The case manager assesses the needs of clients and their families and identifies relevant and cost effective resources which can be made available to them in order to obtain maximum benefit for the client, the family and the budget holder. A plan is prepared and implemented to create a support package, individually tailored for each client.

The key activities in which a case manager would become involved are set out below in brief. Co-ordination and communication remain essential and integral to all aspects of case management.

1. Assessment

The gathering of relevant information from a range of sources including the individual and their family and different practitioner disciplines. They develop an appreciation of the individual’s illness or injury and how this may impact on their level of independence, personal safety, family and social life, finances and vocational opportunities.

2. Planning

The development of a plan, in association with all concerned parties, which addresses guidance, support and advocacy issues for the individual and the family, and establishes rehabilitation goals, in order to develop management systems, recruit and train the necessary support staff and carers and seek out the most appropriate and cost effective resources for the client.

3. Implementation

The support to ensure that the wishes of the client and the family are always heard and understood, to demystify medical jargon and to facilitate open and honest communication between all those involved. In addition, to act as a point of reference for the client, the family and others, a sounding board of knowledge and expertise, and to facilitate the client’s and the family’s decision-making and acceptance of changed circumstances.

The systems to co-ordinate health, rehabilitation, social service and voluntary agencies to ensure an individually tailored programme of rehabilitation is provided for each client, to establish the necessary level of care at home or in a residential setting, and to liaise with external agencies to help obtain the funding necessary to meet these needs.

The task of implementing, reviewing, monitoring and changing the programme, as required, to ensure that the client’s and the family’s needs are sustained, rests with the case manager, who has a duty of care to the client and a responsibility to ensure that the appropriate services are accessed and that continuity and consistency of support are developed and maintained.

The case manager is obliged to prepare and maintain written records and produce reports, to monitor the client’s progress and care, at regular intervals as determined by the client or their representatives.

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