation needs, responsibilities and rights Responsibilities of the organisation include the following: Provide services that: o Addresses the needs and the rights of the client o Meets ethical and legislative requirements o Meets service standards Ensure that the case manager and the workers have the required skills and knowledge to work effectively in their roles. Ensure that resources needed to implement the case plan are available for case managers and workers. http://communitydoor.org.au/sites/default/files/A_GUIDE_TO_INTEGRATED_SERVICE_DELIVERY_TO_CLIENTS Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 65 Rights of the organisation providing services include: The right to receive whatever resources have been agreed to with their funding body. The right to expect people who receive services to keep their arrangements and to work with staff members respectfully. The right to expect workers to follow organisational policies and procedures and to work within their job role descriptions, meet service standards and follow ethical principles. The organisation also needs resources relevant to its work. It also needs information from the person receiving services about the person’s situation, needs, goals and other factors affecting the case. Funding for organisations can be accessed in a number of ways, such as: ➢ Commonwealth-direct funding For certain areas of community services, the Commonwealth Government provides funding for organisations that are identified as eligible for supplementary funding. Organisations or services can only use this funding to cover costs arising from the Equal Remuneration Order (ERO). These costs include staff wages and staff on-costs. ➢ Commonwealth-state agreements For specific States’ efforts in delivering services in key sector, the Commonwealth provides funding mechanisms. The Australian Government is currently providing supplementary funding for the following programs of States/Territories: - National Affordable Housing Specific Purpose Payment - National Disability Services National Specific Purpose Payment - Transitioning Responsibilities for Aged Care and Disability Services, and Home and Community Care Programme Review Agreement - National Partnership Agreement Supporting National Mental Health Reform ➢ State/Territory-direct funding State or Territory government also directly funds services/organisations through different departments. The eligibility and funding requirements are provided in the State’s or Territory’s funding agreement which outline the terms, conditions and obligations of funding, service delivery, accountability for both the department and the funded agency. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 66 Family needs, responsibilities and rights Different cultures and different families will see rights and responsibilities differently. These variations may be culturally based and related to how different roles are constructed. While the family is not the primary focus of the support plan, families can provide support and insights into the client’s history and needs. Involving families must be done sensitively and carefully. Their right to seek legal advice at any stage of an intervention and the right to participate and be involved in what care will meet the needs of the client must be taken into consideration. Families who will be part of the support for the client should be informed that they have the responsibility to give enough information to the service provider so that the care plan can be developed and delivered. In cases where the client’s family might not be present or involved in the client’s life, understanding his or her family structure and dynamics is still necessary as these influence a person’s values and beliefs. It is also helpful for the case manager to recognise a family’s communication pattern and decision- making processes, as this will help establish a good working relationship with the family members involved in the care of the client. Family structure and dynamics Family structure can be defined in terms of parents’ relationships to children in the household (e.g. biological or nonbiological), parents’ marital status and relationship history (e.g. divorced, separated, remarried), the number of parents in the family, and the parents’ sexual orientation. Family dynamics are the patterns of relating, or interactions, between family members. Each family has a unique set of dynamics, which will impact the members’ development, ideas, and ways of behaving as well as how we interact with others. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 67 Communication patterns followed by families ▪ Consensual – Family members communicate freely about thoughts, feelings and activities, but at the same time, parents are the final decision-makers about important issues. ▪ Pluralistic – Family members believe in the value of ‘life lessons’ and expect their children to develop through their interactions with people outside the family unit. Decisions are made as a family with everyone having equal input. ▪ Protective - Family members do not value open conversation and children are expected to obey their parents and parents do not usually share the reasoning for their decisions. ▪ Laissez-Faire – Family members are often described as ‘emotionally divorced’ from one another. Not much is discussed among members of the family and parents often don’t have an interest or investment in the decisions made by their children. Decision-making processes utilised by families ▪ Consensus – A particular course of action is mutually agreed on by all involved. There is equal commitment to the decision, as well as satisfaction with the decision by family members. Consensus decisions are agreed on through discussion and negotiation. ▪ Accommodation – The family members’ initial feelings about an issue are conflicting. This type of decision making may involve a voluntary compromise in which approval is made by all persons concerned, or a sacrifice, made by one family member so that others may have their own way. ▪ De facto – Decision-making occurs when things are allowed to ‘just happen’ without planning. May also be made when arguments occur to which there was no obvious resolution or when issues were not brought up and discussed. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 68 Community needs, responsibilities and rights The community and its resources are the primary partners which may assist you, as the case manager, to deliver as much of the ‘help’ or service needed by the client as possible. With this in mind, the needs, responsibilities and rights of the community must be considered in creating the case management plan. While the community has a right to a safe and secure environment, it also has the responsibility to ensure it does not disadvantage those within the community or restrict the rights of its members in any way. As a case manager, make sure that the needs, responsibilities and rights of the community are balanced with the rights of the client receiving support. To do this, it may be beneficial to involve a community member in the case management meeting to ensure all responsibilities and boundaries are clearly defined. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 69 3. Develop an Appropriate Case Management Plan A case management plan is formulated on information gained in the client’s initial assessment. It documents the client’s priorities, short- and long-term goals, and identifies actions and required support resources. To be effective, the plan needs to be client-focused, client-directed and based on a holistic approach to assessment. The case management plan provides structure for the client, service providers and stakeholders. For service providers and stakeholders, it can be used as a key source of information about the client’s needs, goals and intended actions. It is a tool that creates focus and sets some realistic boundaries around the work you, as the case manager, and the client can do together. What does the client want That fits with resouces in the service system Within the time available Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 70 3.1 Collaborate with the Client to Identify Strengths, Abilities and Goals and Develop an Agreed Approach to Case Management Case management plans are developed in collaboration with the person receiving services and other stakeholders. The person receiving services is the primary stakeholder and has the primary responsibility for making decisions about their goals and needs. Developing a case management plan is a chance for you and your client to step back, work out what the end goal is for you to work together and think through the steps that are needed to achieve these goals. Collaborative planning Collaboration recognises that each party in a case management plan has something to contribute and that each part is equally valued. As an agreed approach to case management, collaboration is used to ensure that the person is empowered to develop and retain as much autonomy and control over their life as possible. Collaborative planning with the client helps them build self-reliance and play an active role in achieving the results they want. Collaborative planning is partly to increase the client’s engagement with the plan, but it is also a key tool in building trust by showing competence (Ballew and Mink, 1996). It also acknowledges the fact that client’s needs are often best served via collaboration between specialised services. Identify client strengths, abilities, and goals Strengths-based case management focuses on the inherent strengths and skills that people already have, and can be used as building blocks. This approach accepts that people aren’t defined by their problem, diagnosis or illness. Instead, they are defined by their capacity for growth and change. A strengths-based approach is a specific method of working with and resolving challenges experienced by the engaged person. It does not attempt to ignore the problems and difficulties. Rather, it attempts to identify the positive basis of the person’s resources (or what may need to be added) and strengths that will lay the basis to address the challenges resulting from the problems. The strengths of a person give one a sense of how things might be and ideas about how to bring about the desired changes. (Source: A Strengths-Based Perspective, Resiliencyravb xc Initiatives) https://www.esd.ca/Programs/Resiliency/Documents/RSL_STRENGTH_BASED_PERSPECTIVE Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 71 Assisting the client in identifying and recognising their own strengths forms an essential part of the assessment process. This information can be used to inform the case management approach that will be used. Explore the client’s strengths, abilities, and goals by asking questions that: Invite him or her to share his/her stories and enable them to clarify the challenges: o What’s happening? How do you feel about this? How long has this been a concern? o How is it affecting you and others? Help him or her explore his/her aspirations, dreams, interests, and goals o What do you want to be happening instead? o What will it look like when this concern is addressed? Help him or her explore his/her strengths and the exception to the concern o What strengths do you have that might be helpful? What do you do well? o What is happening when the concern is not present? Help him or her identify resources that might help him/her reach their goals o Who else might be able to help? o What other skills and resources might be helpful? Enable his or her to specify concrete steps towards his/her goals o What steps can be taken given your picture of the future, strengths and resources? o Who will do what? When? How? By when? Best practice in identifying client strengths, abilities, and goals ✓ Work on strengths assessment to identify what client wants/desires in various life domains ✓ Identify client’s talents, skills, and environmental resources that are currently available to assist in setting goals ✓ Explore talents, skills, and environmental resources that client has used in the past that could potentially be accessed and used in setting goals ✓ Prioritise wants/desires held by client in order to identify potential goals for the case management plan ✓ Use strengths-assessment to identify specific strategies for goal setting Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 72 3.2 Develop a Case Management Plan to Reflect Initial Assessment of Needs The case management plan is developed from the assessment information and lists the goals which the client wishes to work on. Each goal is broken down into actions or tasks which are allocated to the worker or client to do within a time frame. During the initial needs assessment, the case manager and the client identify: Immediate actions that need to be taken The client’s interests and preferences The client’s current circumstance The client’s strengths and abilities The various domains of the client’s life must be taken into consideration when developing the plan. These areas; social, cognitive, spiritual/cultural, physical/medical, and psychological/emotional, can impact one another. Thus it is important to consider the person’s needs collectively rather than individually when developing the case management plan. In developing the case management plan, the case manager needs to give priority to factors that will be easily accomplished. Questions to be considered include: Can the client accomplish the goal/s alone? Can the goal be broken down into smaller tasks? What resources are available to assist the client? Is there someone who can help the client to implement the goal/s? Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 73 3.3 Work with the Client to Identify the Full Range of Immediate, Short and Long- Term Needs of the Client and Other Relevant Parties A client’s needs may range from immediate safety issues, such as the risk of harm to self or to others, to medical requirements relating to acute illnesses, and longer-term needs regarding recovery and life management. After the assessment, immediate needs are identified, and the case manager must ensure that these needs are met. At the same time, short-term and long-term needs are recognised and included in the plan to guarantee that these will be met in the longer term. A useful roadmap for identifying needs is Maslow’s hierarchy of needs. The hierarchy starts with the basic physical needs such as the need for food and shelter. The second level of needs involves safety. Satisfying these needs involves protection from physical harm, including living in a safe neighbourhood. The third level includes needs related to belonging. Belonging needs are met when one is accepted and valued by a group, the family being the first social grouping. The next tier involves self-esteem needs, and the final level is the need for self- actualisation. The case manager first ensures that the client’s basic physical and safety needs are met, and then works with him or her on meeting its other needs. (Source: Maslow’s Hierarchy of Needs, Simply Psychology, 2016) http://www.simplypsychology.org/maslow.html Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 74 Identified immediate needs require an immediate response from the case manager, client or both. You must work with the client to determine an immediate action plan, with clear time frames. Ensure that it is clear to the client that immediate action and support is only to address immediate concerns and that through the development of the case management plan, less urgent and longer- term action planning can take place. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 75 3.4 Establish and Agree On Processes to Monitor and Change Case Plan Monitoring of the case plan with the client helps to identify progress, prioritise next steps and ensure efficiency in achieving goals. Monitoring occurs as an ongoing and proactive process to constantly inform the client, case manager, agency, and other providers with progress, gaps and areas of change. A formal case plan review should be conducted every three to six months by the case manager and client. A review will determine: The frequency and depth of any reassessments needed. Whether identified goals remain current. If the plan is satisfactory to the client and service providers. Any changes to the client, their situation or their environment. If decision-making has helped towards identified goals and the impact of goal achievements. Whether all strategies are adequately resourced, and all partners are contributing towards goal achievement. Ensure that monitoring and review include accurate and timely case notes on all activities undertaken and client responses to them. Organisations will benefit from conducting internal audits of client files to ensure agency case management standards are maintained consistently. Process to monitor and change case plan Review progress and re-strategise Identify barriers and respond to change Celebrate milestones Review agency/service involvement and possible transition or exit strategy Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 76 Review progress and re-strategise ▪ Engage and support the client with acknowledgement of their capacity, growth, insight, and motivation. ▪ Review the progress of the client towards planned outcomes, service and support activities against the case plan. ▪ Update and/or refine case goals, strategies and objectives to meet client needs and ensure goals are realistic and achievable. Consider the involvement of additional agencies or supports if necessary. ▪ Document and acknowledge progress. Identify barriers and respond to change The monitoring process is likely to identify gaps or barriers to progressing objectives of the case management plan. Work with the client and other service providers to identify the challenges/barriers and openly problem-solve: ▪ Is the goal still relevant? ▪ Has the situation changed? ▪ Is there new information that needs to be considered? Consideration of the client’s environment is critical to understanding barriers and developing best responses. Case managers will need to be creative and persistent, and provide an individualised response to difficulties arising, working within the client’s capacity and service’s resources. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 77 Celebrate milestones ▪ Ensure recognition is given at any level of achievements toward goals. ▪ Celebrate the successes and acknowledge the efforts of all involved in helping to achieve this. Ensure the client is acknowledged for their role and contribution. Review agency/service involvement and possible transition or exit strategy ▪ Determine whether or not the client still requires agency/service involvement. ▪ Review if your service is still the most suitable/appropriate service to be providing the lead case management role or if another service may now be more suited. ▪ If another service is identified as the preferred lead agency, take a proactive role in respectfully integrating a transition to a new service. This is discussed further in the evaluation, transition, or exit stage and should be planned well in advance to reduce any potential client anxiety relating to this change. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 78 3.5 Identify Strategies to Deal with Complex or High-Risk Situations Complex or high-risk situations that can be identified during case management planning include: ▪ Life-threatening/high-risk situations (thoughts of suicide/self-harm, violence/harm to others, drug overdose, refusal of help/medication, etc.) ▪ Cases where at least three (3) of the following factors are combined: o Serious/sustained abuse o Multiple difficulties present in family o Intellectual or psychiatric disability o Chronic and serious drug addiction affecting individual’s capacity to participate in their own care ▪ Where a wide range of other agencies are involved, for example, community services, legal, medical and police agencies. ▪ Where involvement of protective and custodial agencies with the family has been over a lengthy and sustained period. ▪ When the age of the client creates special considerations. ▪ Cases with high public/political sensitivity requiring sensitive and experienced case investigation and management. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 79 Strategies to deal with complex or high-risk situations Categorise risks and prioritise them to ensure that you can respond to the most urgent situation(s) appropriately and immediately. Assist the client in determining the urgency of need, and to recognise when personal safety, or the safety of others, is at risk and take action to avoid harm. Familiarise yourself with the service’s policy and procedure, protocol or process on dealing with complex or high-risk situations. Document information provided by the client very carefully. Make a judgment whether the situation at hand is a crisis and requires a formal crisis response. In working with clients in a crisis, you are aiming to: o Support the client to move out of the crisis phase as soon as possible o Provide individual and agency support o Mobilise the client’s own support system o Use outside supports as required Depending on the crisis, you may have a legal responsibility to notify authorities or emergency services if needed. Even if it is not an emergency, your service may require you to inform your supervisor when a crisis arises. A major priority in crisis is to make sure people involved, including you, are safe and secured from any immediate physical danger. Arrange for immediate support for key people involved in the crisis. This includes significant others and/or people who have involvement with the client now or in the past. o Support can also be moral and/or emotional, such as arranging for debriefing for people directly involved or for a friend/relative to be with your client during the time of crisis. Use crisis services or agencies as appropriate. Crisis services offer short-term assistance and support. Many are specialist services which deal with people experiencing a particular kind of crisis, such as: o Emergency accommodation o Material/financial aid o Respite care o Domestic violence outreach/refuge o Sexual assault counselling/advocacy Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 80 3.6 Match Requirements of Case Plan to Experience, Workload and Geographical Location of Worker or Service Provider Match requirements to experience, workload, and geographical location of worker The practice of case management is complex, involving multiple roles and skills. The case manager’s qualification and experience should be congruent with the skills required to fulfil his or her case management responsibilities. Case managers should accept cases and duties only on the basis of existing competence. Should the case manager need additional knowledge or skill to perform case management responsibilities, he or she should pursue professional development activities (including supervision and other activities) to acquire the necessary competence. Workload is the amount of work required to successfully manage assigned cases and bring them to resolution. Workload reflects the average time it takes a worker (1) to do the work required for each assigned case and (2) complete other non-casework responsibilities. The workload of the case manager must be considered during case management planning as the complexity of cases varies from one client to another. The complexity of the case also dictates the involvement and the tasks that the case manager will be responsible for. The location of both the client and the case manager must also match because additional time must be factored in for planning, travelling, and post-visit activities. Contact frequency must be included in the plan; specific types of clients or intervention may require a high contact frequency at specific points of the case management process. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 81 Match requirements to service providers If the client requires support that does not fall within the scope of your agency, you may need to investigate other options and refer them to another service provider. The following are the things you need to consider to match the requirements of the case management plan to the service providers available: Is this the best possible service provider to refer to this client to? Will they be able to adequately meet the needs of the client? Are there specific protocols (cultural and/or otherwise) that must be followed to ensure effective referral processes? Understanding the services and requirements of the agencies that are going to be included in the case management plan will enable you to provide best possible support to the client. 3.7 Assist Clients to Set and Achieve Realistic Targets for Change or Action and to Take Personal Responsibility Once the immediate, short- and long-term needs are identified, related strategies and specific goals are developed to address these needs. Ensure goals are SMART. Work with the client to identify their primary goal with you; this goal should be measurable, so the client knows when it has been achieved. Maximise the strengths of the client and their networks when determining actions and be confident about client and agency resources and capacities. Develop a plan of action for achieving goals with the client and include any other services to be involved. Develop goals and strategies that are specific to achieving the desired outcomes. SMART Goals Specific Measurable Attainable Realistic Timely/Time-bound Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 82 Strategies for motivating, supporting and encouraging the client to take personal responsibility Employing strategies to motivate, support, and encourage clients is one of the responsibilities of case managers. There are a number of ways to support clients who need to be motivated, to make decisions for themselves, to have the confidence to act on those decisions, and take responsibility. You can encourage clients to take personal responsibility by: Asking them how they think a situation should be handled, rather than telling them how to handle it. Assisting them to think of options based on prior success in their individual situation, rather than options based on theory. Assisting them to select an option rather than telling them which one to choose. You can support clients to take personal responsibility by: Encouraging them to reach a decision. Emphasising that they have reached a decision and now they need to act on it. Affirming their ability to make decisions and develop steps to reach their goals. Also, offering or arranging practical help can support clients to take on personal responsibility. It is important not to overlook practical matters, for example, those associated with a client’s capacity to accept and access programs they are referred to. Attention to practical matters, such as the cost of equipment or transport, can ensure that they are able to access programs and resources more easily and increase the chance of their success. However, it is important in this process to refrain from doing things for clients that they can do for themselves. Encouraging dependency can disempower people, prolong intervention and set up failure. Focusing on the client’s strengths and what is working in their situation motivates them to take on responsibility and move towards change. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 83 4. Monitor and Review Casework Activities and Processes The case management plan needs to be treated as a dynamic document that can be updated in response to the client’s changing needs. Not only many client’s needs change, but goals may no longer be relevant or may have been achieved ahead of schedule. Case managers need to have formal processes in place to regularly monitor and change the plan as required. Monitoring and review mean evaluating progress on the case management plan to determine whether it is effectively meeting goals or whether the plan needs to change. A plan will usually include review dates to ensure this happens regularly. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 84 4.1 Implement Strategies to Regularly Monitor the Effectiveness of Case Management Processes Against Agreed Goals, Service Provision and Client and Stakeholder Satisfaction When actions have been planned, work with the client to establish how the plan will be maintained and reviewed. Together you need to decide how, and how often, the plan will be reviewed. If, as part of the monitoring process, a client’s personal information is to be shared with another service, written permission must be provided by the client. The agreed monitoring and review activities and processes generally include: Monitoring case plan implementation. Facilitating review activities and feedback from workers on the progress of intervention. Liaising with service providers and significant others. Advising on how case plans can be modified, ensuring that changes are communicated appropriately. Regular meetings with client/families/significant others. Referring to goal plans developed and individual’s progress towards these goals. Strategies to regularly monitor the effectiveness of case management processes include: Scheduling meetings at regular intervals Preparing and distributing referral forms Preparing and distributing feedback forms Preparing and distributing client consent forms Developing a directory of services Developing methods of communication between services (phone, face-to-face meeting, email) Accompanying the client to a service Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 85 4.2 Assess the Need for Changes in Case Plan and Develop Strategies for Appropriate Alternatives and/or Ongoing Interventions Regular and scheduled monitoring allows you and the client to celebrate achievements, review progress and plan the next steps. It is also a chance to begin to work towards exit planning once the client has made significant progress. Monitoring is also a chance to check that the service system is working as it should. If a need is not being met because a service is unavailable or unwilling to help, then advocacy or a change of plans may be needed. Review can take place one on one with the client or in a case management meeting including workers from other services that are working with the person. Work with the client through a review of achievement against the plan. You may also work with the client through an analysis of change compared with the original assessment tool. Reviews can be scheduled regularly or triggered by a change in circumstance. Case management plans are adjusted regularly to fit with changing priorities and goals. Some considerations assist in assessing the need for changes include: Has the identified problem changed or what is different? Were the desired outcomes achieved? What was not achieved? What were the barriers that prevented goals being achieved? To be able to develop strategies for appropriate alternatives and/or ongoing interventions, each client is provided with opportunities for ongoing assessment and reassessment of their needs. Re- assessment to be able to develop appropriate alternatives or to determine whether there is a need to modify the case management plan may be necessary if there is: Change in the client’s medical condition Change in the client’s social stability and network Quality care issue Risk management issue Concern regarding the transition/exit plan Change in the client’s functional capacity and mobility Evolving needs apart from those identified during assessment Issues in the availability of community resources/services Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 86 4.3 Negotiate with Relevant Parties any Proposed Changes Arising from Case Review A schedule of regular meetings should be set up with the client. During these meetings, the plan can be reviewed, and indicators of success examined. If it appears that targets are not being met, the plan may need to be revised. If agreed to by the client, the case manager should communicate with the service providers to gain an insight into the client’s progress. Communication may occur through a formal meeting or conference session, via telephone or in writing via email or letter. Negotiating the revision of the case management plan and goals should always be in collaboration with the client. Some clients are able to carry on with the work that needs to be done, while others may remain ambivalent and hesitant. The case manager must be flexible enough to allow goals to be changed or revised and to help clients explore the possible barriers that will impact on the client’s capacity to carry these out. Negotiation with the clients is easier if the evaluation process is explained during initial interviews. Apart from the clients, the case manager must also negotiate with other relevant parties especially when there are changes arising from the case review. All relevant parties must be informed of the proposed changes and must be provided with the opportunity to discuss the changes and reach an agreement that will benefit the client. Negotiation is an ongoing part of a collaboration with the client, support system or caregiver, providers, and other pertinent stakeholders. The following steps may be used in negotiating with them: 1. Identify the proposed changes from the case review. 2. Understand and explore the proposed changes. Identify whether these changes will pose an issue or conflict with relevant stakeholders. 3. Identify the actual conflict and decide what must be achieved to resolve it. 4. Identify and explore alternatives by listing all the possible solutions—brainstorm if necessary. 5. Choose a course of action and agree on it. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 87 4.4 Document All Casework Interventions in Compliance with Evidence-Based Practice and Confidentiality Requirements Case notes are an integral and important part of practice for case managers. Record-keeping practices have an impact on client outcomes such that poor case notes can result in poor decision- making and adverse client outcomes. A case note is the term applied to a chronological record of interactions, observations and actions relating to a particular client. It is also used to record details of the interaction of other services regarding a client issue. Information that should be included in a case note The guiding principle for deciding what information should be included in a case note is whether it is relevant to the service or support being provided. According to the Australian Association of Social Workers (2016), the type of information that is considered relevant will depend on the context of practice, however, below are some broad guidance: A range of biopsychosocial, environmental and systemic factors impacting on the client. This includes consideration of an individual’s culture, religion and spirituality. Risk and resilience factors. Facts, theory or research underpinning an assessment. A record of all discussions and interactions with the client and persons/services involved in the provision of support including referral information, telephone and email correspondence. A record of non-attendance, either by the case manager or the client, at scheduled and agreed meetings or activities. Evidence that the case manager and the client have discussed their respective legal and ethical responsibilities, that may include: o Client rights, responsibilities and complaints processes. o The parameters of the service and support being offered and agreed to. o Issues relating to informed consent, information sharing, confidentiality and privacy. o Efforts to promote and support client self-determination and autonomy. o Specific responsibilities to clients in particular settings (e.g. private practice or rural settings). o Professional boundaries and how dual relationships may be managed. o Record-keeping and freedom of information. o Discharge planning. o Relevant legislative requirements and their possible implications for practice. Details of reasons and any related actions or outcomes leading up to, or following, the termination or interruption of a service or support. https://www.aasw.asn.au/ https://www.aasw.asn.au/ Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 88 General principles for good record keeping Information about a client should be impartial, accurate and complete with care taken to ensure that: Only details relevant to the provision of a support or service to which the client has consented are recorded. Information recorded is relevant to statutory practice, especially when working with involuntary clients. Notes are free from derogatory or emotive language. Subjective opinions are qualified with relevant background information, theory or research. Relevant information is not omitted. When recording information about third-parties, such as information about a client’s relationship with significant others, it is equally important to separate fact from opinion. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 89 How and when should case notes be recorded Case notes can be recorded manually or electronically and should: Include on each page the name and date of birth or other identifying information of the client. This can be handwritten, typed or constitute an electronic tag where an electronic case recording program is utilised. Be dated. Be recorded as soon as possible after an interaction or event. Be typed or clearly readable if handwritten. Include the name, signature and profession/role of the author. Include the time of contact, particularly where there is a high volume of interactions in a day. Changing or amending a case note Care should be taken to avoid errors or omissions. In some instances, it is illegal to change, white- out or amend case notes after the fact (on a later date). If a change must be made to correct an error or omission, the change can be recorded as a new and separate case note. In addition to outlining the error or omission as part of this new case note, it is also advisable to: Provide an explanation for the inaccuracy of the information recorded, and add a note in the margin of the original case note referring the reader to the additional or amended detail. A case note should never be amended or changed in light of additional information obtained at a later date. This should always constitute a new case note. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 90 Legislative responsibilities with regard to case note recording Case notes may be subject to a range of legislative processes and requirements, during and following, the conclusion of the professional relationship. The nature of these requirements may differ greatly according to the State and the nature or context of practice. Organisations may have policies and procedures for ensuring these and other legislative obligations are met, in addition to general guidelines for case note recording and management. As such, it is important for case managers to: ✓ Be familiar with the specific legal requirements and processes impacting on practice. ✓ Consider the implications of federal and State legislation to the recording of case notes. ✓ Understand how these requirements are implemented within your organisation (where relevant). Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 91 4.5 Implement Case Closure in Accordance with Organisation Procedures The case manager should appropriately terminate case management services based on established organisation procedures. Case closure planning begins during the development of the case management plan and continues throughout the entire case management process. The ultimate aim of case management is to implement and identify a diverse range of formal and informal supports and resources to enhance a client’s ability to be as independent as possible. The disengagement phase comes about when the client reaches their nominated goals and is acting independently. Case closure planning or exit planning is a supportive way to help clients prepare to continue without the service you have been providing. Some services have guidelines that only allow service provision for a time-limited period. Possible reasons for case closure The case manager may withdraw case management support for a number of reasons including the following: The client moves out of the service area The case manager is unable to locate the client Identified problems are resolved, and the client is now independent The client enters a residential facility (i.e. nursing home, correctional centre, etc.) and services are no longer needed The client chooses to withdraw from services Resources necessary to support the client are not available from your service The client dies Tasks to be completed for case closure While all services will have specific requirements in relation to case closure, there are a number of common tasks that need to be successfully completed in the process: Identifying the need for the client to exit from the case management process. Advising the client verbally and in writing of the decision and reasons to withdraw from case management services. Conducting an exit interview with the client, their family and their significant others to facilitate transition to other services, if appropriate. Reviewing the achievements of the case management plan in meeting agreed on goals. Completing the transition process. Collecting any supplied equipment. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 92 Notifying the client, all service providers and informal support networks of relinquishment of the case management role. Completing and securely storing all documentation. Services need to determine what information they need to record when a client exits a service, when the case is closed, and how that information is to be recorded. Client exit form – may be used to record exit details and follow up plan Exit planning checklist – an alternative to a client exit form is to keep a checklist of the kinds of information you may need to record when a client leaves. This checklist can be used as a prompt and the information recorded in case notes. After the client has exited the service, it is important that the case manager maintain a relationship to enable positive engagement and support to transition and stabilise into their accommodation and the community. This is formalised and implemented via outreach services to the client and in collaboration with other service providers and significant people in the client’s life. Be sure to check your organisation’s policies and procedures as not all services are able to provide this follow-up. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 93 II. ASSESS CO-EXISTING NEEDS 1. Prepare for Assessment Assessment is a dynamic and ongoing process of gathering and analysing relevant information to determine appropriate support services. Due to the often-complex nature of the issues facing clients, assessment is not always a single event or a linear process. Assessment occurs at different times throughout case management. It is essential to prepare for assessments to ensure that the assessment process takes into account the different physical, emotional, social, cognitive, and cultural needs of individuals. Establish rapport during initial consultations to identify the need for assessments. When you identify a need, negotiate an appropriate time and place for assessment, and inform the person about relevant policies, such as their right to privacy. The individual also needs to provide their written consent for the assessment. To ensure the individual understands the process, you need to arrange for an interpreting service. When preparing for assessment, the following questions should be considered: Is an assessment required? What is the reason for the assessment? What issues/needs are being assessed? Which type of assessment will best address these needs/issues? Will the assessment tool be relevant to the person’s individual characteristics and circumstances? What is my role in the assessment process? Does the person require referral to a more qualified or specialised agency for assessment? How will the assessment be conducted? Where should you conduct the assessment? What resources will you need to conduct the assessment? Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 94 1.1 Identify and Prepare Assessment Tools and Processes According to Organisation Policy and Procedures A diverse range of assessment tools and processes are available for use in the community service sector. Identification of the most appropriate assessment tool requires a thorough understanding of the types of tools available, their use in different contexts, and the processes, policies, procedures, and guidelines of your organisation. Different types of assessments The type of assessment required varies depending on the context and the person’s specific needs. Generic assessment Generic assessment involves the collection of information about a client’s situation in greater depth. This information may include past and current health conditions, service utilisation, socioeconomic and financial status, insurance coverage, home condition and safety, availability of prior services, physical/emotional/cognitive functioning, psychosocial network system, self-care knowledge and ability, and readiness for change. This type of assessment identifies the client’s key problems to be addressed, as well as individual needs and interests. Intake assessment Intake assessment is the initial meeting with the client during which the case manager gathers information to address the client’s immediate needs to encourage his/her engagement and retention in services. This type of assessment may also be used to screen clients to determine if they need case management services and if so, to determine the model of case management most appropriate to meet a client’s needs and to assess the client’s willingness and readiness to engage in case management services. Social assessment Social assessment is the process of determining individuals’ perceptions of their own needs or quality of life, and their aspirations for the common good, through broad participation and the application of multiple information-gathering activities designed to expand understanding of the community. This type of assessment helps in identifying and interpreting the social conditions and perceptions shared by the community or organisation level. Social history report Social history report focuses on, and describes, the social aspects of the client’s functioning and their situation. This documents the social aspect of the past and current life experiences of the client. Information collected can assist the social work practitioner or the case manager to better understand the client’s level of functioning and the most appropriate plan of intervention. Risk assessment Risk assessment focuses on identifying any immediate or potential risks to the safety of the client or others. This is used to determine the client’s vulnerability to harm and potential risk including immediate housing circumstances, physical and mental health concerns and any external safety risk, such as domestic or family violence. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 95 Biopsychosocial assessment Biopsychosocial assessment is used to identify the unique contributions of multiple domains of possible factors to an individual’s overall physical and psychological health. This approach looks into the varying levels of physical, cognitive, emotional, behavioural, and environmental factors that contribute to the overall assessment of a client. Roles and responsibilities of the following who may be involved in the assessment process Case Manager The Case Manager’s role in the assessment process is to facilitate the ongoing gathering and appraising of data from various sources to identify areas where the Case Manager and the client will focus their efforts. Responsibilities of the Case Manager include: Ensuring that the clients understand their rights and responsibilities, supported by evidence of the client’s consent Gathering information about clients while respecting their confidentiality and privacy Identifying and prioritising the client’s initial needs to inform more comprehensive assessment once initial screening is completed Understanding the client’s individual, diverse and/or special needs so that the appropriate services and support for client development occurs Stratifying and analysing risk factors that the client experience/may experience Communicating the needs of the client which fall within the aims and objectives of the program Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 96 Considering the client’s current situation, probable future situation and ensuring holistic needs Communicating the criteria for disengagement with client Facilitating information sharing across the client, key stakeholders and agency Client The client’s role is to collaborate with the case manager, agency and other key stakeholders in determining his/her individual, diverse and special needs, including aspirations choices, expectations, motivations, preferences and value. Responsibilities of the client include: Informing the service if they will not be available to attend an appointment Respecting the rights of the case manager, staff, management, volunteers and other clients Taking responsibility for the decisions that they make Providing accurate and complete information that enables the case manager/staff to provide appropriate service Following through on tasks that have been agreed to Respecting and abiding by the rules of the services (as long as these are reasonable and have been agreed to in the first place) Key stakeholders The key stakeholders’ (a person or group with a direct interest, involvement, or concern regarding the client and/or the case management care plan) role in the assessment process is to provide input on the identified client needs and/or issues. Responsibilities of the key stakeholders include: Assisting the client and case manager in identifying diverse and/or special needs/s, risk factors, and issues regarding the client’s level of competency/capacity Collaborating with the client and case manager in prioritising and addressing risks, and identifying risk management strategies Participating in ongoing planning and consultation with the case manager and the client Providing feedback on referrals to alternative programs or settings where the client’s individual, diverse and/or special needs and goals can be met more appropriately as suggested by the case manager Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 97 Agency The agency or provider’s role is to provide case management services to effectively and efficiently coordinate and organise the range of services clients would be referred to in the health and community services industry. Responsibilities of the agency or provider include: Providing equitable and non-discriminatory access to people eligible for service Providing adequate information about the service, how services will be delivered, and how the client will be involved in any decisions that affect them Ensuring that there are documented policies and procedures to maintain client’s privacy and confidentiality Ensuring that policies and procedures for handling complaints are in place so that client can raise issues and have them deal with in open and supportive environments Providing services in a safe manner and secure environment Responding effectively to a client’s decision to involve an advocate in their dealings with the service Roles and types of assessment tools Assessment tools are used to support comprehensive assessment and provide baselines for future assessments. It can also help identify the indications for particular interventions. Types of assessment tools ▪ Demographics and background ▪ Employment and socioeconomic class ▪ Need for longer-term support ▪ Past medical history and background ▪ Previous agency involvements ▪ Psychosocial and behavioural health ▪ Psychosocial support systems ▪ Normed depression screening tools Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 98 Assessment tools—reliability and validity It is important to consider the reliability and validity of the results when using questionnaires and screening tools. The tools should accurately measure what they are supposed to, and they should be reliable in that they produce the same results across time and can be interpreted in the same way by different case managers. Methods of collecting information ▪ Self-reports – involves direct communication with the person. Corroboration from other sources should be sought if the person’s capacity to provide accurate information is in doubt. ▪ Informant reports – these reports from other key sources may be informal (family members, carers and neighbours) or formal (GPs, service providers, teachers). It is often assumed that carer reports will be more accurate than those provided by people themselves. ▪ Health records – these are existing health records, such as referral summaries, medical records or previous assessment reports, which can be accessed with the person’s consent. Preparing for assessment Prepare the client for assessment by clearly explaining the assessment processes, and ensuring that he or she has the advocacy and additional support they require to complete the assessment and express their needs. Establishing rapport When conducting complex assessments, it is important to first establish rapport with the client. Assessments are often conducted in individual sessions, meaning one assessor is assessing one client. There are several reasons why establishing rapport is important. Rapport: ▪ helps establish trust between the assessor and the client ▪ helps facilitate effective communication between the assessor and the client ▪ makes the client feel comfortable and more open to assessment ▪ helps the client to not feel judged or undervalued ▪ is required for valid testing and assessment, and accurate results ▪ minimises client apprehension and resistance Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 99 Impact of the setting on the process Arranging an assessment that involves other parties, such as the client’s family members or a health professional must be scheduled at a time and location that suit all relevant parties. All relevant parties must be informed of the time and place well ahead of schedule so they can make arrangements. The assessment must be conducted in a location that is convenient for the case manager, the client, and other relevant parties. Ensure that the assessment will be conducted in a safe and secure environment. There are times that the assessment will be conducted in the client’s home or in the service. Even in different environments, the case manager is responsible for conducting the assessment in a comfortable room that is private to ensure that confidentiality can be maintained and that others cannot hear the conversation. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 100 1.2 Gather Existing Information about the Person Establish the sorts of information you need as a basis for working with a client, thinking broadly about what aspects of a person’s life will impact on his or her ability to achieve their goals. Existing information about an individual can be gathered from a variety of sources. Additional ways of collecting information include: Interviews with the person Questionnaires Specific screening tools Speaking with the person’s family members, guardian, carers, and friends Speaking to other care workers and service providers Observing the individual Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 101 Assessment of needs and strengths across life domains may include, but are not limited to the following: Children Cultural Employment, education, and training Health and well-being Housing and accommodation Interpersonal relationships (family and social systems) Personal safety planning Daily living requirements Financial and legal Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 102 1.3 Seek Additional Information from Specialists and Other Sources as Required to Determine the Range of Issues that May Be Affecting the Person Assistance from external and specialist assessment support may be required to undertake a thorough assessment (e.g. psychiatric services, physiotherapy services, etc.). With the client’s consent, use internal or external specialist supports to help inform the assessment. Additional services which are currently involved, or have a history of involvement, can also inform the assessment process. Such services can assist in validating information gathered. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 103 1.4 Organise Practical Aspects of Assessment in Consultation with the Person Being Assessed Prepare the client for assessment by clearly explaining the assessment processes and ensuring that they have the advocacy and additional support they require to complete the assessment and express their needs. The practical aspects of the assessment must be discussed with the client. These aspects include the: Reason for the assessment Role of the client in the assessment process Role of the case manager in the assessment process Where and how the assessment will be conducted Rights of the client, including his or her right to: o Privacy and confidentiality o Refuse to give personal information o Access personal information o Make a complaint Legal and ethical considerations to guide your assessment practice ▪ Confidentiality - There is an obligation that restricts an individual or organisation from using or disclosing information about a person that is outside of the scope for which the information was collected. In the course of the assessment process, the case manager must treat all information as confidential, unless otherwise required by law. ▪ Disclosure - Information about clients or confidences made by clients and others must not be disclosed, unless: o Client’s consent is in existence o Required by law o There are compelling and overwhelming moral and ethical reasons for disclosure. When and if records are required to be shared across professions or agencies, information will be disclosed only to the extent that it reasonably addresses/supports the client’s needs and meets the essential requirements of those to be notified. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 104 ▪ Duty of care - The obligation to take responsible care to avoid injury to a person whom, it can be reasonably foreseen, might be injured by an act or omission. Duty of care exists when someone’s actions could reasonably be expected to affect other people. A breach of duty of care exists when it is proven that the person who is negligent has not provided the appropriate standard of care. ▪ Informed consent - The client must be given sufficient information about assessment to make a decision for consent to be given voluntarily. Without full consent, assessment should not take place. Before assessment commences, the client must fully understand and consent to: o The assessment taking place o The purpose of the assessment o How assessment is conducted o The dissemination of assessment results and personal information to other relevant parties ▪ Privacy - Client’s records must be protected, stored and secured, and where applicable, retained for any required statutory period. When and if records are required to be shared across professions or agencies, information will be disclosed only to the extent that it reasonably addresses/supports the client’s needs and meets the essential requirements of those to be notified. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 105 1.5 Provide Information About the Assessment Process to the Person and Obtain Consent Client involvement in the assessment and selection of services to meet their needs is good professional practice, but there is also a legal obligation to obtain client consent. Some legislation (e.g. Child Protection Act of 1999, Qld) enshrines the client’s right to participate in decision-making related to case management. Before assessment commences, the client must fully understand and consent to: The assessment taking place The purpose of assessment How the assessment is conducted The dissemination of assessment results and personal information to other relevant parties Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 106 The essential elements of the law about consent are as follows: The person who is giving consent must have the intellectual capacity and maturity to understand the situation they are consenting to, the choices that are available and the consequences of their decisions (i.e. the likely risks and benefits). This applies to all people, regardless of age and whether or not they have a disability. In order for a person to provide informed consent, the person must be given sufficient accurate information about the matter or procedure, and that information must be presented in such a way that the person can fully understand it. Any consent must be freely given and must not be obtained by force, threat, deception or undue influence. A person may be able to make decisions and give valid consent in some areas of their life but not in others depending on their skills and experience. Consent must be obtained in writing from the client being assessed. The record of consent must detail exactly what the client has consented to. If the assessment results need to be shared, the client must be informed about who results will be shared with and the purpose of sharing results. The record of consent must be filed according to organisation policies. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 107 2. Analyse the Person’s Needs Using a Collaborative Approach The analysis and prioritisation of needs identified during assessment should be undertaken in collaboration with the person and, if necessary, through consultation with a specialist. A specialist’s input is of particular importance if the person’s needs are complex and urgent. Once the needs are identified, information about available services can be compiled and the person’s eligibility to access the services can be determined. Decisions about how to proceed can then be made by the client. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 108 2.1 Work Within Scope of Own Role and Seek Assistance from Colleagues and Experts as Required The scope of work provided by a case manager varies according to organisation context. In many services, a particular case manager takes on the responsibility for providing support consistently to a client. Day-to-day tasks may be carried out by other staff or workers. However, the case manager completes the assessments (where appropriate) and gathers other relevant information. The case manager may need to consult with others when analysing client assessment results, such as other workers or service providers who have provided input to the process. For example, where a psychologist has identified that a client is depressed, the case manager may need to discuss how this may affect other areas of the client’s life, such as their ability to engage in self-care tasks and relate to others. It is a must that the case manager adheres to his or her own work role and responsibilities and does not attempt to interpret results outside his or her own scope of practice. It is important to clarify your own work role and work with organisational protocols, your scope of practice, your position description and your qualifications. When necessary, seek assistance from colleagues and experts. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 109 2.2 Empower the Person to Identify and Prioritise Their Own Needs Empowerment is the ongoing capacity of individuals to act on their own behalf to achieve a greater measure of control over their lives and destinies. Empowerment is consistent with a collaborative approach and client self-determination. Use verbal and nonverbal communication skills, such as empathy, active listening and maintaining eye contact when identifying the diverse needs of the client. Effective interpersonal communication skills can be used to communicate respect and empower clients. By assisting the client to identify their own needs, the case manager empowers him or her and enhances his or her participation in the assessment process. It is good practice to prioritise needs in close collaboration with the client, and if necessary, with the client’s family, guardian or carer. Viewing the client as an equal, who plays an important role in the case management process, promotes the client’s sense of control and self-efficacy, which in turn promotes active participation in dealing with issues. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 110 2.3 Evaluate Needs Based on Full Range of Relevant Information Case managers need to adopt an approach that emphasises the need to look at the whole person and consider their physical, environmental, emotional, social, spiritual, and lifestyle situation. To achieve this, the case manager must attempt to understand the interplay of personal, relationship, and social factors that affect the current situation for each client. In evaluating the client’s needs based on a full range of relevant information, the case manager should: Appreciate the complexity of the client’s concerns/situations and the environment in which these concerns/situations occur. Understand how these concerns/situations affect the client in all aspects of their functioning; physical, emotional, spiritual, and mental. Establish an effective and trusting relationship with the client to be able to explore their needs. Liaise with other significant people or organisations in the client’s life to facilitate the client’s goals and action plans. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 111 2.4 Identify and Analyse Complex, Multiple and Interrelated Issues Working with clients in a holistic approach allows the case manager to realise that individuals and the situations in which they find themselves, may be very complex. Clients are likely to present with multiple issues, and it is the case manager’s task to be able to effectively identify and analyse these possible interrelated issues. People with complex needs may have to negotiate several issues in their life, such as physical or mental illness, substance abuse and disability. They may be living in unsatisfactory circumstances and lack access to suitable housing, employment or meaningful daily activities. Each individual with multiple and complex needs has unique concerns tied closely to the interaction between his/her social, economic and health care needs, and so requires an individualised response. The case manager must apply his or her knowledge of complex issues to identify specific needs. This includes working with an awareness that one complex issue will often obscure another. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 112 Cycle of Disadvantage A common feature of many clients, who present with complex needs, is a history of marginalisation and disadvantage, trauma (including childhood and/or adult sexual, physical and/or emotional abuse), dysfunctional family relationships, low education attainment, low or no employment and stigmatisation. (Source: Complex Needs Capable, NADA, 2013) http://www.nada.org.au/media/45224/complex_needs_capable_web_120813 Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 113 MENTAL HEALTH Many people with mental illness have a complex array of needs that must be considered. Rates of mental illness are high for people with intellectual disability, autism spectrum disorders, alcohol and drug use, physical disability, brain injury, problematic gambling, and those who are experiencing homelessness. Multiple physical health problems are also commonly present. Many people with high and complex needs remain undiagnosed and not effectively connected to mental health services. The experience of coexisting conditions frequently goes hand in hand with: Financial problems Lack of family or carer Lack of housing Loneliness and social isolation Poor physical health and disease Stigma and discrimination Uncontrollable symptoms of mental illness Unemployment ALCOHOL AND OTHER DRUGS Although drug and alcohol misuse is the primary presenting need for a person seeking to access drug and alcohol programs, all people present with multiple needs that may include: Borderline personality disorder Child protection issues Cognitive impairment Criminal justice system involvement Family breakdown Homelessness Mental illness Poor physical health Unemployment Every person accessing drug and alcohol services has multiple needs. However, it is the interaction of these multiple needs that leads to complexity. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 114 IMPRISONMENT People may come into contact with services at a number of points in the criminal justice system. They may self- refer before their offending matters come to the attention of the police or courts, be referred by the court as part of their bail or sentencing conditions, be on a diversion program, or have finished their sentence and be exiting prison. There are many health and social factors that are overrepresented in people involved in the criminal justice system as compared to the general population. These include higher levels of drug and alcohol problems, mental health issues and cognitive impairment. Other complex issues may include: Abuse Dysfunctional relationships and domestic violence Neglect and trauma Parental incarceration: juvenile detention Poor educational attainment and consequent limited employment opportunities Previous episodes of imprisonment Unstable housing CHILD PROTECTION Child protection involves the protection of all children and young people from harm or neglect. There are many different causes of harm that can have a detrimental effect on a child’s physical or emotional health, development and well-being. Forms of child abuse include neglect, physical, sexual or emotional. Children who require protection are those who have suffered harm, are presently suffering harm or those who are at risk of suffering significant harm. These injuries can impact a child’s mental health. Children who suffer from abuse or neglect may experience effects of low self- esteem, anxiety, depression or PTSD. Neglect can impact upon a child’s cognitive development due to lack of adequate cognitive stimulation. Physical health may also be impacted due to poor nutrition, injury and lack of medical care. There are many factors that may contribute to child abuse, and poverty has been considered the single best predictor of child neglect. While these issues alone are not indicative that child abuse is occurring, in some instances they may impact upon the parent’s ability to ensure that a child is safe from harm or neglect. Other potential indicators of child abuse include lack of support, unemployment, financial pressures, poverty, mental health issues, limited parenting skills, and alcohol and drug dependence. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 115 FAMILY VIOLENCE Domestic violence occurs in both heterosexual and homosexual relationships and includes married, de facto and separated adolescents and adults. Domestic violence is also commonly referred to as relationship violence, intimate partner violence and gender-based violence. In Indigenous communities, ‘family violence’ is often the preferred term as it encapsulates the broader issue of violence within extended families. Domestic violence is not limited to physical violence and involves a range of different forms of abuse: sexual, psychological, social, and economic abuse. It is also associated with a range of problems, such as: Child maltreatment and neglect Impact on general health and well-being of individuals by causing physical injury, anxiety, depression, impairing social skills Increased likelihood of engaging in practices harmful to health (e.g., self-harm or substance abuse Physical abuse which also increases the risk of criminal offending and a significant proportion of women in prison HOMELESSNESS ‘Homeless’ is statistically defined as a person who does not have suitable accommodation alternatives. They are considered homeless if their current living arrangement: Is in a dwelling that is inadequate. Has no tenure, or if their initial tenure is short and not extendable. Does not allow them to have control of and access to space for social relations. A number of complex, multiple and interrelated issues linked to people experiencing homelessness include: Discrimination Domestic and family violence Lack of income Mental illness Physical health and disability Poverty Substance addiction Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 116 POVERTY Poverty describes the inability to afford essential goods and services that most people take for granted. People living in poverty not only have low levels of income, they also miss out on opportunities and resources such as adequate health and dental care, housing, education, employment opportunities, food and recreation. Consequently, the living standards of people in poverty fall below overall community standards. Poverty is a complex situation by itself and is made more complex by the following interrelated issues: Abuse, neglect and trauma Discrimination Dysfunctional relationships Family violence Greater levels of physical and mental illness Health risks, such as smoking and poor diet Homelessness HEALTH People who have complex health needs require both medical and social services and support from a wide variety of providers and caregivers. Chronic and complex health care arises due to the impact and severity of diagnoses and/or conditions. Chronic and complex health care issues are characterised by those that involve many risk factors, may take time to develop, resulting in a long illness (which often cannot be cured), or can lead to functional impairment or disability. Multiple, interrelated issues which may affect the complexity of one’s health condition may include: Conflicting conditions, chronic pain, medication intolerance, unexplained symptoms, cognitive issues Depression resulting in poor medication adherence, addiction and anxiety Family stressors or neglect/abuse Low levels of health literacy Unaffordability of medication due to poverty or unemployment Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 117 AGE Clients with complex needs can be of any age. Many issues can impact the client’s age and his or her ability to participate in the management of his or her needs. These include issues related to transport, physical access, social acceptance, and communication. The needs of some clients, who have complex needs, will change over time as they age. DISABILITY According to the Australian Institute of Health and Welfare, over half of Australians with disability had a combination of two or more intellectual, psychiatric, sensory/speech, acquired brain injury and physical/diverse disabilities. Support needs of people with early onset multiple disabilities vary depending on the nature of their disabilities and their life stages. As they grow older, they may have higher support needs at an earlier age than people with single or late-onset disability. The more disabilities people had, the more likely they were to need help with ‘core’ daily activities of self-care, mobility and communication. Some combinations of disabilities had more marked effects on people’s activity, participation in major life areas and related need for assistance. A substantial proportion of care for people with multiple disabilities was provided by their family members and friends. Multiple, interrelated issues which may affect the complexity of one’s disability may include: Abuse, neglect, and trauma Assistance with core activities Community/social participation restrictions (inability to go out more due to disability) Discrimination Drug use Dysfunctional relationships Education restrictions Homelessness Mental health problems Significant behaviour problems (e.g., difficult behaviour) Unemployment Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 118 BEHAVIOURS OF CONCERN Behaviours of concern were previously known as challenging behaviours. A behaviour is considered to be of concern when it threatens the quality of life or physical safety of an individual, other people such as family or carers, or the community. This term is used to describe behaviour that interferes with an individual’s support and daily life. Examples of behaviours of concern include: Verbal or physical aggression ▪ Indicators of imminent harm to others o Social withdrawal o Excessive feelings of isolation or rejection o Being a victim of violence o Feelings of being picked on or persecuted o Verbal and/or non-verbal expression of violence o Uncontrolled anger o Patterns of impulsive and chronic hitting, intimidating, and bullying behaviours o History of violent and aggressive behaviour o Intolerance of differences and prejudicial attitude o Drug or alcohol abuse o Inappropriate access to, possession of, and use of firearms Self-harm ▪ Indicators of self-harm o Behaviour changes, severe anxiety, or extreme agitation o Withdrawing from family, friends, and society o Engaging in risky behaviours or activities o Displaying dramatic mood changes o Communicating an intent to kill or harm oneself or other suicide ‘talk’ o Preoccupation with death and dying o Increasing alcohol and drug use o Giving away special possessions o Loss of interest in usual activities o Actively looking for ways to kill oneself o Dramatic changes in personal appearance Destruction of property Impulsive or dangerous behaviour Disinhibition Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 119 Hyper-sexuality A disorder or injury can affect the brain functions which control emotions, impulses, self-awareness and the ability to monitor behaviour. Other interrelated issues include: Alcohol and/or drug issues Dual diagnosis (diagnosed as having more than one condition) Issues related to past experience of trauma or neglect Multiple disabilities, adversities and/or disadvantages Severe or profound intellectual disability Significant medical conditions and/or deteriorating health EMPLOYMENT The complex and interrelated factors that may contribute to, or result from, unemployment must be considered when determining a person’s service requirements. For instance, if a person who is unemployed, homeless, has an untreated mental illness and a physical illness, they may require a coordinated multi-agency approach. Housing and financial services, medical and mental health services may all be required to support the person to address needs in order to contribute to the person’s work-readiness. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 120 CULTURE AND RELIGION Case managers are facing new challenges in case management planning for a diverse population, which can present barriers to the traditional case management plan due to cultural and religious beliefs. Almost one quarter of Australia’s population were born in another country, yet mainstream services mirror only broad Australian values and attitudes. Many multicultural clients may prefer to talk with a Case Manager from their own cultural background, but often this may not be possible. It is therefore important that case managers are able to offer a consistent and competent service to all clients regardless of their culture and religion. While a person’s cultural, ethnic, or religious identity is likely to have a significant influence on his or her needs, other related issues may include: Age, gender, education, and socioeconomic status Denial of human rights, forced separation from members of their family/family fragmentation (specifically with refugees) Exploitation Exposure to violence (domestic and family violence) Homelessness Illness and starvation Level of proficiency in English Physical, emotional, and sexual abuse Racism and discrimination Unemployment Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 121 2.5 Evaluate Issues of Urgency and Eligibility At times, an assessment made may require immediate response from the case manager, client or both. As much as possible, the case manager must work with the client to determine an immediate action plan, with clear time frames. Ensure it is clear to the client that immediate action and support is only to address immediate concerns, and that through the development of case plan, less urgent and longer-term action planning can take place. Evaluate the individual’s eligibility Eligibility is the process where client’s needs and characteristics are compared against criteria for acceptance into programs or service. When a client is taken into a service or is referred to another service, the case manager must be aware of the eligibility criteria for each service. Many organisations have criteria which specify who can and cannot access a particular service. Sometimes, these are determined by the agreements that organisations have with their funding bodies. For example, a service may only take young people between the ages of 12 and 24, or a disability service may only take clients who are in receipt of a disability pension. The case manager needs to be aware of the eligibility criteria for his or her service and to find out about other services before a client is referred. Agencies and organisations are usually restricted by the number of clients they can have. An accommodation service will have a limited number of beds, as well as a detox unit. A counselling service will need to control the caseload of their workers, and many centres have waiting lists because of this. It is up to the case manager to keep well informed about what is currently available in their area and know whether services have waiting lists. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 122 2.6 Assess Potential Risk Factors for Service Delivery Risk factors are the aspects of a person (or group) and environment or personal experience that make it more likely or less likely that people will experience a given problem or achieve a desired outcome. Risk factors are key to figuring out how to address concerns/issues/needs. It is a matter of taking a step back from the problem, looking at the behaviours and conditions that originally caused it, and then figuring out how to change those conditions. The more risk factors a person has, the greater the likelihood they will engage in a given unhealthy behaviour. Assessing potential risk factors for service delivery can be accomplished using a risk assessment tool. One good example is the SAAP client risk assessment tool. *Double click on the icon above to open the assessment tool Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 123 3. Determine Appropriate Services 3.1 Consider Service Delivery and Referral Options from Strengths-Based Perspective Individuals often need supports and resources that may include people, organisations, information, knowledge, material resources, and decision-making resources. For many community agencies, their mandate and identity are often reflected in the type of services and resources they offer. This can be a challenge in that the services offered takes a central role in the delivery model practised; this is what we offer, and the client needs to accommodate. In a strengths-based perspective, not only are the types of resources important but how they are offered and mobilised to complement the intended client’s strengths and goals is just as important. If external resources and supports are not offered in the context of what is meaningful and building upon the person’s existing strengths and resources, it can undermine the person’s ability to learn and be self-determining. It can send a message such as: ‘You have no strengths that are relevant’. (Source: A Strengths-Based Perspective, Hammond and Zimmerman, 2017) Reasons for referral What are some reasons for needing to refer a client? The client may ask to be referred to another service. The client may have underlying issues that need to be dealt with by someone who specialises in that area (e.g. sexual assault issues, detox). The client may be dealing with multiple issues (e.g. mental health issues as well as drug dependency) or with multiple drug use. The client may need specialist care (e.g. they may have an acquired brain injury or a disability that requires special equipment). The client may feel more comfortable working with people of a particular cultural or linguistic background. The case manager might not have the skills or experience to work with some clients. The case manager may not have been very successful in helping a client. The client might be moving to a new suburb or location. The case manager might be leaving their job at the agency. A person’s strengths and capabalities are supported as necessary by resources in their natural networks. If necessary, commonly used community resources are added, and only if necessary, specialised resources are introduced. https://www.esd.ca/Programs/Resiliency/Documents/RSL_STRENGTH_BASED_PERSPECTIVE Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 124 There are also situations when we may choose not to refer a client, despite the fact that we are not able to provide the perfect service for them. Such scenarios could include: The client has started making changes in their lives and referring them to another service could interrupt the change process. A client has had a negative experience with another service and refuses the referral. Other issues impact on the success of the referral (e.g. the service is too far away, or the client has no transport, or there is no childcare or no interpreter service). There are no places available at the other service, and the client would have to be placed on a waiting list. In these circumstances, you would be better to maintain the client at your service until the situation alters. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 125 3.2 Evaluate Internal Capability and Other Service Networks to Determine Best Fit for the Person Your organisation will be able to cater to some needs, but not all. It is, therefore, appropriate to find out about services other agencies and organisations provide. There are benefits to including external support mechanisms: client will have access to a wider range of services, will have a broader support network, and will be less likely to become dependent on you or your agency. You can learn more about other agencies and service providers by: Joining professional networks Subscribing to other organisations’ mailing lists Using an Internet directory (e.g. https://www.infoxchange.org/au/) Speaking with clients about services they are currently using or have used in the past Contacting other organisations to clarify details about the services they provide Reading your local paper. Local newspapers often provide paid and unpaid publicity for a variety of community-based organisations Your role, as the case manager, is to sort through the options with your client to let them know what is available. To accomplish this, you need a good understanding of the services in your area and should be able to accurately assess the needs of the client. Keep up to date with what is available and what the criteria are for entry to other services. Try to keep track of changes in staffing as well as policy changes that might affect the type of services that an organisation delivers. Maintaining a database or contact list is a good way to manage information about available service and support options, so you always have access to the information you need. https://www.infoxchange.org/au/ Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 126 3.3 Provide the Person with Service Information and Support Their Decision-Making Process Clients have the right to be informed about different service options so that they can make decisions about which option will best meet their needs. It is important to encourage and support clients in making decisions that are consistent with their case management plan. As the case manager, you must identify, seek out and make available any support required to assist people to make their own decisions and act upon them. There are some common factors which can affect the client’s ability to make good decisions. However, most can be addressed with some thought about how they affect each individual. Some of these include: The type of decision being made Timing The complexity of the decision The urgency of the decision Currency of the decision The availability of information The physical environment The sensitivity of the decision Personal issues faced by the person Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 127 3.4 Encourage the Person to Advocate on Their Own Behalf to Access Services At times, case managers will need to advocate on behalf of their client to ensure access to adequate supports and the involvement of relevant services. Be clear about the need for which you are advocating and the reason the involvement of others is critical. There are also times that a client may wish to refer themselves to a service. This is desirable, so, where possible, the client should be encouraged to self-refer. Clients need to: Be aware of how to approach service providers and make their needs known. Have skills in communicating to express what they need to find out about their responsibilities. Have the confidence to ask questions and approach new people. Be literate so they can read information from the service provider and fill out appropriate forms. The case manager has to find out about the client’s level of competence by accessing other assessments, watching the client, interacting with them, speaking with others involved in the client’s care and asking the client. It is the case manager’s job to ensure that clients are equipped to self-refer. To assist the client to advocate on his or her own behalf and to promote their autonomy, the case manager should: Provide the client with information about how to self-refer. Helping the client develop communication skills through role-plays. Encourage the client by providing positive feedback and engaging in other reaffirming activities. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 128 Keep in mind that high-level support is not always the best form of support. The best form of support is one that encourages client competence, self-worth and self-efficacy as well as facilitating access to appropriate services. The following diagram shows examples of different levels of support. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 129 4. Complete Reporting 4.1 Document the Outcomes of the Assessment Process According to Organisation Procedures Documentation is perhaps the most important part of case management. Documentation serves as the proof that services were rendered. An organisation’s policies and procedures provide specific guidelines for documenting the outcome of the assessment process. If you are unsure of the policies and procedures that apply in your workplace, ask a more experienced co-worker to assist you, or refer you to your organisation’s guidelines or manuals. Documentation of the outcomes of the assessment process may vary on the basis of organisational setting and practice speciality. What is important is that it should reflect the individual needs and strengths of each client. Assessment process documentation with the client and other members of the client’s system may include the following domains, as they pertain to client priorities, strengths, and service needs: Motivating factors in seeking case management services or reason for referral to the social work case manager. Living arrangements, including suitability and safety of the home environment. Vocational history (for example, employment, education, volunteer work, or significant hobbies), challenges, and goals. Language preferences and proficiency levels. Preferred methods of communication and learning (such as oral explanation, written information, or practical demonstration). Degrees of literacy, including health, behavioural health, and financial literacy. Cultural values, beliefs, and practices (including, but not limited to, spirituality and religion) related to client’s goals for case management. Effects of culturally based discrimination on client’s ability to realise case management goals. Psychosocial strengths, protective factors, and points of resilience. Family composition, structure, roles, and communication patterns. Relationships with community organisations or other social supports. Physical, cognitive, and psychosocial functioning, including the ability to fulfil social roles. Desire and capacity for independence. Desire for support from other members of the family or client system. Desire and capacity of family or other members of the client system to support the client. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 130 Need for economic or other psychosocial resources, supports, and services ability to navigate relevant service systems (such as educational, employment, healthcare, housing, legal, nutritional, social services, or transportation systems). Individual and systemic barriers to client’s participation in the community or use of resources and services. Changes in resources, policies, and programs needed to support the client and, if applicable, other members of the family system. Behavioural health, including coping style, crisis management skills, substance use history, and risk of suicide or homicide. Health conditions and impact of those conditions on the client’s goals. Risk of abuse, neglect, or exploitation of or by the client, and underlying causes for such mistreatment. Lifespan planning (which may include advance care planning, anticipation of caregiving responsibilities, permanency planning for minor children, retirement planning, or other domains). Past strategies used to resolve the client’s concerns or enhance the client’s strengths. Client’s perceptions of changes needed to improve her or his situation. Client’s engagement in case management process and participation in shared decision making. Congruence with, and adherence to, pre-existing service plans. Patterns of service over- and underutilisation. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 131 4.2 Maintain and Store the Person’s Information According to Confidentiality Requirements Confidentiality is the protection of personal information. Confidentiality means keeping a client’s information between you and the client, and not telling others including co-workers, friends, family, etc. Examples of maintaining confidentiality include: Individual files are locked and secured. Support workers do not tell other people what is in a client’s file unless they have permission from the client. Information about clients is not told to people who do not need to know. Client’s medical details are not discussed without consent. Adult clients have the right to keep any information about themselves confidential, which includes that information being kept from family and friends. There is, however, no such thing as absolute confidentiality in the case management industry. Case managers and workers are required to keep notes on all interactions with clients and often to keep statistics about who is seen and what issues are addressed. There are few exceptions to the general rule of confidentiality, and they all have legal bases. These include: If the client tells you they have committed a serious crime. If the client is a child and is being abused or is at risk of abuse. If you are concerned that the client might harm themselves or someone else. If a child is under the age of 16 years, and especially under the age of 14, parents legally have the right to know what happens in counselling. Making records available to the police if they have a warrant to inspect documents. Making information available in the case of suspected or confirmed physical or sexual abuse. Responding to a summons or subpoena. Responding to a request under freedom of information legislation. In the case where legal obligations override a client’s right to keep information private and confidential, a community service organisation has the responsibility to inform the client and explain in a way that they can understand, the limits of confidentiality. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 132 Checkpoint! Let’s Review 1. All case managers need to be aware that there are State and federal laws the cover confidentiality. Research these Acts related to privacy and confidentiality of clients. Write your answers in the space provided. Answers: Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 133 4.3 Provide the Person’s Information to Other Services According to Consent and Confidentiality Requirements As much as maintaining confidentiality within the service is important, it is also essential to ensure that client privacy is protected when liaising with external agencies. Services should ensure with all referrals, that appropriate and accurate information is provided. The only information that needs to be shared is basic contact details for the client, the reason for the referral, the extent and nature of your involvement with the client and your role in the future. Under the freedom of information legislation, clients are within their rights to request to see their client file. Any written correspondence in relation to the client is kept in this file. Wherever possible, work in close partnership with your client, initiate the referral together and agree on what information needs to be shared. Bear in mind that another important consideration in sharing information is not withholding information that the service should know if they are to fulfil their duty of care to the client and other clients within the service. Client permission must be gained (preferably in writing) before sharing information. It is a good idea to discuss with the client what you are going to talk about with the other agency. Also, be sure that the client understands the policy and criteria of the service to which they are being referred. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 134 5. Evaluate Assessment and Referral Processes 5.1 Seek Feedback About Assessment Processes from the Person and Other Networks Obtaining feedback from clients and other networks is important in ensuring that on an individual level, the assessment processes utilised are continuing to meet client needs which may change over time, and on a broader level to obtain information that will be useful for case management planning. However, clients tend to provide very little formal feedback on the assessment. For this reason, case managers should encourage informal feedback from clients to provide varied and frequent opportunities to give feedback. Opportunities for informal feedback include: Discussing the assessment process informally with clients and other networks during follow-ups via email, phone or face-to-face. Encouraging clients to talk on a one-to-one basis about their needs and the services provided. Feedback concerning difficulties with the assessment process, way to improve the processes or positive feedback on specific aspects of the assessment should be briefly recorded in writing in the client’s case notes. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 135 5.2 Monitor Processes and Their Outcomes in Terms of Success in Meeting the Person’s Needs Assessment is an ongoing activity, not a one-time event. Reassessment serves both monitoring and evaluative functions, enabling the case manager and the client to determine whether services have been effective in helping achieve the client’s goals. During the reassessment process, the case manager and client, and if appropriate, the other support systems of the client, revisit the needs, assets, and priorities identified in the initial assessment and discuss the client’s emerging concerns. On the basis of such reassessment, the case manager and the client may determine the case manager goals or service plans that need to be adjusted. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 136 5.3 Routinely Seek Feedback and Reflect on Own Performance As part of your work as a case manager, you should also evaluate how well you are using and developing your professional skills. Reflective practice is when one takes the time to think about what he or she has been doing at work and how well he or she has been doing it. Reflective practice is the process of monitoring and analysing our work so that you can improve our work practices. Self-evaluation is a circular process. One reflects on what has happened, he or she adjusts his or her responses or practise new skills, implement these responses or new skills and then repeat the reflection process again. Seeking feedback from others Self-evaluation is important for case managers in order to identify and develop their skills in a constantly changing work environment. Part of a case manager’s professional development involves securing feedback about our individual performance from a variety of sources. Feedback about one’s performance can be sought from: Clients Members of the work team Other workers in the service Workers in related services/agencies Colleagues, peers, team leaders, supervisors, and managers Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 137 5.4 Use Feedback and Own Evaluation as a Basis for Improving Processes As in all aspects of case management, the processes utilised, and the services provided, should be continually reviewed to ensure these are relevant, appropriate, and effective. Evaluation helps case managers to recognise and use resources in the most effective and efficient way possible. It makes him or her accountable for the actions he or she take and the decisions we make. There is no point in seeking and receiving feedback about how services can be improved if the information will not be used to actually redevelop processes or resources, or change the way service is provided. It must be ensured that there is a process in place where feedback is reviewed by staff and management and suggested changes are implemented. Using feedback and own evaluation allows case managers to: Determine the effectiveness of the services provided. See whether a particular intervention was appropriate for the client. Minimise the effects of an intervention that is inappropriate. Bring about improvements in the services delivered. Respond to controversy or criticism. Provide information to management and funding bodies. Enable planning for the future about the types of services that are provided. Draw conclusions about what works best for clients. Review and reflect on the skills and strategies utilised. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 138 III. COORDINATE COMPLEX CASE REQUIREMENTS Complex needs are not easily defined. They depend on the individual and their situation, and are often referred to as ‘multiple unmet needs’. Complex needs can be viewed as a framework for understanding multiple, interlocking needs that span health and social issues. People with complex needs are understood as having multiple issues in their lives which can include mental health and/or addictions, developmental issues, involvement in the Criminal Justice system, problems finding and maintaining housing etc. These needs, often in combination with one another, require individuals to access services and support from a wide variety of government systems and community organisations. Each individual with multiple and complex needs has unique concerns tied closely to the interaction between his/her social, economic and health care needs, and so requires an individualised response. 1. Establish Coordination Function 1.1 Work with the Client and Other Services to Determine the Service Provision Requirements A multifaceted approach is needed to address client issues. This approach should incorporate a range of service and support options that are appropriate to each client’s individual needs. Clients have the right to be informed about different service options and provision requirements so that they can make decisions about which will best meet their needs. Community organisations and agencies will require different requirements depending on the services they provide. These include, but are not limited to the following: ▪ Personal and social support — Provides support for personal or social functioning in daily life. Such activities promote the development of personal skills for successful functioning as individuals, family members and members of the wider community. Personal and social support activities include the provision of information, advice and referral, personal, social and systemic advocacy, counselling, domestic assistance, provision of services that enable people to remain in their homes, and disability services and other personal assistance services. The purpose of such support is to enable individuals to live and function in their own homes or normal places of residence. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 139 ▪ Support for children, families and carers — Seek to promote child and family welfare by supporting families and protecting children from abuse and neglect or harm through statutory intervention. ▪ Training, vocational rehabilitation and employment — Assist people who are disadvantaged in the labour market by providing training, job search skills, help in finding work, placement and support in open employment or, where appropriate, supported employment. ▪ Financial and material assistance — Enhance personal functioning and facilitate access to community services, through the provision of emergency or immediate financial assistance and material goods. ▪ Residential care and supported accommodation — Provided in special purpose residential facilities, including accommodation in conjunction with other types of support, such as assistance with necessary day-to-day living tasks. ▪ Corrective services — In relation to young people and people with intellectual and psychiatric disabilities on court orders that involve correctional and rehabilitative supervision and the protection of public safety, through corrective arrangements and advice to courts and releasing authorities. ▪ Service and community development and support — Provide support aimed at articulating and promoting improved social policies; promoting greater public awareness of social issues; developing and supporting community-based activities, special interest and cultural groups; and developing and facilitating the delivery of quality community services. Activities include the development of public policy submissions, social planning and social action, the provision of expert advice, coordination, training, staff and volunteer development, and management support to service providers. Clients with complex needs may need the services of a combination of the following: Mental health and allied health professionals Specialists, general practitioners, and nurses Housing services Family therapists Aged care services HACC services Disability support services Drug and alcohol services Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 140 Some of these services may address immediate needs, while others may be part of longer-term strategies. While it’s true that clients’ needs can change, it is important to develop a plan of action that includes information about time frames for service delivery. Checkpoint! Let’s Review Research about the common service requirements of community care providers in your state/territory. For example, if you are in Queensland, organisations delivering Community Care services enter into a Service Agreement with the Queensland Government. Community Care providers are also required to demonstrate or provide evidence that the Community Care services are being delivered in compliance with the Human Services Quality Standards (HSQS). There are two main methods for this process: 1. Self-assessment using a template provided by the government, OR, 2. Provide evidence of other relevant current accreditation or certification, e.g. accreditation against the Australian Government’s Home Care Standards. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 141 1.2 Negotiate Collaborative Working Arrangements for All Services Involved When there are a number of services involved with the same client, it is important that case managers and workers liaise to ensure that the client’s needs are met in the best possible way. Conflict can occur between services if communication and negotiation do not occur. Services could find that they are overlapping in their roles rather than complimenting each other. Without negotiating the working arrangements, disagreements can occur over what kind of support the client requires and who should provide it, important information is not shared, and services can be quite unaware about what each other provides. When this happens, it is the client that suffers and not the services, workers or case manager. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 142 Services should aim for the following working arrangements: Stay client focused. Focus on what the client identifies as his or her main goals and priorities, not on what the case manager or services may see as important. Develop a trusting relationship between the client and the various services. Develop clear lines of communication between the client and the various services. This may involve regular phone calls or meetings, or written reports, depending on what is deemed appropriate by the parties involved. Define clear roles, responsibilities, and limitations of each service and the client. This should clearly relate to client goals, skills and expertise of the services, the service type, and the client’s preferences. Respect and value the contribution that each individual and agency makes to the case management process. By negotiating roles and working arrangements clearly, clients are able to receive assistance that might otherwise not be possible. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 143 1.3 Develop a Plan to Identify All Available Services, Their Appropriateness, Timeframes and Expected Outcomes Principles and practices of planning for individuals with complex needs For clients experiencing complex issues that include combinations of physical, social, economic and personal factors, planning complex service inputs should be holistic; it should accommodate each client’s strengths and address all the factors that act as barriers to their well-being. It is the case manager’s responsibility to ensure that these factors and barriers are identified so he/she can work with each client, their family and their carers to develop an appropriate set of support processes involving service providers. Service inputs may include formal interventions, support services, services to clients, and services to family and carers. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 144 A clear plan for working together should specify: How referrals are made (e.g. by telephone or writing) What sort of referrals can and cannot be accepted. This should be in line with the service’s eligibility criteria for accepting clients. The kinds of information that can be shared among agencies with the client’s consent. How that information can be used (e.g. can it be written into a report for distribution to all parties involved?) Time frames for responses and for service delivery Nature of services that can be provided Process for communicating and sharing information Ongoing involvement of the referring agency Time frames for service delivery Clients will have long-term goals that may relate to any of the following areas: Their living situation, for example, moving from a metropolitan location to a rural area, moving into residential care, accepting home support, deciding who they wish to live with. Educational needs, for example, developing new skills, relearning skills lost through injury or illness, undertaking formal or informal training. Vocational needs, for example, finding and maintaining employment or making a career change. Leisure and spending time doing things they enjoy, such as reading, walking or listening to music. Community access, for example, achieving social inclusion or joining community groups. Health, including physical and mental health and primary, secondary and tertiary care. Family support, including support for their carers. Communication, including understanding others and being understood. Advocacy and personal support, including support to achieve their rights. Human relationships, for example, learning how to interact appropriately to build good relationships. Behaviour management, for example, minimising behavioural issues and learning how to cope with stressful situations and deal appropriately with everyday challenges. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 145 1.4 Work with the Services to Agree on Coordination Requirements and Boundaries It is important, that, when working in collaboration with others, the needs and the abilities of the other services/workers are respected. As with all plans, the roles and responsibilities of each stakeholder should be worked out, and there should be a clear understanding of what type of support will be provided and how. The requirements and boundaries of the case manager, such as the following, should be delineated: Determine what services are available within the community. Develop protocols with other agencies that specify the process, eligibility, information sharing processes, time frames for responses, nature of services to be provided and arrangements for case management and coordination of services. Develop relationships with network partners. Ensure services are not duplicated. Ensure services are not working in conflict with each other. Ensure that other services are aware of your service and the role it plays in the network. Facilitate case management meetings. Facilitate communication. Identify issues indicating the need for improved communication between services. Meet formally and informally with another case manager to identify common issues, or gaps that may exist and services to the community. Monitor client confusion, concerns and barriers. Monitor overall impact of service interventions. Obtain written information about other agencies that you may need to access; find out about the services they offer, fees, eligibility, waiting lists and so on. Participate in a network. Provide a central point of contact for the client. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 146 2. Support the Client to Access Multiple Services 2.1 Identify, Implement and Maintain Duty Of Care Responsibilities Duty of care refers to the responsibility of case managers to avoid injury to a client or relevant others who it can be reasonably foreseen, might be injured by our act or omission. A duty of care exists when someone’s actions could reasonably be expected to affect or harm other people. Fulfilling our duty of care responsibilities involves taking adequate care to avoid injury. To do this, case managers need to consider the following: The client’s capabilities and capacities The dangers of the situation The client’s awareness of risks Assessments regarding the client’s needs and vulnerabilities The potential seriousness of the injury Placing the least restriction on client’s rights Compromising the rights of a few people as possible Empowering clients to take control over and responsibility for the situation Safety of other clients, their significant others and members of the public. Examples of risks and responsibilities relating to duty of care Children and young people Risks of harm Responsibilities The child or young person’s basic physical or psychological needs are not being met or are at risk of not being met. Investigate and assess concerns that a child or young person has been harmed or is at risk of significant harm. Report to the authorities if there are reasonable grounds to suspect that a child or young person is at risk of harm and if there are concerns about the child’s safety, welfare and well-being. Follow reporting responsibilities as stated within the workplace policies and procedures The child or young person has been or is at risk of being physically or sexually abused or ill-treated. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 147 People with a disability Risks of harm Responsibilities Limited communication skills and/or lack of an effective advocate. Apply a person-centred approach focused on supporting and empowering a person to have control of and make informed choices and decisions about their own life. Ensure people with disability and their parents and carers are informed of and supported to exercise their rights. Reliance on others for daily living. People experiencing domestic violence Risks of harm Responsibilities Parent/carer history of violent behaviour both inside and outside the household. Assess domestic violence threats to adult victims by applying the Domestic Violence Safety Assessment Tool, another risk assessment tool or using professional judgment. Have clear referral pathways for children and for adult victims to access the support they need to stay safe from domestic violence. Report and record as required in the workplace policies and procedures and within the laws applicable in your State Presence of other life stressors such as unemployment or recent loss/es. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 148 A situation of elder abuse Risks of harm Responsibilities Older person and the carer are socially isolated, lacking supportive contacts and social networks. Report any suspicion of abuse. Make an appropriate referral to assess their capacity if there is a concern that the older person does not have competence to make decisions. An older person may be dependent on others for social, emotional, physical, financial and spiritual support. Someone contemplating suicide Risks of harm Responsibilities Current thoughts with expressed intentions/past history/plans. Take the person and the threat seriously. Advise the person that threats of suicide or self-harm are taken seriously and that you may need to refer them to someone who is more appropriately trained or qualified to provide assistance. Report and record accordingly to the workplace policy and procedure or relevant legislation. Unstable mental illness. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 149 2.2 Provide Information to the Client About the Coordination Role Coordination in relation to case management involves having an understanding of the role of other services and developing cooperative working relationships with relevant services. For case managers, coordination is about developing a relationship with the client that seeks to foster collaborative decision-making in assuring the services are well targeted and client-centred. Clients must understand that coordination is most importantly about building a positive working relationship in order to develop care plans that address their needs, strengths, and goals. Specifically, the case manager’s coordination role includes the following: Collaborate and actively build relationships with other service providers to support efficient work towards the case plan goals. Ensure all agencies are aware of each other’s involvement. Identify and reduce service or support barriers, gaps or overlaps that may arise. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 150 2.3 Work with the Client to Establish Communication Requirements Maintain open communication channels with all stakeholders, including the client and hold them accountable for tasks to be undertaken. Regular communication helps to maintain a coordinated focus on achieving outcomes and meetings or case conferences with all stakeholders can support this process. Make sure information shared is accurate and be sure to discuss progress, challenges and proposed solutions with the client at all stages of implementation. Discuss with the client the methods of contacting him or her for updates and follow-ups; phone, face-to-face meeting, home visit, email, etc. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 151 2.4 Assess Need and Arrange Interpreter, According to Client’s Needs Case managers work with a diverse range of clients who, because of their disability or personal, emotional, and cultural situation, may require workers to develop and use specialist communication skills. The case manager must be able to adapt their communication style to meet the needs of different client groups in a fair, non-judgemental, and effective manner. Areas of specific need which should be considered when communicating with clients include: Disability (including but not limited to intellectual impairment, physical impairment, psychiatric disability, hearing or vision impairment, learning difficulties, and attention deficits) Literacy (e.g. false assumptions about level of intelligence and understanding, concerns about the content of documents and forms, what is being written down) Language (e.g. non-English-speaking backgrounds, not familiar with service-specific jargon and acronyms) Gender, age, experiences, emotional well-being and other individual attributes. Critical situations - crises traditionally cause disorganisation of thought and hence need special skills by workers in establishing rapport with clients Culture (including experiences in other countries, music, spirituality, customs, gender, social expectations, body language, and position in the community) Remote location (limited access to services and resources, distance travelled) Irrespective of their particular needs, all clients must be treated with dignity and all communication must demonstrate respect and be open and non-judgemental. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 152 Arrange for interpreters Interpreters include language interpreters and cultural interpreters, who can provide a cultural context for communication. Translators work specifically with written materials. When you are working with interpreters: The interpreter or translator should be neutral: their purpose is only to relay the message from one person to another. The interpreters should not provide advice or give opinions. Be aware of factors that could impact on the interpretation process. For example, differences in dialect or conflicting politics, beliefs or values may cause a person to reject an interpreter. Make it clear to the interpreter that the message must be communicated as you intended. Ask them to check with you for nuances or to clarify meaning to ensure this occurs. A registered interpreter will be required to complete a document stating that they are fulfilling their role as described above. Address all questions, eye contact and body language to the client as if you are asking the questions directly. The focus of the communication should be on the worker and the client – not on the worker and the interpreter. Bear in mind that non-professional support people such as family members, carers or professional advocates are not neutral. If these people are to act as interpreters, be aware that the communication may be influenced by advice or emotional involvement. If these people are utilised for interpreting in medical or legal matters any decisions made can be challenged or become a legal challenge. Further Reading Professional interpreters are available for a fee from the Translating and Interpreter Service (TIS) https://www.tisnational.gov.au/ https://www.tisnational.gov.au/ Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 153 2.5 Work with the Client and Other Services to Identify Barriers to Attaining Outcomes As someone who works with clients who have complex needs, it is important for the case manager to further develop his or her knowledge and understanding of issues that may affect the client’s ability to attain outcomes. It is important that the case manager works with other services in identifying these barriers to enable them to take steps to modify outcomes or the environment or provide additional supports or services to help the client. Barriers to attaining outcomes may be tangible or perceived. Tangible barriers Tangible barriers to participation are those barriers you can readily identify. They are often physical factors that can be seen and touched or factors that relate to real objects or events, such as: A lack of available and accessible transport Insufficient finances to pay for services A lack of adaptive equipment Inaccessible buildings or areas A lack of accessible toilet facilities Perceived barriers Perceived barriers to participation are often far more difficult to identify. They include the actions or inactions of people or groups, perceived attitudes and approaches, and social expectations about behaviour and inclusion, for example: The failure of an organisation or business to offer signage in multiple community languages or to provide translation services when required. The failure of an organisation or business to make their website fully accessible to people who use screen-reading software or require larger fonts to read the text. Attitudes of reception staff to make a person feel welcome and included, or not. Attitudes of face-to-face staff to make a person feel disempowered and not part of a group. Activities/services that are needlessly high in cost. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 154 2.6 Work with the Client to Prioritise Needs and Communicate These with Service Providers When working with the clients to prioritise his or her needs, it is important that the case manager considers needs holistically rather than focusing on the presenting issues alone. Once the needs are prioritised, the case manager must ensure that each service provider communicates with each other to facilitate seamless service delivery and coordination. Case managers must also ensure that each service provider is clear about their responsibilities in relation to a client via a case management plan and that regular meetings are held with relevant stakeholders. 2.7 Facilitate Case Conference and Meetings to Coordinate Responsibilities and Roles A case manager organises and oversees the delivery of services to clients. They connect clients to the community and other relevant resources and work to protect the rights and the well-being of the client. When working with clients to meet their needs, different parties are often involved, including family members and health professionals. It may be necessary to organise conferences or meetings with these parties to plan and regularly review the delivery of a service and/ or if a particular issue arises. Case conferences and meetings need to be outcome driven and not just about providing and sharing information. In general, the purpose of case conferences and meetings is to: Ensure client involvement, or if more appropriate, a child/client representative. Review client’s situation, agency assessments and progress towards case plan goals. Discuss issues, concerns or gaps in current service delivery. Outline expectations of the client and participating agencies moving forward. Develop actions that support the case plan and agree on the roles each agency has in achieving next steps. Develop and agree on service referrals. Improve or maintain strong, client centred service coordination. Case conferences need to include the client or at a minimum ensure their views are represented. The meetings should be held in a place and through a process that enables the client to feel that they can actively and safely contribute to the discussion. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 155 When situations arise that a client is not willing or able to attend or participate, it is important to have a clear communication strategy to ensure that their views are captured prior to the meeting and that they are informed of the outcomes. A case conference without the client being present should only be called under special circumstances. A client may not be present because they cannot be located; where a case conference is necessary to progress the case plan because of risk or, the client is a child under the age of 12 years and their ability to participate and/or be represented has been discussed with a parent/guardian or child specialist. Further Reading Access the Case Management Guidebook to know more about case meetings 2.8 Work with Other Services to Minimise Client Confusion and Concerns in a Coordinated Manner Principles and practices of working across multiple services Working across multiple services involves service delivery coordination initiatives. These may be conceived in various ways depending on the specific needs of the client. Initiatives may simply involve linking two or more distinct service providers to promote cross-agency information sharing and/or referrals, or a more complex service delivery coordination that requires formalised measures to ensure that different agencies work together in a structured and planned manner. Practices may include referral protocols, services directories, informal interagency networks/working groups, and cross-agency awareness training. Issues that cause client confusion, concerns, and barriers Needing to provide the same information to multiple services Not understanding how services complement each other Not understanding the relevance of different service inputs Time required to commit to service demands http://www.casemanagementguidebook.ie/Protocols/Protocols/Interagency-case-meetings.aspx Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 156 Issues faced by clients, their family and carers, accessing multiple services A lack of quality and/or specialist staff. Chaotic daily life or complex lives that limit the clients, their family and carers to consider the benefits of the service. Communication difficulties, including being unable to understand what the services are offering. Hostility or disapproval towards the service from trusted family members and carers. Intimidation, fear or distrust about accessing a service. Provision of services that is or is perceived as irrelevant, inappropriate or stigmatising. Service duplication. Service fatigue. Service location is difficult to get to, or the client or geographically isolated or is unable to access transport. Impact of service duplication Service providers may struggle to reconcile organisational differences which limit the effectiveness of coordination efforts. Potential competition for resources between providers. Gaps or inconsistencies in service provision. Service fatigue. There is a tendency to treat people as passive recipients rather than active participants. If poorly coordinated and fragment, people may have difficulty navigating and receiving the support they need. Multiple access points where many people have to tell their stories too many times to different parties. Often costly and inefficient. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 157 Impacts of generational abuse and welfare dependency Individuals who have experienced generational abuse: Can develop into parents who physically abuse their own children. Can have relational problems both with significant others and in less intimate relationships. May enter relationships where they are emotionally abused or in which they abuse others. May expose their children to age-inappropriate sexual information or may become overprotective. May form quick, over-involved and inappropriate attachments with others leaving them vulnerable to abuse. Find it difficult to tolerate intimacy, and may remain socially and emotionally distant. Can fail to meet the nurturance needs of their own children if and when they became parents. If they have witnessed domestic violence, they are at an increased risk of entering adult relationships in which there is intimate partner violence. May have Posttraumatic Stress Disorder and other mental health concerns that impair their ability to parent effectively. May have anger management problems, depression, anxiety, and substance abuse disorders. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 158 Case coordination Case coordination includes communication, information sharing, and collaboration with other mainstream and specialist services that are required to support the client to achieve identified goals. Involvement of other services is required to addresses potential gaps in meeting social, developmental, behavioural, educational, informal support network, and financial needs in order to achieve client outcomes. Coordination activities may include: Providing assistance to the client to support the client to navigate the service system, for example, through providing information about the available services and access criteria and processes. Making referrals to other mainstream and specialist services or programs, such as drug and alcohol, mental health, family services, anger management programs. Facilitating access to other services, such as attending meetings and helping clients to complete paperwork. Reducing barriers to obtaining services, for example through supporting clients to access relevant health, mental health and legal services. Sharing and exchanging information, such as assessments and case plans, with other services, with the client’s consent. Joint working with clients, as required. Maintaining regular contact with other services involved in the client’s case, with the client’s consent, to inform monitoring and review of the case plan. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 159 3. Monitor Client Progress 3.1 Facilitate Communication Between Service Providers to Identify and Manage Service Duplication One of the greatest challenges in having a client access multiple services is confusion, which has an impact on understanding roles, responsibilities, and actions. When agencies come together, each often believes that it is responsible for providing case management with a dedicated case manager in place. This conflict usually occurs either because no formal discussion has been undertaken regarding which agency will take the lead, or that a specialist agency is also coordinating a range of specialist services for a client. In such cases it remains important and necessary to identify who the lead agency/case manager is for the client, recognising that, while individual case managers are involved in coordination/facilitating action and referrals within the field of expertise, one agency still needs to be identified as the leader who will plan and coordinate the overall responsibility for the client. It is important to note that being the lead agency means taking responsibility for the direction, but it does not presume sole decision-making powers. It is important that the case manager of the lead agency keep in close communication, to avoid duplication and ensure the case plan is being implemented smoothly. It is also an opportunity to keep informed of other stakeholders and who is liaising with them. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 160 3.2 Work with the Client and Services to Monitor Progress Toward Outcomes Ongoing monitoring and revision of case management plans and timeframes are essential in helping the client set achievable goals that increase confidence, self-determination and motivation for further change. Many of the skills and strategies used in interventions are utilised in the evaluation process, as listed below: Engaging the client and involving them as the centrepiece of the evaluation process. Contracting at the beginning of the intervention that an evaluation will take place and identify how it will be undertaken. Negotiating the revision of case management plans and goals in collaboration with the client. Disengagement and confirmation of how follow-up contact is to take place, for example, by telephone or mail and who will contact the client. Discussing issues of confidentiality involved with the evaluation process. Clear and concise record keeping and documentation of intervention processes. Liaison with others such as individuals, professionals or services involved in the intervention process. 3.3 Obtain Client Feedback About Services Clients are experts in their own life experiences and are best placed to provide feedback about how services and responses can best support them and address their needs. It is therefore important to capture client input and feedback to inform continuous improvement of services. Feedback can be sought in a number of ways: Face-to-face or telephone interviews Online surveys Written questionnaires Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 161 Although the mechanism for seeking feedback may vary depending on the client’s preference, questions should be consistent to enable comparability to inform service improvements. Good practice in seeking feedback from clients includes: Ensuring confidentiality of responses. Recognising the client’s time in completing the feedback. Minimising the likelihood that the client feels pressured into answering in a particular way. These mechanisms for seeking feedback complement wider feedback activities, such as focus groups and point-in-time surveys that may take place for specific program evaluations or reviews. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 162 3.4 Identify and Implement Further Support Required to Meet Changing Needs and Progress Towards Outcomes Ongoing monitoring and evaluation of client case management plans and timeframes are essential in helping the client achieve their desired goals. The client is centrally involved in the evaluation process as the case manager will not be the only person who helps the client in goal achievement. The key role of the case manager at this point will be to assess just how often the client needs to be contacted or seen, with regard to the progression of the case management plan. A goal that is agreed to in the client case management plan may change or need to be revised over time. The client’s progress will be influenced by many factors, and therefore the case management process needs to be flexible. Revision of goals and outcomes are undertaken throughout the process of case management allowing responsiveness to the individual’s changing circumstances and progression through case plan objectives. Knowledge gained by working with clients and service systems is used to advocate at both individual and system levels. Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 163 REFERENCES Australian Association of Social Workers (AASW). (2015). Scope of social work practice: Case management & care coordination. Retrieved from: https://www.aasw.asn.au/document/item/8310 Australian Human Rights Commission. (2008). Homelessness is a human rights issue. Retrieved from https://www.humanrights.gov.au/publications/homelessness-human-rights-issue Australian Human Rights Commission. Face the facts: Lesbian, gay, bisexual, trans and intersex people. Retrieved from https://www.humanrights.gov.au/face-facts-lesbian-gay-bisexual-trans-and- intersex-people Australian Institute of Family Studies. (2003). Family structure, child outcomes and environmental mediators. Retrieved from https://aifs.gov.au/publications/family-structure-child-outcomes-and- environmental-mediators/changing-patterns-family Australian Institute of Family Studies. (2016). Mandatory reporting of child abuse and neglect. Retrieved from https://aifs.gov.au/cfca/publications/mandatory-reporting-child-abuse-and-neglect Australian Institute of Health and Welfare. (2017). Services for homeless people. Retrieved from http://compliantlearningresources.com.au/network/lotus/files/2017/11/aw97-c07 Australian Primary Schools Mental Health Initiative. (2014). Engaging with aboriginal and torres strait islander communities. Retrieved from https://www.kidsmatter.edu.au/sites/default/files/public/Handbook_engaging_with_web Case Management ANTA Toolbox. Handout 1: Conduct case management meetings. Retrieved from https://www.dlsweb.rmit.edu.au/toolbox/casemang/w3c/reception/chccm3a/_handouts/handout _01.htm Case Management Guidebook. Interagency case meetings. Retrieved from http://www.casemanagementguidebook.ie/Protocols/Protocols/Interagency-case-meetings.aspx Case Management Society of Australia and New Zealand (CMSA). (2013). National standards of practice for case management. Retrieved from https://user-clvm5gg.cld.bz/2013-Standards- Fb2015version/1#zoom=z Communicate effectively in a community services setting. Retrieved from http://lrr.cli.det.nsw.edu.au/web/11236/lo/8604/8604_00.htm Department of Health and Ageing. (2012). National Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) Ageing and Aged Care Strategy. Retrieved from https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/08_2014/national_ageing_and _aged_care_strategy_lgbti_print_version Family & Community Services. Elements of case management. Retrieved from http://www.community.nsw.gov.au/kts/case-management/elements#monitoring Government of South Australia, Department for Communities and Social Inclusion. (2013). Case management framework: Specialist homelessness and domestic and aboriginal family violence services (SHS). Retrieved from: https://www.sa.gov.au/__data/assets/pdf_file/0017/13508/Case_Management_framework Health Communication Capacity Collaborative. Theory of planned behaviour. Retrieved from http://www.healthcommcapacity.org/wp- content/uploads/2014/03/theory_of_planned_behavior https://www.aasw.asn.au/document/item/8310 https://www.humanrights.gov.au/publications/homelessness-human-rights-issue https://www.humanrights.gov.au/face-facts-lesbian-gay-bisexual-trans-and-intersex-people https://www.humanrights.gov.au/face-facts-lesbian-gay-bisexual-trans-and-intersex-people https://aifs.gov.au/publications/family-structure-child-outcomes-and-environmental-mediators/changing-patterns-family https://aifs.gov.au/publications/family-structure-child-outcomes-and-environmental-mediators/changing-patterns-family https://aifs.gov.au/cfca/publications/mandatory-reporting-child-abuse-and-neglect http://compliantlearningresources.com.au/network/lotus/files/2017/11/aw97-c07 https://www.kidsmatter.edu.au/sites/default/files/public/Handbook_engaging_with_web https://www.dlsweb.rmit.edu.au/toolbox/casemang/w3c/reception/chccm3a/_handouts/handout_01.htm https://www.dlsweb.rmit.edu.au/toolbox/casemang/w3c/reception/chccm3a/_handouts/handout_01.htm http://www.casemanagementguidebook.ie/Protocols/Protocols/Interagency-case-meetings.aspx https://user-clvm5gg.cld.bz/2013-Standards-Fb2015version/1#zoom=z https://user-clvm5gg.cld.bz/2013-Standards-Fb2015version/1#zoom=z http://lrr.cli.det.nsw.edu.au/web/11236/lo/8604/8604_00.htm https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/08_2014/national_ageing_and_aged_care_strategy_lgbti_print_version https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/08_2014/national_ageing_and_aged_care_strategy_lgbti_print_version http://www.community.nsw.gov.au/kts/case-management/elements#monitoring https://www.sa.gov.au/__data/assets/pdf_file/0017/13508/Case_Management_framework http://www.healthcommcapacity.org/wp-content/uploads/2014/03/theory_of_planned_behavior http://www.healthcommcapacity.org/wp-content/uploads/2014/03/theory_of_planned_behavior Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 164 Human Services. (2012). Social housing advocacy and support program (SHASP): interim integrated case management guidelines. Retrieved from http://www.dhs.vic.gov.au/__data/assets/pdf_file/0011/746966/1_shasp_interim-integrated-case- management-guidelines-1112 Kyrios, M. Overcoming the barriers to behaviour change in complex environments. Retrieved from https://www.baker.edu.au/Assets/Files/Overcoming%20the%20Barriers%20to%20Behaviour%20 Change%20in%20Complex%20Environments%20-%20Professor%20Michael%20Kyrios National Association of Social Workers (NASW). (2013). Social work case management. Retrieved from https://www.socialworkers.org/LinkClick.aspx?fileticket=acrzqmEfhlo%3D&portalid=0 National Association of Social Workers. Social work & care coordination. Retrieved from http://compliantlearningresources.com.au/network/lotus/files/2017/11/CareCoordinationBriefin gPaper National LGBTI Health Alliance. (2013). LGBTI cultural competency framework. Retrieved from http://www.lgbtihealth.org.au/sites/default/files/Cultural%20Competancy%20Framework NSW Department of Community Services. (2009). Working with Aboriginal people and communities: a practice resource. Retrieved from http://www.carersaustralia.com.au/storage/2011Working%20with%20Aboriginal%20People%20a nd%20Communities NSW Department of Education. (2009). Implement and monitor agreed upon activities and processes in community services. Retrieved from http://lrr.cli.det.nsw.edu.au/web/11236/lo/8379/8379_00.htm NSW Department of Education. (2009). Work with and support other organisations to enhance service delivery. Retrieved from http://lrr.cli.det.nsw.edu.au/web/11236/lo/8386/8386_00.htm NSW Department of Education. (2009). Work within a case management framework. Retrieved from http://lrr.cli.det.nsw.edu.au/web/11236/lo/8376/8376_00.htm http://www.dhs.vic.gov.au/__data/assets/pdf_file/0011/746966/1_shasp_interim-integrated-case-management-guidelines-1112 http://www.dhs.vic.gov.au/__data/assets/pdf_file/0011/746966/1_shasp_interim-integrated-case-management-guidelines-1112 https://www.baker.edu.au/Assets/Files/Overcoming%20the%20Barriers%20to%20Behaviour%20Change%20in%20Complex%20Environments%20-%20Professor%20Michael%20Kyrios https://www.baker.edu.au/Assets/Files/Overcoming%20the%20Barriers%20to%20Behaviour%20Change%20in%20Complex%20Environments%20-%20Professor%20Michael%20Kyrios https://www.socialworkers.org/LinkClick.aspx?fileticket=acrzqmEfhlo%3D&portalid=0 http://compliantlearningresources.com.au/network/lotus/files/2017/11/CareCoordinationBriefingPaper http://compliantlearningresources.com.au/network/lotus/files/2017/11/CareCoordinationBriefingPaper http://www.lgbtihealth.org.au/sites/default/files/Cultural%20Competancy%20Framework http://www.carersaustralia.com.au/storage/2011Working%20with%20Aboriginal%20People%20and%20Communities http://www.carersaustralia.com.au/storage/2011Working%20with%20Aboriginal%20People%20and%20Communities http://lrr.cli.det.nsw.edu.au/web/11236/lo/8379/8379_00.htm http://lrr.cli.det.nsw.edu.au/web/11236/lo/8386/8386_00.htm http://lrr.cli.det.nsw.edu.au/web/11236/lo/8376/8376_00.htm Learner Guide CHCCSM005 Develop, facilitate and review all aspects of case management CHCCCS004 Assess co-existing needs CHCCSM004 Coordinate complex case requirements Page 165 NSW Department of Family and Community Services. (2012). Specialist homelessness services case management resource kit. Retrieved from http://www.housing.nsw.gov.au/__data/assets/pdf_file/0020/325226/SHSCMRK QCOSS Community Door. (2015). Respond holistically to client issues. Retrieved from http://etraining.communitydoor.org.au/mod/page/view.php?id=78 QCOSS Community Door. (2015). Utilise specialist communication skills to build strong relationships. Retrieved from http://etraining.communitydoor.org.au/mod/page/view.php?id=112 Queensland Council of Social Service (QCOSS). A guide to integrated service delivery to clients: For community service organisations. Retrieved from http://communitydoor.org.au/sites/default/files/A_GUIDE_TO_INTEGRATED_SERVICE_D ELIVERY_TO_CLIENTS Queensland Government. (2010). Working with people from culturally and linguistically diverse backgrounds. Retrieved from https://www.communities.qld.gov.au/resources/childsafety/practice-manual/prac- paper-working-cald State Government of Victoria – Human Services. (2012). Families with multiple and complex needs. Retrieved from http://search.ror.unisa.edu.au/record/UNISA_ALMA11143248070001831/media/digital/open/9 915909586101831/12143248060001831/13143247130001831/pdf TAFE NSW. (2009). Personal values, belief and attitudes. Retrieved from https://sielearning.tafensw.edu.au/MCS/CHCAOD402A/chcaod402a_csw/knowledge/values/val ues.htm TAFE NSW. (2009). Duty of care. Retrieved from https://sielearning.tafensw.edu.au/MCS/CHCAOD402A/chcaod402a_csw/knowledge/duty_of_c are/duty_of_care.htm TAFE NSW. (2009). Work ethically. Retrieved from https://sielearning.tafensw.edu.au/MCS/CHCAOD402A/chcaod402a_csw/lo/8511/8511_00.htm #ID0EYHAC The Department of Health. (2013). People with coexisting conditions and complex care needs. Retrieved from http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-n-recovgde- toc~mental-pubs-n-recovgde-10~mental-pubs-n-recovgde-10-com The National Psychologist. (2000). Relapse prevention therapy: A cognitive-behavioural approach. Retrieved from http://nationalpsychologist.com/2000/09/relapse-prevention-therapy-a-cognitive-behavioral- approach/10491.html Victorian Council of Social Services (VCOSS). Briefing paper 8: Clients with multiple complex needs. Retrieved from http://vcoss.org.au/documents/2015/05/8_Client-needs_P5 http://www.housing.nsw.gov.au/__data/assets/pdf_file/0020/325226/SHSCMRK http://etraining.communitydoor.org.au/mod/page/view.php?id=78 http://etraining.communitydoor.org.au/mod/page/view.php?id=112 http://communitydoor.org.au/sites/default/files/A_GUIDE_TO_INTEGRATED_SERVICE_DELIVERY_TO_CLIENTS http://communitydoor.org.au/sites/default/files/A_GUIDE_TO_INTEGRATED_SERVICE_DELIVERY_TO_CLIENTS https://www.communities.qld.gov.au/resources/childsafety/practice-manual/prac-paper-working-cald https://www.communities.qld.gov.au/resources/childsafety/practice-manual/prac-paper-working-cald http://search.ror.unisa.edu.au/record/UNISA_ALMA11143248070001831/media/digital/open/9915909586101831/12143248060001831/13143247130001831/pdf http://search.ror.unisa.edu.au/record/UNISA_ALMA11143248070001831/media/digital/open/9915909586101831/12143248060001831/13143247130001831/pdf https://sielearning.tafensw.edu.au/MCS/CHCAOD402A/chcaod402a_csw/knowledge/values/values.htm https://sielearning.tafensw.edu.au/MCS/CHCAOD402A/chcaod402a_csw/knowledge/values/values.htm https://sielearning.tafensw.edu.au/MCS/CHCAOD402A/chcaod402a_csw/knowledge/duty_of_care/duty_of_care.htm https://sielearning.tafensw.edu.au/MCS/CHCAOD402A/chcaod402a_csw/knowledge/duty_of_care/duty_of_care.htm https://sielearning.tafensw.edu.au/MCS/CHCAOD402A/chcaod402a_csw/lo/8511/8511_00.htm#ID0EYHAC https://sielearning.tafensw.edu.au/MCS/CHCAOD402A/chcaod402a_csw/lo/8511/8511_00.htm#ID0EYHAC http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-n-recovgde-toc~mental-pubs-n-recovgde-10~mental-pubs-n-recovgde-10-com http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-n-recovgde-toc~mental-pubs-n-recovgde-10~mental-pubs-n-recovgde-10-com http://nationalpsychologist.com/2000/09/relapse-prevention-therapy-a-cognitive-behavioral-approach/10491.html http://nationalpsychologist.com/2000/09/relapse-prevention-therapy-a-cognitive-behavioral-approach/10491.html http://vcoss.org.au/documents/2015/05/8_Client-needs_P5